Irish doctors targeting the elimination of cervical cancer by 2040

Screening and the HPV vaccine are having a positive effect here

DR Nóirín Russell can remember a time when she was working as a Senior House Officer in Cork, when young mothers were presenting to her wards with advanced cervical cancer.

Thankfully this is now something that Dr Russell, clinical director of Cervical Check, feels is rare thanks to the advent of screening here.

And as part of the World Health Organisation’s strategy to eliminate cervical cancer, Ireland is on track to reach these targets using screening and the HPV vaccination.

‘Ireland’s screening uptake rates are very good. We are still on 73 per cent which is significantly higher than England and Wales,’ says Dr Russell, pointing to the elimination goal of over 70 per cent.

‘We are already hitting that but we would like to be at 80 per cent.’

The recent extension of the screening age limit from 60 to 65 following a 2016 report is expected to raise the uptake percentage soon as women from that cohort are tested as the 2016 report recommended more cervical cancer could be caught up to the age of 65.

So if you are aged between 25 and 65, you are invited to go to cervicalcheck.ie and put in your PPS number to see if you are due a smear test.

Often women under the age of 25 are worried that they are not being called but there is good reason for that.

‘Evidence shows that screening under 25 years would introduce more harm and less benefit, as HPV infection is really common in younger women and causes transient cellular abnormalities, but most of those will turn back to normal once the HPV infection is cleared,’ explains Dr Russell.

‘Cervical cancer is incredibly rare under the age of 25 and cellular abnormality is common so you run the risk of finding lots of cellular abnormalities that are left to their own devices. But if you screen for them it puts younger women at risk of first of the anxiety of worrying there is something wrong but also at risk of having treatments they don’t need which can then have an impact on their fertility, pregnancy loss rate and pre-term birth rate. You introduce a lot more risk without any additional benefit.’

The current way that screening tests are checked involves looking for the HPV virus or its presence first and foremost.

‘The test is taken in the same way but the first thing that the laboratory does is look for HPV,’ says Dr Russell. ‘If you have the HPV virus then that sample is checked for cell abnormality.

‘We know that approximately 12 per cent of the population at any one time will have HPV infection; half of those will have abnormal cells and half will not.

‘So if a woman gets a test where HPV is detected and there are no abnormal cells, then she has a repeat HPV test within 12 months; so she is put into an increased follow up space. If someone has two HPV tests that are positive they then gets referred to colposcopy which is a diagnostic test looking for any evidence of cellular abnormality and to determine if there is any need for treatment.

‘It’s a better way of finding out who in the population is at risk of having cells on their cervix that ended treatment at the pre-cancer stage to prevent them moving on and turning into cancer. That is a better way of looking at risk than looking at the cells first.’

Screening decreases a woman’s risk of getting cervical cancer but it is also essential that women know the symptoms of the cancer too. It will never be the case that cervical cancer will disappear completely but the elimination strategy aims to have cases below four per 100,000 people.

‘There are three pillars for elimination,’ says Dr Russell. ‘If we have all of our young women vaccinated, if everyone came for screening and if everyone who had abnormalities were treated we know that we could get cervical cancer down from ten per 100,000 people to less than four per 100,000.

‘So it is really important for women to know the symptoms of cervical cancer. Screening is for well women with no symptoms. You do it at regular intervals - three yearly up to 30 or every five years if you are over 30. But it is really important that women know what symptoms to look out for in between screening.

‘If someone develops bleeding in between periods, bleeding after sex, bleeding after the menopause or unusual vaginal discharge then they need to see their GP and they need to be referred into a gynaecology clinic for extra tests. Once you have symptoms you need to be assessed and have a diagnostic test and it is really important that if a woman develops symptoms even after a negative screening test, these symptoms need to be investigated.’

Screening can detect early abnormalities which means that women can be treated promptly.

‘Of cervical cancer detected at screening 80 per cent of women are detected at stage one and the primary goal is that we would like screening to detect abnormal cells before cancer develops,’ says Dr Russell.

‘Every year we screen around 270,000 women; 6,500 women will have a treatment for precancerous abnormalities and the vast majority will never get cancer. That is the main workload of the programme.

‘But we also know every year around 100 to 120 women of that 270,000 will get a diagnosis of cervical cancer. Women who are detected with cervical cancer via screening are usually detected at stage one and then the survival for stage one is incredibly high, well over 90 per cent and for stage 1A it is 97 per cent. If you are detected at the very earliest stage - 1a - the survival rate is the same as someone who never had cervical cancer.’

One issue with screening is that if people move house, the letter for their screening test might go to their old address which is why Dr Russell says women should check online at cervicalcheck.ie to see if they are due a test.

‘Go to the register, put in your PPS number and find out if you are due a screening test - you don’t need to wait for the letter,’ says Dr Russell. ‘You can attend a GP or practice nurse in any practice across Ireland and it’s free - it takes around 10 or 15 minutes. If you are due you can make your appointment, you don’t need to have a letter in your hand.’

Something that is also important

‘Ireland’s screening uptakes are good’

‘It’s really important to know the symptoms’

‘We want to get the rate to four per 100,000’

to remember is that those who have received the HPV vaccination still need to attend their screening appointments.

‘Vaccination covers the high risk strains of HPV but there are still strains that are not covered by vaccination so it’s really important that women who are vaccinated still come from screening,’ says Dr Russell. ‘And 10 per cent of cancers are not HPV-related so it is important that women still come for screening and are aware of the symptoms.’

But progress is being made and around the world – Ireland included. Those who have been vaccinated in the first cohort are reaching screening age with dramatic results.

‘Last year we published incredible research from Ireland that shows the first vaccinated 25year-olds are now coming into the screening programme and the rate of high grade abnormalities has plummeted,’ says Dr Russell. ‘There are significantly less young women with abnormal cells coming into the programme at age 25 and their lifetime risk of getting cervical cancer is minimal.

‘Elimination is a WHO terminology and it is about eliminating cervical cancer as a public health problem, so getting the rate down to less than four people per 100,000 of the population,’ says Dr Russell. ‘I fully believe Ireland is on track to do that by 2040.’