CervicalCheck- a 'good news' story

  • Niall Hunter, Editor

After a delay of nearly a decade, a national cervical screening programme, CervicalCheck, was finally launched in September 2008.

Two years later, with over half a million free smear tests now provided to women aged 25 to 60 under the scheme and 100 women diagnosed with cervical cancer during its first year of operation, it can certainly be deemed one of the rare health service "good news" stories.

However, its introduction and implementation has not been without its challenges and controversies.

National Cancer Screening Service Director Tony O'Brien outlined at the launch of CervicalCheck's first year results how the scheme was born against a grim background: a disorganised and uncoordinated screening system for cervical cancer that had failed to check rising death rates from the disease.

The aim of cervical screening is to detect cervical cell changes before they become cancerous rather than simply detecting cancer, and the scheme appears to be on the way to achieving its aim of successful early intervention.

Now, CervicalCheck, in conjunction with the new HPV vaccination programme, is well placed to make inroads into a disease that kills over 80 women every year, with nearly 300 cases occurring each year.

Mr O'Brien pointed out that the CervicalCheck programme has the potential, should an 80% screening uptake rate be achieved, of reducing mortality from the disease by as much as 80%.

CervicalCheck has to date made progress towards that goal. In the first year, 14% of women who had smear tests showed low grade (low risk) abnormalities with 1.4% having high grade abnormalities.

Under the programme Over 11,000 women were referred to colposcopy for further investigation, and 4,700 women had treatment at colposcopy - this treatment if often required to eradicate pre-cancerous cells (CIN).

It is under the colposcopy heading that one of the challenges for CervicalCheck has emerged, the old familiar health service problem of waiting times.

In the first year of the programme - 2008 to 2009 - just over 5% of patients deemed to have high grade cervical abnormalities following a smear test were left waiting longer than three months for a colposcopy appointment, while 16% with low grade abnormalities were waiting more than three months, while 10% in this category were waiting more than two months.

Of concern too is that one-third of women who made colposcopy appointments either cancelled or did not attend for a scheduled appointment.

CervicalCheck's target is to have 90% of women with high grade cervical abnormalities waiting no more than four weeks for colposcopy.

It admits that there were slower than anticipated improvements in these waiting times, with hospital capacity issues and a major demand for screening services providing a major challenge for the programme.

However, according to the head of colposcopy with CervicalCheck, Dr Grainne Flannelly, the programme is now working on getting waiting times down and increasing capacity in the designated public hospital clinics where colposcopy for the programme is carried out.

"We want to make sure that women with high grade abnormalities are seen within a four week period."

She said two years into the programme, this was now being achieved in hospital centres around the country with the exception of some in the east.

Dr Flannelly said the first two years of CervicalCheck have seen significant advances in the delivery of colposcopy services despite unprecedented demands placed on these services in early 2009.

These demands, according to CervicalCheck can be put down to the fact that a new programme had just been launched on an unscreened population, and to the "Jade Goody" factor.

CervicalCheck says there was a surge in demand for its services in early 2009, coinciding with the launch of its public awareness campaign and the death at the time of Jade Goody from cervical cancer.

In addition to putting pressure on colposcopy services, this surge also challenged the capacity of laboratories to analyse samples in a timely manner. However, this delay in lab test turnaround time was addressed, and 98% of smears were being processed within two weeks in August 2009 compared to only 59% the previous May.

The decision to outsource the lab processing of smears to a US company proved controversial, and CervicalCheck has since added another US-based cytology service to process smears. This company is to open a lab in Ireland next year.

The programme has, however expressed satisfaction with the outsourcing arrangement in terms of turnaround time and quality.

CervicalCheck has also faced criticism, mostly from doctors, for implementing a change in the way women could access the scheme in September 2009.

For the previous 12 months it had been operating an open access system, where any woman who wanted a free smear could arrange an an appointment with any of the registered GPs or practice nurse smeartakers in the scheme. It then moved to a "call, recall" system, where women had to be invited for screening.

Concern was expressed in some quarters about this, amid fears that some women would slip through the screening net; however, CervicalCheck says these fears proved unfounded.

According to Tony O'Brien, there were concerns that the scheme would actually collapse as a result of this change of policy. "However, it continued to sustain high levels of activity Every population screening programme needs to have a call-recall system in order to maximise uptake by having a sustainable cycle of screening."

This month, CervicalCheck added a "direct programme entry" system to call-recall. This allows smeartakers to recruit new eligible women, in particular those from minority populations and "harder to reach" women, into the programme.

Registerted smeartakers can now organise a smear test for new eligible women without the woman having a letter of invitation.

Mr O'Brien said it had always been planned to introduce this the direct entry option and it was not done in response to criticism about potentially at-risk women not being picked up for screening under call, recall.

He said he was confident the programme has been a success and that it will achieve its aim or reducing the incidence and morality from cervical cancer in Ireland.

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