CERVICAL SCREENING UPDATE
Louise Cadman
Research Nurse Consultant and Nurse Colposcopist
Centre for Cancer Prevention
Wolfson Institute of Preventive Medicine
E-LfH Learning Portal – (e-SRH) Sexual and
Reproductive Healthcare – Cervical Screening
Learning objectives:






State the objectives of the cervical screening programme
Identify the principles of screening programmes
Explain the way screening programmes operate in the UK
Identify the causes and prevalence of cervical screening
abnormalities
Manage cervical screening results correctly
Explain colposcopy to a patient
Cervical cancer – the size of the problem
Worldwide cervical cancer incidence 2012
• fourth most common cancer worldwide for females
• seventh most common cancer overall
• >527,000 new cases diagnosed
• 266,000 deaths
• 85% in the developing world
The 20 most common cancers in women, 2011
Number of New Cases, UK
Breast
Lung
Bowel
Other Sites
Uterus
Ovary
Malignant Melanoma
Non-Hodgkin Lymphoma
Brain, Other CNS & Intracranial Tumours
Pancreas
Kidney
Leukaemia
Cervix
Bladder
Oesophagus
Stomach
Oral
Myeloma
Thyroid
Liver




0
10,000
12th most common cancer
amongst females in the UK
2851 cases/year
972 deaths/year
67% survived ≥ five years
(2005-2009)
20,000
30,000
40,000
50,000
Age-specific incidence rates and number of cases
diagnosed by five year age group, England 2009
6 in 10 of all new cases of cervical cancer are diagnosed in women under 50 years
European Age-Standardised Cervical Cancer Incidence
& Mortality Rates per 100,000 Female Population, UK
18
Incidence
16
Mortality
per 100,000
14
12
10
8
6
4
2
0
Year
Prepared by Cancer Research UK
Original data sources:
Office for National Statistics. Cancer Statistics: Registrations Series MB1. http://www.ons.gov.uk/ons/search/index.html?newquery=series+mb1
Welsh Cancer Intelligence and Surveillance Unit. http://www.wcisu.wales.nhs.uk
Information Services Division Scotland. Cancer Information Programme. www.isdscotland.org/cancer
1975 - 1977
1976 - 1978
1977 - 1979
1978 - 1980
1979 - 1981
1980 - 1982
1981 - 1983
1982 - 1984
1983 - 1985
1984 - 1986
1985 - 1987
1986 - 1988
1987 - 1989
1988 - 1990
1989 - 1991
1990 - 1992
1991 - 1993
1992 - 1994
1993 - 1995
1994 - 1996
1995 - 1997
1996 - 1998
1997 - 1999
1998 - 2000
1999 - 2001
2000 - 2002
2001 - 2003
2002 - 2004
2003 - 2005
2004 - 2006
2005 - 2007
2006 - 2008
2007 - 2009
2008 - 2010
2009 - 2011
Per 100,000
1975-2011 European age-standardised incidence rates
of cervical cancer per 100,000 population, by age,
females, Great Britain
40
20 to 24
25 to 34
35 to 49
35
50 to 64
65 to 79
80+
30
25
20
15
10
5
0
Years
Number of cases by morphology, England
1988-2009
3000
2500
Squamous
2000
Adenocarcinoma
1500
Unclassified
Epithelial
Adenosquamous
Neuroendocrine
1000
Other Epithelial
Other
500
Year of Diagnosis
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
0
Cervical screening as secondary
prevention of cervical cancer
Cervical screening → ↓morbidity ↓ mortality
! Limitations:
 does not prevent:





