The "Jade Goody effect": What now for cervical cancer prevention?

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51
©FSRH J Fam Plann Reprod Health Care 2010: 36(2)
Introduction
The illness and early death of the reality television star,
Jade Goody, 12 months ago propelled the issue of cervical
cancer into the headlines. One significant result of this
media attention was an expansion in the demand for and
uptake of cervical cytology screening.
The large increase in the number of cytology tests
requested had a significant impact on colposcopy and
pathology workloads. The effect will continue to be felt for
many months, since each newly screened cohort results in
more women attending for colposcopy and an increase in
appointments for conservative evaluation of low-grade
disease, treatment and follow-up. The media attention and
the resulting impact on cytology and colposcopy services
also provoked interest in examining how the UK screening
programme can optimise cost-effective health gain. This
article considers the national screening programme and the
possible impact of human papillomavirus (HPV)
vaccination and HPV testing on screening and the potential
long-term effects of the current changes to cervical cancer
prevention.
Cervical screening
The UK has seen a reduction of over 50% in deaths from
cervical cancer since the introduction of the national call-
and-recall screening programme in 1988.1This success
depends on coverage: cervical screening has a highly
significant impact when more than 80% of the ‘at risk’
population is covered within the recommended screening
interval.2However, before the publicity surrounding Jade
Goody, there was a decline in the number of 25–30-year-
old women in the UK responding to their invitations to
attend for cytology tests.3In some areas of the country, the
coverage has been less than 68%.4
In discussing the “Jade Goody effect” in the context of
cervical screening, the impact on cervical coverage
reported in the recent statistical bulletin only partially
describes the “effect” as it only includes the period up to 31
March 2009.5In a preliminary analysis of the complete
“Jade Goody effect”, it has been found that there was a
slight rise in participation amongst younger women seen
after her diagnosis in August 2008. A major effect was
noted from February 2009, doubling in March 2009 when
she married and died but then declining over the next 3
months, and by July 2009 the status quo was re-established
[preliminary analysis by the National Health Service
Cervical Screening Programme (NHSCSP), Julietta
Patnick, personal communication, February 2010].
To describe this in more detail: in the first 6 months of
2008 in England, 115171031 women were screened. Of
these, 485 947 were women aged 24.5–49 years who had
The “Jade Goody effect”: what now for cervical cancer
prevention?
Julie Bowring, Patrick Walker
COMMENTARY
J Fam Plann Reprod Health Care 2010; 36(2): 51–54
Royal Free Hospital, London, UK
Julie Bowring, MBChB, MRCOG, Clinical Research Fellow
Patrick Walker, MD, FRCOG, Consultant Gynaecologist
Correspondence to: Mr Patrick Walker, Royal Free Hospital,
London NW3 2QG, UK. E-mail: patrick.walker@royalfree.nhs.uk
not been seen in the previous 3.5 years, and 40 868 women
aged 50–64.5 years who had not been seen for the previous
5 years. In the same period of 2009, 2 095 468 women were
screened, an extra 578 437 women. Of these, 657 234 were
women aged 24.5–49 years who had not been seen in the
previous 3.5 years (35.2% more than in the previous year)
and 511312 were women aged 50–64.5 years who had not
been seen for the previous 5 years (an increase of 25.6%)
(Julietta Patnick, personal communication, February 2010).
In the long-term the increase in screening coverage
triggered by the “Jade Goody effect” should result in a
reduction in cervical cancer cases particularly amongst
younger women, although in the short term there may be an
increased identification of “prevalent” cases.
Age at first screen
In 2003, the English NHSCSP increased the age for first
call to 25 years, whereas it remains 20 years in other parts
of the UK. There is heated debate between those who
advocate a return to earlier screening in England and those
who support the later starting age. The issues underlying
the decision are complex and involve a risk–benefit
analysis as well as an assessment of cost effectiveness.
When the English call-and-recall programme was
introduced in 1988, women were invited from age 20 years.
Compliance and coverage among those under the age of 25
years was only about 50%, and it became clear that the
incidence of cervical cancer in this age group was low, at
3.3 per 1001000.6Conversely, the incidence of HPV
infection of the lower genital tract in young women is high:
a study of college students found a cumulative incidence of
43% over 3 years.7For the vast majority of young women,
a high-risk HPV infection in the genital tract is a common,
self-limiting event:8most individuals demonstrate an
effective immune response and have no clinical
sequelae.8,9 Some women are slow to demonstrate that
response and may be affected by a short-term viral
epithelial change that will regress without the need for
treatment.10 Cervical intraepithelial neoplasia (CIN)
grade 1 will progress to a higher grade requiring treatment
in only 12% of cases.11 The progression of CIN 3 to
invasive cancer has been investigated in untreated women
managed only by punch or wedge biopsy. The percentage
of women with cancer of the cervix after 5 years was
11.3%, increasing to 17% at 10 years.12
Unfortunately, the cytological and colposcopic changes
associated with an acute viral effect against the background
of very active physiological metaplasia in young women13
can lead to an over-diagnosis of high-grade CIN. There is,
therefore, a danger that screening of young women with a
self-limiting viral infection will result in unnecessary
investigations and treatment, notably if a “see and treat”
policy is adopted for high-grade referral cytology.
