Cervical Screening

Introduction

Prevention is better than cure. This common phrase is perhaps the reason why the United Kingdom’s National Health Service (NHS), in 1988, established a program (Central Screening Program) that aimed at ensuring that women from the Kingdom are screened on the cervix (NHS Cervical Screening Program, NHSCSP, 2016). Nonetheless, current statistics by NHS digital (2017) indicate that whereas cervical cervical screening saves lives, over 1.2 million women in the UK failed to take up the screening in the year 2016/2017. Besides, whereas the uptake was at 72% during that period, there is a wide variation in uptake among various population groups such as those living in marginalized areas, those with little access to the healthcare system; and among various age groups. Existing research has identified various reasons for the low uptake of cervical cervical screening in the UK and beyond. For instance, following the fateful cervical cervical screeningevent that occurred to Jade Goody, it was inferred that low uptake of cervical cervical screening could be emanating from cultural reasons (Donnelly, 2009). Particularly, according to Donnelly (2009), Jades event was an eye-opener to various health stakeholders in the UK healthcare system because it revealed how cultural aspects are tied to health inequality, a phenomenon that most women were found to relate with. More importantly, the NHS Digital (2017) has largely attributed low coverage of cervical cervical screening in the UK to low turnout, especially after establishing that at least 4 in 5 women eligible for cervical cervical screening fail to attend the exercise.

Having established the importance of cervical cervical screening uptake, this paper seeks to educate readers on the importance of attending a cervical screening – based on a service user who had an opportunity to undergo cervical cervical screening during a travel health consultation session. From the standpoint of a novice general practice nurse (GPN), cervical cervical screening services are directly related to the NHS cervical cervical screening program and therefore it is important to develop skills and knowledge of the practice to ensure that national policy and standards of practice are adhered to. Ideally, according to Royal College of Nursing (RNC, 2015), developing such knowledge and skill contributes to the empowerment of young women who should attend cervical screening, and helps in strengthening of health and well-being of such women by reducing mortality rates through quality care. Moreover, this essay is inspired by the idea that GPNs have a role to educate women on the importance of cervical screening uptake both locally and internationally (NHS Cervical Screening Program, NHSCSP, 2016).

The Case Study

In reference to the Nursing and Midwifery Council (NMC 2018) standards of practice, the real name of the service user in this paper will be concealed so as to maintain confidentiality in respect to the required professional practice and behaviour practice of GPN. Having said so, the service user, Ann (not her real name) is a 25-year-old woman who refused to uptake cervical screening services despite receiving several invitation letters; because she felt cervical screening exercise was not urgent and did not have to occur during her travel health consultation. Ideally, Ann felt that she would rather go abroad for a year than take an appointment for cervical screening. When she later attended the screening, signs of cervical screening were observed and a question was raised as to why she had not attended earlier calls for screening. However, she explained that she had delayed taking the appointments due to difficulties in taking time off from work.

Against the backdrop of Anne’s case, it is important to acknowledge the GPN’s role of acknowledging and respecting the patient’s choices while being non-judgmental sensitive and caring in a manner that avoids unnecessary assumptions (RCN 2015). Besides, NMC (2018) point out that while delivering holistic care, GPNs should adhere to social inclusion – a phenomenon that requires GPNs to constructively challenge their patients whenever they detect any beliefs by the patient that could exclude them from access to care. Nonetheless, while constructively challenging the patient, GPNs should rely on evidence-based information that supports them in making decisions and choices that promote their well-being (RCN, 2015). This insight corroborates with the general standards and ethics of nursing professional practice espoused under the NHS 6Cs of nursing namely: care, compassion, competence, communication, courage, and commitment (NHS, 2017). For instance, constructively challenging Ann on her failure to take cervical screening is a show of care because it seeks to improve her health and general well-being. Besides, challenging Ann over her choices and priorities that could deny her access to healthcare requires courage and competence because such a conversation must be backed by evidence of proof.