oncogenic HPV infection

precursor lesions (high grade Cervical Intraepithelial Neoplasia (CIN))
less efficient for early stages of adenocarcinoma
screening programmes not achievable in many
countries
may not detect lesions which progress quickly in time
only effective if women attend regularly, when invited
NHS Cervical Screening Programme
Coverage
Five year coverage of the target age group (25-64),
Primary Care Organisation, England, 31st March 2013
Source: KC53, Health and Social Care Information Centre.
Cervical screening coverage by London Primary Care
Organisation, 2012-13
(% less than 5 years since last adequate test)
Kensington & Chelsea PCT
Richmond & Twickenham PCT
Tower Hamlets PCT
Hillingdon PCT
Brent Teaching PCT
Haringey Teaching PCT
Barnet PCT
Hammersmith & Fulham PCT
Croydon PCT
Islington PCT
Ealing PCT
Lewisham PCT
Newham PCT
Bromley PCT
Lambeth PCT
Barking & Dagenham PCT
Harrow PCT
Redbridge PCT
Enfield PCT
Sutton & Merton PCT
Waltham Forest PCT
Bexley Care Trust
Southwark PCT
Hounslow PCT
Kingston PCT
Camden PCT
Westminster PCT
Wandsworth PCT
City & Hackney Teaching PCT
Havering PCT
Greenwich Teaching PCT
60.0
77.5
76.8
76.5
73.2
70.3
65.0
70.0
75.0
%
80.0
85.0
NHS Cervical Screening Programme, 20032013: coverage-less than 5 years (%)
90
85
25-64
25-29
80
30-34
%
35-39
40-44
75
45-49
50-64
70
50-54
55-59
60-64
65
60
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
Five year coverage of the target age group (25-64)
England at 31st March, 2003 to 2013
© Data prior to 2005, re-used with the permission of the Department of Health.
Source: KC53, Health and Social Care Information Centre.
Anatomy of the cervix
The Uterine Cervix

Uterus ÷
Upper body
 Cervix


Cervix
Cylindrical
 ~ 3cm length
 ~ 2.5cm diameter
 1/3 protrudes into the
vaginal vault
 Os – the hole
 Ectocervical = outside the
external os
 Endocervical = inside
cervical canal

Stratified squamous epithelium
Columnar epithelium
Squamo-columnar junction (SCJ)
Cervical Epithelium

Squamous epithelium




Columnar epithelium




Usually on ectocervix
Cells are multilayered
Usually appears as smooth,
shiny, pale pink
Mostly endocervical
Single layer column shaped cells
Delicate and usually appears red
(ectopy when on ectocervix)
Squamo-columnar junction
(SCJ)
Transformation zone
HPV Infection in the Cervix
HPV infects cell
integrates its
DNA into the
host cell DNA
Persistence 
cell damage
(pre-cancer)
Eventually
cancer



Normal
Epithelium
HPV Infection
Months
CIN I
CIN II
CIN III
Years
Cancer
Decades
Dyskaryosis – identified by cytology
CIN 1
CIN 2
CIN 3
Screening intervals and sample
taking
Screening Intervals in England

