Cervical Cancer Screening

Question 1

What are the requirements of a good screening programme?

Answer 1

It must target a disease that is relatively widespread amongst the target population and be an important health problem.

It must provide a treatment to improve the outcome of the individual with the disease.

It must be cost effective.

There should be a recognisable latent or early symptomatic stage of the disease.

The natural history of the disease should be well understood.

Question 2

What are the requirements for a test used in a screening programme?

Answer 2

The test should be simple, safe, precise and validated.

It should be acceptable to the population.

There should be a policy on how to further investigate when the test is positive.

Question 3

What are the requirements for the treatment of a disease in a screening programme?

Answer 3

The treatment should be effective for patients identified through early detection.

The treatment should lead to better outcomes if the condition is detected early.

It should be clearly defined as to which patients to treat.

Question 4

What cancer screening programmes does the NHS run?

Answer 4

Breast, Bowel, and Cervical Cancer Screening Programme.

Question 5

What is the aim of the cervical cancer screening programme?

Answer 5

To reduce the number of women who develop invasive cervical cancer (incidence) and the number if women who die from it (mortality).

Question 6

What is the target population of the NHS CSP?

Answer 6

Women aged 25-64.

Question 7

Cervical cancer is the ____ most common female cancer in the UK and the ____ most common worldwide.

Answer 7

Cervical cancer is the 11th most common female cancer in the UK and the 2nd most common worldwide.

Question 8

Does cervical cancer have a precursor stage?

Answer 8

Yes, it has a necessary precursor stage which lasts several years, cervical intraepithelial neoplasia (CIN).

Question 9

What are the risk factors of cervical cancer?

Answer 9

HPV, 
Number if sexual partners,
Age at which sexual intercourse is initiated,
Number pregnancies,
Immunosuppression.

There is currently a HPV vaccination in this country targeting 12-13 year old girls.

Question 10

What is the test used for the cervical cancer screening programme?

What are the limitations of this test?

Answer 10

LBC. A sample is collected from the cervix using a cervix broom. The head of the broom is placed in a vial filled with a preservative. The lab processes the slide by examining the cells from the fluid in the vial.

The nature of this test is very subjective. There can be sampling errors. Interval cancer can develop.

The patient should be informed that there isn’t 100% detection rate of abnormalities.

Regular screening tests are more protective than a single test.

Question 11

Who manages the CSP on England?

Answer 11

The NHS CSP.

Question 12

Who manages the CSP Wales and Scotland?

Answer 12

The UK National Screening Committee.

Question 13

When did cervical screening start in the UK?

Answer 13

The 1960’s.

Question 14

When was the NHS CSP set up?

Answer 14

1988.

This involved computerised call and recall and led to cancer rates falling by 42% from 1988-1997.

Question 15

How much does screening cost per year?

Answer 15

Currently screening costs £157 million per year. It is currently commissioned by the primary care trusts.

Question 16

How many people are involved in the delivery of the cervical cancer screening programme?

Answer 16

More than 100k.

Question 17

What is the demographic of woman screened in England and at what frequency?

Answer 17

Women 25-49 are invited for screening every 3 years.

Women 50-64 are screened every 5 years.

Question 18

In Wales what is the age range of women tested and how often will testing be offered?

Answer 18

In Wales women aged 20-64 are invited for screening every 3 years.

Question 19

In Scotland what is the age range of women screened and how often?

Answer 19

Women aged 20-60 are screened every 3 years.

Question 20

Who is screening offered to in Northern Ireland?

Answer 20

Women aged 20-65 every 3 years.

Question 21

What is cervical cancer screening a test for?

Answer 21

Cervical screening is a test for precancerous changes, not cervical cancer.

Question 22

Why does the NHS undertake cervical screening?

Answer 22

Early detection can prevent 75% of cancers developing saving approximately 4,500 lives per year.

In the last 20 years the incidence of cervical cancer has halved and mortality has reduced by 2/3rds.

Cervical cancer is now an uncommon disease in the UK. Incidence is increasing in the lower age range.

Screening however is not 100% effective.

Question 23

How many women are in the NHS cervical screening programme?

Answer 23

Approximately 14.6million.

Question 24

Approximately what percentage of cervical cancer results end up being normal?

Answer 24

91%

Question 25

Approximately what percentage of cervical cancer screening tests are diagnosed as invasive cancers or glandular neoplasia on cervical smear?

Answer 25

Less than 0.1%

Question 26

What is the NHS CSP responsible for?

Answer 26

Quality assurance resource centres.

Assuring there is an EQA scheme in place.

Training.

Regulations and Guidelines.

Introduction if new technology such as primary HPV testing, LBC, HPV testing and automated screening.

The NHS CSP is driving for a 14 day turn around time. The target for the 14 day turnaround time is 98%.

Question 27

Discuss the Invasive cervical cancer audit.

Answer 27

The purpose of the cervical cancer audit is to monitor the effectiveness of the cervical screening programme and to identify areas of good practice and where improvements can be made.

