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Reducing the Risk of Cervical Cancer
NORTHERN AREA CERVICAL SCREENING COORDINATING GROUP
FIRST ANNUAL REPORT
2000
Reducing the Risk of Cervical Cancer
September 2001
1 Introduction
2 The Value and Limitation of Cervical Screening
3 The Cervical Screening Serviuce in NHSSB Area
4 Quality Control
5 Quality Standards
6 Feedback to Smear Takers
7 Register of Abnormal Smears/Fail Safe
8 Training Seminar
9 Future Developments
10 Recommendations
Appendices Annex 1
Appendices Annex 2
Introduction
Cervical screening programmes are effective in preventing about 80% of cervical cancers in women who attend for regular smear tests. However, a number of errors and problems in Great Britain have tended to undermine public confidence in the programme. This has led to an increasing focus on improving and assuring the quality of the cervical screening programme.
The Northern Area Cervical Screening Coordinating Group was established in January 2000. Its 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.
The Group reports directly to the Director of Public Health through its Chairman. It held 4 meetings during the year and this is its first annual report. The membership of the Group is set out in Annex 1.
In addition to its monitoring role, the Group identified the following priorities for its first year:
- Developing a register of patients with abnormal smears and a fail-safe mechanism to ensure that women who have had an abnormal smear are properly followed up; and
- Training and education activities for doctors, nurses and biomedical scientists,
including the provision of individual, annual feedback to smear takers, and
update courses provided by Antrim Cytology Laboratory.
The Value and Limitations of Cervical Screening
2.1 In Northern Ireland as a whole there are around 80 cases of invasive cervical cancer and 30 deaths each year. Cervical cancer is the 10th most common cancer in women. On average, women have a 1-in-120 chance of developing cervical cancer by the age of 74 and a 1-in-300 chance of dying from the disease.
2.2 The Cervical Screening Programme aims to reduce the number of women who develop invasive cancer of the cervix and the number of women who die from it. It does this by regularly screening all women at risk so that conditions, which might otherwise develop into invasive cancer, can be identified and treated. It is important to remember that the purpose of the test is to detect a treatable, pre-cancerous condition.
Women who have regular smear tests are at a low risk of developing cervical cancer, not no risk. A smear test every 5 years will prevent over 80% of cervical cancers in the population screened. No screening test is 100% effective and a high quality programme will not prevent every case of cervical cancer or every death from cervical cancer. All screening tests, by their very nature, produce false positive results (a smear test reported as abnormal when it is in fact normal) and false negative results (a smear test reported as normal when it is in fact abnormal).
The Cervical Screening Service in NHSSB Area
3.1 All women aged between 20 and 65 years are sent a postal invitation every 5 years to attend for a cervical smear test. The invitation advises woman to obtain the smear test through their GP. It is issued centrally by a regional call/recall computer system. Some GPs carry out this work independently of the regionally organised system and a number of these practices will call women for a smear test every three years. In many practices it is a suitably trained nurse who actually takes the smear on behalf of the GP.
3.2 Women can also elect to obtain a smear test through the Family Planning Service or Action Cancer. In this instance the results, including advice as to any appropriate action, will be forwarded both to the person responsible for the taking of the smear and to the woman’s own GP.
3.3 The majority of smear tests taken in the Northern Board are sent to the Cytopathology Department in Antrim Hospital Laboratory to be screened. A small number of smear tests are sent to the LINK Laboratories in Belfast. Once in receipt of the result of the smear test it is then the duty of the GP, whose name appears on the request form to the laboratory, to initiate any further action. This may include referral to a gynaecologist or colposcopist; treatment for any infection or inflammation found; recall at various intervals if unusual features have been discovered requiring close monitoring or immediate repeat of the smear. However, most smear test results are normal and no specific further action is required.
3.4 When a test is normal, women receive this information by contacting their GP, or in some cases by letter from the GP practice. Where a GP practice utilises the Regional Screening Service, letters will be sent to women based on information from the laboratory concerned.
3.5 When a test is abnormal the smear taker will normally contact the woman as quickly as possible to discuss the result and what action may be required.
