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A tragic death, but nothing to do with ‘denying young women smear tests’

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Under the headline ‘Denying young women smear tests is a disgrace’, Barbara Ellen wrote in the Observer: ‘It's heartbreaking to hear of a 26-year-old woman dying of cervical cancer. Worse still to learn that this woman, Becky Ryder, asked for a smear test two years earlier, when consulting a doctor about abnormal bleeding, but was refused as she was under 25.’

She went on to explain that her widower is campaigning to bring the age for screening back to 20 years, but suggested that they were more likely to ‘encounter is condescension and the mantra of substandard health care: what happened to her is rare’.

Ellen went on to say that ‘Ms Ryder's case was even more extreme because she had the "red flag" of irregular bleeding. However, sometimes there are few early symptoms, which makes screening more necessary than ever.’ [1]

We’ve been offering cervical screening since 1964. Yet journalists such as Ellen have not grasped the fundamental concept of what screening is; a test for asymptomatic women. I have sympathy for Ms Ryder and her family, but there is no point - and no indication - to do a smear test in a woman with symptoms in the hope that the smear will assist.

NHS guidelines [2] for the investigation of symptomatic women under the age of 25 don’t reference taking smears at all – but onward referral as required. Yet the press did not pick up on this, with most simply saying that the critical issue was a smear not being taken [3,4,5,6]. Additionally, most newspapers quoted the Department of Health as saying simply  that screening in under 25s ‘did more harm than good, giving too many false positives that lead to needless treatment’.

But this is only half the story. The reason why smear tests aren’t offered in women under 25 is because they are also ineffective. A study published in the BMJ in 2009 demonstrated not simply this, but also, that only five of 73 women diagnosed with cervical cancer under the age of 25 had not had a smear test. [7]

False reassurance is one thing; another is the false reassurance of a profession. Smear tests have been advocated in the media as useful in the under-25s not just by journalists but by some health professionals.

As Adeola Olaitan, consultant gynaecologist told me, when it comes to symptomatic young women: ‘Although cervical cancer is extremely rare in this age group, the GP should examine the cervix . If it looks abnormal, the correct response is NOT to take a smear but to refer the patient urgently for diagnostic testing. A smear is a screening test in an asymptomatic population.’

 Anne Mackie, director of Programmes at Public Health England agrees: ‘For women who are displaying symptoms, a screening test is not the appropriate test and merely delays the process. Cervical screening is not a test for cancer.’ There is no evidence that a change in age range for screening has been harmful: ‘Since the age was raised, there has been no increase in deaths in women aged 20 to 24 or 25 to 30 years old,’ she said.

Until we manage to explain to the general public the limitations, harms and indications for screening, we will go around in circles. Screening is for the asymptomatic; symptoms need diagnostic assessment; and doing more harmful and ineffective screening helps no one.

 

1. Denying young women smear tests is a disgrace. Observer 2013, online 28 Apr

 

2. Clinical Practice Guidance for the Assessment of Young Women aged 20-24 with Abnormal Vaginal Bleeding. NHS, Mar 2010

 

3. Woman died after being refused smear test for being too young. Telegraph 2013, online 24 Apr

 

4. Woman, 26, who was 'too young' to be given a smear test dies from cervical cancer. Daily Mail 2013, online 24 April

 

5. Woman died of cancer after being refused test because she was 24. Times 2013, online 25 April

 

6. Wife ‘too young’ for smear test dies from cancer at 26. Express 2013, online 25 April

 

7. Effectiveness of cervical screening with age: population based case-control study of prospectively recorded data. BMJ 2009;339:b2968

Readers' comments (1)

  • Vinci Ho

    Perhaps we should always highlight the importance of dealing those 20-24 with unscheduled vaginal bleeding differently . Yes, common causes come first but rarity was always a possibilty and screening with smear is not the answer ........

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