Gynaecology 1 - Louise Cadman

Speaker key

IVInterviewer

LCLouise Cadman

LCMy name is Louse Cadman, I’m a Research Nurse Consultant at the Centre for Cancer Prevention at the Wolfson Institute of Preventive Medicine, and my talk was a cervical screening update.

IVWhat are the key points that GPs should get from your talk?

LCI would like them really not to be complacent about cervical screening. We have a very successful screening programme in the UK, and as a consequence we only see about 3,000 cases of cervical cancer per year with around 1,000 women dying from the disease. However, in the developing world there are a significant number of cervical cancer cases, and worldwide we have over half a million cases or new diagnoses of cervical cancer a year and over a quarter of a million women die.

We think that our screening programme probably saves about 5,000 lives a year in this country or in the United Kingdom, and so although we may not come across so many cases of cervical cancer as perhaps breast cancer, it is still a significant problem.

We have a screening programme because this is a disease that we can detect. Before the cancer occurs we get pre-cancerous changes that we can treat in a relatively simple and straightforward manner and so we can actually prevent this disease in most cases.

Attendance for cervical screening is important because if women don’t come for their screening tests we can’t detect the abnormalities and treat the disease. All women between the ages of 25 and 64 who are registered with a GP are eligible for cervical screening or are called for cervical screening at regular intervals. We want to ensure that 80% of women are screened, and in so doing we could prevent a significant amount of cervical cancer, because the majority of cervical cancer still occurs in this country in unscreened women.

We have overall been achieving this 80% target, but in recent years we have shown that we have been less successful in achieving 80% and have been in around 78% coverage, and we need to be aware of this. We also need to specifically target those age groups that are not attending, so, for example, 25-to 29-year olds and also the older age groups, 50-64.

We’ve had a relatively straightforward screening programme since the computerised call- recall system was introduced in 1988. There have been a number of changes in recent years: first of all, we had the introduction of liquid based cytology which has been very effective in reducing the inadequate smear rate from what was around 10% to between 1% and 2%. In recent years also we have introduced HPV testing as a triage test in those women who have borderline and mild abnormalities on their cytology screening results. The reason we do this is because if a test is negative we know that that woman is at a very low risk of cervical cancer and does not need to be seen in the colposcopy clinic; whereas, if someone is positive they have a slightly increased risk of cervical cancer or cervical abnormalities and so we should offer them colposcopy.

It is important however to be aware that any woman who has ever had sex has a lifetime risk of 70% to 80% of having HPV at some point in their life. For the vast majority of women they will not, and do not have the potential to develop cervical cancer. However, the gap in our knowledge at this stage is knowing who has that potential and who doesn’t and so we treat everyone as if they do, and that is why we refer all women with a positive HPV test to the colposcopy service.

The HPV triage is a little bit complex because we’re also having to get used to the idea that you may see a woman who has a positive HPV result and a normal colposcopy or has HPV on colposcopy who returns to routine screening, or women who have been treated for a high-grade disease who have a negative test of cure HPV test who too return to routine three- or five-yearly screening, and we need to know how to explain this to the women and to ensure that they feel reassured and safe that the system is working for them.

It is important that GPs and practise nurses are fully informed about what actually happens at a colposcopy appointment, not only to understand what their patient is going through but also to be able to offer advice and guidance when needed.

Women tend not to be offered treatment straight away during a colposcopy appointment, although some may be offered what we refer to as see-and-treat; this tends to be the minority. Most women will come for a colposcopy appointment and either undergo no further examination or have a diagnostic biopsy; they’ll then need to wait for that result to come back. If they then require treatment they will be called back to the colposcopy clinic another time.

Important things that GPs may encounter after somebody has had a colposcopy is they may complain that they’re having some bleeding – this is quite typical after a smear that you can get a little bit of spotting, and after a colposcopy you may get spotting from a biopsy, but it shouldn’t be longer than a period, heavier than a period or have any kind of bad odour. If that’s the case then women should be referred back to the colposcopy clinic.

They may also complain that they’ve noticed a little bit of colourful discharge after their colposcopy, and this may simply be that they’ve had a bit of iodine applied or that they’ve had a haemostatic agent applied that can leave the discharge a little bit brown afterwards.

In the future I think GPs and practise nurses need to be aware that things are likely to change with the advent of those girls who received HPV vaccination as part of the school programme or the national programme on catch-up who’ll be coming for cervical screening. It may well be that we need to modify the cervical screening programme from what we currently have; it may also be that we need to tailor it to women depending on whether they have been vaccinated or not, or their age.

There are already trials underway of HPV primary screening and it may well be that we use HPV screening as our primary screening test; and we use cytology as our triage test. At the moment that’s not the case, but that may well be where the future is.

IVWhere can GPs find out more?

LCIf they want any information upon the programme, the NHS cervical screening programme management and guidelines. The screening programme has a very useful website which they can find at For colposcopy they can refer to the BSCCP website which is For women who may want the support of other women in a similar situation they can refer to I can contacted on my email address which is .

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