3.6 Practices using the regional call/recall system are required to inform the system of patients’ current addresses and any name changes prior to invitations to attend for smear tests being sent out. They are also required to indicate if a cervical smear is not indicated by virtue of any relevant medical conditions such as hysterectomy or if a wish has been expressed and appropriately documented that a patient does not wish to be invited for this procedure in any circumstances.
Quality Control
Quality control mechanisms exist at all levels of the cervical screening programme to ensure the objectives of the service are met. They cover all aspects of the screening service including the initial call of the women, the taking of the smear, the screening and diagnosis, the referral to colposcopy and the management arrangements. This is underpinned by a failsafe system to ensure all women with an abnormal smear are followed up. A major aspect of laboratory quality control is obtaining and maintaining Clinical Pathology Accreditation (CPA). This involves a rigorous inspection process, which is carried out by the independent organisation Clinical Pathology Accreditation Ltd. Antrim Laboratory is currently the only laboratory in Northern Ireland with full unconditional CPA accreditation.
In the laboratory stringent External Quality Assurance (EQA) and departmental Internal Quality Control (IQC) maintain quality. EQA includes the participation and successful passing of an annual Proficiency Test. This is undertaken each year by all grades of staff. In addition all the Biomedical Scientists have obtained the National Cervical Screening Certificate. The Laboratory also participates in the Irish Association of Clinical Cytology (IACC) slide circulation scheme.
IQC is undertaken at many points of the smear journey through the laboratory, from checks and counter checks at the point of reception through to the final report being issued. The IQC specifically aimed at the microscopy standards include a second review of all normal smears. In addition, a senior biomedical scientist will re-screen a smear test if there are clinical indications to do so or if a woman has a previous history of an abnormal smear. Individual performance data are produced for each scientist and consultant pathologist, giving their screening and reporting profiles. All abnormal smears are correlated with the histology outcome.
Quality Standards
5.1 A high quality service is required to maximise the benefits of cervical screening and minimise adverse effects. A set of national standards for the Cervical Screening Programme has been produced and recommended for use in Northern Ireland.
5.2 An important function of the Northern Area Group is to monitor the performance of the local programme against the national standards. The table in Annex 2 shows how the cervical screening programme in the Northern Board area is matching up to these standards.
5.3 Just over 74% of the eligible population has attended for a smear test. Although this is below the target of 80%, the figure has risen over the past few years and it compares favourably with the overall Northern Ireland figure of just over 69%. The DHSSPS has stated that Boards, Trusts and the Family Health Services should aim to increase the uptake rate for cervical screening to 75% by 2003.
5.4 The laboratory statistics (objectives 4,5 & 6), which ensure the accuracy of smear reporting and ensure skills are maintained, are satisfactory. However, the percentage of inadequate smears is low. The reasons for this are not clear but in general a low rate of inadequate smears is good. An important factor in keeping the inadequate rate low is the training of smear takers. Antrim Laboratory has provided update courses since 1992 and these may have contributed to the low rate locally. It should be noted that there is wide variation in the rate of inadequate smears in different Board areas in Northern Ireland and the reasons for this are being considered on a regional basis.
5.5 Many smear takers prefer to contact women in person if their smear test result is abnormal and many women do not receive the result of their smear in writing according to the national standard.
5.6 The relevant local data on the colposcopy service are not routinely available. However, at a regional level measures are being taken to rectify this by developing an agreed minimum data set. In addition consideration is being given to the computerisation of colposcopy records. The data relating to colposcopy that are presented in Annex 2 are based on the results of a recent regional audit.
Feedback to Smear Takers
During the past year a system has been put in place to provide smear takers with individual information about the smears that they have taken. This feedback includes information on the number of smears taken as well as the number of abnormal smear tests and the number of inadequate smears.
6.2 It is important that the cervix is fully visualised to ensure that an adequate sample can be taken. Smears can be inadequate for a variety of reasons e.g. it may be due to insufficient cells on the slide, the cells may be masked by blood or inflammatory cells or the slide may have been poorly fixed. Such smear tests cannot be properly read in the laboratory. Reducing the number of inadequate smears, however they arise, is an important quality objective. The feedback system, which is now in place, informs the smear taker of the percentage of smears that were inadequate.
