The what, why and how of health and development

Calls to lower the age for cervical screening are well-intentioned but misplaced

It may seem timely that this year’s cervical cancer prevention week (Jan 22nd – 28th) fell just days after the latest petition calling for lowering the age for cervical cancer screening began circulating online. The petition followed the tragic death of 25-year-old Amber Cliff who passed away earlier this month after a four year battle with cervical cancer. Her death and the petition – signed by nearly 200,000 people – made headlines in the papers after it was revealed that Amber had asked for a smear test from her doctor after experiencing vaginal bleeding and abominable pains but was told, at 21, she was too young. Since her death, campaigners have been calling for screening to be made available to women younger than the current recommended age of 25. It’s not the first petition of its kind but, although these campaigns are started with only the best intentions, the truth is lowering the screening age may not be the solution to preventing further deaths of women like Amber.

To understand why, it’s important to know what exactly the cervical screening test is designed to do. The screening tool is not a test for cancer; rather it is designed to spot women at risk of developing cancer. Since October 2016 the way the screening test does this is by identifying cases of human papilloma virus (HPV). HPV is a viral infection that can cause genital warts, abnormal tissue growth and other changes to cells within the cervix and it is very common among women under 25. Most cases of HPV will clear up on their own but sometimes the cell abnormalities can lead to cervical cancer. In fact, the vast majority of women with cervical cancer will have had an HPV infection. So, lots of women have it and will never get cervical cancer but those who have cervical cancer have probably had it.

As HPV is so common among women under the age of 25, if this group were screened then many would be flagged up for further investigation, including possible having parts of the cervical tissue cut away. As doctors cannot tell which abnormal cells will clear up by themselves and which may develop into cancer, the discovery of any HPV may lead to women having this procedure, which is what current advice suggests. In most cases, it would be completely unnecessary. This is an important point because a systematic review of research found this procedure leads to an increase risk of pre-term birth during later pregnancies (although the risk may be lower for excisions less than 10mm deep). So the argument against lowering the screening age is that women who are not at risk of developing cancer would undergo a procedure that increases their risk of delivering pre-term babies.

However, women over 25 with a HPV infection and cervical cell abnormalities that have not cleared up by themselves are believed to be more at risk of developing cervical cancer. Therefore, the removal of cervical tissue in these cases seen as a necessary risk.

But that’s only half the story of cervical cancer. Following the introduction of HPV vaccine for teenage girls, HPV infections will be much rarer going forward. With fewer women carrying HPV infections, the needs and use of cervical cancer screening may change. It is also worth noting that testing for HPV infection became the primary aim of screening only late last year (it is still being rolled out across England). Previously, the primary aim was to identify abnormal cells and then test for HPV. National guidelines for screening age have been repeatedly examined in recent years, reiterating support for the minimum age of 25, but these have yet to be looked at in the context of HPV testing as the primary aim. No doubt they will be assessed again in the future and new evidence may lead to recommendations being adjusted.

This does not do much, however, to soothe the grief of Amber Cliff’s family, nor anyone else who has lost a young daughter, sister or girlfriend to cervical cancer. Cervical cancer is rare in the general female population and even more so among women that young – but it does happen.

In their 2010 review into the appropriate age for cervical cancer screening, the Advisory Committee on Cervical Screening (ACCS) concluded there was strong evidence supporting the minimum age of 25 but made clear that:

“…a significant proportion of cervical cancer cases in women under 25, women who visited their GP with abnormal bleeding, experienced a delay in diagnosis because they did not receive a full pelvic examination.”

And although headlines and campaigns tend to focus on calls to lower the screening age, many of those who have lost loved ones to this disease recognise that the problem is often more to do with recognising symptoms. Over six years later, Amber’s brother Josh is calling for the same thing the ACCS highlighted in their report. He told the Sunderland Echo he is not necessarily campaigning for routine screening for 18-year-old women but for extra vigilance among doctors whose patients show similar symptoms to Amber. For those who do show symptoms, the smear test used for screening the over 25s would not be appropriate but they may benefit from a pelvic examination.

Although recognising that doctors face a difficult task keeping up to date with guidelines and advice on countless health problems, perhaps the question isn’t about what age we should be screening women, but why might a doctor might not send a young women for a pelvic or specialist examination when she presents with vaginal bleeding and abdominal pains?

 

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