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

Authors:
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;364:24956
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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Article
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To explore barriers to cervical screening attendance in a population-based sample, and to compare barriers endorsed by women who were up-to-date with screening versus those who were overdue. We also tested the hypothesis that women who were overdue for screening would be more generally disillusioned with public services, as indexed by reported voting behaviour in elections. A population-based survey of women in England. Face-to-face interviews were carried out with 580 women aged 26-64 years, and recruited using stratified random probability sampling as part of an omnibus survey. Questions assessed self-reported cervical screening attendance, barriers to screening, voting behaviour and demographic characteristics. Eighty-five per cent of women were up-to-date with screening and 15% were overdue, including 2.6% who had never had a smear test. The most commonly endorsed barriers were embarrassment (29%), intending to go but not getting round to it (21%), fear of pain (14%) and worry about what the test might find (12%). Only four barriers showed significant independent associations with screening status: difficulty making an appointment, not getting round to going, not being sexually active and not trusting the test. We found support for our hypothesis that women who do not attend for screening are less likely to vote in elections, even when controlling for barrier endorsement and demographic factors. Practical barriers were more predictive of screening uptake than emotional factors such as embarrassment. This has clear implications for service provision and future interventions to increase uptake. The association between voting behaviour and screening uptake lends support to the hypothesis that falling screening coverage may be indicative of a broader phenomenon of disillusionment, and further research in this area is warranted.
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The effectiveness of cervical cancer screening programs differs widely in different populations. The reasons for these differences are unclear. Routine and comprehensive audits have been proposed as an ethically required component of screening. We performed a nationwide audit of the effectiveness of the Swedish cervical cancer screening program. We identified all invasive cervical cancer cases that were diagnosed in Sweden from January 1, 1999, through December 31, 2001, and had been reported to the Swedish Cancer Registry (n = 1230 cases). We verified the diagnoses by histopathologic rereview and matched each case subject to five (population-based) age-matched control subjects who were identified from the National Population Register. The Pap smear screening histories for case and control subjects were reviewed for a 6-year period using the National Cervical Cancer Screening Register, which contains data on essentially all relevant cytological and histological diagnoses in Sweden. Odds ratios (ORs), and their 95% confidence intervals (CIs), of cervical cancer according to screening history were calculated in conditional logistic regression models. All statistical tests were two-sided. Women who had not had a Pap smear within the recommended screening interval had higher risk of cervical cancer than women who had been screened (OR = 2.52, 95% CI = 2.19 to 2.91). This risk was similarly increased for all age groups (P(homogeneity) = .96). The risk for non-squamous cell cervical cancers (OR = 1.59, 95% CI = 1.20 to 2.11) was also increased. Women who had not had a Pap smear within the recommended screening interval had a particularly high risk of advanced cancers (OR = 4.82, 95% CI = 3.61 to 6.44). Among women who had been screened within the recommended interval, those with abnormal Pap smears had a higher risk of cervical cancer than those with normal smears (OR = 7.55, 95% CI = 5.88 to 9.69) and constituted 11.5% of all women with cervical cancer. Nonadherence to screening intervals was the major reason for cervical cancer morbidity. The screening program was equally effective for women of all ages and was also effective against non-squamous cancers.
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To examine the association of loop electrosurgical excision procedure (LEEP) and subsequent pregnancy outcomes. A computerized search of MEDLINE and PubMed was conducted using the keys words "pregnancy" and "loop electrosurgical excision procedure," "LEEP," "LETZ," "LLETZ," or "loop excision." References from identified publications were manually searched and cross referenced to identify additional relevant articles. Studies were included that compared women who had had LEEP to women who had not had the procedure and that reported on subsequent pregnancy outcomes. Studies were excluded if there was no control group, if the LEEP was performed during the pregnancy, or if only an abstract was available. Five of 36 articles identified met the criteria for systematic review. Women who had had LEEP were more likely to have preterm birth (odds ratio [OR] 1.81, 95% confidence interval [CI] 1.18, 2.76; P = .006) and low birth weight infants (<2500 g) (OR 1.60, 95% CI 1.01, 2.52; P = .04), but there was no difference in cesarean delivery, precipitous labor, labor induction, or neonatal intensive care unit admission. A subgroup analysis including only studies matching for smoking status revealed that preterm birth was still more common in women who had had LEEP (OR 2.53, 95% CI 1.42, 4.49; P = .001), but birth weight under 2500 g was no longer significantly different. LEEP appears to be associated with subsequent preterm birth, even when smoking status is matched. Studies with adequate sample size are needed to further evaluate the relationship of LEEP and preterm birth, controlling for potential confounders, including depth of the tissue sample.
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Recent reports suggest that the reduction in mortality achieved by the UK national cervical screening programme is too small to justify its financial and psychosocial costs, except perhaps in a few high-risk women. We analysed trends in mortality before 1988, when the British national screening programme was launched, to estimate what future trends in cervical cancer mortality would have been without any screening. Cervical cancer mortality in England and Wales in women younger than 35 years rose three-fold from 1967 to 1987. By 1988, incidence in this age-range was among the highest in the world despite substantial opportunistic screening. Since national screening was started in 1988, this rising trend has been reversed. Cervical screening has prevented an epidemic that would have killed about one in 65 of all British women born since 1950 and culminated in about 6000 deaths per year in this country. However, these estimates are subject to substantial uncertainty, particularly in relation to the effects of oral contraceptives and changes in sexual behaviour. 80% or more of these deaths (up to 5000 deaths per year) are likely to be prevented by screening, which means that about 100000 (one in 80) of the 8 million British women born between 1951 and 1970 will be saved from premature death by the cervical screening programme at a cost per life saved of about pound 36000. The birth cohort trends also provide strong evidence that the death rate throughout life is substantially lower in women who were first screened when they were younger.
Screening preventable cervical cancer risks: evidence from a nationwide audit in Sweden
  • B Andrae
  • L Kemetli
  • P Sparen
Andrae B, Kemetli L, Sparen P, et al. Screening preventable cervical cancer risks: evidence from a nationwide audit in Sweden. J Natl Cancer Inst 2008;100:622 -9 DOI: 10.1258/jms.2010.010012