The audit should provide an early indicator of the pattern of disease incidence . It could explain why some cases occur and what proportion are screen detected. It should be able to indicate in a timely fashion whether alterations in screening ages and frequencies have affected the incidence. If there are many changes going on at the same time the cause of the incidence change may be hard to identify.

The audit has been running since 2008 and some interesting results have come out.

For every case (abnormal result) in the audit there are controls (normal results). It was found that 29% occur in women under 65 whose screening was up to date within the cases. In the controls 62% adhered to the screening guidelines (i.e. Those that took part in the screening according to the guidelines had a lower incidence of developing disease).

The percentage of women never screened has been found to have decreased by approximately 50% compared to the 1996 data.

The percentage of women with stage 1 disease who have never been screened has remained the same.

In 2009-2010 there was a drop in higher stages of disease compared to previous years of the audit.

Question 28

What is the benefit of HPV testing in women that have abnormal screening tests?

Answer 28

HPV test of cure means that women can be returned to normal screening much more quickly if they are HPV negative.

This can potentially greatly decrease the anxiety that they experience.

Question 29

What does the future of the NHS CSP hold?

Answer 29

HPV testing

Automated screening

Potentially HPV primary testing

Question 30

What is the aim of a screening programme?

Answer 30

The aim of a screening programme is to detect and eliminate life threatening disease before the individual has become aware of the symptoms.

Question 31

The call and recall system comprises of 8 main elements. What are these?

Answer 31

1) . Receipt, recording and notification of test results.
2) . Identifying and including all women in the screening programme from the age of 25.
3) . Checking the appropriateness of invitations with the women’s registered GP practice.
4) . Ensuring call and recall is 3-yearly for 25-49 year olds and 5-yearly for 50-64 year olds (or at an earlier interval if specified by the lab) and ensuring invitations are sent out 5-6 weeks before the test date.
5) . Ensuring fail safe systems are in place and GP practices are notified of failure to attend and that these women are returned to the recall cycle at the appropriate interval.
6) . Arranges for transfer of recall records for any women who moves between areas.
7) . Ensures appropriate actions are taken in response to requests to cease recall and that confirmation of ceasing recall is sent to both the women and her registered GP practice.
8) . Provision of information including the statutory statistical reports for the national screening programme.

Question 32

Who is responsible for the commissioning of the call and recall system and for monitoring its effectiveness?

Answer 32

The Primary Care Trusts.

Question 33

What IT system is used to administer call and recall?

Answer 33

The NHS AIS / Open Exeter system.

This system is made available to the relevant labs to enable them to check a women’s cervical screening history.

Question 34

Describe some of the facilities that the open Exeter system provides.

Answer 34

The open Exeter system offers the facilities to……

send invitations for routine tests.

send result letters for women for whom a test result has been entered into the system.

send non-responder notifications to a women’s GP if no test result has been entered into the system after the test date.

Invite women who are registered with the NHS for cervical screening.

Keep track of any follow up investigations for women who have been invited for screening, and if all is well, recall the women for screening in 3 to 5 years.

Question 35

All women must be notified of the results of their test in ______. 95% of women must be notified within ___ days of their test date.

Answer 35

All women must be notified of the results of their test in writing. 95% of women must be notified within 14 days of their test date.

Question 36

In England when is a women sent her first invitation for screening?

Answer 36

At the age of 25.

Question 37

In England who will be screened every 3 years?

Answer 37

Women aged 25-49 years.

Question 38

In England who will be screened every 5 years?

Answer 38

Women aged 50-64 years.

Question 39

In what cases might a women aged 65+ be screened?

Answer 39

Only if they have not been offered screening since the age of 50 or have had recent abnormal results.

Question 40

Why aren’t women screened before the age of 25?

Answer 40

Changes in a young woman’s cervix are normal.

False positives could lead to unnecessary treatment that could affect child bearing.

Any abnormal changes can be easily picked up and treated from the age of 25 onwards.

Question 41

Why are women over the age of 65 not screened?

Answer 41

Women over the age of 65 with three consecutive negative results are taken out of the call and recall system.

It is highly unlikely that they will develop disease.

Women over 65 who have never had a test are entitled to one and those with a recent abnormality will continue to be followed up.

Question 42

What is a ‘prior notifications list’? What options does the GP have?

Answer 42

This is a letter sent out to GPs approximately 6 weeks prior to the call and recall letter being sent out to the women themselves.

The GP has 3 options:

1) . Invite
2) . Postpone - need a valid reason, usually no more than 12 months and can’t be more than the routine recall interval specified by the primary care trust.
3) . Cease - valid reason needed and the PNL must be signed by an authorised signatory in the GP practice.

Question 43

What is the purpose of a call and recall failsafe system?

Answer 43

Each lab runs its own failsafe system.

This is to ensure that when a women is suspended from routine recall for any reason they will be followed up appropriately and thoroughly by the reporting lab.

Question 44

According to the failsafe system for call and recall what will happen if no repeat sample has been received within 3 months of the expected date?

