Ongoing mis-managment of the Cervical Smear Controversy

Ongoing mis-managment of the Cervical Smear Controversy

Last week we found out that yet more Irish women will have to again undergo a completely avoidable repeat cervical smear. This was the latest in a long line of errors in the management of the cervical smear controversy. To understand what is going on you have understand why and how we screen for cervical cancer and how successful it generally has been prior to this.

Cancer of the cervix on average, affects 280 women in Ireland each year. Of these tragically about 90 will die. About 50% of these women who develop cervical cancer are under 45. HPV (human papillomavirus) is a common sexually transmitted viral infection and is the major cause of cervical cancer. It leads to the development of abnormal cells in the cervix which can if you are unlucky enough progress, become more abnormal and morph into cervical cancer.

Cervical cancer screening was introduced to try to detect these abnormal cell changes that when noticed can be easily treated and ultimately prevent cervical cancer. Cervical Check (our cervical cancer screening programme) was first started in 2008 and aims to detect these abnormal changes in the cells by arranging regular cervical smear tests for Irish Women. If abnormal cells are detected and found to be very worrying (high-grade abnormalities), the woman is referred to a Gynaecologist for a colposcopy. If only low-grade abnormalities are found, the smear test is then checked to see if the cells display signs of the HPV virus. If HPV is found, the woman is again immediately referred for colposcopy. Here a biopsy may be taken and it is finally clarified that the woman’s test is either normal, pre-cancer or cervical cancer (although in some cases this too is not always perfectly clear-cut).

Screening for cervical cancer through these smear tests, like any other screening test looking for a disease is not always 100% accurate. Some results will come back saying there are abnormalities but no further disease is found on further testing thus rendering the initial result incorrect (called a false positive). Likewise, some tests will come back saying there are no abnormalities although disease is actually present (called a false negative). This second scenario is what the current cervical cancer screening controversy revolves around- some Irish women were told their smears were normal but then developed cervical cancer within a few years. Their Oncologists were surprised that some of their smears prior to diagnosis failed to spot the initial abnormal cells so it was decided to start an audit of previous smears to see if some abnormal cells were indeed missed by human error or otherwise.

The audit is not yet finished and we still do not yet know if Ireland has a different rate of false negative results for cervical cancer screening compared with other countries. We know that on average for every 1000 cervical smears, about 960 will be negative and of these 960, about 5 will be a false negative. The audit will examine how close our system is to this level of false negatives.
The HSE’s response to this news, which was to offer free repeat smears to any woman who is worried about their previous normal tests, has been terribly mishandled. We and other GPs have been inundated with enquiries from concerned women who have subsequently went on to have a free repeat smear. This demand was predictable but a system was not put in place to cope with this massive uptake and currently a smear test result is taking about 22 weeks to come back (had always usually taken 4-6 weeks). Because of this stunning error, some samples have gone out of date before having their first assessment for abnormal cells. These women will, again, have to repeat their cervical smear test. On top of this, last week we found out that of those samples that have been found to have abnormal cells and thus require testing for HPV, have also now it appears, gone beyond the time period for which they can be assessed accurately for HPV. Again, more women are being recalled for another completely avoidable repeat smear.

These ongoing management problems are unfortunately reducing women’s confidence in the cervical check programme. It is important to point out though that cervical cancer screening does work really well despite these controversies. The Cervical check programme has reduced the amount of new cases of cervical cancer but about 7% annually since its introduction in 2010. In addition, a new more accurate system, soon to be implemented by cervical check, will involve all cervical smears being first tested for HPV and only those who test positive for HPV will have further tests. The main benefit from this new system is that it will have fewer false negatives like in the tragic case of Emma Mhic Mathuna’s. It is the system currently in place in the UK.

The fact that this initial test will only test for HPV shows you how much importance we are placing on eradicating HPV. This will depend on the success of the HPV vaccination programme (designed to eradicate HPV) currently in place for our 12/13 year old girls. Australia became the first country in 2007 to introduce a systematic HPV vaccination programme and early results have shown a 77% reduction in HPV types responsible for almost 75% of cervical cancer. This has led people to believe it may be possible to eliminate cervical cancer in Australia within 20 years due to the HPV vaccine. The anti-vaccination scaremongering movement will have a lot to answer for if this doesn’t happen!