Cervical cancer: Does the smear age need to be lowered?
By Lily Bailey
I've heard it said that everyone lives in fear of cancer, but I'm not sure that's quite right. Sure, most of us know someone who has struggled with or lost their fight against this disease, but whether we think it will happen to us is a different matter.
Particularly, if, like me, you are in your early twenties, and see cancer as something that largely affects people of a certain age. Of course, in the back of my mind I am aware, particularly from high profile cases in the media, that cancer does affect young people, stealing their lives before they have properly begun in an act of what feels like unquantifiable cruelty. But it's rare. It wouldn't happen to me. Right?
Well then, how come I'm being presented with such a concerning smear result? In the first instance, it's rare for a woman of my age in this country to be even having a smear. In 2003, the government raised the age at which the NHS start performing smears on women from 20 to 25. Under these regulations, a 21-year-old like myself would not be going for her first smear for another four years.
The only reason I even went to see a gynecologist was because I had an infection caused by using cheap raspberry bubble bath on my lady parts when my shower gel ran out (I know, I know). I couldn’t get an appointment with my NHS GP for a few weeks, and this wasn’t something I wanted to wait for so I braced myself for bills and decided to go private. I was supposed to get antibiotics and be on my way. Having a smear was not part of the plan, nor would it even have been mentioned had this been an NHS appointment, but my gynecologist offered it, advising me that in her opinion, women should start going for smears within two years of being sexually active. I agreed, not thinking much of it.
Without a cone biopsy, there was a 40% chance the precancerous cells would progress to cancer
But two weeks later, when I was given the results, I was told that I had severely precancerous cells on my cervix. I was informed that if I didn't have a cone biopsy, (an operation which would remove a small part of my cervix containing the cells), there was a 40% chance they would progress to cancer within in a number of months to years. As with any procedure, it was explained that there are some potential risks associated with it. These include a possible increased risk of preterm labour and a small risk of bleeding. Concerned about the risks, I sought a second opinion from another gynecologist, who confirmed to me that I should go ahead and have the operation. On my way home from the consultation, his words rang in my ears:
"It’s ridiculous that the age for taking smears in the UK was raised to 25. I don't know how many times myself and my colleagues are going to have to see young women with progressed cervical cancer, all of which could have been prevented if the smear age had been kept at 20. It's tragic. Anyway, it’s lucky we've got to you in time."
This of course was very scary. But what seemed more scary was the fact that, had I not made my random bubble bath faux-pas, there's no way I would have ordinarily have had my first smear for another few years. Would I have had cancer by then? It didn't bear thinking about. Why had the smear age been raised from 20 to 25 in 2003? Was it, as is so often is the case with our ever-shrinking NHS budget, a case of funding simply being cut?
Not quite. Of course, funding as ever did play a role. As my gynecologist, who works as clinical lead for colposcopy at Queens Hopsital, Romford, for the NHS and also consults privately at Parkside – which is where I saw her – put it: "The population is increasing, while relatively the funding for the NHS is decreasing. Those things don't sit well together."
However, the primary cause for raising the age to 25 was based on the fact that when women under 25 have a smear, an abnormality will show up in about 1/6 of cases. This is much higher than in any other age group.
"It’s all to do with incidence of human papillomavirus, (HPV)," Adib tells me. "HPV causes 99.7% of cervical cancers, and the majority of cervical precancers. Eighty per cent of women who have ever been sexually active will be infected with HPV at some point in their life, but the majority will clear the virus within two years. Forty per cent of women aged 20-24 are going to test positive for HPV. That's higher than any other age group because that's when you're first exposed to the virus. Later, once the immune system has cleared the virus, you then test negative. So most of the abnormalities on the cervix revert back to normal once the virus is cleared, with no treatment.
The decision to raise the test age to 25 was probably based on NHS funding and research into the human papillomavirus
"So the concern then is that by testing women under 25, lots of abnormalities that would have cleared themselves will be unnecessarily treated using cone biopsies, along with their accompanying risks. That is why the age was raised."
Not all lesions on the cervix need treating. It's only if HPV persists that it is more likely to cause a problem than if it is a transient infection. Precancerous changes are graded according to the degree of abnormality into mild (CIN1), moderate (CIN2) or severe (CIN3). Previously all moderate and severe lesions were treated. New research looking at molecular markers now shows that CIN2 lesions can be categorised into those that will resolve on their own, and those that will get worse, so many do not need to be treated, and instead should be carefully monitored.
"The point is," continues Adib, "screening younger women would detect more precancerous lesions, but as our knowledge increases, we won't necessarily be treating them all. I don't treat CIN2 in women under 30 years of age. I advise that 50% of lesions will get better without treatment, 25% may stay the same and 25% may go on to CIN3. I would treat at that point. That way, many unnecessary treatments are avoided."
An artist's impression of cancer cells
With this in mind, I find myself thinking that the argument should not be that it's best to just avoid giving 20-25-year-olds smears for fear of over-treating. Rather, smears should be accessible to young women, with the data gleaned from them being used carefully, and cone biopsies consequently administered more discerningly.
"Cervical cancer is the most common cancer in women under 35," Adib says. "The morbidity associated with cancer is pretty high. And the trauma involved with a cancer diagnosis can be phenomenal. Since the age of smears was raised in 2003, whilst the incidence of cervical cancer is falling in most age groups, it is actually increasing in the 25-30 year olds, back to pre-2003 levels. This is partly because we are not screening women before the age of 25. So by the time they have their first smear at 25, they already have a cancer.
"Until it happens to you, it's easy to sit round a boardroom table and say 'we can’t afford it' or 'we'll do too many extra treatments'. But, ultimately, I believe it's worth the extra cost and time spent monitoring women with moderately abnormal cells, in order to prevent as many cases of cervical cancer as we can."