Focus on women's health: Best practice in cervical screening

A key area of responsibility for practice nurses is performing cervical screening. This Practice Nurse guide is intended to serve as a reminder of best practice for the experienced nurse, as well as an introduction to the theory for those who have yet to take on the role

Every year in the UK over 3,000 women will be diagnosed with cervical cancer. However, it is a largely preventable disease thanks to the cervical screening programme and Human Papilloma Virus (HPV) vaccination.¹

Each year around five million women in the UK are invited for cervical screening. Cervical screening is a screening test to detect abnormalities at an early stage in the cells in the cervix and through this test, it is estimated that early detection and treatment can prevent up to 75% of cervical cancers from developing in the UK. Not going for cervical screening is one of the biggest risk factors for developing cervical cancer and it is within this group of defaulters that almost half will develop cervical cancer.²

To be invited for cervical screening women need to be registered with a GP. The NHS call and recall system invites all women who are eligible for screening and registered with a GP. The system also keeps track of any follow-up investigation, and if all is well, recalls women for screening at either three or five years.

Purpose of Screening

Any screening programme aims to detect abnormalities early so that treatment can be commenced with the aim of preventing any further disease progression. Cervical screening is very effective in detecting pre-cancerous changes and in the majority of abnormal screens, effective treatment can prevent progression to cervical cancer.

GENERAL CONCERNS

Cervical screening attendance across the UK is in decline, particularly for the first and last ages to be invited (25-29 and 60-64). In recent years cervical screening in the 60-64 cohort has fallen dramatically to 72.7% in 2013, a drop of 5.3% from its peak in 2007. Attendance in this group is now at a 16 year low. When coupled with reports suggesting a rise in the number of women having new relationships in later life, (and therefore increasing the possibility of exposure to HPV – the cause of over 99.7% of cervical cancers) – this age group may be at risk of undetected cervical changes.¹

Coverage amongst women aged 50-54 years (which is measured over a 5 year period) was highest at 81.6%.

For younger women aged 25-29 who may be due their first test, only 62% attended screening in 2013. Although this figure had increased to 63.3% (as of 31 March 2014) it still means that less than two thirds of these younger women have been screened in in the last three and a half years. The poor uptake is particularly worrying in this age group because cervical cancer is the most common cancer in women in the UK under 35, but only 7% of deaths occur in this age group.

The greatest number of deaths occur in the 75-79 age group.

A total of 4.24 million women aged 25-64 were invited for screening in 2013-14, but only 3.23 million women were tested.

Among women aged 25-64 with adequate tests in 2013-14, 93.4% had a negative result and 6.6% had a result categorised as abnormal (from borderline change through to potential cervical cancer). Only 1.3% of women tested in 2013-14 had a result showing high grade abnormality.¹

There are a number of risk factors for cervical cancer, including smoking, many sexual partners, older mothers, but the most significant risk factor is human papilloma virus (HPV).

HUMAN PAPILLOMA VIRUS (HPV)

There are over 100 types of HPV, of which there are two high-risk types, HPV16 and HPV18, which cause over 70% of cervical cancers. Of these 100 types, more than 40 will affect the genital area. Genital HPV is categorised as either:

1. High-risk (oncogenic) types that cause cervical intraepithelial neoplasia and invasive cancer. Particular high-risk strains include HPV 16, 18, 31, 33 and 45. These are associated not only with cancer of the cervix but also of the vulva and vagina in women, penile cancer in men, and anal and oral cancers in both men and women.

2. Low-risk types that cause genital warts, HPV6 and HPV11.

It is now universally accepted that HPV is a precursor of cervical cancer, given that 99.7% of cervical cancers are caused by HPV infection. The HPV is a small DNA virus, which infects the deeper layers of the skin and internal lining of structures such as the vagina and the mouth. HPV is often asymptomatic and normally resolves spontaneously – 90% do so within 2 years. Persistent HPV infection causes the cell changes that eventually lead to cancer.

HPV infection is common and over half of all sexually active women will be infected by a strain of genital HPV at some point in their lifetime.

Women are most likely to be infected in their late teens and early 20s, usually when women are most sexually active.

HPV is spread by direct physical contact, i.e. genital contact, hand to genital contact. In fact anyone who is sexually active is at high risk. The risk of acquiring HPV also increases with the number of sexual partners.

