Doctors debate if women should be given a smear test ever five years
Should women now be given a smear test every five years rather than three? Doctors insist it would be safe, but campaigners rail against the proposal, arguing more women could die from cervical cancer as a result
At the start of this year, health chiefs in Wales announced a big change to their cervical cancer screening programme – women would get a smear test every five years, instead of every three.
Public Health Wales called it ‘a really positive development’, while experts insisted the adjustment was a good thing, since new screening methods are so accurate in determining who will and who won’t go on to develop cancer that women simply don’t need to be seen as often.
It might also spare some from unnecessary and potentially risky treatment, they added.
There were quite a few people who didn’t see it that way, however.
‘The blood of thousands of women will be on the hands of whoever decided to make this ridiculous and cruel decision,’ railed one commentator on Facebook.
‘Again women and girls’ healthcare is downgraded,’ another wrote.
‘This will result in increased preventable deaths.’
An online petition demanding the reversal of the decision was quickly launched, and so far has amassed 1.2 million signatures.
‘I don’t think it sounds safe,’ says Rachel Paul, 29, from Llanelli, who started the petition.
‘I understand tests have changed, but I know of so many women who developed cervical cancer between smear tests.
‘The thought of not being able to get a test for five years is really scary.’
Journalist Katie Nicholl, pictured with son George and daughter Matilda, writes about her experience having children after cervical surgery
On January 5, Public Health Wales issued an apology on Twitter: ‘We are sorry. We haven’t done enough to explain the changes to cervical screening and have caused concern.
‘We are working to make this clearer and more information will be available as soon as we can today and in the coming days.’
But the organisation will not back down on the decision.
Medical insiders, speaking to The Mail on Sunday, said that the same change had been scheduled by NHS England later this year.
However, the strength of the backlash to the Welsh move means policymakers are now ‘reconsidering’.
They would ‘have to think carefully about how to present the decision in a more positive light,’ the insiders added.
Professor Peter Sasieni, a cancer prevention expert and head of medical trials at King’s College London, confirmed the delay: ‘It’s been on the cards in England for a while, but Covid delayed the change because it involves a lot of red tape which NHS systems will struggle to cope with.
‘The plan is for smear tests to move to every five years in all four nations within the next year or so.’
Yet the most pertinent question, raised by women themselves, remains: how can it be sensible to have less frequent checks for a cancer that kills 40 per cent of those who are diagnosed late?
Destiny Wade, 28, from Kent, believes she is an example of why three-year screenings should stay.
She was diagnosed with cervical cancer in July 2020, following unusual vaginal bleeding. Her smear test, performed three years earlier, showed no evidence of cancer.
‘If I waited another two years, I’d be dead,’ says Destiny, who has had to undergo multiple operations that have left her cancer-free but infertile. Her story is concerning.
The most pertinent question, raised by women themselves, remains: how can it be sensible to have less frequent checks for a cancer that kills 40 per cent of those who are diagnosed late?
An online petition demanding the reversal of the decision was quickly launched, and so far has amassed 1.2 million signatures
So what’s the truth?
Will moving screening to every five years protect women, or lead to a spike in deaths from cancer?
Firstly, it’s important to point out that the NHS cervical screening programme has been a remarkable success.
Since its inception in 1988, cervical cancer rates have plunged by more than two thirds.
In 1992 alone, research suggests there would have been 57 per cent more cases of cervical cancer had women not been screened.
Nevertheless, about 3,200 women in the UK are still diagnosed with it every year, and 800 die.
And just three-quarters of eligible women aged between 25 and 64 turn up for their smear test – a figure experts are intent on improving.
What lies behind extending the interval between screenings is the fact that today’s tests are vastly better than those they replaced.
Historically, a smear test involved taking a sample of cells from the cervix which were then examined in a lab for pre-cancerous changes.
These were graded as borderline, mild, moderate or severe.
The treatment protocol for moderate and severe cases was always clear – the risk of cancer was significant, and so women were referred for a second investigation, called a colposcopy, during which the cervix is examined and more tissue removed for analysis.
This gives doctors more detail about the level of risk – and whether the woman needs treatment to remove the abnormal cells.
But what to do in the case of women flagged after a smear test with borderline or mild cell changes, which present a lower risk, has long been the subject of debate.
Some are simply monitored to see if the cells change further. In one in three cases, these minor abnormalities disappear without treatment as the body’s immune system kicks in. However, some end up being treated – possibly unnecessarily – and this can cause problems.
A colposcopy, like a smear, involves a speculum – a duckbill-shaped device – being inserted into the vagina to allow access to the uterus. These procedures can be uncomfortable, but are risk-free.
The same cannot be said for treatments to remove abnormal cervical cells.
