Cervical screening: The Jade Goody Effect

1. Cervical screening:The Jade Goody Effect Nicola MacDonald Consultant Gynaecological Oncologist

2. 'Jade Goody effect' increases cervical cancer screening uptake 26 August, 2009 There has been an increase in cervical cancer screening uptake in Scotland, possibly driven by the ‘Jade Goody effect’, according to latest figures. Data for 2009 from Information and Statistics Scotland showed that, of eligible women, 73.4% had been screened in the previous 3.5 years, a rise of approximately 4% compared to March 2008. Of those women with a record of a previous smear taken within the last 3.5 years, uptake rates have improved across all five year age bands within the target age group of 20-60 years. When compared to March 2008, the largest increase in uptake, of more than 6%, was found in the lowest age band of 20-24 years. Scottish public health minister Shona Robison said: Compared to last year’s publication, the percentage of women being screened is up 4 per cent – 6 per cent among women in their early twenties – and around 75,000 more smear tests were carried out. Thousands more women are taking this positive step to protect their health, which is enormously encouraging. “The rise in uptake coincides with the HPV immunisation campaign, which promotes the importance of cervical screening and the very sad illness and death of Jade Goody, who worked hard to raise awareness of cervical cancer. This is clear proof that being more open about this illness and the need for screening can and does encourage women to come forward.”

3. Cervical cancer • 2006 • 2873 new cases diagnosed in UK • 12th most common female cancer • (2% of female cancers) • Lifetime risk of developing cervical cancer 1:136 based on • data from 2001-2005

4. Current issues Age of onset of screening Risks of screening younger women How should we treat young women with abnormal smears/CIN?

5. Age of onset of screening UK Cervical Screening Programme by country

6. Cervical Screening Programme - England 25 First invitation (age 20 until 2003) 25-49 Every three years 50-64 Every five years 65+ Only if not screened since age 50 or if recent abnormal tests

7. Protection offered by varying screening intervals Percentage of cancers preventable: P.Sasieni et al. British Journal of Cancer (2003) 89, 88–93

8. Referral to colposcopy 3x inadequate smears 3x BNC or one BNC in endocervical cells 3x abnormal tests of any grade in 10 years 1x mild dyskaryosis (TOMBOLA trial) 1x moderate or severe dyskaryosis/possible invasion/ glandular neoplasia Abnormal cervix/symptoms/previous treatment and abnormal smear

9. Colposcopy clinic referrals NHS Cervical Screening Programme Annual Review 2008

10. Screening success 1975-2006

11. Cervical cancer incidence by age

12. Cervical cancer mortality 1971-2007

13. Cervical cancer mortality by age 1971-2007

14. Cervical cancer mortality by age

15. Cervical cancer mortality reduction

16. Changing the age of screening onset Issues to consider: 1. Screening is ineffective below age 25

17. Effectiveness of screening with age

18. Women screened under age 25 NHS Cervical Screening Programme Annual Review 2008

19. Changing the age of screening onset Issues to consider: 1. Screening is ineffective below age 25 2. Abnormal smears are common under 25.

20. Abnormal smears in young women 2002 26 women under 25 had cervical cancer 55,000 had abnormal smears (BNC or worse)

21. Natural history of CIN Ostor et al. Int J Gynecol Pathol, 1993;12(2):186-92

22. Changing the age of screening onset Issues to consider: 1. Screening is ineffective below age 25 2. Abnormal smears are common under 25. 3. The consequences of overtreatment of cervical abnormalities are considerable

23. Consequences of screening young women 17.2% risk of preterm labour after conisation c.f. 6.7% who delivered before conisation and 6.2% in women who never had cervical conisation Susanne Albrechtsen et al. BMJ 2008;337:a1343.