HPV infection cannot be treated, but abnormal cell changes can be detected by screening and removed by colposcopy.⁴

HPV vaccine

Since 2012 Gardasil has been the vaccine of choice for the national, school-based vaccination programme. It is licensed for girls over the age of 9 years and protects against 4 types of HPV - HPV16, 18, 6 and 11. Currently vaccination is offered to 13-year-old girls, but the Department of Health is also considering vaccination for boys.⁵

HPV testing

HPV testing was incorporated into the NHS Cervical Screening programme in April 2012. This means that screening can be more effectively targeted, which then reduces both unnecessary procedures, such as colposcopy and anxiety for women.

HPV triage is applied to women with borderline or low-grade cytology screening results, to help the labs determine whether women should be referred to colposcopy. Women with borderline changes or low-grade dyskaryosis are HPV tested to establish if they are high risk HPV positive. If HPV positive they are referred immediately to colposcopy. Women who do not have high risk HPV can be reassured and returned rapidly to routine recall.

The follow up of treated women in the NHS Cervical Screening programme has involved annual screening for up to 10 years before the return to routine recall, but by using the HPV test of cure approximately 80% of treated women will avoid having to undergo annual cytology tests.⁴

Which samples are HPV tested?

Not all samples need to be HPV tested. HPV testing is conducted only on the first occur-rence of a borderline or low-grade sample on eligible women routinely invited for screen-ing. Triage testing is also be done on all borderline and low-grade samples. Test of cure is performed on all women who have been treated for cervical intraepithelial neoplasia (CIN) who have normal, borderline or low-grade cytology six months after treatment.

SCREENING PROGRAMME

Screening is offered at three yearly intervals from the age of 24 years and 6 months, until age 49 years and then five yearly between age 50-64 years. Screening ceases at 65 years unless a women has had a previous abnormal result or she has failed to attend since the age of 50 years.

Under-25-year-olds are no longer invited part of the screening programme, as cervical cancer is rare in this age group. However, changes in the cervix are common and 1 in 3 cytology samples in the under-25 year olds will be abnormal. As most prevalent diseases resolve spontaneously, screening in the younger women could lead to unnecessary referral and possibly over treatment. We now have national guidance available which was published in 2010, on how to manage abnormal vaginal bleeding in 20-24 year olds.³

In primary care, cervical screening is provided in most practices as an additional service, with funding to provide a service that meets national guidelines and extra payment if quality standards are reached. Practices that choose to do so can opt out of providing an additional service, on a temporary or permanent basis, and in that event, CCGs (Clinical Commissioning Groups) are currently responsible for ensuring acceptable local access.

Cervical screening training

Before a registered nurse undertakes cervical screening, it is essential that they undertake appropriate, recognised training, which entails observed, supervised and practical assessment after 20 unsupervised samples, and can demonstrate competence in all aspects of the process . This should be under the supervision of a competent recognised cervical screening mentor. It is also good practice for sample takers to undertake updates at least every three years, either in person or online.³

THE SCREENING APPOINTMENT

Cytology screening should be performed in such a way as to provide an adequate sample for assessment with the minimum of distress or discomfort.⁵ At every stage of the cervical screening process, good communication skills and sensitivity are essential. It is the practice nurse’s role to establish a welcoming, non threatening environment and rapport to put the patient at ease. The sample taker should have sound empathetic listening skills, and unconditional respect for the patient that allows an appropriate response. Ensure that the room is sufficiently warm, and that no one else will enter the room during the consultation.

Clarify the patient’s name and date of birth at the beginning of the consultation and confirm her reason for attending. All practices should have a surgery chaperone policy in place, and a chaperone must be offered. Throughout the consultation, it is vital to maintain the client’s privacy and dignity, ensuring that confidentiality is upheld.

The procedure requires a 20 minute appointment to allow discussion around aspects of the woman’s health and well being, such as body mass index, diet, exercise, smoking and alcohol history, menopause, sexual health, contraception (including long-acting reversible methods), as appropriate.

