Should women get smear tests every five years?

Doctors proposing it insist that it’s safe and will spare patients needless treatment – but it’s enraged many who say more women will die from cervical cancer as a result

AT THE start of this year, health chiefs in Wales announced a big change to their cervical cancer screening programme – women would get a smear test every five years, instead of every three.

Public Health Wales called it ‘a really positive development’, while experts insisted the adjustment was a good thing, since new screening methods are so accurate in determining who will and who won’t go on to develop cancer that women simply don’t need to be seen as often.

It might also spare some from unnecessary and potentially risky treatment, they added.

There were quite a few people who didn’t see it that way, however. ‘The blood of thousands of women will be on the hands of whoever decided to make this ridiculous and cruel decision,’ railed one commentator on Facebook. ‘Again women and girls’ healthcare is downgraded,’ another wrote. ‘This will result in increased preventable deaths.’

An online petition demanding the reversal of the decision was quickly launched, and so far has amassed 1.2 million signatures.

‘I don’t think it sounds safe,’ says Rachel Paul, 29, from Llanelli, who started the petition. ‘I understand tests have changed, but I know of so many women who developed cervical cancer between smear tests. The thought of not being able to get a test for five years is really scary.’

On January 5, Public Health Wales issued an apology on Twitter: ‘We are sorry. We haven’t done enough to explain the changes to cervical screening and have caused concern. We are working to make this clearer and more information will be available as soon as we can today and in the coming days.’ But the organisation will not back down on the decision.

MEDICAL insiders, speaking to The Mail on Sunday, said that the same change had been scheduled by NHS England later this year. However, the strength of the backlash to the Welsh move means policymakers are now ‘reconsidering’.

They would ‘have to think carefully about how to present the decision in a more positive light,’ the insiders added.

Professor Peter Sasieni, a cancer prevention expert and head of medical trials at King’s College London, confirmed the delay: ‘It’s been on the cards in England for a while, but Covid delayed the change because it involves a lot of red tape which NHS systems will struggle to cope with. The plan is for smear tests to move to every five years in all four nations within the next year or so.’

Yet the most pertinent question, raised by women themselves, remains: how can it be sensible to have less frequent checks for a cancer that kills 40 per cent of those who are diagnosed late?

Destiny Wade, 28, from Kent, believes she is an example of why three-year screenings should stay.

She was diagnosed with cervical cancer in July 2020, following unusual vaginal bleeding. Her smear test, performed three years earlier, showed no evidence of cancer.

‘If I waited another two years, I’d be dead,’ says Destiny, who has had to undergo multiple operations that have left her cancer-free but infertile. Her story is concerning.

So what’s the truth? Will moving screening to every five years protect women, or lead to a spike in deaths from cancer?

Firstly, it’s important to point out that the NHS cervical screening programme has been a remarkable success. Since its inception in 1988, cervical cancer rates have plunged by more than two thirds. In 1992 alone, research suggests there would have been 57 per cent more cases of cervical cancer had women not been screened. Nevertheless, about 3,200 women in the UK are still diagnosed with it every year, and 800 die. And just three-quarters of eligible women aged between 25 and 64 turn up for their smear test – a figure experts are intent on improving.

What lies behind extending the interval between screenings is the fact that today’s tests are vastly better than those they replaced.

Historically, a smear test involved taking a sample of cells from the cervix which were then examined in a lab for pre-cancerous changes. These were graded as borderline, mild, moderate or severe.

The treatment protocol for moderate and severe cases was always clear – the risk of cancer was significant, and so women were referred for a second investigation, called a colposcopy, during which the cervix is examined and more tissue removed for analysis.

This gives doctors more detail about the level of risk – and whether the woman needs treatment to remove the abnormal cells.

But what to do in the case of women flagged after a smear test with borderline or mild cell changes, which present a lower risk, has long been the subject of debate.

Some are simply monitored to see if the cells change further. In one in three cases, these minor abnormalities disappear without treatment as the body’s immune system kicks in. However, some end up being treated – possibly unnecessarily – and this can cause problems.

A colposcopy, like a smear, involves a speculum – a duckbillshaped device – being inserted into the vagina to allow access to the uterus. These procedures can be uncomfortable, but are risk-free.

