Letters to the editor: Some women may not want cervical screening

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LETTERS TO THE EDITOR
Some women may not want
cervical screening
We note with concern the method-
ology and conclusions of Waller et al.
1
in their article on ‘Barriers to cervical
cancer screening attendance’. The
authors began with a concern about
falling cervical smear attendance rates
and the premise that barriers exist to
prevent women attending for smears.
They asked women in interviews to
explain their behaviour in not attend-
ing for a smear, using a set of questions
comprising possible reasons for non-
attendance. Yet nowhere do Waller
and her colleagues consider that
women may increasingly have simply
decided not to have a smear.
Non-attendance at smear appoint-
ments – especially when opting out
is near impossible – may be due to a
weighing up of the pros and cons of
smear tests, and not only for the
reasons of discomfort or embarrass-
ment given by the authors. There is
the low chance of avoidance of
cancer as well as the risk of a false-
positive, leading to unnecessary
treatment with its association with
premature birth
2,3
as described to the
general public by the same organiz-
ation that funded this research.
4
Adults must be treated as compe-
tent, but they cannot make decisions
about screening when they are not
presented with it as a choice, with the
potential for harm as well as gain.
The only reasons cited for smear avoid-
ance are effectively a list of excuses
such that one fears being sent to the
naughty step. The authors’ conclusion
that women who may be too busy
both to vote and have a smear may
be ‘disillusioned’ with public services
negates the realistic statistical appraisal
of the efficacy both of voting and of
smear tests. Maybe some women are
under no illusions? When it comes to
screening autonomous adults, pro-
fessionals have to remember that
informed choice is an ethical right.
We ignore this at our professional
peril.
Margaret McCartney
1
and Susan Bewley
2
1
Fulton Street Medical Centre, Glasgow G13 IJE,
UK
2
Kings Health Partners, c/o Women’s Services,
10th floor North Wing, St Thomas’ Hospital,
Westminster Bridge Road, London SE1 7EH, UK
Correspondence to: Dr Margaret McCartney;
margaret@margaretmccartney.com
Competing interests: None declared.
REFERENCES
1 Waller J, Bartoszek M, Marlow L, Wardle J.
Barriers to cervical cancer screening
attendance in England: a population based
survey. J Med Screen 2009;16:199–204
2 Crane JM. Pregnancy outcome after loop
electrosurgical excision procedure: a systematic
review. Obstet Gynecol 2003;102(5 Pt
1):1058–62
3 Shennan AH, Bewley S. Why should preterm
births be rising? BMJ 2006;332:924 – 5
4 CancerHelp UK. Pregnancy after treatment for
an abnormal smear. See http://www.
cancerhelp.org.uk/type/cervical-cancer/
smears/pregnancy-and-abnormal-cervical-
cells#other (last checked 29 January 2010)
DOI: 10.1258/jms.2010.010007
Dr Waller and colleagues reply
McCartney and Bewley
1
make a valid
point that ‘adults must be treated as
competent’ and that the decision to
attend for screening must be a choice
– we absolutely agree. However, they
have misunderstood our methods. We
interviewed a population-based
sample, and assessed endorsement of
potential barriers to cervical screening
attendance in all women, not just
those who were overdue for screening.
At no point did we ask women to
‘explain their behaviour in not attend-
ing’, and this is demonstrated by the
fact that almost as many regular atten-
ders endorsed the statement that
smear tests are embarrassing as did
non-attenders.
We acknowledge that for some
women, the decision not to attend
screening is a legitimate, informed
choice. But the high endorsement of
practical barriers in our study points to
thefactthatmanywomendowant to
go for screening, but are prevented
from doing so by practical factors.
Although the benefits of screening for
any one individual are small, the
reduced mortality rate from cervical
cancer in the UK over the last 30 years
points to the success of the screening
programme,
2
and it is well-documented
that women who do not attend regu-
larly for screening are at increased
odds of developing cervical cancer.
3
To suggest that the decision not to
attend for screening, or not to vote, is
based on a ‘realistic statistical appraisal’
of the efficacy of these behaviours is
too simplistic. It overlooks the fact that
human behaviour is highly complex,
and is affected bya multitude of psycho-
logical and situational factors, as well as
rational decision-making. While it is, of
course, our duty to ensure that women
are able to make an informed choice
about screening, we must also make
sure that if they are positively inclined
towards attending, it is as easy as possible
for them to do so.
Jo Waller, Marta Bar toszek, Laura Marlow
and Jane Wardle
Cancer Research UK Health Behaviour Research
Centre, Department of Epidemiology and Public
Health, UCL, Gower Street, London WC1E 6BT, UK
Correspondence to: Jo Waller;
j.waller@ucl.ac.uk
REFERENCES
1 McCartney M, Bewley S. Some women may
not want cervical screening. J Med Screen
2010;16:52
2 Peto J, Gilham C, Fletcher O, Matthews FE. The
cervical cancer epidemic that screening has
prevented in the UK. Lancet
2004;364:249–56
3 Andrae B, Kemetli L, Sparen P, et al. Screening
preventable cervical cancer risks: evidence
from a nationwide audit in Sweden. JNatl
Cancer Inst 2008;100:622– 9
DOI: 10.1258/jms.2010.010012
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