There are a number of ways this can be done, for example, using a heated wire loop or a minor operation to cut out the tissue.
But these procedures can have significant downsides.
The cervix is the muscular ring at the entrance to the womb, and any treatment on it can weaken it. And this can affect how a pregnancy progresses.
KATIE NICHOLL: I’m glad they zapped abnormal cells on my cervix, but wish I’d been told of the risks
I remember very little about my first smear test – other than being incredibly alarmed when, afterwards, I was called by the doctor and told they’d found abnormal cells on my cervix.
A further test – a colposcopy – was required, and then there was worse news.
The cell changes were graded CIN3, one of the worst kinds.
It wasn’t cancer, but there is a high chance these cells can become cancerous if left untreated.
My doctor recommended I have surgery to ‘scrape them away’, and I agreed without a second thought.
There was a bit of bleeding afterwards, and I took a couple of days off work.
At a follow-up appointment they told me they’d got everything.
Smear tests after that were clear. And that, I thought, was that.
I got pregnant just under a decade later, in 2012, aged 34.
Everything was going fine until, at four months during a routine scan, the obstetrician asked: ‘Have you had surgery on your cervix?’
I explained I had, and she told me she believed the operation had caused my cervix ‘to shorten quite significantly’, and this would affect its ability to stay closed.
This meant, basically, there was a quite significant risk that my cervix wouldn’t hold out for the remainder of my pregnancy, and I could miscarry or give birth very prematurely.
It was terrifying.
We had spent years struggling to conceive before opting for IVF, which had been successful first time. Now I was facing the very real prospect of losing my baby.
If a shortened cervix is picked up early during pregnancy, there’s a procedure to insert a stitch that holds it closed.
But this wasn’t an option at my stage, as that operation could also trigger a miscarriage.
I was told sex was out of the question, as was exercise that involved any kind of impact, such as running.
I was advised not to get stressed, or run myself ragged at work. But that was it.
I was constantly worried. I remember feeling like an emperor penguin holding this precious egg inside me, not wanting to uncross my legs.
In the end, my cervix did hold out.
Matilda was born a week early, healthy and weighing 5 lb 8oz. It was lucky, I was told, that she wasn’t too heavy and didn’t put too much pressure on my cervix.
Also, my labour was quick and easy. I didn’t need pain relief.
I’m told this is one silver lining to having a weak cervix: you don’t have to push so much.
My second pregnancy, with George, now four, wasn’t affected in the same way, although no one has been able to tell me why.
I don’t regret for a second having the CIN3 cells removed.
But I do wish someone had told me about the potential complications.
As it was, nothing was mentioned, and you’re nervous enough during a first pregnancy.
If I’d known, perhaps I’d have been more prepared for the possibility that I was at higher risk.
I’m 44 now, and because of my history I choose to have a smear test every year. It gives me peace of mind.
Five years feels a long time to wait, especially if something fast-growing appears.
But the idea that women might have the treatment I had unnecessarily does bother me – you don’t want to go through that unless you absolutely have to.
In some women who have had cervical treatments, there is an increased risk of a miscarriage or premature birth.
Treatment can also, rarely, cause stenosis, where the cervix narrows or closes.
Of course, if treatment is to remove abnormal cells that are more likely to become cancer, the benefit outweighs this small risk.
However, as consultant obstetric and gynaecological surgeon Clive Spence-Jones says: ‘If early cell changes are discovered, and they don’t resolve, it can cause anxiety in patients.
‘And so it might seem like the cautious approach to offer further investigations and treatment in order to prevent cancer, but this also means treatment sometimes ends up being given unnecessarily to patients who might never have progressed or developed cancer. And then you could have created a risk to future pregnancy.’
A big step forward came in 2020 when the initial screening test was changed. Instead of taking cell samples, it looks for the presence of the human papillomavirus (HPV), known to be the cause of most cervical cancers.
Around 80 per cent of adults are thought to carry HPV on the body, and in most cases it is harmless.
However, for reasons not fully understood, in some cases it can invade the body’s tissues, triggering cell changes that lead to cervical and other cancers.
If HPV is present in a sample taken at cervical screening, women are likely to undergo a colposcopy and other tests to determine if they need treatment or more regular screening.
But, importantly, studies have shown that if a woman tests negative for HPV, she has a less than one per cent chance of developing cervical cancer within five years – hence the change in the cervical screening interval.
Doctors and cervical cancer charities seem agreed: the move is safe. Indeed, research by King’s College London in 2018 estimated that HPV screening every five years is such an accurate method it would lead to nearly 500 fewer cases of cervical cancer every year in the UK, compared with the test every three years.
Crucially, as the new method is more precise, fewer borderline cases are flagged up, meaning fewer women being overtreated.