25 years - first invitation

from GP lists

invitation should not be before age 24.5 years

25–49 years - three yearly

50–64 years - five yearly

65+ years - only screen those not screened
since age 50 or with recent abnormal tests
Summary percentage preventable by 3and 5-yearly screening
Annual
3 yearly
5 yearly
76%
61%
30% (39%)
88%
84%
73%
87%
87%
83%
20–39 years
40–54 years
55–69 years
*
The percentage in parentheses is obtained by replacing RRs greater than one with 1.0 when averaging
Benefit of cervical screening at different ages: evidence from the UK audit of screening histories
P Sasieni, J Adams and J Cuzick
British Journal of Cancer (2003) 89, 88–93.
Samples examined by source of sample,
2012-13
In women who
are heavy
cigarette
smokers
On taking or
starting to
take an oral
contraceptive
On insertion
of an IUCD or
IUS
Additional cervical
screening is not
In women who
have had
justified in any of the
multiple
following situations
sexual
providing the woman
partners
has undergone
screening within the
previous three to five
years and is on routine
In women with
recall:
pelvic
infection
In women with
vaginal
discharge
In women with
genital warts
On starting or
taking HRT
Antenatally,
postnatally or
after
termination of
pregnancy
Would you
like to empty
your bladder
before we
start?
Be realistic in the length
of time it should take
This should
not take
longer than
five minutes
but I will
keep you
informed
Some women may wish
to agree a non-verbal
sign
Prior to the
examination
Please
indicate if
you would
like to stop
and I will be
guided by
you
You are
unlikely to be
able to relax
but try to
avoid lifting
your bottom
off the couch
Avoid the word relax!
31
You may
experience
some
discomfort
but let me
know if it is
unbearable
Would you
like to have
anyone else
in the room
with us?
Would you
like me to tell
you what I
am doing as
we go along?
Some women prefer it if
you ‘just get on with it’
Taking a sample
• Wash hands and wear gloves. Close the speculum before starting and then gently insert into the
vagina and aim for the posterior vault
• Open the blades approximately 5mm and guide speculum until the anterior lip of cervix can be seen.
Only open the speculum wide enough to reveal the whole cervix
• Do not over-expose the cervix and vagina as this may cause discomfort to the woman
• If you cannot visualise the cervix, consider repositioning the woman by raising her hips, adjust the
speculum rotating it so locking ratchet faces up or down or using a condom to support vaginal walls
• Inspect the cervix; noting appearance, colour, amount and colour of vaginal secretions and the location
of the transformation zone
• Obtain the sample using the appropriate sampling device ensuring all the transformation zone is
sampled and ensure sample placed in LBC vial as per protocol
• Remove speculum – it may be necessary to open it slightly first to release the cervix before removing it
and ensure safe disposal of all equipment in accordance with local health and safety guidelines
Following the examination
If you cannot visualise the
cervix, and nor can any
colleague you ask to
assist, then the procedure
should be abandoned and
referral made to a
colposcopy clinic
Explain that
spotting
following the
test is possible
and to be
expected
Ensure that the
woman knows how
and when she will
receive her results.
Complete the
sample request
form accurately
If additional tests or
swabs were taken
these should be
discussed and
arrangements
made for her to
receive these
results and any
follow-up treatment
Reassurance
should be given
about what will
happen if a result is
abnormal and what
will happen next
From: Cervical screening - RCN guidance for good practice
Results and referral to colposcopy
Results of adequate tests for women
aged 25-64, 2012-13
Total number of results: 3,283,438
• 99.8% of reports authorised within 0-2 weeks (0-14 days)
• 0.2% of reports authorised within 3-4 weeks (15-28 days)
Cytology results by region and Primary Care
Trust, 2012-13
100
98
96
94
%
92
90
88
86
Severe dyskaryosis or worse
Moderate dyskaryosis
Mild dyskaryosis
84
Borderline changes
82
Negative
80
Cytological referral for colposcopy
or further assessment



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


URGENT Suggestion of invasive carcinoma (x1)
to be seen within 2 weeks
Suggestion of glandular lesion (x1)
Severe dyskaryosis (x1)
URGENT Moderate dyskaryosis (x1) to be seen within 4 weeks
Mild/borderline and hr HPV +ve (x1)
ROUTINE Persistent unsatisfactory smears (x3)
to be seen within 8 weeks
3 abnormal tests, any grade, in 10 year
period
Treated for CIN, have not been returned to
routine recall and a subsequent test is
reported as mild dyskaryosis or worse
Cytology terminology and result codes
Previous terminology
(BSCC 1986)
New Terminology
Borderline changes
Borderline changes in squamous cells (not HPV Tested)
8
Borderline changes in squamous cells (HPV tested)
B
Borderline changes in endocervical cells (not HPV Tested)
9
Borderline changes in endocervical cells (HPV tested)
E
Low-grade dyskaryosis (not HPV Tested)
3
Low-grade dyskaryosis (HPV tested)
M
High-grade dyskaryosis (moderate)
High-grade dyskaryosis (severe)
High-grade dyskaryosis ?Invasive squamous carcinoma
7
4
5
?Glandular Neoplasia endocervical type
?Glandular Neoplasia (non-cervical) (not HPV Tested)
6
0
?Glandular Neoplasia (non-cervical) (HPV tested)
G
Negative (Not HPV tested)
Negative (HPV tested)
Inadequate
2
N
1
Mild dyskaryosis
Borderline changes
with koilocytosis
Moderate dyskaroysis
Severe dyskaroysis
Severe dyskaryosis?
Invasive
?Glandular neoplasia
Negative
Inadequate
Result
code
Referral for colposcopy or further
assessment


Clinically suspicious cervix
Post-menopausal bleeding


Symptoms → gynaecologist → colposcopy




Not using HRT
URGENT to be seen within 2 weeks
Post-coital bleeding

(particularly in women > 40 years of age)
Intermenstrual bleeding
Persistent vaginal discharge
Previous treatment for CIN