Consent to screening

Patient consent for any medical procedure is a legal requirement in the UK. Consent must be uncoerced and informed, and the benefits of any interventions must out-weigh any harmful effects. In the case of taking a cervical screening sample, consent is implied rather than being expressed. Attendance at the surgery for the procedure implies consent to the procedure, although a full explanation should still be given. Responsibility for this lies with the sample-taker, and a nurse’s language/terminology is critical in helping to reassure the patient.⁶

Prior to the cervical sample being taken, a thorough, relevant history should be taken. This will include any abnormal bleeding i.e. heavy periods, post coital, inter-menstrual or post menopausal bleeding and/or unusual vaginal discharge. At this point the nurse can consider whether a cytology sample is still appropriate or if a direct referral to colposcopy is necessary. If the sample taker is unsure of any of these aspects then advice should be sought.

Contraception should then be checked – is the patient taking combined oral contraception or progestogen-only contraception, or using long-acting reversible contraception, or on hormone replacement therapy or tamoxifen? It is important for the laboratory to be aware of this information as different hormones can alter the picture of the cellular material.

Completion of Laboratory Form (HMR101)

Pre-populated forms may be accessed by different means.

Electronic forms can be generated (providing the practice has registered) from Open Exeter,⁷ a web-enabled viewer supported through the NHS which provides the facility for CCGs/agencies to share information held on the NHAIS (Exeter) database with other NHS organisations.

Clear, concise and legible details are essential.

THE PROCEDURE

Cervical screening should be performed in a warm room, and a range of speculae from virgin to Winterton (Disposable or CSSD) should be available, along with liquid cytology sample pots with fixative (in date), cytobrushes, lubricant, non latex gloves (preferably), transport bag, height adjusted couch-with disposable couch roll, screens/curtain and ad-justable task light, plus waste disposal, laboratory forms and ball point pen. Other swabs e.g. for chlamydia or high vaginal swab for bacterial infection should be readily available in case it becomes apparent these are also required.

Points to consider when choosing the speculum:

• Age of the women
• Build of the women
• Parity

It is good practice to inspect the women’s abdomen for any signs of scarring, including whether she has had a Caesarean section.

In the absence of a couch with stirrups, the woman should be asked to lie on her back, and asked to bring her knees up and apart while keeping her heels together.

While putting the woman at ease, try to maintain eye contact throughout the procedure and avoid any unnecessary conversation.

Observe labia for warts, redness, discolouration or Bartholin cysts, etc.

If using a metal speculum, warm and lubricate with warm water just prior to insertion. If using plastic, a very small amount of lubricating jelly can be used, providing it is not applied to the tip of the speculum, which could impair the quality of the sample when coming into contact with the cervix.

Gently part the labia with gloved thumb and index finger of non-dominant hand. With the dominant hand, prepare to insert the speculum handles down (if using lithotomy), handles up (if using a flat couch or if known retroverted uterus) avoiding impinging on the clitoris and urethra by placing the handles slightly to one side, to avoid causing irritation or pain. Inserting the speculum with handles down gives a greater depth of examination with more chance of reaching the cervix, except when the uterus is retroverted. Occasionally it is necessary to position the client in the left lateral position to visualise the cervix when the uterus is retroverted.

Push against the posterior vaginal wall as this area has the fewest pain sensors and also keeps pressure away from the clitoris and urethra. Gently open up the speculum and use the screw mechanism to keep the handles open as soon as a good view of the cervix has been located. Asking the woman to cough when opening the speculum pushes the cervix down and also acts as a distraction.⁸ If the cervix cannot be visualised, clenched fists or a pillow under the buttocks can bring the cervix into view. Digital examination may be necessary to find the cervix and, if the walls of the vagina are lax, using a condom or thumb of a latex free glove, with the tip cut off, over the speculum may assist in holding the vaginal walls firmly.

Inspect the vaginal walls and cervix, noting that the appearance of the cervix, which varies during a woman’s life, depending on her age, parity and hormonal milieu.

Once good visualisation of the cervix has been achieved, insert the end of the cytobrush into the cervical os and rotate clockwise, five times through 360°, with pencil like pressure. The lateral bristles will splay over the ectocervix. Only consider using an endocervical brush in addition to a cytobrush if there is stenosis of the os or to pick up glandular cells when following up a previous glandular abnormality. An endocervical brush should never be used alone and if it is used, it should only be rotated 90°.