Although the incidence of side effects following loop
excision treatment for CIN is low (about 3%),14 the
resulting shortening of the cervix may put future
pregnancies at risk in a small proportion of women;
removal of a specimen greater than 1.5 cm in height is
associated with an increased risk of preterm labour.14–16
Arbyn et al. suggested that following excisional treatment
there may be a significantly increased risk of preterm
labour less than 37 weeks (relative risk >2),14 cold knife
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cone excision was also associated with a significantly
higher risk of both severe and extreme prematurity, under
32 and 28 weeks, respectively.17 Furthermore, a small
proportion of women treated for CIN in their early 20s will
require a second treatment in their later 20s for persistent or
recurrent disease. In a recent article Ørtoft et al. reported a
further increased risk of preterm delivery after two
treatments for CIN 3 (adjusted hazard ratio 9.9), thus
significantly contributing to the risk of future pregnancy-
related morbidity.18 Delaying investigation and treatment
until after age 25 years reduces the risk of these
complications, especially as the average age at first
pregnancy in the UK has risen to approximately 30 years.19
The counter-argument is that a small number of women
under the age of 25 years do develop cervical cancer,6and
some of these cases could be prevented if screening
commenced at age 20 years. In a perfect world we would
of course all wish that these could be avoided. However,
the risk–benefit argument centres on how many
unnecessary colposcopy and loop excision procedures –
with the concomitant risk of future pregnancy morbidity –
society is prepared to accept to reduce the likelihood of an
occasional case of cancer among young women. It can also
be argued that with more widespread use of modern
fertility-sparing surgery for early invasive cancer, the small
number of women who develop cervical cancer in their
early 20s might still be treated successfully by their first
cone biopsy, an extended second cone biopsy or
trachelectomy without completely losing their reproductive
potential.20
The debate is confounded because the data that formed
the basis for the change in policy up to age 25 years are
historical.21 Also, at the time the decision was reached, the
savings made by avoiding ‘unnecessary’ cytology tests in
younger women allowed the National Health Service
(NHS) to make some definite health gains as follows:
●Introduction of liquid-based cytology (LBC)
●Establishment of 3-yearly screening in England up to
the age of 50 years
●Maintenance of 5-yearly screening after the age of 50
years in all areas of the UK.
The key, perhaps, is the length of time from first contact
with HPV until there is a realistic possibility that a CIN 3
lesion may become an early invasive lesion. Data from The
Netherlands suggest that this interval is about 8 years,22
which implies that the key determining date for first
cytology test is 8 years after first intercourse. Reports
continue to show that the age at first intercourse is falling
in the UK, with a substantial number of girls under 16 years
of age being sexually active.23 Therefore, now that
screening begins at 25 years of age in England, a
proportion of women will have come into contact with
HPV 10 years or so before their first cytology test.23,24
Screening interval: impact of primary and
secondary screening tools
The negative predictive value of a negative HPV test is
very high.22 Therefore, normal cervical cytology
accompanied by a negative HPV test should enable an
increased screening interval – perhaps 5–8 years, given the
natural history of HPV-associated CIN.21 For women aged
under 35 years, the prevalence of HPV may be too high to
use HPV testing as a primary screening tool (even more so
among the under-30s),25 but the technique would probably
be more efficient and effective than cytology screening
alone for women over the age of 35 years.26
A secondary test used in response to a positive primary
test is referred to as a reflex test. Thus a cervical screening
programme might consider cytology plus reflex HPV
testing at age 25–35 years, and HPV testing plus reflex
cytology for women over 35 years of age.
A sudden increase in the number of cytology tests, as
was experienced with the “Jade Goody effect”, results in
detection of a large number of minor abnormalities
(borderline nuclear change or atypical cells of
undetermined significance) and mild dyskaryosis.
