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Have women avoided having smear tests due to the pandemic?

Posted: 15/06/2021


Cervical cancer is the fourth most common cause of cancer and the fourth most common cause of death from cancer amongst women. [1] Prognosis is dependent on when the pre-cancerous or cancerous cells are diagnosed and therefore it is vital for women to be screened regularly to check for cancerous cells. There are concerns that fewer women are taking up their right to cervical screening as a result of the Covid-19 pandemic.

What is a smear test?

The cervix, which is the entrance to the womb from the vagina, is where cervical cancer forms. During a smear test, a nurse will use a speculum (nowadays a plastic speculum rather than metal) and insert it into the vagina, usually using lubricant gel. This feels strange but not painful. A small brush is put through the speculum and rubbed on the surface of the cervix. The cervix may bleed slightly in women who are on the contraceptive pill. The procedure is very short, usually just taking a minute or two.

Some women report feeling a little sore following the procedure. The sample can take four weeks to come back but might take much longer. Sometimes, a second smear test is needed when the sample has been inconclusive.

If the sample shows HPV (human papillomavirus), the individual will be contacted. If they have HPV but no abnormal cells, they will be invited to further screenings in one year and in two years. If an individual has HPV and some abnormal cells (known as dyskaryosis), they will be invited to have a colposcopy, which is another examination of the cervix.

If left untreated, mild dyskaryosis may return to normal or may develop into moderate and then severe dyskaryosis (which often becomes cervical cancer).

Ordinarily, when attending a smear test, another person can be in attendance for support. However, there are currently restrictions on this due to the Covid-19 pandemic.

Cervical Screening Awareness Week: Monday 14 June to Sunday 20 June 2021

As it is Cervical Screening Awareness Week, the clinical negligence team at Penningtons Manches Cooper is encouraging all eligible women to attend their smear tests. More information on the 2021 campaign is available at the Jo’s Trust website.

Many women are failing to attend their smear tests, and there may be a number of reasons for this. Women from black and minority ethnic backgrounds may be less likely to attend a screening. [2]

Young women who had the HPV vaccine are now turning 25. There are concerns that these younger women are frequently not going to screenings as they are vaccinated for HPV. However, it is important to remember that the vaccine does not prevent all strains of HPV that can cause cervical cancer.

HPV

There is a strong link between cervical cancer and the human papillomavirus (HPV), with HPV being the most common cause of cervical cancer. The HPV vaccine has been given to adolescent girls since 2008.

Almost all cases of cervical cancer are caused by one of the many forms of HPV. It is thought that cervical cancer could be largely eliminated globally if all countries vaccinated adolescents. [3] However, that goal is a long way off and it is still as important as ever for women to attend cervical screening tests. [4] The NHS website states: ‘Although the HPV vaccine can significantly reduce the risk of cervical cancer, it does not guarantee that you will not develop the condition. You should still attend cervical screening tests, even if you've had the vaccine.’ [5]

What effect has the Covid-19 pandemic had on smear tests?

The cervical screening programme is fully functional and women should still attend their smear test when invited. The procedure is unchanged, except the nurse or doctor will be wearing a mask and gloves and women may be unable to bring someone with them for support. Smear test results should not be delayed due to Covid-19. If a woman is aware she is overdue for a smear but has not been invited, she should call her GP. [6]

A study by Jo’s Trust surveyed 851 women between 29 May and 9 June 2020. It found that about 25% were worried about the risk of contracting Covid-19 when attending their screening. Others were afraid of burdening the NHS and 12% believed it was wise to delay their screening during the pandemic. At the same time, women may be concerned that their cases will not be referred correctly due to the increased workload of the NHS or that cases of mild or moderate dyskaryosis will not be referred to colposcopy (as they might ordinarily be) to reduce workload. Mild or moderate cases are not as high-risk as cases of severe dyskaryosis, but in a minority of cases cervical cancer can develop rapidly and potentially mild cases could develop into cervical cancer in spite of screening.

