tag:theconversation.com,2011:/us/topics/pap-smear-4433/articlesPap smear – The Conversation2022-02-02T14:35:26Ztag:theconversation.com,2011:article/1760412022-02-02T14:35:26Z2022-02-02T14:35:26ZCervical cancer is a disease of inequity: here’s how to save 60 million lives<figure><img src="https://images.theconversation.com/files/443740/original/file-20220201-19-1lp3oar.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">People in the world's poorest countries have not benefited equally from the recent advancements made in cancer.</span> <span class="attribution"><span class="source">Jonathan Torgovnik for The Hewlett Foundation/Reportage by Getty Images</span></span></figcaption></figure><p><em>The World Health Organization <a href="https://www.who.int/health-topics/cancer#tab=tab_1">estimates</a> that cancer a leading cause of death around the world. The cancer burden is on the rise, putting more pressure on already strained systems in low- and middle-income countries. These regions are <a href="https://www.who.int/news-room/fact-sheets/detail/cancer">least prepared</a> to deal with the growing number of cancer patients. People in the world’s poorest countries have not benefited equally from the recent advancements made in cancer screening, prevention and treatment. Inequity also exists between patient profiles and within countries, even wealthier ones – not everyone gets the same chance at a good outcome. <a href="https://www.spotlightnsp.co.za/2021/11/25/face-to-face-prof-lynette-denny-reflects-on-an-extraordinary-life-of-service/">Lynette Denny</a> is a global expert on cervical cancer – the <a href="https://www.who.int/news-room/fact-sheets/detail/cervical-cancer">fourth most common</a> cancer among women. She spoke to The Conversation Africa about the drivers of cervical cancer and how to close the care gap.</em> </p>
<hr>
<h2>Most (90%) new cervical cancer cases and deaths are in low- and middle-income countries. What are the key factors driving this?</h2>
<p>Cancer of the cervix is a disease of <a href="https://www.tandfonline.com/doi/full/10.1016/S0968-8080%2808%2932397-0">inequity</a> of access to healthcare. It is an almost entirely preventable disease. Here’s why.</p>
<p>The natural history of cervical cancer begins with infection of the cervix with certain types of human papillomavirus (HPV). Over 200 types of HPV have been described over the last 40 or so years. About 40 are associated with infection in the genital tract of men and women. Of these 40 types, about 14 types are associated with cancers of the anus or genitals, particularly cervical cancer. These are known as the high-risk types. Types 16 and 18 of HPV are the most common and account for over <a href="https://www.who.int/news-room/fact-sheets/detail/cervical-cancer">70%</a> of cervical cancers globally.</p>
<p>The majority of people who acquire HPV infection won’t have any symptoms and will get over the infection without any serious problem. But they can still pass the infection on to others. </p>
<p>In a minority of cases the HPV infection becomes persistent. And over time, this infection causes changes in the cells of the cervix. These are known as precancerous changes. Left untreated or undetected, they will progress to invasive cervical cancer over time – ranging from five to 20 years.</p>
<p>If these precancerous changes can be detected, though, they can be removed surgically and this prevents progression to cervical cancer. Detecting them is what the Pap smear has done since the <a href="https://www.ncbi.nlm.nih.gov/books/NBK470165/">1940s</a>. Where implemented in national programmes, at 3-5 yearly intervals in all women in society over the age of 25-30 years, there has been a dramatic <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2762353/">decrease</a> in cervical cancer incidence and death.</p>
<p>But providing the Pap smear to all women requires a complex infrastructure. It requires ability to perform the Pap smears, to transfer the smears to the laboratory, where they need to be prepared and interpreted by laboratory technicians and from there returned to the patients. These requirements have made Pap smear-based cervical cancer screening programmes prohibitively expensive in low- and middle-income countries. The failure to establish these programmes is the major cause of the high incidence of and mortality from cervical cancer in these settings. Where screening does exist, it is opportunistic and confined mainly to urban areas and to women who have health insurance.</p>
<h2>What are the most effective and affordable ways of preventing cervical cancer?</h2>
<p>The ideal would be to test at least 70% of women between 25-30 years old, through a system with adequate human and consumable resources, excellent infrastructure, built-in quality control and robust referral systems. The Pap smear is affordable and cost-effective in most high-income countries but not in low- and middle-income countries. </p>
<p>Preventing HPV infection is tricky. The most effective method is vaccination against HPV. The other is total abstinence from any sexual activity (not very realistic). There is however some protection provided by condom use (at every sexual encounter), which is estimated to be <a href="https://pubmed.ncbi.nlm.nih.gov/24488594/">around 70%</a> (compared to over <a href="https://data.unaids.org/publications/irc-pub06/jc941-cuttingedge_en.pdf">90%</a> protection against HIV transmission through correct use of condoms).</p>
