Reducing the Risk of Cervical Cancer

Northern Area Cervical Screening Coordinating Group
Second Annual Report 2001/02 December 2002

1.) Introduction

2.) New Regional Computer System

3.) Training Courses

4.) Feedback To Smear Takers: Inadequate Smears

5.) Failsafe

6.) Quality Standards

7.) Colposcopy Waiting Times

8.) Follow Up After Hysterectomy

9.) Recommendations

10.) Update on last year’s recommendations

11.) New recommendations

12.) Useful Sources Of Information

Annex 1 - Membership and Remit of Group

Annex 2 - Cervical Screening 2001/2002 pdf

Introduction

This is the second annual report from the Northern Cervical Screening Coordinating Group. The primary function of this multidisciplinary Group is to monitor and improve the quality of the cervical screening programme in the Northern Board area. The membership of the Group and its full remit is set out in Annex 1. It meets every 3 months.

The overall quality of the local programme remains high and women should have every confidence in it. We will continue to ensure that standards are maintained and that the quality of the programme is continually improved. We remain concerned, however, that around 23% of women who are invited for screening do not attend.

Women aged between the ages of 20 and 65 can reduce their risk of cervical cancer by attending for a cervical smear test at least once every 5 years. The risk can also be reduced by using a barrier method of contraception such as a condom and by not smoking.

The risk can be increased in women with many sexual partners or whose partners have had many sexual partners. It may also be increased by long term use of the oral contraceptive pill. However, for most women, the benefits of the pill outweigh any risk and all eligible women should attend for cervical screening whether they are on the pill or not.

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New Regional Computer System

In Northern Ireland, a central computer system has been used to support the cervical screening programme since it started in1988. This central system contains a database of information on all women to be offered cervical screening and has a call/recall function that invites women at regular intervals. The computer also contains relevant laboratory information e.g. information on previous smears and biopsy results.

Whilst the existing system has served the screening programme and laboratories well since its introduction, it needs to be updated. Therefore a formal project was established in July 2001 to review the current, and future, information technology needs of the cervical screening service and the laboratories. Members of the Coordinating Group participated in this work which has now been completed.

It has been recommended that the current computer system should be replaced with the NHS Information Authority ‘Exeter’ system, to support the call/recall function, and with the Masterlab system to support the laboratories. These systems will be linked electronically. It is hoped that the new system will be in operation in 2004.

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Training Courses

The quality of the cervical screening programme is heavily dependent upon the ability of the smear taker to take and prepare an adequate smear. All smear takers must be properly trained. To this end the cytopathology department at Antrim Hospital provides cervical screening update courses for both nursing and medical staff.

The courses include lectures from biomedical scientists, consultant pathologists and consultant gynaecologists on smear taking, as well as the pathology, management and treatment of abnormalities of the cervix. The latest information on the programme and new developments, such as liquid based cytology and testing for Human Papilloma Virus (both discussed in our report last year) are included on the programme. The courses are advertised widely and further details can be obtained from the cytopathology laboratory at Antrim.

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Feedback to Smear Takers: Inadequate Smears

This is the second year that smear takers have been provided with individual information about the smears that they have taken. This includes information about the number of inadequate smears submitted to the laboratory.

A smear will be inadequate if:

• the smear taker has not seen the whole of the cervix; and
• taken a sample of cells from the whole circumference of the area of the cervix known as the transformation zone.

The biomedical scientist looking at the slide in the laboratory cannot determine if the cervix was properly visualised and sampled by the smear taker. He or she relies on this information being recorded on the smear request form.

The scientist can only report on the material presented on the slide. The smear is reported as inadequate if:

• the cervical cells are scanty (i.e. spread too thinly on the microscope slide);
• the cervical cells are spread too thickly on the slide;
• the cervical cells are obscured by blood cells, inflammatory cells or bacteria;
• the smear does not contain the right type of cells; or
• the smear has not been adequately fixed (prepared).

It is not currently possible to eliminate inadequate smears completely, as some are due to factors beyond the control of the smear taker e.g. the shape of the woman’s cervix or her hormonal status. However, it should be possible to keep the number of inadequate smears to a minimum. Smear takers should be aiming to ensure that the number of inadequate smears they submit for screening is no higher than 10%.