Symptoms, risk factors and treatment

The symptoms of cervical cancer vary and many women will not show any symptoms until later development of the cancer. However, in many cases, key symptoms include:

  • bleeding between periods or after menopause;
  • pain during intercourse;
  • vaginal discharge; and
  • pain between the hip bones. [7]

The risk factors include being positive for HPV, being sexually active or having many sexual partners, as well as smoking or having had four or more pregnancies.

In the UK, all women aged 25 to 49 are invited for a screening every three years. For women aged 24 or 25, it is important that they attend a screening as soon as they are invited.

Women aged 50 to 64 are invited every five years. Women aged 65 or over are not routinely checked but can still be screened if they have not been seen since they were 50, have had recent abnormal tests or have never been screened.

The NHS treatment options for early cervical cancer include surgery to remove the cervix (and sometimes womb) or radiotherapy, while treatment for advanced cervical cancer can include chemotherapy. However, screening often reveals very early cancer, for which the treatment is less invasive – this may involve removal of the cancerous cells using a ‘large loop excision’ (also known as ‘LLETZ’) under local anaesthetic or a biopsy under general anaesthetic.

After treatment, patients will need to attend regular follow-up appointments every three to six months for the first two years and every six to twelve months for a further three years. [8]

The importance of being referred correctly

Cervical cancer is the only one of the five gynaecological cancers (womb, ovarian, cervical, vulval and vaginal) that can be screened effectively. Screening can prevent the development of cervical cancer before it starts, in many cases. However, there are some parts of the process where mistakes can be made; for example, samples are sometimes misread. [9] If screening is regular, one misread sample may not be disastrous as cervical cancer is usually slow to develop and dyskaryosis or cancerous cells may be detected at the next screening.

However, in rarer cases, key chances to prevent the development of cervical cancer are missed and cancer does develop. In one case, a woman secured a £250,000 settlement following her gynaecologist’s failure to spot the signs of cervical cancer. Her treatment was much more aggressive than should have been necessary and caused her to become infertile. In another case, a woman’s sample was misread and a further sample of hers was misread again three years later. Due to these errors, cervical cancer developed.

How can we help?

Alison Johnson, clinical negligence partner at Penningtons Manches Cooper, represents women with gynaecological claims which have sadly often arisen from a negligent delayed diagnosis of cervical (or other gynaecological) cancer. Alison encourages women to attend their smear test as soon as they are invited and to check when their last smear test was undertaken and their next smear test is due. If an individual has any concerns about smear test timing or worries that they may be experiencing any unusual gynaecological symptoms, they should contact their GP surgery straightaway for advice.

The specialist team at Penningtons Manches Cooper has experience representing clients who have suffered physical and psychological injuries, fertility issues and financial losses as a result of misdiagnosed cancer.

This article has been co-written with Dominik Young, a trainee solicitor in the clinical negligence team. 

 

[1] World Cancer Report 2020: https://www.iarc.who.int/cards_page/world-cancer-report/
[2] Jo’s Trust: https://www.jostrust.org.uk/sites/default/files/materials/Christine%20Ekechi%20-%20Cervical%20Cancer%20Screening%20Knowledge%20%26%20Attendance%20Amongst%20Black%20Women.pdf
[3] Guardian, 3 March 2018: https://www.theguardian.com/commentisfree/2018/mar/04/eliminating-cervical-cancer-globally-is-within-reach-if-governments-act
[4] Guardian, 20 February 2019: https://www.theguardian.com/society/2019/feb/20/cervical-cancer-hpv-vaccine-screening-research
[5] NHS Website: https://www.nhs.uk/conditions/cervical-cancer/treatment/
[6] Eve Appeal: https://eveappeal.org.uk/supporting-you/cancer-and-coronavirus/cervical-screening-and-colposcopy-guidance-during-covid-19/
[7] Cancer Research: https://www.cancerresearchuk.org/about-cancer/cervical-cancer/symptoms
[8] NHS Website: https://www.nhs.uk/conditions/cervical-cancer/treatment/
[9] https://www.hg.org/legal-articles/delayed-diagnosis-of-cervical-cancer-19518


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