<p>HPV vaccination was introduced in the year <a href="https://pubmed.ncbi.nlm.nih.gov/23199957/">2006</a>. There are currently three vaccines against various types of HPV. The current WHO <a href="https://www.who.int/reproductivehealth/publications/cancers/cervical-cancer-guide/en/">recommendations</a> for preventing cervical cancer encompass vaccination against HPV in girls (and boys if resources allow) aged 9-12 years, combined with effective screening of women aged 30-49, at least twice in a lifetime using a high quality screening test. </p>
<p>The tests currently recommended are those that are able to detect HPV DNA on the cervix. These tests detect precancerous lesions of the cervix. A doctor can take the sample or women can be taught to <a href="https://pubmed.ncbi.nlm.nih.gov/33105451/">take their own sample</a> and deliver it to their nearest clinic for evaluation. </p>
<p>Services for the early detection and treatment of cervical cancer are essential, along with provision of palliative care for those with advanced disease. </p>
<p>The treatment of early stage cervical cancer is removal of the womb and if appropriate, removal of the upper vagina and removal of the pelvic lymph nodes. For more advanced cancers, the treatment of choice is chemo-radiation to the pelvic area.</p>
<h2>What is getting in the way of implementing these interventions?</h2>
<p>The most important obstacles to establishing national cervical cancer programmes include:</p>
<ul>
<li><p>Failure of healthcare sectors of government to prioritise cervical cancer and therefore failure to allocate resources.</p></li>
<li><p>Competing health needs among women in low- and middle-income countries. Maternal mortality and high incidence of HIV, malaria and tuberculosis divert funding away from cervical cancer prevention. Other basic needs to be met include safe drinking water and proper sanitation. Civil strife and widespread poverty also stand in the way of meeting people’s needs. </p></li>
<li><p>Lack of political will and lack of understanding of the impact on individuals, families, communities and society as a whole of women dying prematurely. This has widespread <a href="https://pubmed.ncbi.nlm.nih.gov/18850430/">socio-economic costs</a> at a national level.</p></li>
<li><p>There is a powerful investment <a href="https://www.who.int/initiatives/cervical-cancer-elimination-initiative">case</a> being developed urging governments to prioritise cervical cancer prevention and to eliminate it by at least 2030. If all countries join in the effort, it is <a href="https://www.who.int/publications/i/item/9789240014107">estimated</a> that over 60 million women’s lives will be saved.</p></li>
</ul><img src="https://counter.theconversation.com/content/176041/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Lynette Denny does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>People in the world’s poorest regions have not benefited equally from the recent advancements made in cancer screening, prevention and treatment.Lynette Denny, Chair and Professor of Obstetrics & Gynaecology, University of Cape TownLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1696282021-11-08T03:02:10Z2021-11-08T03:02:10ZCervical cancer screening in New Zealand: self-testing at home will improve equity of outcomes for non-European women<figure><img src="https://images.theconversation.com/files/430649/original/file-20211107-69725-1a5p26h.jpg?ixlib=rb-1.1.0&rect=24%2C49%2C2716%2C1557&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">Shutterstock/Siriluk ok</span></span></figcaption></figure><p>Despite New Zealand’s national cervical screening programme (<a href="https://www.nsu.govt.nz/health-professionals/national-cervical-screening-programme">NCSP</a>), Māori women are <a href="https://www.thelancet.com/journals/lanonc/article/PIIS1470-2045(21)00206-0/fulltext">more than twice as likely</a> as European women to be diagnosed with, and die from, cervical cancer.</p>
<p>Similarly, the screening programme has not been equitable for Pasifika and Asian women. Like Māori women, Pasifika women have lower screening rates and higher rates of <a href="https://www.nsu.govt.nz/system/files/resources/final_ncsp-guidelines-for-cervical-screening-new-zealand-5_june_2020.pdf">cervical cancer incidence and mortality</a> than European women. Asian women also have lower screening rates but lower incidence and similar mortality to European women. </p>
<p>Women who don’t access the screening programme are often referred to as “hard-to-reach” or “disengaged” but, in reality, the inequities are a systems issue. These groups are under-served and suffer the majority of <a href="https://www.health.govt.nz/system/files/documents/publications/unequal-impact-ii..pdf">cases of cervical cancer</a>. </p>
<p>Our <a href="https://www.thelancet.com/journals/lanwpc/article/PIIS2666-6065(21)00174-7/fulltext">study</a> explored whether self-testing would help the least-served groups. We show self-testing, particularly at home, raises screening rates among women who have never or rarely accessed the screening programme and experience the most barriers.</p>
