Screening Programme Dr G Dorman QA Lead for Colposcopy Cervical cancer 8090 new cases of invasive cervical cancer per year 3040 deaths per year Associated with persistent infection with high risk subtypes of Human Papilloma Virus HPV ID: 1044406
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1. The Northern Ireland CervicalScreening ProgrammeDr G DormanQA Lead for Colposcopy
2. Cervical cancer80-90 new cases of invasive cervical cancer per year 30-40 deaths per yearAssociated with persistent infection with high risk subtypes of Human Papilloma Virus (HPV)
3. Aim of screeningTo reduce mortality and morbidity associated with cervical cancer by identifying and treating pre-cancerous changesScreening can prevent 70% of cervical cancers
4. Screening programme milestonesNI CSP established 1988/89Quality assurance structures – July 2000Exeter cervical cytology module – 2006/07Liquid Based Cytology – Nov 2007QA Committee established – Feb 2008HPV immunisation introduced – Sept 2008Age range and intervals policy change – Jan 2011
5. PHA screening functionsCommissioningCo-ordinationQuality Assurance
6. Invite for screening Smear test at GP practice/family planning clinicNormal result Abnormal result Colposcopy(with biopsy & treatment)Cancer - referralto MDTEnhanced follow-up
7. What is Quality Assurance (QA)? The maintenance of minimum standards & continuous improvement in the performance of all aspects of screening programmes to ensure participants have access to a high quality service wherever they live.
8. Why is QA Integral to Cancer Screening?All screening can do harm as well as goodEthical imperative in screening is differentBalance of benefit and harm – tipped in favour of benefit
9. Quality Assurance (QA)Monitoring against standardsSupporting staff in achieving high qualityCulture of continuous improvementTaking action where standards are not met
10. QUALITY STANDARDSStatistical DataPeer ReviewVisitsAuditProfessionalmeetingsTrainingShared learningExternal QASchemesQuality ManagementSystems/failsafeQUALITY ASSURANCE
11. Regional QA StructureDirector of Public HealthQA CommitteeCall/RecallPrimary CareAdvisory GroupColposcopyAdvisory GroupLaboratoryAdvisory GroupQA DirectorService Representatives
12. Role of QARCSupport the QA structure & functionsLink between different aspects of the programme, individuals, organisations, national screening office etc.Focus of information & data for the programme
13. Benchmark against UKStandardised returnsKC 53 – coverage KC 61 – laboratory dataKC 65 – colposcopy dataAnnual statistical bulletin for the NI CSPQA data
14. Coverage rates by TrustNI coverage = 77.32% (2010/11)Coverage = % of eligible women with a screening result in last 5 years
15. The ‘Jade Goody effect’?2007/08 – 154,116 samples2008/09 – 161,205 samples2009/10 – 146,785 samples2010/11 – 138,000 samples
16. 5 year coverage by age group
17. Policy change From Jan 2011AgeScreening interval25 – 49 yrs3 years50 – 64 yrs5 years
18. Why not to screen the <25sHigh rate of abnormalitiesMajority of abnormalities are not persistentVery low rates of cancer in this age groupScreening of no added benefitPotential to do harm – interventions & treatment, anxiety, future risk of premature birth
19. Who should be screened?Vault smears are not part of the screening programme – take individual advice from gynaecologistWomen who only have sex with women can still get cervical cancerDon’t automatically exclude women with learning difficultiesHPV vaccinated women should still be screened
20. When to cease screening?AgeAbsence of cervixPatient’s informed request for no further cervical screening testsCeasing under the Mental Capacity Act (2005)1 (only in very exceptional circumstances)‘other’ - radiotherapy specifically to the lower genital tract or permanent inability to access the cervix.
21. Endorsed in CMO circularissued Sept 2010**a smear is not a diagnostic test**
22. Challenges aheadPromoting uptake - inequalitiesImproving patient experience – turnaround times, direct referral to colposcopy, results letters to womenInformation systems – encouraging primary care practices to use the central call/recall systemHPV (vaccine & testing) - impact on screening programme
23. HPV Triage and Test of Cure.
24. Only 15 to 20% of women with borderline nuclear changes or mild dyskaryosis have a significant abnormality that needs treatment.High-risk HPV testing in this group is effective in identifying which women may need treatment.All cervical samples showing borderline nuclear changes or mild dyskaryosis are tested for high-risk HPV.Women who test positive for high-risk HPV are referred immediately to colposcopy.Women who are high-risk HPV negative can be safely returned to routine recall.What is HPV triage?
25. Women who have a normal, borderline or mild cervical screening result sixmonths after treatment for CIN and who also test negative for high-risk HPVhave a very low risk of residual disease.Samples taken six months post treatment that are normal, borderline or mild are HPV tested.Women whose samples are high-risk HPV negative will proceed to three yearroutine recall – avoiding the need for up to 10 years of annual cervicalscreening. Women who have a moderately or severely abnormal cervical screening resultor are high-risk HPV positive six months after treatment will be referred back tocolposcopy.What is HPV test of cure?
26. HPV triage and test of cure are being rolled out across the NHS Cervical Screening Programme Implementation will follow national protocols. Each woman will receive an HPV factsheet with her invitation for screening.The usual procedure for obtaining informed consent for cervical screening will also cover high-risk HPV testing (as HPV testing will be performed automatically if indicated by the test result).The original LBC sample is used if high-risk HPV testing is indicated; no further sample needs to be provided.The Cervical Screening Programme: HPV triage and test of cure
27. The Cervical Screening Programme: HPV triage and test of cure(continued)HPV test results are included in the cytology report, along with appropriate management recommendations.Women will receive their cytology and high-risk HPV results in a letter (currently from the PCT).The procedure associated with each type of recommended action (routine recall, repeat test, or refer to colposcopy) will continue to be as set out in the currentpractice guidelines.All women in the screening age range 25 to 64 are eligible for HPV triage and test of cure.HPV triage and test of cure will apply whether women attend their GP practice, GUM or Contraception and Sexual Health Services/Family Planning Clinic.
28. HPV transmissionHPV transmission is via intimate contact. Studies have shown that infection in virgins is rare, though any type of non-penetrative sexual contact is associated with increased risk.Condoms offer only a degree of protection, because of the HPV field effect over the whole of the genitalia.Up to 80% of the population have had HPV at some point in their lives. In most women HPV will not cause long term harm and will be cleared by their immune system.
29. TerminologyWomen are frequently confused by the term ‘wart virus’. It is incorrect and should be avoided.Using the term ‘HPV positive’ can arouse concern and may be confused with ‘HIV positive’.Result letters will indicate that ‘high-risk HPV’ has been detected.
30. How do I protect myself against HPV?HPV infection cannot be treated, only CIN.Attend cervical screening regularly. Vaccination is now available to protect against 16, 18 subtypes.HPV vaccination will help to prevent HPV infection/CIN in the future.
31. Information on HPVInformation available on HPV includesmaterial sent to sample takers material provided for women material more generally available.
32. Further information/contactQuality Assurance Reference Centre (QARC)Public Health Agency,18 Ormeau Avenue, BelfastTel: 028 90311611www.cancerscreening.hscni.net