Dealing with a patient who has a 10-year smear gap
Mrs Brown has come today with
a cough. You notice from her records that she has not had a smear for 10 years. Dr Melanie Wynne-Jones discusses what you should do.
What are your responsibilities in cervical screening?
These are defined by the NHS cervical screening programme1. The primary care team's role is to inform women about the programme, encourage regular smears and provide information about test results, follow-up and treatment. GPs must also refer for further investigation and treatment where appropriate, even if someone else took the smear. In 1996/7 the programme cost £130 million; this included 450,000 unscheduled smears2.
GPs also have to co-operate with the PCO which runs the call, recall and results notification system, by checking the patients' demographic and cytology records are accurate.
Target payments help GPs to pay their staff to do this work. Payments are made if more than 50 per cent or 80 per cent of eligible women have had an adequate smear within the previous five years (hysterectomised women
can be excluded, but defaulters are not).
Why hasn't Mrs Brown had a smear?
She may have slipped through the net by moving, changing doctors or ignoring screening invitations. Practices should audit their cytology records for gaps regularly, for the sake of their targets, as well as individual patients.
She may think that she must be all right because she has no symptoms, that a single smear is sufficient, or that smears only detect cancer and are therefore pointless. Monogamous and currently celibate women often mistakenly believe they are not at risk.
However, she may be deliberately avoiding smears through embarrassment, because she has symptoms that she secretly worries are cancer or sexually transmitted, has vaginal dryness, or because she found her last smear upsetting (women still occasionally report lack of privacy or a chaperone, or that their examination was rough or painful). Sensitive questioning may allow her to reveal the real reason without feeling embarrassed or ignorant.
How dangerous is this for Mrs Brown?
In 1997 there were 2,740 new cases and 1,222 deaths from invasive cervical cancer in England and Wales, a 26 per cent fall in incidence over five years3. But almost 19,000 women were found to have CIN3.
Mortality rates have fallen by 40 per cent since 1979, and are now falling by 7 per cent a year, partly due to better coverage (up from 45 per cent in 1988/9 to 83.7 per cent in 1999-2000). Screening may prevent 1,100 to 3,900 cases of cervical cancer annually4.
Almost half of new cases occur in women who have never had a smear test, although
15 per cent have had a test in the previous five years. This may reflect the limitations of screening and/or variations in disease progression.
A single screen at the age of 40 reduces the cumulative incidence of cervical cancer by 20 per cent5. Five-yearly screening (aged 20-64) reduces it by 83.6 per cent1 (91.2 per cent and 93.3 per cent for three-yearly and annual screening).
Pilot projects are evaluating whether liquid-based cytology and human papilloma virus testing could improve results.
What are the risk associations for cervical cancer?
· High-risk subtypes of HPV (especially 16, 18, 30, 33)
· Multiple sexual partners
· A sexual partner who has had multiple partners
· Not using a condom (long-term use of the oral contraceptive may increase risk)
· Smoking (doubles the risk)
· Early or frequent pregnancy
· Manual social class
· Living in the northern half of the UK
What arguments might you use to persuade her?
It is important to correct any misconceptions about the smear examination itself (privacy, chaperone, discomfort, etc) and interpretation of the result. Statistics may convince or frighten her; stress should be put on detecting early and treatable changes. Information leaflets and videos on smears and colposcopy are available in a variety of languages (see below).
Should you offer to do a smear now?
Only in exceptional circumstances. Many women prefer to prepare themselves mentally and physically, and if she feels coerced this may reinforce negative feelings.
What if Mrs Brown still refuses?
All women should be offered advice about risk factors for cervical cancer as well as contraception where appropriate, and sexually transmitted diseases. This can be done as part of health promotion, a well-woman service, or opportunistically. Some women get irate if they are asked repeatedly. It is not ethical either to badger Mrs Brown or to remove her from the list for the sake of reaching cytology targets.
Mrs Brown should be told that she can change her mind, and may well do so, having thought about it or discussed it with relatives or friends. Her records should show that she has been offered both a smear and relevant advice.
· Cervical cancer mortality is falling, partly due to the cervical screening programme
· Five-yearly screening for 20-64-year-old women reduces cumulative incidence of cervical cancer by 83.6 per cent
· GPs receive target payments for participation in the programmae
· Women may refuse smear invitations through ignorance or fear; health education
1 NHS Cervical Screening Programme www.cancerscreening.nhs.uk/cervical
2 The Performance of the NHS Cervical Screening Programme in England Report by the Comptroller and Auditor General HC 678 1997/8, April 22, 1998
3 Office for National Statistics, Monitor Population & Health, MB 1998/2002
4 Sasieni et al. British Journal of Cancer.
1996, vol 73, 1001/5
5 Miller AB. Cervical cancer screening programmes. Geneva; WHO, 1992
6 Hakama M, Miller AB, Day NE. Screening for cancer of the uterine cervix. Lyon: IARC, 1986
Patient information resources
NHS Cancer Screening Programmes,
The Manor House, 260 Ecclesall Road South, Sheffield S11 9PS. Tel: 0114 271 1060.
British Society for Colposcopy and Cervical Pathology. Website: www.bsccp.org.uk