Theresa Freeman-Wang, consultant gynaecologist at the Whittington NHS Trust in London and an expert in cervical screening and colposcopy, says: ‘Women are worried because they are used to the idea of being screened every three years. Some would like to be screened more frequently, but evidence shows that if a woman tests negative for HPV then her risk of developing an abnormality, or indeed cervical cancer, is negligible.’
Added to this, girls have been vaccinated against HPV at the age of 13 since 2008, and boys of the same age since 2019. Ms Freeman-Wang continues: ‘We have a vaccinated population coming through now, and so screening every three years for them in particular isn’t necessary.’
Kate Sanger, head of policy at Jo’s Cervical Cancer Trust, says: ‘Surgery for cell changes can involve part of the cervix being taken away. It can weaken the cervix and affect a woman’s ability to carry children. It can also lead to infections and bleeding, impacting mental and physical health. It’s not something you want unnecessarily.’
Prof Sasieni adds: ‘If we test less then we free up more resources – and I don’t necessarily mean financial resources, though that’s obviously a factor. We could spend those resources finding the millions of women who aren’t currently being screened at all. There’s a massive benefit in focusing more effort on that.’
Family doctors agree. ‘A lot of women shy away from the test because they find it embarrassing, and as a result we are constantly chasing people up,’ says Dr Nisa Aslam, a London GP. ‘If we spaced out the time between tests, we might see more people coming forward.’ Dr Aslam stresses that screening is not the only means of spotting cervical cancer. ‘Just because you’ve had a smear test recently, doesn’t mean you shouldn’t look out for symptoms such as regular bleeding or, after sex, vaginal discharge, or bleeding between periods. If you experience any of these, you should see your GP.’
However Rachel Paul, who created the Welsh petition, is unconvinced. ‘Anyone like myself who is anxious should be given the option to get a smear test every three years.
‘I shouldn’t be forced into having my test every five years – it should be my choice.’
Ms Sanger says Jo’s Cervical Cancer Trust ‘fully supports’ NHS England adopting the five-year policy, but believes ‘better communication’ is needed.
She adds: ‘The cervical screening programme is getting better and better at catching cancers, and we need to make that clear.’
Over-50s needed to trial ‘exciting’ Covid pill
By Eve Simmons for The Mail on Sunday
Over-50s with Covid-19 symptoms can now access anti-viral drugs as part of a landmark UK study.
No input from the GP is necessary – patients simply register their interest in taking part in the University of Oxford trial on a website.
It comes a fortnight after The Mail on Sunday revealed that many of the most high-risk patients, such as those with blood cancer, have struggled to access the drug, despite it being approved for this group of patients since November.
Molnupiravir has been shown to cut the risk of hospitalisation due to Covid by up to a half when treatment begins within the first five days of symptoms developing.
Taken as four oral capsules every 12 hours for five days, it prevents viral cells from replicating, reducing the severity of Covid illness.
Molnupiravir is one of several anti-viral Covid treatments, including Sotrovimab and Ronapreve, to receive the green light in the past three months.
Molnupiravir has been shown to cut the risk of hospitalisation due to Covid by up to a half when treatment begins within the first five days of symptoms developing. Taken as four oral capsules every 12 hours for five days, it prevents viral cells from replicating, reducing the severity of Covid illness
Until now they have been available only to high-risk patients, such as those with immune system problems due to cancer treatments or transplants.
The new Oxford trial is looking to recruit healthy, vaccinated middle-aged and older volunteers, who are experiencing symptoms and have a positive PCR or lateral flow test, to discover if the drug is as effective in this group.
Over-18s who suffer with specific underlying conditions, listed on the study website, are also eligible. So far, only 4,200 participants have signed up, out of a target of 10,600.
The trial’s chief investigator Chris Butler, Professor of Primary Care in the Nuffield Department of Primary Care Health Sciences, said: ‘It is early on in the illness, when people are still being cared for in the community, that treatments for Covid-19 could have their greatest benefit.
‘So far, a lot of the research has focused on finding out if well-known drugs can be repurposed to treat Covid-19.
‘This new trial will test whether exciting, new anti-viral treatments that are more specific to Covid-19 help people in the community recover faster and reduce the need for treatment in hospital.’
The trial will also assess the effectiveness of treatments on preventing the spread of Covid by offering treatment to household contacts of participants.
Once volunteers have provided health details online and been accepted on the trial, they will be randomly allocated into one of two groups – usual NHS care, or the drug.
Those in the drug group will receive the recommended supply of tablets through the post.
Participants are also required to take part in a daily online questionnaire for 28 days, or take a call from the trial team on days 7, 14 and 28.
Follow-up calls are made after three and six months, to ask about potential long Covid symptoms.
For more information and to sign up, visit panoramictrial.org.
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