<h2>Clear preference for home testing</h2>
<p>This is the first evaluation of the effectiveness of mailed self-testing kits for cervical cancer screening in Aotearoa New Zealand. </p>
<p>We invited Māori, Pasifika and Asian women between the ages of 30 and 69, who had never been screened or were more than five years overdue, to take part in a community-based, randomised controlled trial with three different tracks. </p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1187596089941094401"}"></div></p>
<p>Our aim was to assess whether two invitation methods for self-testing improved screening participation over usual care (the third track). Women were either invited to take a self-test at their usual general practice or were mailed a kit to take a self-test at home. </p>
<p>We compared participation rates with the usual care process of an invitation to come to the GP clinic for collection of a standard Pap smear.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/self-collected-cervical-screening-is-a-great-way-to-prevent-cervical-cancer-how-can-we-get-more-people-doing-it-163360">Self-collected cervical screening is a great way to prevent cervical cancer. How can we get more people doing it?</a>
</strong>
</em>
</p>
<hr>
<p>There were 3,553 women in the study. Although the absolute level of participation was modest, we showed that participation was statistically significantly higher for self-testing at home, compared to the usual Pap smear at the GP clinic. </p>
<p>Māori were 9.7 times more likely to agree to self-test at home. For Pasifika women, participation was six times more likely; for Asian women it was 5.1 times more likely. </p>
<p>Self-testing at the clinic was preferred, respectively 4.1, 3.3 and 1.6 times over the Pap smear. Overall, our results show access to screening at home is much preferred over other options.</p>
<h2>A brief history of cervical cancer screening</h2>
<p>Our understanding of cervical cancer goes back to the 1928 discovery by George Papanicolaou (hence Pap smear) of profound abnormalities in cervical cells. He realised this could be used as a method of early cancer diagnosis. </p>
<p>The process was subsequently <a href="https://pubmed.ncbi.nlm.nih.gov/15405936/">refined in the 1950s</a> after which the Pap smear was increasingly used for screening and early diagnosis.</p>
<p>By the 1970s, there was clear circumstantial evidence that cervical cancer was caused by a sexually transmitted agent, which was later identified as the human papillomavirus (HPV). This has allowed two crucial developments in the control of cervical cancer: effective vaccines with increasing coverage against high-risk HPVs and reliable screening using a vaginal swab.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/hpv-vaccine-cuts-cervical-cancer-cases-by-almost-90-but-one-in-ten-girls-still-havent-been-vaccinated-170887">HPV vaccine cuts cervical cancer cases by almost 90% – but one in ten girls still haven’t been vaccinated</a>
</strong>
</em>
</p>
<hr>
<p>From 2015, and increasingly around the world, vaginal samples (collected using a swab by women themselves or by healthcare professionals) have been used to identify the presence of HPVs with a <a href="https://pubmed.ncbi.nlm.nih.gov/26209409/">high degree of reliability</a>. </p>
<p>This screening approach does not need to involve any other person and has a number of advantages over a standard clinically obtained Pap smear. It allows collection at home and caters to those who prefer greater privacy or have less time. It is empowering because it places health management in a woman’s own hands. </p>
<p>This is an exact parallel with self-collected swabs for sexually transmitted infections (STIs), which are well accepted as standard of care. Self-testing for cervical cancer screening is increasingly available around the world.</p>
<p>The accuracy of HPV self-testing is <a href="https://www.thelancet.com/journals/lanonc/article/PIIS1470-2045%2813%2970570-9/fulltext">similar</a> to <a href="https://pubmed.ncbi.nlm.nih.gov/22907569/">professionally taken samples</a> and it <a href="https://www.ncbi.nlm.nih.gov/books/NBK184624/">improves participation</a>. However, most studies have not targeted Indigenous or ethnic minority women. They remain under-served <a href="https://pubmed.ncbi.nlm.nih.gov/31809806/">essentially everywhere</a>.</p>
<h2>How to ensure equity</h2>
<p>Aotearoa New Zealand already has extensive experience with free mail-out screening for bowel cancer. Giving women the opportunity to self-test at home at no cost will result in the greatest impact toward improving equity of access to cervical cancer screening. </p>
<p>However, the National Cervical Screening Programme indicated that self-testing at home is not an option in their initial rollout of screening based on the <a href="https://pubmed.ncbi.nlm.nih.gov/4367340/">detection of human papillomavirus</a> (<a href="https://www.immune.org.nz/diseases/human-papillomavirus-hpv">HPV</a>), the leading <a href="https://pubmed.ncbi.nlm.nih.gov/10451482/">cause of cervical cancer</a>. </p>
