Tuesday, 31 May 2011

Health issues - cervical screening

Back to health, 'cos there is always something to write about health, and how many of us have not been through so many similar scenarios? (Although seems not everyone had my exciting operational childhood).

On one post, I said that I believed in my youth that cervical screening was A Good Thing. This was primarily because I knew stuff all about it. I am not saying it is a bad thing, but you really don't need to do 1000 Hail Marys if you choose not to take up a screening appointment.

IMNRHO, cervical screening receives far too much airtime. Why does it receive so much publicity when it is hardly one of the most common cancers? Possibly because it combines two irresistible subjects, cancer prevention and sticking things up women, to put it bluntly. And for all those women out there who have had smears, that is exactly what it is and what it feels like.

However, I shall now add to the airtime, as I find it an interesting topic, not least because of the amount of ignorance out there. I'll start with mine.

I can't remember what or where I first heard about cervical screening. Probably, like lots of other women of my generation, something I read about in a magazine. And my first fuzzy impressions were that it was important to go for one as it would prevent cancer. In case you are already bored - just read one more comment. Cervical screening, in itself, does NOT prevent cancer. Nor is the purpose of the programme to detect it.

So having heard about this strange procedure where someone sticks something up you and it could possibly be slightly uncomfortable, what happens next? Well, again, in my antiquated day, the first experience was usually when you braved the local doctor to ask for a prescription for the pill. My GP was OK to be fair so this is not a criticism of him, more of the system, or lack of it at the time. But ask for pill, and jump on couch, open legs and nasty cold thing is stuck up.

When I had my first cervical smear, there was no organised call and recall programme. Screening was provided by GP surgeries but on a sporadic basis depending who your GP was etc etc. Call and recall (as it's called in NHS jargon) which is the incredibly organised invitation system, was introduced in the late 80s. My mother received an invitation in her early 60s and asked me what to do. I figured a) she wouldn't really like the experience and b) she had managed 60 years of her life without a smear so best leave it alone.

Some years later, I took over responsibility for the local screening programme in my health authority, and we had a call and recall programme up and running. We had merged two districts so we had one running a three year programme, and one running a five year programme. We also had GPs doing their own thing. Nightmare.

First though, a few facts, just in case the women's mags didn't include them, or you don't read the nice leaflets the NHS now provides. Or you don't live in the UK.

1) Cervical screening tests for the presence of pre-cancerous cells. That is, cells that may, or may not, later turn into cancerous cells.

2) If there are abnormal cells, this is described as dyskaryosis. Dyskaryosis can be borderline, mild, moderate or severe.

3) What you want to receive is a normal (negative) result. This is not negative by any stretch of the examination, it means that there are no indications of dyskaryotic cells. Moving up the scale, you can get a borderline one, or an abnormal one (refers to mild, moderate or severe dyskaryosis). Or if it can't be read, you get an inadequate one. Doesn't mean you or the smear are inadequate, just that it couldn't be properly read back in the lab, eg not enough cells, or too much mucous, blood or goodness knows what on the sample.

4) All screening programmes provide false results, usually known as false positives or false negatives. A false negative is when you are given the all clear and a problem is later discovered. A false positive is when you are told there is a problem - and possibly given unnecessary treatment for that - and, you didn't need it.

5) You do NOT have to attend for a smear test, however much pressure your local clinic or surgery puts on you. It is your choice.

6) From 1990, UK GPs got extra money for reaching certain targets for the amount of women they managed to screen. So, if they got half the women on their surgery list in for screening they got one payment, if they topped 80% they got more. Mmmm, ever think your GP has your best interest at heart? Or their pocket? What is the use, in a cash-strapped public sector service, of screening women who are at low risk of developing cervical cancer just to stick more bucks in a GP's pocket?

7) If you want to know more, check out the NHS cancer screening website. Their public information leaflets look awfully like the ones I developed more than ten years ago, but hey ho, these things happen. Seriously, though, I do think there is a lot of good info out there and saves me repeating it all.


And - here is another very good page.

Next up - a few horror stories??


Eliz52 said...

I just lost a long post...anyway, it's nice to read some comments by an informed woman.
I'm Australian and rejected screening, as a low risk woman, over 25 years ago.
We still screen young women KNOWING this is of no benefit, but causes great harm and distress.
"No country in the world has shown a reduction in the incidence of or the mortality from cervical cancer in women under 30, irrespective of cervical screening" (Comment made in Assoc Prof Davy's article) Yet all countries have evidence of harm from false positives and over-treatment, BUT, we keep testing, worrying and harming young women and even more than that, IMO, we're conducting unauthorized experiments on them. The screening age has not been raised (I suspect) because the Govt wishes to assess the effectiveness of Gardasil - an article appeared in the "Lancet" recently - yet no one asked young women whether this was acceptable to them.

We also test 2 yearly - too often = more false positives - 77% if the lifetime risk of referral to possibly help fewer than 0.45% of women.
Our doctors also receive undisclosed target payments which means, conflict of interest.

I also have a sinking feeling that most of this testing is unnecessary - if we tested women at 30 with the HPV blood test and it was negative - these women could forget about testing unless their risk profiles changed - of course, they're not given the option - doctors "assume her risk profile might change". (See: comments made by Assoc Prof Margaret Davy and Dr Shorne in, "Cervical cancer screening" in "Australian Doctor" 2006 - of course, the article is directed at other doctors, not women!) IMO, it is inappropriate for doctors to make assumptions about us or our partners or risk our health "just in case".
You might care to join the discussion on the Blogcritics site, "Unnecessary pap smears" - thousands of posts, many from women harmed and distressed by screening and over-treatment.

Australia is considering a call and recall system which will give them greater control of women - the numbers testing are falling here and desperate measures are being considered to "capture" these "non-compliant" women.
IMO, this is one of the greatest abuses of our bodies, health and rights today. It shows paternalistic attitudes and the double standard are alive and well in medical circles. The same thing applies to breast screening. I'll never understand why it's acceptable to so many to mislead, pressure/coerce and harm women and call it cancer screening "for our own good"?
Thanks for some refreshing reading!

Eliz52 said...

I also disagree with the linking of birth control to cancer screening - it's coercion and violates the legal and ethical requirement to obtain informed consent for screening. Our doctors no longer refuse women the Pill if they decline screening, but this was the practice up until 15 years ago. It still happens in the States - women routinely denied the Pill unless they agree to pap tests PLUS other unnecessary gyn exams like bimanual pelvic, recto-vaginal and breast exams.
Most of our doctors still use these consults to pressure women or they say, "you must have a pap test" so women are still being manipulated...
Some doctors even link screening to HRT or pre-natal care.
Anything to reach targets!

roughseasinthemed said...

Thanks Eliz52 for the US perspective and your interesting and well-written comment. I so wish women knew more about the screening programme and as you say, specifically about the need for informed consent.

roughseasinthemed said...

I only just discovered your first comment - it was lurking in my spam folder, but very salient reading.