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Preventing Cervical Cancer in Ireland

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Trends

Incidence Mortality

46 years

56  yearsComparison to other countries

9th most frequently diagnosed cancer in women (270)

Mortality has been increasing since 1978

Ireland relatively more cancers      

12th most common cause of cancer death in women (103)

The average age at diagnosis

The average age of death

Cervical cancer in Ireland-key statistics

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Cervical cancer rates

2012

European Comparison

• Ireland had the same cervical cancer incidence rate as Poland

• Higher incidence than most of western Europe

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Infection is very common Only a minority of infections persistMost women are infected within 18 months of becoming sexually active

This is a necessary step in the development of precancer and cancer

The Natural history of HPV infection

•Transmission by sex•Lifetime risk 80% ‐most within 18 months

Exposure

•Transient•Most resolve within 18 months

Infection•Less than 20% persist

•No antibodies detectable

Persistence

•Virus integrates into host DNA

Malignant Transformation •Loss of tumour 

supressor gene E2•Uncontrolled cells division

Pre‐cancer

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Strategies aimed at preventing deaths from cervical cancer 

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Vaccination against the HPV virus

Primary prevention Secondary protection Early detectionScreening for precancerous changes of the cervix

Prompt assesment and referral for women who have symptoms

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2014201320122011201020092008

Timeline

CervicalCheck startsNational Screening Programme. 

HPV vaccination Catch up 18 year olds. 

Death of Jade GoodyUnprecedented levels of screening

HPV vaccination For secondary school first years. 

HPV testing post treatmentAt colposcopy. 

Colposcopy follow up

Cervical cancer control in Ireland –2008‐2017

2015

HPV triage of LSIL and ASCUS

HPV testing for uncertainty

2016

HIQA HTAHPV as primary screen

Expansion ofcolposcopy. 

2017

Next steps?

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Cervical cancer is preceded by precancerous condition called CIN

CIN does not have symptoms and can be present for ten to fifteen years before it turns into cancer

Smear tests take scrapings of cells from the cervix which the pathologist can categorise as normal or not according to the size of the cell’s nucleus

Rationale for Cervical Screening

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Cervical screening programmes aim to

Detect and treat precancerous abnormalities

Reduce the chance of developing cervical cancer.01 02

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Cervical Screening Programmes 

Taking the tests, tracking and analysingThe test

Maintaining the register and keeping it up to date

Population register

Colposcopy and histology.Diagnosis and treatment 

Quality Assurance

Organisation

Coverage

Organised cervical screening programmes reduce the incidence and mortality from cervical cancer 

Ingredients for success

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Define the population of women to be screened?

Not women >60• Anatomical Changes• Prevalance of high grade CIN is low

• Cytology performs poorly

Not Below 25• Incidence of cancer is low

• Prevalence of transient changes relatively high

• Screening not protective Exceptions – colposcopy, post transplant, dialysis and HIV

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Key target of CervicalCheckMore than 80% of the population (1.1 million women) should be up to date with their cervical screening

Coverage

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CervicalCheck ‐ Screening Promotion

Communication Change behavior Target Research

Screening promotionmessages

Making screening easy and popular

Populations/areas of low uptake

Interventions that influence behaviour change

Develop Distribute Encourage Specific

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Improving screening –helping women to remember

Information service • Freephone 1800 45 45 55

• Freepost • Email info@cervicalcheck.ie

• Website www.cervicalcheck.ie

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CervicalCheck Coverage

Geographical

Coverage> = 80%71 - 80%< = 70%

Eligible Women ScreenedSeptember 2010 - August 2015

Age groups

Current Coverage – 79.7%

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Five year coverage – trends since 2014 

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Smear takers / Healthcare professionals

5000 smeartakers contracted to CervicalCheck accessible via website

Training programme for nurses and gp trainees

CME for registered smeartakers

On line training resource 

41% of women  first heard of the programme 

from health care professional

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The test ‐ cytology

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Outsourcing Irish LabsChallengesBethesda terminologyGeographical challenge for MDTDisruption of training in Cytology 

2013 – repatriation of  half of the cytology testing to Ireland to two laboratories

60/40 Layout

US Labs

Irish labs

Cytology

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Cytology

NormalMost results show no abnormality

High gradeThese abnormalities need further investigation

Low gradeSome of these abnormalities will need further investigation

Cytology results  N  % NAD (no abnormality detected)  260,748  90.06% Low Grade       ASCUS  11,582  4.00% 

AGC (borderline glandular)   366 0.13% 

LSIL  11,806  4.08% High Grade       ASC‐H  1,290  0.45% HSIL (moderate)  1,813  0.63% HSIL (severe)  1,780  0.61% Query invasive squamous carcinoma  39  0.01% AGC favour neoplasia 

54 0.02% 

Query glandular neoplasia / (AIS) / adenocarcinoma 

49  0.02% 

Total  289,527  100.00% 

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Advantage of HPV testing as a second line or triage test

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HPV testing and CervicalCheck

Primary testing –HIQA report awaitesd

Post Treatment 2012

Management of Uncertainty 2014

Triage of low grade smears 2015

HPV testing  

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Cervical Screening – reality check

Screening aims to detect asymptomatic disease

Screening doesn’t always prevent cancer

Screening tests are not 100% accurate; abnormalities may be missed or wrongly identified.  