<p>This will be a serious missed opportunity to improve equity. The key to achieving equity is for all women to access screening, including those who may agree only to testing at home.</p><img src="https://counter.theconversation.com/content/169628/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>John Donne Potter received funding from the Health Research Council of New Zealand for this work. </span></em></p><p class="fine-print"><em><span>Naomi Brewer does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>New Zealand is already using self-screening kits for bowel cancer. Giving women the opportunity to self-test for cervical cancer at home will improve equity and lift participation.John Donne Potter, Professor, Research Centre for Hauora and Health, Massey UniversityNaomi Brewer, Research Fellow, Research Centre for Hauora and Health, Massey UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1041872018-10-04T10:25:20Z2018-10-04T10:25:20ZDelay in replacing the Pap smear with HPV screening is costing lives<figure><img src="https://images.theconversation.com/files/239160/original/file-20181003-52684-1q5xt0t.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/download/confirm/631110194?src=FtCAM0plkt37pYpLxBivvg-1-1&size=medium_jpg">Iryna Inshyna/Shutterstock.com</a></span></figcaption></figure><p>It was <a href="https://academic.oup.com/jnci/article/100/7/492/920141">established</a> a decade ago that testing for the presence of HPV – the virus that causes cervical cancer – is a better cervical screening test than the Pap smear. Yet in England, the Pap smear is still used, and it’s costing lives. </p>
<p>Current screening for cervical cancer is done through the collection, staining and microscopic examination of cells from the cervix (“cytology”). The stain used to assess collected cells was developed in the early 1950s by George Papanikolaou, hence the name: Pap test. During screening, clinicians look for abnormal cells. If any are found, they remove them to stop cervical cancer developing. The cervical screening programme in the UK today was introduced in 1988, and it is estimated to save <a href="https://www.cancerresearchuk.org/about-cancer/cervical-cancer/getting-diagnosed/screening/about">2,000 lives</a> a year. </p>
<p>In 1983, a German virologist called <a href="https://scienceblog.cancerresearchuk.org/2014/09/16/hpv-the-whole-story-warts-and-all/">Harold zur Hausen</a> discovered that HPV caused cervical cancer and the first HPV test was invented 15 years later. </p>
<p>Because having the virus is necessary for developing cervical disease, HPV testing is better than a Pap test at identifying those at risk. Also, a negative HPV test is more reassuring than a negative Pap test because cytology is more likely to produce “false negative” results – in other words, not showing disease when there is disease.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/239130/original/file-20181003-52681-1679axy.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/239130/original/file-20181003-52681-1679axy.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/239130/original/file-20181003-52681-1679axy.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/239130/original/file-20181003-52681-1679axy.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/239130/original/file-20181003-52681-1679axy.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/239130/original/file-20181003-52681-1679axy.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/239130/original/file-20181003-52681-1679axy.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">An abnormal Pap test.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/download/confirm/480485131?src=Obg4zZbUsiOwex9IaExXfQ-1-24&size=medium_jpg">Komsan Loonprom/Shutterstock.com</a></span>
</figcaption>
</figure>
<p>In 2003, the US was the first country to introduce HPV-based screening. At the time, Pap smear testing in the US was perceived to be of low quality, so they included HPV testing alongside to ensure better quality screening. Mexico introduced HPV testing in 2008 and Turkey in 2014 (these countries had no high-quality national cytology-based programme before the introduction of HPV testing).</p>
<p>The pace of change in the EU has been considerably slower. The Netherlands and Sweden introduced the HPV test in 2017, while Italy will finish deploying the test at the end of 2018. </p>
<p>Public Health England and the NHS, who are responsible for the screening programme in England have, until recently, aimed to switch to the HPV test in April 2019, but are now working towards a deadline of December 2019. Introducing HPV testing into existing screening programmes has been much more complicated than expected. </p>
<p>England is by no means the only country that has experienced delays. The hard lesson to learn here is that much earlier planning is needed to ensure a timely introduction of better tests. </p>
<p>Given the effectiveness of the Pap smear, you might think that a short delay in replacing it with an HPV test would have minimal consequences. In fact, our latest research, published in the <a href="http://journals.sagepub.com/doi/full/10.1177/0969141318800355">Journal of Medical Screening</a>, shows that for every month HPV testing is delayed in England, the chance to stop 48 extra women from developing cervical cancer is missed.</p>
<h2>The high cost of delay</h2>
<p>For our study, we used a mathematical model to estimate the number of new cancer cases that would be diagnosed by 2030 in England, assuming that HPV testing replaces the Pap smear in 2020 rather than in 2019. We also calculated the life expectancy for this excess cancer. </p>