Answer 44

If no repeat sample has been received within 3 months of the expected date then a reminder letter will be sent to the smear taker.

Recall will be adjusted according to information received.

Two letters will be sent to remind the smear taker then a third will be sent to the hospital-based programme coordinator. It is then their responsibility to inform the PCT cancer lead who will then endeavour to ensure that the women attends for screening.

Question 45

In a cytology laboratory which staff members must be HPC registered?

Answer 45

The biomedical scientists.

Question 46

In a cytology laboratory which staff members have no requirement to be HPC registered?

Answer 46

Administration staff, Medical laboratory assistants, Cyto screeners.

Question 47

Describe the role of the administration staff within a cytology laboratory.

Answer 47

Bands 2-4

Duties include data entry, results entry, dispatch of results, handling phone enquiries.

No min qualifications.

Must be PC literate.

Question 48

Describe the role of the MLA’s within a cytology laboratory.

Answer 48

Bands 2-4.

Work under BMS supervision.

Perform wide range of tasks including sample preparation, filing and data entry, but not screening of cervical cytology samples.

No min qualifications required but should complete training log and undergo competency assessment.

Question 49

Describe the role of the cytology screeners within a cytology laboratory.

Answer 49

Trainee Cyto screeners are band 3. They are undergoing training for primary screening of cervical cytology samples. Until qualified they must not report out cervical screening reports.

To progress they must complete a city and guild diploma in cervical cytology over a 2 year period.

Qualified Cyto screeners are band 4-5. They must hold a City and Guild diploma in cervical cytology or equivalent. Their main duty is to primary screen cervical cytology samples and report out those which are negative or inadequate.

Cyto screeners may undertake MLA duties in addition to screening.

Microscopy is to be performed for 5hrs maximum at a time.

Their minimum workload is 3000 cases per year.

Question 50

Describe the role of the BMS1 staff within a cytology laboratory.

Answer 50

Band 5-6.

Main duty is to primary screen cervical Cyto samples and report out those which are negative or inadequate.

Hold specialist diploma and city and guild diploma in cervical cytology.

Min workload is 3000 cases per year.

May also be involved with non-gynae Cyto services.

Question 51

Describe the role of the BMS training officer within a cytology laboratory.

Answer 51

This is a band 7 role held in addition to their main role.

Responsible for training of all non-medical trainees (including trainee BMS staff and cytoscreeners).

Required to be city and guild assessors. To be registered with the local Cyto training centre.

Question 52

Describe the role of the supervisory BMS staff within a cytology laboratory.

Answer 52

Band 7-8 MSc level and may hold a higher specialist diploma.

May supervise up to 4 other members of staff.

Involved in primary screening and checking.

Role includes discussion of difficult cases with staff, staff training, monitoring of specimen preparation, audit and health and safety.

Minimum workload of 3000 cases per year.

May also be involved with the non-gynae cyto service.

Question 53

Describe the role of the lab manager / scientific head within a cytology laboratory.

Answer 53

Band 8.

Responsible for the operational management if the department.

Wide range of duties.

May or may not continue to be involved with the evaluation of cervical cytology samples.

Question 54

Describe the role of a consultant BMS within a cytology laboratory.

Answer 54

Aka advanced practitioners or clinical cytologist.

Band 8.

Must hold an advanced specialist diploma in cervical cytology (IBMS/RCPATH).

Able to report abnormal cervical cytology samples and make recommendations regarding patient management.

Participate in MDTM / CPC.

Act as intermediaries between the laboratory and clinical staff.

May have a role in the teaching of junior medical and non medical staff.

May take part in research.

Minimum workload is 750 cases per year.

May also be involved with non-gynae cytology sample reporting.

Question 55

Describe the role of the hospital based programme coordinator?

Answer 55

Band 8.

May form part of the role held by a consultant pathologist, consultant BMS, Cytology lab manager or colposcopist.

The role is to oversee the coordination, quality and effectiveness of the cervical screening programme.

They form a valuable link with screening commissioners, PCT leads and QA centres.

They are responsible for the national invasive cancer audits.

Question 56

Describe the role of the medical consultants within a cytology laboratory.

Answer 56

Consultant cellular pathologists often participate in histo, cyto (cervical and non-gynae) and mortuary workloads.

They supervise the lab service and are clinically responsible for the quality of the service.

They participate in MDTM/CDC.

They review histology for the non-invasive cancer audit.

They act as intermediaries between laboratory and clinical staff.

They are responsible for educating trainee medical and non-medical staff.

They perform diagnostic service by reporting abnormal cervical cytology samples and making recommendations regarding patient management.

They have links with research.

Minimum workload is 750 cases per year.

Question 57

What ongoing education must BMS staff participate in?

Answer 57

All BMS staff must be HPC registered and undergo CPD activities.

Question 58

What ongoing education must screening staff participate in?

Answer 58

All screening staff (including BMS staff) must participate in EQA, attend 3 day update training every 3 years and undergo 4 days of in house training every year.