The search for answers in cervical cancer screening

Healthcare should not be used for political gain, as in the case of the Government’s response to the recent cervical screening programme controversy.  The actual problems at the core of the controversy were straightforward. A number of tests, initially reported as negative, were subsequently found to have evidence of disease and the women involved were not informed of this.  So, how is this rectified by offering women a repeat smear test if they, or their GP, are concerned? The CervicalCheck website indicates that GPs have been given the information necessary to make an informed decision. But the information does not answer three important questions frequently asked by women. Why is it not possible to review my previous test result rather than subject me to another test? How confident can I be that my previous test result is accurate? Where will my test be processed? In the absence of this information, the only reasonable option is to offer a further test and hope that this is also reported as normal.

The CervicalCheck website also states that a smear test is a “simple procedure that only takes a few minutes”. In the UK, a cervical screening campaign suggested that women put having a cervical smear test on their to-do list, alongside booking a hair appointment or buying cinema tickets. But consulting your doctor about a smear test is not the same as asking your hairdresser for advice on whether to have a half or a full head of highlights. I suspect many men have no idea of the complex decisions women have to make in the hairdressers, just as I suspect they do not give much thought to the anxieties, fears, embarrassment and discomfort that women experience when it comes to having a  smear test. I would choose to have 20 blood tests over this most intimate and invasive procedure, as would the many women who turn up at my surgery, having taken time off work and/or arranged childcare. Women only attend for smear tests because medical professionals and public campaigns convince them that this is the best way to protect their health. 

Dr Robert O’Connor, Head of Research at the Irish Cancer Society, stated recently that the advantages of cervical screening far outweigh the risks (<strong><em>Medical Independent</em></strong>, 17 May). According to the article, in the decade since cervical screening was introduced in Ireland, more than 1,300 cancers and 87,000 high- and low-grade abnormalities have been diagnosed. This means that for the 130 women diagnosed with cancer each year, 8,700 women will have either repeat tests, colposcopy, biopsy, laser or large loop excision of the transformation zone (Lletz procedure). Cervical cancer is rare. Abnormal smears are common. But no-one knows which ones will turn out to be significant, so all women are followed-up and treated.  Of those who require biopsies, many will experience bleeding, infection or premature delivery. Many women experience considerable anxiety while waiting for their test result, a well-recognised harm of screening, and many others delay presenting to their doctor with significant symptoms because they have had a normal test. This “simple procedure that only takes a few minutes” has an impressive array of potential unintended consequences. 

The article also states that cervical screening saves lives, and GPs are urged to protect the programme. The evidence for this is that prior to the introduction of the cervical screening programme, cervical cancer rates in Ireland were increasing. Since its introduction, the rates have been falling. But correlation does not necessarily equal causation and diagnosing cancer does not always translate into saving lives. Even though the decline in cervical cancer rates coincided with the introduction of the programme, it could still be due to a myriad of other factors, such as: Improved overall health; changes in sexual behaviours; reduced child-bearing; or reduction in sexually-transmitted diseases. Dr Margaret McCartney, in her book <em>The Patient Paradox: Why Sexed-up Medicine is Bad for Your Health</em>, explains that the decline in cervical cancer mortality rates in the UK pre-dated the introduction of the cervical screening programme. In reality, the only way to know if cervical screening saves lives is to perform a randomised, controlled trial that compares a group of women who have had screening with a similar group who have not.  This has never been done. At one time in the early 1970s in the UK, such a trial was suggested but deemed unethical. Yet the ethics of subjecting millions of women to an invasive test without clear evidence of the benefits and potential harmful effects is ignored.

It is disappointing that the political answer to this controversy has been to ask GPs to paper over the cracks, rather than addressing the real issues of test limitations and poor communication with patients.