The false‐negative rate of smears was found to be 18 percent in a New Zealand audit (2004)

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Predictive value of cytology versus HPV testing

Cytology – problems with sensitivity – Needs to be repeated at regular intervals

HPV testing improves the CIN3 negative prediction

Challenge – how to manage HPV positive women

Dillner BMJ 2008

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Primary HPV testing

• HPV testing more sensitive 

• Especially in women over 30

• HPV vaccinated cohort is now aged 23 years.

• HTA due to be published by HIQA in 2017

Back to main

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Normal HPV Infection Precancer Cancer

Infection

Clearance

Progression

Regression

Invasion

Relative risk HPV, CIN and cancer

Schiffman, Wentzensen et al. JNCI 2011

Pop

ulat

ion

prev

alen

ce

Age

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Facilities

Staffing

Systems Management

Information Technology

Governance

Diagnosis and treatment for women -quality assured colposcopy

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Diagnosis – a balanced view

• Low grade CIN  ‐ the majoritywill resolve ‐ Emphasis is on reassurance and follow up

.

• High grade CIN – Likely to persist and some will develop cancer

• Emphasis is on treatment

01 02

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60/40 LayoutTreatment works Follow upTreatment of CIN reduces the risk of cervical cancer by 90%Most are done in OPD under local anaesthetic

After treatment – women are still at risk and need close follow up

163

11.8 8.9 2.9 4.6 7.5 6.5020406080

100120140160180

Cumulative rate of invasive 

cancer per 100

0 wom

en

Treatment of precancerous changes

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Long term considerations –effect of Excision on Pregnancy

Meta‐ analysis suggested increased risk preterm delivery and 

midtrimestermiscarraige

Related to the depth of excision

More common if multiple treatment

Recent evidence –depth of excision less than 1 cm no increased 

risk

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In 2007 – 7000 new patient appointment 

opportunities 

2008‐ new patient capacity  increased 

to 16,500 

2015 – capacity increased to 19,500 to accomodate HPV traige of low grade abnormalities

CervicalCheck  colposcopy services

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CervicalCheck growth in annual new patient attendances

10,094

16,811

17,437

16,621

14,796

15,786

16,549

17,909

0 2,000 4,000 6,000 8,000 10,000 12,000 14,000 16,000 18,000 20,000

Year 1

Year 2

Year 3

Year 4

Year 5

Year 6

Year 7

Year 8

Number of first visits

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Improving access to colposcopy – reducing waiting times

Target

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Improving access to colposcopy –Impact on follow up attendances

10,094

16,811

17,437

16,621

14,796

15,786

16,549

17,909

9200

30884

20769

43202

44,341

40,869

39557

38835

0 5,000 10,000 15,000 20,000 25,000 30,000 35,000 40,000 45,000 50,000

Year 1

Year 2

Year 3

Year 4

Year 5

Year 6

Year 7

Year 8

Number of follow‐up visits Number of first visits

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Improving Diagnosis – Biopsy Rate – Year eightresults

It is good practice to perform a biopsy in the presence of an atypical Transformation Zone to confirm the diagnosis. Target >90%

The biopsy should be suitable for analysis more than 95% of the time

95%

99%

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CervicalCheck ‐Detection of high grade abnormalities – the first seven years

2,036

3,212 3,253

4,666 4,439

5,407

6,4927,114

4,037

5,518 5,296

6,462

5,421

7,0347,649

8,885

100 145 129 151 160 175 222 1870

1,000

2,000

3,000

4,000

5,000

6,000

7,000

8,000

9,000

10,000

Year 1 Year 2 Year 3 Year 4 Year 5 Year 6 Year 7 Year 8

Num

ber

Low grade CIN High grade CIN Cancer

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Number of women screened. Five year coverage is now 79.5%

Number of women have been treated for high grade precancer

Number of cancers detected. 

1,000,000 + 50,000 + 1,200 +

Achievements to date

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0

50

100

150

200

250

2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014

Numbers of cervicalcancers according to age

<25 25‐50 51‐60 61+

0

500

1000

1500

2000

2500

3000

3500

4000

2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014

Carcinoma in Situ (CIN3/AIS) according to age

<25 25‐50 51‐60 61+

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Cervical cancer rates

Figures to 2014

NCRI, 2017

Incidence dropped by 7% between 2010 and 

2014

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Trends in presentation of Cervical Cancer in Ireland according to age group

0% 50% 100%

2001

2003

2005

2007

2009

2011

2013

Presentation of cancers Age 25‐50 

UnknownAutopsyIncidentalSymptomsScreening‐total

0% 50% 100%

2001

2003

2005

2007

2009

2011

2013

Presentation of Cancers age 51‐60

UnknownAutopsyIncidentalSymptomsScreening‐total

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Prevent more cancers

Prevent precancer –

Screen smarter

The future why high uptake of HPV vaccination is important to CervicalCheck

• Vaccination prevents 

against glandular 

cancers

• Reduce need for 

treatment which can 

effect pregnancy 

outcome

• Allow us to use  

smarter screening 

tools 

Cervical Cancer Control

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nowledgements