If the client has a wide ectropion of the cervix, a second cytobrush can be used to sample the wide transformation zone (See Box). Material should be collected by sweeping the transformation zone at least twice. Material sampled from both brushes should be put in the same vial and clearly indicated on the form.

Immediately the sample has been taken, the brush should be agitated vigorously up and down ten times in the liquid cytology pot and then from side to side ensuring all the sample material has been removed from the brush into the solution. Check the brush to ensure that no material is clinging to the fronds. NB, in certain laboratories, the head of the cytobrush is removed and left in the liquid cytology pot. Replace the lid straight away, making sure that the black marks on the lid of the pot meet, to avoid spillage of the test.

Directly this has been done, check the condition of the cervix for any bleeding and obtain any other swabs if also required. Before removing the speculum, open it up very slightly to disengage the cervix. Warn the client if likelihood of any bleeding/spotting.

Allow privacy to get dressed before then explaining to the client the process of when and how she will receive her results and what the results mean. Nationally, women in the UK should receive their results by post within two weeks of her test. Check that the clients details are correct on her form and the sample taker’s code and signature/name have been documented correctly, along with information on the condition of the cervix, whether the woman is taking hormones, and confirm the cervix has been visualised and sampled with 360º sweep x five times. Some areas may ask if the transformation has also been vis-ualised. This information must also be documented in the woman’s medical record.

If you cannot visualise the cervix it is important that help is sought or if this is not possible to ask the women to return for another test.⁹

The sample pot should be labelled with three identifiers, the client’s forename, surname and date of birth.

When ending the consultation the women must understand that a sample has been taken and how she will receive her result. All clients must receive their results by letter from the primary care support services and an explanation of the possible results and follow up should be given to the client. They should also understand that help, support and written information are available.

Laboratory staff who examine the cell samples look for cervical cells showing pre-malignant changes (dyskaryosis) and grade them accordingly: dyskaryosis may be mild, moderate or severe. A sample that shows dyskaryosis and is HPV positive will prompt referral to colposcopy and possible biopsy. CIN grades 1-3 show how far dyskayotic cells have progressed into the squamous epithelium.

CONCLUSION

Uptake rates for cervical screening are declining, despite the evidence that an effective screening programme, together with HPV immunisation, has rendered cervical cancer an almost entirely preventable condition. This article does not attempt to explore the reasons why women may decline screening, but it is clear that a competent, confidant and experienced practice nurse can make the experience less unpleasant. Practice nurses also have many opportunities in their consultations with women to encourage them to attend for screening – it could save their lives.

REFERENCES

1. Public Health England. Cervical Screening: Programme, 2015. https://www.gov.uk/guidance/cervical-screening-programme-overview

2. Jo’s Cervical Cancer Trust. Not eligible for cervical screening – under 25. http://www.jostrust.org.uk/about-cervical-cancer/cervical-screening-smear-test-and-abnormal-cells/cervical-screening-under25

3. NHS Cancer Screening Programme. NHSCSP 23 (Archived). Taking sample for cervical screening - A resource pack for Trainers, April 2006. http://www.cancerscreening.nhs.uk/cervical/publications/nhscsp23.html

4. Royal College of Nursing. Human Papilomavirus (HPV) and cervical cancer – The facts, 2012 https://www2.rcn.org.uk/__data/assets/pdf_file/0011/78716/003083.pdf

5. Public Health England. NHS Cancer Screening Series No 4 Consent to Cancer Screening, 2009 http://www.cancerscreening.nhs.uk/publications/cs4.html

6. Royal College of Nursing. Cervical Screening: RCN Guidance for Good Practice, December 2006. https://www.rcn.org.uk/__data/assets/pdf_file/0007/78730/003105.pdf

7. Public Health England. HMR101 Request/Report Form (Open Exeter). http://www.cancerscreening.nhs.uk/cervical/hmr101.html

8. The STI Foundation. Greenhouse P. Female Genital Examination, e-Learning for Sexual Health and HIV, http://selnet.org.uk/files/training/stif-e-learning.pdf

9. Xavier Bosch, F. The aetiology of Cervical Cancer NHSHCP, 2005

http://www.pennine-gp-training.co.uk/HPV-Triage---Test-Protocol.pdf