Not returned to routine recall
Test result > mild dyskaryosis
Direct referral for
colposcopy
Sample taken
Sample taken
Sample
processed and
cytology results
available
Sample
processed and
cytology results
available
Sample taker
receives results
and made aware
of direct referral
Smear taker referral
for colposcopy
Sample taker
receives results
and refers to
colposcopy
Direct referral
from laboratory
to colposcopy
Referral from GP
to colposcopy.
Patient sent
appointment
Colposcopy Programme and Management Guidelines (2010) state that:
At least 90% of women with an abnormal test should be seen in a colposcopy clinic within 8
weeks of referral and that at least 90% of women with a test result of moderate or severe
dyskaryosis should be seen within 4 weeks
COLPOSCOPY
Louise Cadman
Research Nurse Consultant and Nurse Colposcopist
Centre for Cancer Prevention
Wolfson Institute of Preventative Medicine
Aims of Colposcopy

To determine extent of the lesion
Visualise the entire squamocolumnar or the
colposcopy is ‘unsatisfactory’.
 Identify the transformation zone (TZ).



Obtain directed biopsies from abnormal/suspicious areas
To confirm nature of lesion and to rule out
invasion
Colposcopy



A specialist technique
Gives a magnified image
of the cervix
Solutions applied which
reveal changes in the
epithelium


5% acetic acid
Iodine
Colposcopic signs
MARGINS
IODINE
COLOUR
VESSELS
Normal Colposcopy
 with acetic acid
with iodine 
CIN I
 with acetic acid
with iodine 
2012-3 Procedure at colposcopy by reason for
referral (N=3,320,389)
100
90
80
Percent
70
60
Other
50
Ablation with biopsy
40
Ablation without biopsy
Excision
30
Diagnostic biopsy
No procedure
20
10
0
All referrals Inadequate Low Grade High Grade
Reason for referral
Clinical
Clinical
Indication - Indication Urgent
Non urgent
Treatment Methods
Large Loop Excision of the
Transformation Zone - LLETZ
Large Loop Excision of the
Transformation Zone - LLETZ
LLETZ

Local anaesthetic

Cuts blocks up to 1.5 cm
deep

Provides a specimen for
histology

Good haemostasis

Quick and simple

Little thermal damage to
cervix or specimen
Cold coagulation
Heats superficial
tissues to 100°C
 Suitable for small
lesions / low grade
CIN
 Rapid (20 seconds
per field)

Cryocautery
Freezes using
nitrous oxide
 Treatment
ablates
affected area
 Treats to a
depth of 4 mm

LASER
Light
Amplification
Stimulated
Emission of
Radiation
Cold knife cone biopsy
Future developments
Prophylactic Vaccines
Gardasil
Cervarix
(Sanofi Pasteur MSD)
(GSK)
 Quadrivalent
 Bivalent
 HPV
 HPV
types 6,11,16
and 18
 Adjuvant –
aluminium salts
types 16 and
18
 Adjuvant – ASO4
UK vaccination programme introduced in September 2008
Recent results for HPV prevalence in
England

Previous calculation:
 number of cancers could be reduced to  1000

6000 cytology screening samples + pathology samples
HPV 16 and 18 found in
 76.4% of squamous cell cancers
 81.9% of adenocarcinomas
 63% of CIN 3
 91% of high grade glandular lesions
Frequently found multiple HPV types in a lesion
Number of cancers could be reduced to  700



Howell-Jones R, et al Br J Cancer 2010:103;209-16; doi:10.1038/sj.bjc.6605747
Monitoring after vaccination

Monitoring essential:


type-specific HPV tests needed
Duration of protection 15 - 30 years?

booster needed?

Relevance of antibody levels

Detection of non-vaccine HPV types
Cuzick J, et al. Vaccine 2008; 26S:K29–K41
Fraser C, et al. Vaccine. 2007; 25:4324–4333
David MP, et al. Gynecol Oncol. 2009
Screening in the era of vaccination:
challenges and possibilities




HPV as primary screen?

Increase screening
interval to ?5 years

Transience of infection
At what age to start?
Maybe age 30?
Triage using cytology?
When to refer for
colposcopy?
Swab
Median duration time of HPV infection
 Tampon
(months)
 Vaginal
Any
9.8washings
 Brush
hrHPV
9.3

lrHPV
8.4
16
12.4
18
9.8
New developments

Nonavalent human papillomavirus (HPV)
vaccine, including HPV-types
6/11/16/18/31/33/45/52/58

Therapeutic vaccine:
 ProCervix
- bivalent HPV 16 and 18
therapeutic vaccine
Useful websites
64
www.cancerscreening.nhs.uk
www.bsccp.org.uk
www.jostrust.org.uk