24. Obstetric outcomes after cervical treatment Knife cone biopsy and radical diathermy ablation were associated with RR2-3 of perinatal mortality, severe and extreme prematurity and low birth weight LLETZ and ablative therapy with cryotherapy or laser were not associated with a significant increase in any of the outcomes measured Arbyn et al. BMJ. 2008 Sep 18;337:a1284

25. Changing the age of screening onset - summary • Cervical cancer is rare in women under 25 • Screening is ineffective in women under 25 • Smear abnormalities are common in young women and • overtreatment carries a significant risk of adverse • pregnancy outcome

26. Suggestions for improving screening: 1.Educate women about cervical cancer and screening. ?invite women at the age of 24+

27. Screening coverage by age

28. Women’s perceptions Populus survey March 2009: Women overestimate the risk of cervical cancer 30% could not name a symptom of cervical cancer 33% of women over 35 claim never to have been invited for screening Most common reasons for not attending screening: Pain, forgetting to go, embarrassment, too little time

29. Improvement Foundation Analysing the causes of poor uptake in 25-34 year olds across six sites: Systems and processes Barriers to uptake Awareness Publicity

30. Suggestions for improving screening: 1. Educate women about cervical cancer and screening. ?invite women at the age of 24+ 2. Use HPV testing to triage women who require colposcopy for low grade abnormalities to reduce overtreatment

31. HPV triage ARTISTIC trial Prevalence of HPV decreased with age: 40% at age 20-24 12% at age 35-39 7% or less age 50+ Prevalence increased with cytological grade 10% of normal cytology 31% of BNA 70% mild /86% moderate/96% severe dyskaryosis+

32. HPV triage HPV 16 or 18 accounted for 64% of infections in women with severe or worse cytology One or both strains were found in 61% with severe cytology but in only 2.2% with normal cytology The majority of young women in Greater Manchester have been infected with a high risk HPV by the age of 30

33. Risk of CIN with persistent HPV infection Castle et al. and the PEG group in Costa Rica assessed the risk of CIN and cervical cancer if HPV persisted for one year Three-year cumulative incidence of CIN2+:

34. Suggestions for improving screening: 1. Educate women about cervical cancer and screening. ?invite women at the age of 24+ 2. Use HPV testing to triage women who require colposcopy for low grade abnormalities to reduce overtreatment 3. Encourage vaccination with HPV vaccine

35. HPV vaccination • Should reduce CIN3 rates by 50% • • Full benefit to age 30 of vaccination will take 16 years –50% benefit around 2016 • • Catch up – minimal effect on cancers in women under 30 years of age • • Screening will still be necessary • • Registry is essential to tailor screening to vaccination

36. Suggestions for improving screening: 1. Educate women about cervical cancer and screening. ?invite women at the age of 24+ 2. Use HPV testing to triage women who require colposcopy for low grade abnormalities to reduce overtreatment 3. Encourage vaccination with HPV vaccine 4. “Individualise” treatment of high grade CIN in young women

37. Individualised treatment of CIN High grade CIN: Use knife cone biopsy for suspected invasive disease or glandular abnormalities Tailor the size of LLETZ specimens to the lesion – depth need not be so great as previously thought Avoid excessive diathermy for haemostasis

38. Individualised treatment of CIN Low grade cytology referrals to colposcopy: TOMBOLA shows punch biopsy and selective treatment detects as much high grade CIN over three years as immediate LLETZ. See-and-treat risks overtreatment – nearly 60% of immediate LLETZ specimens contained no CIN (31%) or CIN 1 (28%) More women in the LLETZ arm reported heavy bleeding

39. Changing the age of screening onset - summary • Cervical cancer is rare in women under 25 • Screening is ineffective in women under 25 • Smear abnormalities are common in young women and • overtreatment carries a significant risk of adverse • pregnancy outcome

40. Rather than lowering screening age: 1. Educate women about cervical cancer and screening. ?invite women at the age of 24+ 2. Use HPV testing to triage women who require colposcopy for low grade abnormalities to reduce overtreatment 3. Encourage vaccination with HPV vaccine 4. “Individualise” treatment of high grade CIN in young women