Intended for healthcare professionals

Observations Medicine and the Media

GMTV’s Dr Steele is wrong to promote cervical screening in under 25s

BMJ 2011; 343 doi: https://doi.org/10.1136/bmj.d6167 (Published 28 September 2011) Cite this as: BMJ 2011;343:d6167
  1. Margaret McCartney, general practitioner, Glasgow
  1. margaret{at}margaretmccartney.com

Should young women have cervical smear tests below the age of 25? The evidence says it is harmful, so why are some general practitioners requesting it anyway, asks Margaret McCartney

“Women used to be routinely screened from the age of 20. But in 2003 the government raised the age to 25 in England because it said early testing might actually do more harm than good. But we’ve been approached by GPs who say what this actually means is tests that they’re carrying out on women under 25 that they think are necessary are being rejected and in some cases are even being destroyed by the labs just because they fall outside of the screening guidelines.” So began an item on BBC television’s Newsnight programme.

The programme asked English laboratories what they did with cervical smear tests from women aged under 25 years old. It found that more than 700 tests last year had not been read because the women were outside the guideline age. There was substantial variation between laboratories, and the journalist Anna Adams concluded that some laboratories thought that it was “the right thing” to read the smears but that others didn’t. She said, “What that means is hundreds of young women are going in for these invasive tests that aren’t even going to be looked at . . . GPs say they’re the ones that know which patients should and shouldn’t be screened, and they’re angry their clinical acumen could be ignored.”

Clare Gerada, chairwoman of the Royal College of General Practitioners, then appeared on the programme, saying, “I think if a GP has made a clinical decision to do a cervical smear then that smear should be processed. The decision not to process it should not be made by a lab with no details about why that smear has been done.” She described a rejection of a smear test in these circumstances as “horrifying.”

In defence of the decision not to screen under 25 year olds, Karen Denton, from the NHS screening programme, said, “The guidelines are quite clearly that women under 25 shouldn’t be screened . . . One in three of them will have an abnormal test result. This doesn’t mean they are at increased risk of cervical cancer . . . [but] is incredibly anxiety provoking, very upsetting, and it’s likely to lead on to further investigation and treatment, and it’s the treatment which can have a future effect on pregnancy outcome. So actually, these women are not being harmed and are being benefited by not having their cervical cytology test reported.”

Here the programme took an unexpected turn. Anna Adams stated, “The screening programme says that GPs should refer young women under 25 with symptoms to a gynaecologist; that guideline is not popular with everyone.” John Shephard, a gynaecologist, then described this as “crazy” and said that GPs could manage these women adequately.

Yet there is a clear distinction between screening women who have no symptoms and the diagnosis and treatment of illness in women with symptoms. This point seemed to be lost in the programme and yet is of crucial importance. Screening isn’t for women with genital symptoms. And there is no evidence that screening under 25 year olds produces benefits—only harms.

Angela Raffle, a consultant in public health in Bristol, has previously researched the risks and benefits of cervical screening. She says that it was “never explicit policy to target women under 25.” She added, “It happened by default, and concerns from professionals had been growing throughout the 1990s. This led to the advisory group saying to the government that it isn’t justifiable. Some pathologists will just go by what they see down the microscope and see abnormal cell changes. But others are more public health minded and will take on the evidence.”

She also says that there have been problems with publicity campaigns before. “After the tragic death of Jade Goody [the television celebrity who died from cervical cancer], Max Clifford felt, I think, that campaigning to get the policy on screening age lowered was the one thing he could do for her. But there were enough people around continually articulating the evidence.” However, many of the anecdotes that were used about young women having cervical cancer, she says, actually concerned women who had symptoms that were not picked up by screening. “In fact, cervical screening is a hopeless thing to do in symptomatic women: it doesn’t help.”

Peter Sasieni, of the Wolfson Institute of Preventive Medicine, has investigated the evidence for cervical screening in under 25 year olds. “Unfortunately the evidence is that screening at such a young age is ineffective,” he said. “Women screened in their early 20s are no less likely to get cervical cancer in their 20s than are those screened from age 25. Screening very young women will lead to the detection of cervical lesions that gynaecologists will want to treat, but the evidence is that in young women many of these lesions would have spontaneously disappeared even without treatment. There is also concern that such treatment can lead to premature deliveries in subsequent pregnancies. On balance, many experts believe that screening at age 20 does more harm than good—a position with which I would agree.”

Chris Steele, a television doctor, appeared on Newsnight to say that “we don’t want to see young women dying” and that “cervical cancer is a disease that is totally preventable.” On his website he says, “The reason, given by the Dept of Health, for not doing smears under 25 is that they do more harm than good!! If this were the case, where is the harm occurring in all the other countries?” and, “Because the under 25s can’t get smears, these young women are dying of undiagnosed cervical cancer.” In an email following a phone conversation he said, “I ask you to give me some leeway and understanding, as the purpose of my words is [to] create awareness, and my intentions are not to provide grossly inaccurate information or scaremonger . . . What does disturb me, and most doctors, is the cold approach taken by academics who are basing decisions solely on stats, figures, numbers. Have they not thought about the human cost, the suffering of patients and their families? Have these people ever had to sit and face a 24 year old girl (with two young children) and explain that she has got cancer of the cervix, and it’s terminal. I have, and so have several gynaecological oncologists at my local hospital, the Christie Hospital, a respected centre of excellence. Not one single oncologist there agrees with screening from 25 years!”

Yet it is in the public interest to provide evidence rather than emotion, especially around emotive areas such as cancer in young women. There is evidence of harm from treatment given after abnormal smear test results (Obstetrics and Gynecology 2009;114:504-10, doi:10.1097/AOG.0b013e3181b052de) and evidence that screening does not prevent under 25s dying from cervical cancer (BMJ 2009;339:b2968, doi:10.1136/bmj.b2968). If we wanted to serve young women better, we could start by explaining what screening is and whom it is for and be clear about its harms and limitations. And then we would do the “right thing” and stop performing cervical screening for all women under the age of 25.

Notes

Cite this as: BMJ 2011;343:d6167