Cancer Screening

Which areas from the NHS Outcomes Framework (NHS OF) were identified as requiring improvement in regards to cancer?

• Under 75 mortality rate from cancer

• One-year survival from all cancers

• Five-year survival from all cancers

What is the most common type of cancer in the UK?

Breast cancer

What is screening?

• A way of identifying apparently healthy people who may have an increased risk of a particular condition

• The aim is to offer screening to people who are most likely to benefit from it

• National programmes are available throughout the UK on the NHS

What cancer screening programmes are run in the UK?

1. Breast cancer

2. Bowel cancer

3. Cervical cancer

All invitations are sent to patients by their GP surgery

Breast cancer screening

• Uses mammograms (x-ray)

• 2 images are taken per breast

• Breasts are compressed to take images which can be uncomfortable

• Open to women aged 50-71

• Women can be screened if over 71 but wont be automatically invited

• Unless high risk, women are screened every 3 years. However, they may be called earlier if considered high risk

Bowel cancer screening

• Uses the faecal immunochemical test (FIT)

• This test is done at home

• The patient collects a small sample of faeces and posts to laboratory

• The laboratory checks for tiny amounts of blood

• Available to 54-74 year olds to do a home test every 2 years (expanding to include 50-53 years old)

• 75+ can opt into 2 yearly home tests but not automatic

What virus are almost all cervical cancers linked to?

Human papillomavirus (HPV)

Which HPVs are most common in cervical cancer

• There are more than 100 types of HPV

• At least 15 types of hPV are linked to cervical cancer

• HPV 16 and 18 are most common

How can HPV lead to cervical cancer?

• In many cases, the body can remove HPV cells without them causing any further problems

• However, sometimes HPV cells remain in the body which can cause changes to the cells of the cervix

• This leads to cervical cancer

Aim of cervical cancer screening

Detect the presence of other types of HPV linked to cervical cancer (‘high risk HPV’)

Which demographic should be invited by letter from their GP surgery for cervical cancer screening?

Anyone with a cervix aged 25 to 64 years old:

Under 25 - invited up to 6 months before you turn 25

25 to 49 - every 3 years

50 to 64 - every 5 years

65 or older - only if a recent test was abnormal

What does cervical cancer screening involve?

• A ‘smear test’ removes a small sample of cells from the cervix

• The sample is checked for ‘high risk HPV’ cells

• If high risk HPV cells are not found, no further tests are done at this time - the patient continues to be called at the appropriate interval for the age range (3-5 years)

• If high risk HPV cells are found, the sample is checked for any changes in the cells of the cervix

• An abnormal result at this point means that high risk HPV cells have been detected - it does not mean the patient has cancer

• If there are no cervical cell changes, the patient is asked to attend their next smear earlier (usually annually) until the HPV infection has cleared

• If there are cervical cell changes, the patient will be referred for a colposcopy (a microscope is inserted through the vagina to look at the cervix)

Types of changes to the cells of the cervix that can be viewed during cervical cancer screening

• Borderline or mild changes - low grade dyskaryosis

• Moderate or severe changes - high grade dyskariosis

• These changes are very unlikely to be cancer

• But these cells may need to be treated before they get the change to turn into cervical cancer

How do changes in the cells of the cervix progress to cervical cancer?

• Cervical cancer takes years to develop

• Pre-cancers changes are common (6% of tests are abnormal)

• These changes include:

  • Cervical intraepithelial neoplasia (CIN)

  • Cervical glandular intraepithelial neoplasia (CGIN) which is less common

  • This depends on which cells are affected

• Low grade dyskaryosis - roughly equivalent to CIN grades 1

• High grade dyskaryosis - roughly equivalent to CIN grades 2 (moderate) and 3 (severe)

• The progression from HPV infection to CIN or CGIN and then cervical cancer is very slow - 10-20 years

• So screening is crucial and regular attendance is effective at minimising risk

What are some additional means of preventing cervical cancer?

HPV vaccine

• For 12 - 13 year old children - boys and girls

• For those who ‘missed out’ on the childhood vaccine up to the age of 25

• Men who have sex with men (‘MSM’) - up to 45, for those who would have missed the childhood vaccination programme when it was only offered to girls

Why is the HPV vaccine offered to boys as well as girls?