6.3 Some inadequate smears are inevitable, although with good technique this number can be kept to a minimum. If the smear taker is noted to have a high level of inadequate smears he or she will be sent a detailed breakdown of the reasons why each of these smears was considered inadequate. This information will also be available on request to all smear takers.
Register of Abnormal Smears/ Fail Safe
The value of any screening programme is reduced if the appropriate action is not taken following an abnormal smear result. The Antrim Cytology Laboratory is currently establishing a failsafe system to underpin the current system of recalling women who have an abnormal smear. Under the current system 3 reminder letters are sent out by the central call/recall computer to the woman’s GP if there is no record of follow up action. These letters are issued at approximately 6 monthly intervals.
The laboratory will establish a register of women who have not received follow up after an abnormal smear. Following the issue of the 3rd reminder letter from the central computer the woman’s GP will be notified by the laboratory and asked to provide information regarding any follow up action. To date the operational mechanism has been established to undertake this service and proforma sheets have been drawn up. These will inform the NHSSB Cervical Screening Coordinator of the women who according to the laboratory register have received no follow up after an abnormal smear result. This laboratory based register is to become operational in October 2001. The Coordinating Group will evaluate it after 1 year of operation.
Training Seminar
8.1 Antrim Laboratory held a successful "update course" on cervical screening in November 2000. The programme covered many aspects including the anatomy and pathology of the cervix, reporting terminology, quality assurance and new developments. It was well attended and the feedback received from the delegates showed that they found the day educational, informative and relevant to their smear taking practice. The laboratory in return received feedback and a greater understanding of the problems experienced by smear takers. The next course is planned for June 2001.
Future Developments
The Antrim Laboratory was one of the first laboratories in the UK to trial a new way of preparing cervical smears called liquid based cytology (LBC). Although the sample is collected in a similar way to the standard smear test a special brush is used and the smear taker does not prepare the test slide. Instead the end of the brush is mixed with a vial of preservative fluid and the whole sample is sent to the laboratory. In the laboratory a machine then deposits a thin layer of cells onto a microscope slide which is examined in the usual way. Preliminary indications from the trial and other studies indicate that the proportion of inadequate slides is reduced and the pick up rate for abnormalities is increased, with a reduction in the number of false negative results.
LBC also facilitates testing for human papilloma virus (HPV). Persistent infection with HPV is associated with cervical cancer. Testing for the virus could help to inform the clinical management of women, who have borderline or mild abnormalities on the cervical smear test, by identifying those who are at a greater risk of developing cancer of the cervix. A mechanism involving DNA technology to facilitate routine HPV testing is currently being researched in Antrim Laboratory.
These pilot studies on method and implementation reflect changes that are occurring elsewhere in the UK where there are pilot studies on LBC in 3 centres in England, 3 centres in Scotland and 1 in Wales.
Recommendations
The Coordinating Group has made the following recommendations:
- The Group should develop an action plan to increase the overall uptake rate for cervical screening in the Northern Board Area. In particular this plan should identify and target areas of low uptake.
- There should be further development of the training of smear takers.
- Smear takers should ensure that all women receive the result of their smear test in writing within 6 weeks of the smear being taken.
- Action should be taken by the Trusts and appropriate individuals within the Units to reduce colposcopy waiting times in The Northern Board.
Annex 1
NORTHERN AREA CERVICAL SCREENING
CO-ORDINATING GROUP
Chair
Dr F Kennedy Cervical Screening Coordinator, Consultant in Public Health Medicine, NHSSB (January 2000 to July 2000)Dr A Mairs Cervical Screening Coordinator, Consultant in Public Health Medicine, NHSSB (From July 2000)
Members
Mrs A Annett 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 (January 2000 to July 2000)
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 C Kilgallen Consultant Pathologist/Head of Cytopathology Department Antrim
Area Hospital (From July 2000)
Dr S Redmond Family Planning Doctor, Broughshane Medical Centre
Mrs H Robinson Primary Care Facilitator, NHSSB
Secretariat
Mrs H Fyfe Personal Secretary, NHSSB
Dr M Dowds Senior House Officer in Public Health Medicine, NHSSB
Quality Standards for Cervical Screening
Click
here for the Quality Standards for Cervical Screening Annex 2 (as .pdf,
see downloads for reader)
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