Each GP has a cypher code (a unique identifying number) and this number is entered on all requests to the cytopathology laboratory accompanying a cervical smear. However, in many cases a suitably trained nurse takes the smear on behalf of the GP. This is then sent to the laboratory using the GP’s cypher code, as nurses do not yet have their own cypher codes.
During 2001/02 a total of only 8 GPs had an inadequate smear rate of greater than 10% associated with their cypher code. This represents 3.1% of GP cypher codes in the Northern Board area. Whilst there is always room for improvement it has to be recognised that the percentage of inadequate smears in the Northern Board area is low compared with national figures and lower than in other Board areas.

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Failsafe

During the year a laboratory based failsafe system was established in the Northern Board area. Failsafe is designed to ensure that women with abnormal smears are not lost to follow up and have their abnormality diagnosed and treated. It involves the laboratory notifying the smear taker if there is no computer record of follow up action e.g. attendance for treatment of the condition by a gynaecologist.

The new laboratory failsafe system supplements the current regional system, whereby the central computer issues the smear taker with 3 reminder letters 6 months apart. If, following the last reminder letter, there is still no record of follow up, the laboratory issues a letter and questionnaire to find out what has happened to the woman so that appropriate action can be taken. This laboratory based failsafe system will be audited after one year.

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Quality Standards

Screening is different from other health care interventions. Patients usually come to the health service to seek advice and help. The patient may feel unwell or anxious about a problem or have certain symptoms or signs of disease. Screening, however, involves the health service actively seeking apparently healthy people to apply tests, which can detect early signs of serious disease. This makes it vitally important that screening programmes are of the highest quality and that the benefits of any programme are maximised and the disadvantages minimised.

In order to ensure the delivery of a high quality service a set of national quality standards has been developed. The local programme is monitored against these standards. Quality improvement is constantly sought and the standards are sometimes reset to reflect this. This means that from time to time some elements of the programme will fall below the standards set. The nature of continuous quality improvement is to constantly stretch and test the service. This reduces complacency and allows action to be taken swiftly when shortcomings are identified.

Annex 2 shows how the local programme compares with the national standards. Since our last annual report some of the national standards have been changed. Monitoring evidence of sampling from the transformation zone (objective 2 in last year’s report) is no longer recommended and the acceptable values for each of the measurements in objective 3 have been revised.
In the 5 year period up to 31st March 2002 77% of the eligible population of women in the Northern Board area attended for a smear test. The national target is 80% (objective 1 in Annex 2). However, an 80% attendance rate has never been achieved in Northern Ireland.

The local target set by the DHSSPS is for Boards, Trusts and primary care professionals to cooperate to increase the coverage rates for cervical screening in Northern Ireland to 72% by 31 March 2003 and 75% by 31 March 2004. This target has already been achieved in the Northern Board area.

The table below shows the coverage rate in the Northern Board compared with the Northern Ireland average over the past few years. Rates in the Northern Board have been consistently higher than in other Board areas. The coverage rates have also increased year on year. This has indeed required cooperation between the Board, local Trusts and primary care professionals. Those who work in the primary care sector deserve particular credit for continually promoting the programme and providing a high quality service to women.

Cervical Screening: Coverage Rate by Year for the Northern Health & Social Services Board and Northern Ireland.

There is, of course, no guarantee that the coverage rate will continue to increase and we are aware that there are areas of low coverage within the Northern Board. There is therefore no room for complacency and we will continue to work towards ensuring that all eligible women can make an informed choice about cervical screening and have access to a high quality service.

Annex 2 shows that most of the other standards have been met. Progress towards objective 2 (that all women should receive their smear test result in writing) is discussed in paragraph 9.3 and progress towards objective 7 (waiting times for colposcopy) is discussed in paragraphs 7.1 to 7.2.

Objective 9 states that 90%, or more, of women who are treated at their first colposcopy visit should have evidence of cervical intraepithelial neoplasia (CIN). This is the treatable precancerous condition that the smear test is designed to look for. The figure for the Northern Board is 86.2%. This figure may be low because of the policy in the Northern Board of referring women with mild abnormalities of the cervix directly for colposcopy, rather than repeating the smear test again. However, we will keep this under review.

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Colposcopy Waiting Times

In our last annual report we recommended that action should be taken by Trusts to reduce waiting times for colposcopy. The table below shows the waiting times for patients seen in 2001.

7.2 The national standard is that more than 90% of women should be seen within 8 weeks. This standard has not yet been reached as only 66.5% of women were seen within this time period. However, the accuracy of the waiting time data has been improved and action has been taken to ensure that regular, additional colposcopy clinics are provided.