• HPV also linked to mouth and anal cancers

• Risk of cervical cancer in men who have sex with men

Results of screening in general

Normal result (negative result):

• Patient has a low risk of having the condition

• This does not mean the patient will never develop the condition in the future. They are just low risk at the current time

Higher-risk result (positive result):

• Patient may have the condition

• The patient will be offered further test (diagnostic tests) to determine if they have the condition

• Depending on the outcome, they may be offered treatment

Benefits and risks of screening

Benefits:

• Able to identify cancer earlier

• Patient can be diagnosed prior to symptoms

• Potential for more favourable treatment outcomes as the cancer is treated earlier

• Patients can make informed decisions if they know they have/have an increased risk of having a health problem

• Can prevent deaths from cancer

Risks:

• Not completely accurate and the test itself may have side effects

• False positives - leading to unnecessary further investigations or treatment

• False negatives - patient may ignore symptoms that occur at a later date

• May lead to diagnosis of another cancer

• Patient may be diagnosed despite having no symptoms - causes the patient shock and anxiety

• Result is only accurate at that exact point in time

Testing vs Screening

• In addition to screening, in the UK we can also test for markers that are known to be linked to certain types of cancer

• However, these markers are not accurate/specific enough to warrant a nationwide screening programme

Prostate Specific Antigen (PSA) Testing

• PSA is a protein made only by the prostate gland

• Some of it leaks into the blood. The amount varies with age and overall health

• PSA is raised in a number of prostate problems, including prostate cancer. However, it does not identify every type of prostate cancer

• A raised PSA does NOT mean a person has cancer

• The test can also miss approx. 15% of cancers

Who is it offered to?

• This means that routine PSA testing is only offered if patient is symptomatic or has a higher-than-average risk of prostate cancer for their age

• There are plans to launch a programme in 2027 for men aged 45-61 who have BOTH a BRCA2 gene mutation AND a family history of breast, ovarian, pancreatic or prostate cancer

• Prostate cancers can be very slow growing, so it is possible for a man to live his life without any symptoms of an undiagnosed prostate cancer

PSA Testing

Normal blood PSA levels depending on the age of the patient

Lung Health Checks

• Aims to diagnose lung cancer earlier when treatment may be more successful

• Lung health checks are running whilst a screening programme is being developed

To be eligible, patients must be:

• Registered with a GP

• Over 55 but younger than 75

• Current or ex-smoker

Test:

• Uses spirometry to assess inspiration and experiation

• Reduced air flow can be attributed to several respiratory conditions, not just cancer

• If assess as high risk for lung cancer, patient may be offered a CT scan

Uptake of cervical cancer screening

• In 22/23, average uptake in England was 68.7%

• This figure is falling annually

• If all eligible, women regularly attended screening, 83% of cervical cancers could be prevented

Demographics who frequently dont attend cervical cancer screening

• Younger eligible women 25 to 29

• Women over 50

• Ethnic minorities

• People from lower socioeconomic-economic groups

• Women with learning disabilities

• Lesbian and bisexual women

Reasons why women dont attend cervical cancer screening

• Embarrassed about having a smear test

• Worried about the result of the test

• Concerned about the procedure and whether it will be painful

• Access to screening and appointment times are inconvenient

• They do not think they are at risk

• They are simply unaware of screening

• Cultural or language barriers

• No female sample takers available

• Not understanding HPV and the role it plays in cervical cancer development

• Change of address / contact details (invitations rely on GP records)

• Pregnant at time of invitation and then forget to attend at a later date - GPs usually recommend they attend 2 months after the end of their pregnancy

• Patient doesn’t realise they are eligible

[some of these are applicable to all screenings]

How can pharmacists help?

• The pharmacy is an accessible and local service

• Don’t need an appointment to talk to a pharmacist

• Familiarity with regular patients, which can help identify which patients are eligible

• Trusted by and have a good rapport with local community

• Able to spot red flag symptoms

• Advise patients to seek medical advice when they may not have thought necessary

• Able to promote most up-to-date information (e.g. some programmes changing eligibility)

• Make direct referrals to secondary care

• Promotion of screening programmes in general

What can be done to improve the uptake of screening invitations?

• Education

• Pre-screening text messages / reminders to attend appointments

• Remind patients to update contact details

• Development of a self-test kit for cervical cancer

Eligibility for cervical, breast and bowel cancer for people of mixed gender identities