The same cannot be said for treatments to remove abnormal cervical cells. There are a number of ways this can be done, for example, using a heated wire loop or a minor operation to cut out the tissue.

But these procedures can have significant downsides. The cervix is the muscular ring at the entrance to the womb, and any treatment on it can weaken it. And this can affect how a pregnancy progresses.

In some women who have had cervical treatments, there is an increased risk of a miscarriage or premature birth. Treatment can also, rarely, cause stenosis, where the cervix narrows or closes. Of course, if treatment is to remove abnormal cells that are more likely to become cancer, the benefit outweighs this small risk.

However, as consultant obstetric and gynaecological surgeon Clive Spence-Jones says: ‘If early cell changes are discovered, and they don’t resolve, it can cause anxiety in patients. ‘And so it might seem like the cautious approach to offer further investigations and treatment in order to prevent cancer, but this also means treatment sometimes ends up being given unnecessarily to patients who might never have progressed or developed cancer. And then you could have created a risk to future pregnancy.’

A big step forward came in 2020

when the initial screening test was changed. Instead of taking cell samples, it looks for the presence of the human papillomavirus (HPV), known to be the cause of most cervical cancers.

Around 80 per cent of adults are thought to carry HPV on the body, and in most cases it is harmless. However, for reasons not fully understood, in some cases it can invade the body’s tissues, triggering cell changes that lead to cervical and other cancers.

If HPV is present in a sample taken at cervical screening, women are likely to undergo a colposcopy and other tests to determine if they need treatment or more regular screening.

But, importantly, studies have shown that if a woman tests negative for HPV, she has a less than one per cent chance of developing cervical cancer within five years – hence the change in the cervical screening interval.

Doctors and cervical cancer charities seem agreed: the move is safe. Indeed, research by King’s College London in 2018 estimated that HPV screening every five years is such an accurate method it would lead to nearly 500 fewer cases of cervical cancer every year in the UK, compared with the test every three years.

Crucially, as the new method is more precise, fewer borderline cases are flagged up, meaning fewer women being overtreated.

Theresa Freeman-Wang, consultant gynaecologist at the Whittington NHS Trust in London and an expert in cervical screening and colposcopy, says: ‘Women are worried because they are used to the idea of being screened every three years. Some would like to be screened more frequently, but evidence shows that if a woman tests negative for HPV then her risk of developing an abnormality, or indeed cervical cancer, is negligible.’

Added to this, girls have been vaccinated against HPV at the age of 13 since 2008, and boys of the same age since 2019. Ms Freeman-Wang continues: ‘We have a vaccinated population coming through now, and so screening every three years for them in particular isn’t necessary.’

Kate Sanger, head of policy at Jo’s Cervical Cancer Trust, says: ‘Surgery for cell changes can involve part of the cervix being taken away. It can weaken the cervix and affect a woman’s ability to carry children. It can also lead to infections and bleeding, impacting mental and physical health. It’s not something you want unnecessarily.’

Prof Sasieni adds: ‘If we test less then we free up more resources – and I don’t necessarily mean financial resources, though that’s obviously a factor. We could spend those resources finding the millions of women who aren’t currently being screened at all. There’s a massive benefit in focusing more effort on that.’

Family doctors agree. ‘A lot of women shy away from the test because they find it embarrassing, and as a result we are constantly chasing people up,’ says Dr Nisa Aslam, a London GP. ‘If we spaced out the time between tests, we might see more people coming forward.’ Dr Aslam stresses that screening is not the only means of spotting cervical cancer. ‘Just because you’ve had a smear test recently, doesn’t mean you shouldn’t look out for symptoms such as irregular bleeding or bleeding after sex, or increased vaginal discharge. If you experience any of these, you should see your GP.’

However Rachel Paul, who created the Welsh petition, is unconvinced. ‘Anyone like myself who is anxious should be given the option to get a smear test every three years.

‘I shouldn’t be forced into having my test every five years – it should be my choice.’

Ms Sanger says Jo’s Cervical Cancer Trust ‘fully supports’ NHS England adopting the five-year policy, but believes ‘better communication’ is needed.

She adds: ‘The cervical screening programme is getting better and better at catching cancers, and we need to make that clear.’