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Follow up after Hysterectomy

8.1 Each year in the Northern Board area around 470 women, aged 65 and under, have a hysterectomy. The operation carried out is usually a total hysterectomy. This involves removal of the body of the uterus (womb) along with the cervix (neck of the womb). A small number of women (about 32 each year) have a sub-total hysterectomy, which involves removing only the body of the uterus, leaving the cervix behind.

Once a woman has a total hysterectomy she is discharged from the cervical screening programme. However, some of these women will require what is known as a vault smear. This is a smear test taken from the top of the vagina. These smears are not part of the cervical screening programme, but very important in monitoring the health of the woman.
Women who have had a subtotal hysterectomy still require regular cervical smears as part of the cervical screening programme.
The Coordinating Group has produced evidence-based guidance on the cytological follow up of women following hysterectomy. This is aimed at health care professionals and is set out in Annex 3.

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Recommendations

Update on Last Year’s Recommendations

Last year we made 4 recommendations. The first of these was to develop an action plan to increase overall uptake. This was developed and shared with other Boards and discussed at a regional workshop on increasing uptake.

The second recommendation was that there should be further development of the training of smear takers. The Cytopathology Laboratory at Antrim Area Hospital has developed a half-day training course specifically aimed at GPs. This is in addition to a full day course aimed at all smear takers. The Royal College of Nursing and Marie Curie Cancer Care run more intensive courses. A letter has gone to all smear takers highlighting the need for appropriate training.

The third recommendation was that all women should receive the result of their smear test in writing within 6 weeks. This has been accepted regionally and mechanisms are now being proposed to ensure that all women receive written confirmation of their results. It is likely that implementation of this recommendation will depend upon the installation of the new computer system for cervical screening.

The fourth recommendation was for action to be taken to reduce colposcopy waiting times. As noted above this action has been taken and we will continue to monitor the situation.

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New Recommendations

9.5 The Coordinating Group has made the following new recommendations:

• All smear takers should attend update training at least once every 3 to 5 years.
• A survey of the level of training of smear takers should be carried out.
• The Coordinating Group should produce local guidelines for smear takers.
• There should be an audit of the laboratory failsafe system.

All colposcopists must be accredited by the British Society of Colposcopy and Cervical Pathology (BSCCP).

10 Useful Sources of Information About Cervical Screening

10.1 The Northern Area Cervical Screening Coordinating Group’s First Annual Report is available on the Northern Board’s website at www.nhssb.n-i.nhs.uk. It includes discussion on the value and limitations of screening, a description of the local service and an outline of the quality control mechanisms that are in place.

10.2 Information on the national cervical screening programme can be found at www.cancerscreening.nhs.uk. This site includes information for the public on screening appointments; risk factors for cervical screening; oral contraception and cervical cancer and the Human Papilloma Virus. It also contains a patient information leaflet "Cervical Screening: The Facts", which is available to download in a number of languages.

10.3 General information about screening, as well information about cervical screening, and useful links are available at the National Screening Committee’s website at www.doh.gov.uk/nsc

10.4 Information about the Irish Cervical Screening Programme is available at www.icsp.ie

Annex 1

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Northern Area Cervical Screening Coordinating Group

Membership

Chair

• Dr A Mairs Cervical Screening Coordinator, Consultant in Public Health Medicine, NHSSB

Members

• Ms S Ashton Research Officer, Northern Health & Social Services Council
• Dr D Boyd Medical Adviser (Primary Care), NHSSB
• Dr J Carson Consultant Pathologist/Head of Cytopathology Department Antrim Area Hospital
• Ms U Cowan Treatment Room Sister, Garvagh Health Centre
• Dr M Charlton General Practitioner, Fairhill Health Centre, Magherafelt
• Dr G Dorman Consultant Obstetrician / Gynaecologist, Antrim Area Hospital
• Mrs J Jamison Head Biomedical Scientist, Cytopathology, Antrim Area Hospital
• Dr S Redmond Family Planning Doctor, Broughshane Medical Centre
• Mrs H Robinson Primary Care Facilitator, NHSSB

Secretariat

• Ms H Fyfe Personal Secretary, NHSSB

Remit

The Group’s remit is to:-

• advise the Director of Public Health on quality issues pertaining to the Cervical Screening Programme within the Board’s area;
• review and monitor all aspects of the programme, including quality assurance;
• coordinate activities within the Cervical Screening Programme in the Board’s area;
• identify and disseminate examples of good practice, and encourage relevant local audits in relation to cervical screening;
  prepare such reports as may be requested by the Director of Public Health

Click here for Quality Standards for Cervical Screening 2001/2002 (as .pdf, see downloads for reader)

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