Why It Was Important For Ann to Be Screened At Age 25 Years

The age at which women should begin cervical screening has been controversial and subject of debate years. For instance, while European guidelines prefer women to begin cervical screening between the ages of 20-30 and not before the ages of 25-30 (Arbyn et al, 2010), several countries have deviated from these guidelines, including Australia and USA which starts the screening from 18 years (Australian Institute of Health and Welfare, 2018; US Department of Health & Human Services, 2018). Against this backdrop, several studies have revealed evidence of the importance of cervical screening from the age of 25 years. For instance, a case-control study conducted by Makkonen et al (2017) in Finland revealed that because the underlying cause of cervical screening is the persistent infections by oncogenic types of Human papillomavirus (HPV), screening is most effective when begun from age 25 years, and that screening programs for women of 25 years helps in developing more effective treatments of lesions responsible for cervical cytology abnormality and HPV. This justifies why Ann should have begun screening from age 25. However, the reliability of these findings could have been affected by the researcher’s observation bias, besides the fact that they contrast with the findings of (Landy et al, 2014).

Landy et al (2014) conducted a study to investigate the benefits and harms of beginning cervical screening from age 20 years compared to screening from age 25 years. The study relied on secondary data from cervical screening institutions to estimate the number of women who had undergone screening tests, those with abnormal results after the test, those who had been treated and those diagnosed with cervical cytology abnormality and HPVs. While the study found more benefits of screening from age 20, and may lead to between three and nine fewer cases of cervical screening than screening from age 25, the applicability of these findings are limited by several shortcomings of the study methodology including the fact that the researchers were not able to access some data for purposes of making estimations regarding the impact of screening from age 20 compared to age 25, and therefore conducted some indirect calculations – hence affecting the reliability and credibility of the study findings.

Why UK Screens From 25 Years Old

The UK’s decision to screen women for cervical screening from age 25 years was informed by various pieces of evidence that are worth noting. For instance, according to NHSCSP (2016), women under the age of 25 have experienced a high prevalence of HPV after coitarche, hence being a sexually active age group; they are highly predisposed to HPV-associated changes. However, this does not apply to Anne because she is 25 years of age. Besides, NICE (2019) indicates that because younger women are less likely to experience a persistent HPV, there is a possibility that samples taken from women under the age of 25 years will undergo spontaneous regression of abnormalities detected from samples of cytology taken from such women. Ideally, this justifies the low incidence of cervical screening among women of the age group below 24 years, and why Ann was ripe for the screening. Hence, NHSCSP argues that against these pieces of evidence, it is highly likely that screening women below age 25 years will result in a large number of referrals for colposcopy. NHSCSP further argues that the multiple colposcopy referrals subject women to psychological torture characterised by anxiety – a phenomenon that it against the nursing practice and professional values. This is amid claims by NHSCSP that women are likely to experience negative consequences on their ability to carry children for pregnancy terms when treatments are administered through colposcopy even for abnormalities that can be resolved without any intervention. However, NHSCSP also acknowledges a counterargument by several other scholars that there is a substantially lower risk of women treated with colposcopy to develop preterm delivery, especially within the NHS England – at least compared to studies from other countries (Castanon et al 2012). Nonetheless, the NMC code of conduct (2018) requires practitioners to

exercise care and safety in every clinical procedure because, in case of any eventuality, the individual nurse involved is accountable for their actions and decisions. Therefore, it can be argued that from professional and practice standard point of view, NHSCSP adheres to the NMC codes of conduct on patient safety by recommending cervical screening from 25 years and was actually right for sending Ann an invitation from screening.

