Transcript Cervical screening: the Jade Goody effect

Cervical screening:
The Jade Goody Effect
Nicola MacDonald
Consultant Gynaecological
Oncologist
'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.”
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
Current issues
Age of onset of screening
Risks of screening younger women
How should we treat young women with abnormal
smears/CIN?
Age of onset of screening
UK Cervical Screening Programme by country
Target age-group
Frequency of invites
England
25-64
Every 3 or 5 years
Wales
20-64
Every 3 years
Scotland
20-60
Normal practice,
every 3 years
Northern Ireland
20-64
Every 3 or 5 years
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
Protection offered by varying screening
intervals
Percentage of cancers preventable:
Annual
3-yearly
5-yearly
20-39
76%
61%
30%
40-54
88%
84%
73%
55-69
87%
87%
83%
P.Sasieni et al. British Journal of Cancer (2003) 89, 88–93
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
Colposcopy clinic referrals
2003/4
2004/5
2005/6
2006/7
2007/8
Persistent inadequate
9%
9%
8%
5%
3%
Borderline changes
17%
16%
16%
16%
17%
Mild dyskaryosis
22%
23%
27%
30%
31%
Moderate dyskaryosis
17%
16%
15%
14%
14%
Severe dyskaryosis
13%
12%
13%
14%
14%
Potential invasive cancer
<1%
<1%
<1%
<1%
<1%
Potential glandular cancer
1%
1%
1%
1%
1%
Clinical indication urgent
4%
4%
4%
4%
4%
Clinical indication non-urgent 13%
14%
13%
12%
12%
Other
4%
4%
4%
4%
4%
NHS Cervical Screening Programme Annual Review 2008
Screening success 1975-2006
18
16
14
females
12
10
8
6
Year of diagnosis
2005
2002
1999
1996
1993
1990
1987
1984
1981
1978
4
2
0
1975
Rate per 100,000 population
Figure 1.2: Age standardised (European) incidence rates,
cervical cancer, Great Britain, 1975-2006
Cervical cancer incidence by age
Figure 1.1: Numbers of new cases and age specific
incidence rates, by sex, cervical cancer, UK 2006
300
15
200
10
100
5
0
0
Age at diagnosis
Rate per 100,000
population
20
0-4
5-9
10-14
15-19
20-24
25-29
30-34
35-39
40-44
45-49
50-54
55-59
60-64
65-69
70-74
75-79
80-84
85+
Number of cases
400
Female cases
Female rates
Cervical cancer mortality 1971-2007
Figure 2.2: Age standardised (European) mortality rates,
cervical cancer, UK, 1971-2007
10
6
4
2
Year of death
2007
2004
2001
1998
1995
1992
1989
1986
1983
1980
1977
1974
0
1971
Rate per 100,000
8
Cervical cancer mortality by age 1971-2007
Figure 2.3: Age-specific mortality rates,cervical cancer, UK, 1971-2007
30
25-44
45-64
65-74
75-84
85+
20
15
10
5
Year of death
2007
2004
2001
1998
1995
1992
1989
1986
1983
1980
1977
1974
0
1971
Rate per 100,000 females
25
Cervical cancer mortality by age
Figure 2.1: Number of deaths and age-specific
mortality rates, cervical cancer, UK, 2007
80
10
Female deaths
Female rates
8
60
6
40
4
20
2
0
0
Age at death
Rate per 100,000
100
12
0-4
5-9
10-14
15-19
20-24
25-29
30-34
35-39
40-44
45-49
50-54
55-59
60-64
65-69
70-74
75-79
80-84
85+
Number of deaths
120
Cervical cancer mortality reduction
Table 2.2: European age-standardised mortality from
cervical cancer by age group, England and Wales
Rate per
100,000
females
Age Group
25-34
35-44
45-54
55-64
65+
1950-1952
1.8
7.4
18.0
30.0
33.7
1998-2000
1.3
4.0
5.2
6.2
11.8
27.0
47.0
71.0
79.0
65.0
percentage
decrease
Changing the age of screening onset
Issues to consider:
1. Screening is ineffective below age 25
Effectiveness of screening with age
Women screened under age 25
Age
15-19
2003/4
14,927
2004/5
8,166
2005/6
5,009
2006/7
3,508
2007/8
2,840
20-24
367,362 285,681 186,567 138,935 96,926
NHS Cervical Screening Programme Annual Review 2008
Changing the age of screening onset
Issues to consider:
1. Screening is ineffective below age 25
2. Abnormal smears are common under 25.
Abnormal smears in young women
2002
26 women under 25 had cervical cancer
55,000 had abnormal smears (BNC or worse)
Natural history of CIN
Regression Persistence Progression
Invasion
CIN1 60%
30%
10%
1%
CIN2 40%
40%
20%
5%
CIN3 33%
-
-
12%
Ostor et al. Int J Gynecol Pathol, 1993;12(2):186-92
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
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
<24/40
Relative risk
4.0
24-27/40
4.4
28-32/40
3.4
33-36/40
2.5
Susanne Albrechtsen et al. BMJ 2008;337:a1343.
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
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
Suggestions for improving screening:
1. Educate women about cervical cancer and screening.
?invite women at the age of 24+
Screening coverage by age
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
Improvement Foundation
Analysing the causes of poor uptake in 25-34 year olds
across six sites:
Systems and processes
Barriers to uptake
Awareness
Publicity
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
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+
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
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+:
HPV status
HPV +/+
HPV -/+
Incidence
17.0%
3.4%
HPV +/HPV -/-
1.2%
0.5%
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
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
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
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
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
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
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