Experience from the LBC pilots suggests reflex testing for
HPV (QIAGEN©Hybrid Capture 2, QIAGEN Ltd,
Crawley, UK) can allow a return to standard recall for up to
50% of those with borderline changes and up to 15% of
those with mild dyskaryosis, and earlier onward referral to
colposcopy for HPV-positive women.27
In the UK, women remain on increased surveillance for
up to 10 years following treatment for high-grade
dyskaryosis.28 The introduction of HPV testing alongside
cytology screening 6 months after treatment might allow
over 75% of treated patients to return to standard recall.29
The NHSCSP is actively considering the use of HPV
testing as triage for minor abnormalities and as a test of
cure as part of the sentinel site programme.30
In the future it may make sense to introduce HPV
testing as the primary screen for vaccinated women, with
either type-specific or cytology-based secondary screening.
It may also be possible to increase the screening interval
for HPV-negative vaccinated 25-year-old women.31
HPV vaccination programme
In England, a routine immunisation programme targeting
12–13-year-old females (school year 8) and a catch-up
programme for females aged 17–18 years was
commenced during the academic year 2008/2009. A
phased catch-up programme for females in school years 9
to 12 during the 2008/2009 academic year will be
completed during the 2009/2010 academic year. In
January 2010, the Department of Health published a
report outlining the annual HPV vaccine uptake in
England for 2008/2009.32 Results showed that for the
routine programme in England targeting 12–13-year-old
females, 80.1% completed all three doses of the vaccine.
For the catch-up programme in England aimed at 17–18-
year-old females, 62.2% received their first dose of the
vaccine, however only 31.8% completed all three doses.32
This number is expected to become higher in subsequent
years.
Girls who receive the vaccine before they start sexual
intercourse can expect an up to 70% reduction in their
future risk of needing colposcopy and treatment related to
CIN.33–36 The degree of protection for those who are
already sexually active at the time of vaccination is not
certain, but will be less than among the sexually inactive.37
Looking forward
Anxiety: positive or counterproductive?
Anecdotal reports from colposcopy clinics suggest that one
of the significant effects of the media attention surrounding
Jade Goody’s illness was a large increase in anxiety among
young women with symptoms such as postcoital bleeding
and those who were diagnosed with an abnormal cytology
test. In a way, this anxiety had a positive effect, by
increasing coverage rates and reducing non-compliance
with follow-up. However, it is undesirable to have high
levels of anxiety among people who are well or have only
minor disease. Studies of the anxiety associated with
cytology screening and, in particular, referrals for
colposcopy show that the provision of adequate
information can reduce high anxiety levels.38,39
Although it might appear tempting to increase coverage
and uptake for screening by highlighting rare, unhappy
52 ©FSRH J Fam Plann Reprod Health Care 2010: 36(2)
Bowring and Walker
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outcomes such as Jade Goody’s early death, such an
approach is generally counterproductive. The introduction
of HPV vaccination should mean that the next generation
of women is better informed about HPV and CIN and about
the real risks of cancer and the true significance of an
abnormal cytology result.
A return to stigma?
An interesting question for the longer term is the effect that
vaccination will have on attitudes to CIN. For a time in the
1970s and 1980s, a diagnosis of CIN had a stigmatising
effect because it was associated with factors such as
multiple sexual partners and young age at first intercourse.
To some extent this effect has been ameliorated by the
demonstration that HPV infection has a very high
cumulative incidence.6As such infections become rarer,
they may be a danger that some of the old stigma attached
to an abnormal cytology test might return. This would not
be desirable.
Conclusions
The publicity surrounding the illness and death of Jade
Goody has increased the uptake of cytology-based
screening and led to calls for a review of the current
guidelines on screening intervals and the age at first screen.
Those charged with making these difficult decisions are
examining the efficacy that may be obtained by using the
negative predictive value of a negative HPV test within the
current screening programme. In the future it may be
possible to modify the programme further by altering the
test used for primary screening, most notably among the
vaccinated population.
The great success of the current NHSCSP has been
based on high coverage and a simple and pragmatic
approach to screening guidelines: currently cytology with
increased use of HPV testing as triage. Once the 12–13-
year-old vaccinated cohort reaches 25 years of age, the
prevalence of high-risk HPV types will be significantly
lower for this group. A high coverage and simple approach
is likely to be maintained, with primary HPV screening
becoming the sensible strategy. Care will need to be taken
in the crossover period when a partly vaccinated, partially
protected, cohort of 14–18-year-olds currently completing
vaccination first enter the screening age.
Statements on funding and competing interests
Funding None identified.
Competing interests None identified.
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54 ©FSRH J Fam Plann Reprod Health Care 2010: 36(2)
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cervical cancer prevention?
The ''Jade Goody effect'': what now for
Julie Bowring and Patrick Walker
doi: 10.1783/147118910791069420
2010 36: 51-54 J Fam Plann Reprod Health Care
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