Discuss Lifestyle Choice and Its Impact on Developing Cervical Cytology abnormality and HPV

While HPV has been established as the main risk factor for cervical cytology abnormality, it is not the only cause of the disease. Research evidence has revealed various ‘co-factors’ that are can contribute to, or predispose an individual to cervical cytology abnormality and HPV, one of them being lifestyle choices (NHSCSP, 2016). For instance, research by Massad et al (2012) indicates that sexual lifestyle can be a major risk factor for cervical screening because sexual activities such as oral sex and genital skin-to-skin contact predispose individuals to HPV. Richardson et al (2007) also point out that becoming sexually active at a younger age also exposes individuals to cervical screening because, as argued, there are a lot of changes that occur at puberty. NHSCSP (2016) also insists that having sexual intercourse with more than one partner can predispose Ann to cervical screening because it increases an individual’s exposure to HPV – because it is transmitted through sexual intercourse. Another aspect of lifestyle that predisposes women to cervical screening is smoking. According to Labeit et al (2013), smoking affects the possibility of HPV disappearing. On the flipside, if HPV fails to disappear, the woman can develop Squamous Intraepithelial Lesion (SIL), a condition which is precarious to the cervix

and increases chances of contracting cervical cytology abnormality and HPV (Jo’s Cervical Cancer Trust, 2019). Nonetheless, poor attitude towards personal health – as displayed by Ann who declined calls of cervical screening just because she was traveling; can predispose an individual to cervical cytology abnormality and HPV.

According to British Columbia Cancer Screening (2019), early screening enables the identification of abnormal cells in the cervix that when treated early enough, can prevent Ann from developing cervical cytology abnormality and HPV. NHSCSP (2016) also argues that early screening of screening may help detect cervical screening early enough before it spreads, hence making it easier to treat. Moreover, an early screening of cervical screening enables the development of less treatment, hence less recovery time. But NHSCSP (2016) reveals that whereas early screening is highly advantageous for the health and well-being of the patient, some screening exercises may indicate positive for cell abnormalities even if such sells are not available, a phenomenon termed as ‘false positive’. It is also possible for the early screening exercise to indicate unavailability of cell abnormalities yet such cells may be available – also called false negative.

Financial Implications for Screening and Not Attending Cervical Screening

As the organization responsible for healthcare costs and expenses, one major priority of NHS is to reduce the cost of delivering healthcare services, considering the tight government budget (Landy et al 2014). Hence, there is great importance in the prevention of cervical screening because such exercises lead to early detection and prevention of the disease (NHS, 2013). This underscores why Ann could have heeded o earlier calls for screening. Besides, it reflects on GPN’s role in ensuring that women eligible for screening are strongly advised to undergo screening no matter the circumstances (NHSCSP, 2016). Public Health England (2019) argues that cervical screening is a typical form of disease prevention, and enables the saving of the huge costs involved in treating cervical cytology abnormality and HPV. it was the role of the GPN to explain to Ann that failing to attend screening would expose her to greater cost of the disease compared to the cost she would have incurred in attending screening (even though she did not have any financial constraints). This assertion has been supported by several other studies evaluating the economic benefit and cost of early cervical screening. For instance, Demos (2014) indicate that high rates of cervical screening would help save the survivor’s personal finances and save the UK government 6 million pounds worth of tax revenues.

Evidence by Demos (2014) also indicates that the treatment of cervical screening costs the NHS 21 million pounds per year, with women having the most advanced stages of the disease undergoing the most expensive procedures. Whereas an early stage screening can be treated with as low as 500 pounds, an advanced stage cervical screening requiring a full hysterectomy and chemotherapy may cost up to 25,000 pounds (Demos, 2014). This reveals the importance of screening because as highlighted herein, early screening may help in the detection of the disease in its early stages, making it cheaper and easier to treat. Hence, early screening will not only enable the costs incurred by NHS and survivors in the management of screening but also allow the NHS to cheaply deliver effective care services to survivors in line with the NMC requirements for quality and affordable care for all (NHSCSP, 2016).

Conclusion and Recommendations

Cervical screening has been established as an important exercise that enables an early detection and management of one of the most prominent public health burden – cervical cytology abnormality and HPV. Evidence provided by this paper suggests that there are both health and economic benefits of cervical screening, with corresponding costs of forgoing the same. This underscores the need for the development of effective clinical approaches to cervical screening and the opening of a new discourse in the practice of cervical screening.

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References

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