<p>We also used a measure of disease burden called QALY (quality-adjusted life years) to estimate the cost of the excess cancers. A QALY includes both the quality and the quantity of life lived following the diagnosis of cancer. It is used to compare health interventions when deciding which is better value for money. </p>
<p>We calculated that a one-year delay in implementing HPV screening would lead to a loss of 1,595 quality-adjusted life years, with a value of £32m. In estimating the cost per QALY, we used conservative assumptions, making the huge cost of delayed introduction even more shocking. As such, it’s vital that there are no further delays in the roll-out of HPV testing in England.</p><img src="https://counter.theconversation.com/content/104187/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Alejandra Castanon does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Many countries have swapped Pap smears for the more accurate HPV screening. Why is the UK so far behind?Alejandra Castanon, Epidemiologist, Queen Mary University of LondonLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/904962018-02-01T22:46:32Z2018-02-01T22:46:32ZDoctors must stop misleading women about cervical screening<figure><img src="https://images.theconversation.com/files/204382/original/file-20180201-123837-1a3j4bw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">While cervical screening has saved countless lives, we overscreen in Canada. Women don't need to be screened until the age of 25 for cervical cancer.</span> <span class="attribution"><span class="source">(Shutterstock)</span></span></figcaption></figure><p>Cervical screening is one of the most effective screening tests, responsible for substantial reduction in death from cervical cancer. This disease <a href="https://doi.org/10.1186/1471-2458-12-992">used to affect two per cent of Canadian women and kill one per cent</a>. </p>
<p>But as with so many good things, the procedure can be overused, and Canadian doctors are overscreening their female patients.</p>
<p>It is time to change cervical screening policy: Start at a later age, and do it less often. Canadian provinces used to start testing from a woman’s first sexual activity. In 2011, Alberta changed this to start screening at age 21, and other provinces followed suit. </p>
<p>After examining the evidence, I maintain <a href="https://doi.org/10.1503/cmaj.160636">we should start even later — at age 25</a>. Alberta and British Columbia have made this change; other provinces are considering it.</p>
<h2>Screening under age 25 has little impact</h2>
<p>Cervical cancer is largely a late result of an earlier infection with human papilloma virus (HPV) — a wart virus. It can <a href="https://www.dx.doi.org/10.1158/1055-9965.EPI-08-0707">develop several years after women become sexually active but mainly shows up when women are in their 40s or older</a>. </p>
<p>I was a member of a team of epidemiologists and a gynecologist who examined the Canadian evidence from before screening started. We found that there was <a href="https://doi.org/10.1186/1471-2458-12-992">almost no cervical cancer in women under age 25 and very little under age 30</a>. For many years, Canadian doctors performed pap tests when they prescribed contraception, so young women were tested annually. Yet this made no measurable difference to the numbers of invasive cancers.</p>
<p>In Britain, a large case-control study found that <a href="https://doi.org/10.1136/bmj.b2968">screening women aged 20 to 24 had little or no impact on rates of invasive cervical cancer up to age 30</a>. Sadly, the few women who do get cervical cancer at these ages have rapidly advancing disease, and neither screening nor treatment seems to help much.</p>
<h2>Screening causes harm</h2>
<p>If excess screening was only an unpleasant nuisance for women, it might be acceptable, but there is more: It causes harm. </p>
<p>When young women are infected with vaginal warts, it is difficult to distinguish the cellular changes from cancer. Consequently, <a href="https://content.cancerview.ca/download/cv/prevention_and_screening/cccic_microsite/documents/cccicmonitoringevalqualityindicatorspdf?attachment=0">more than 10 per cent of women under 30 have “abnormal” pap tests</a>, but this rate drops for older women. </p>
<p>A positive screening test <a href="http://sti.bmj.com/content/85/7/508">causes anxiety</a> for many women, though HPV warts often go away on their own by the time a repeat test is done.</p>
<p>If the tests appear abnormal, women are referred for further examination by colposcopy (when the cervix is examined under magnification, usually by a gynecologist) and small samples (biopsies) are removed for microscopic examination. </p>
<p>Some biopsies appear abnormal — a “pre-cancer” — and such women may have a larger <a href="http://www.cancer.ca/en/cancer-information/diagnosis-and-treatment/tests-and-procedures/cone-biopsy/?region=on">“cone biopsy”</a> or “<a href="http://www.cancer.ca/en/cancer-information/diagnosis-and-treatment/tests-and-procedures/loop-electrical-excision-procedure/?region=on">loop electrosurgical excision</a>” taken to remove the abnormal area at the entrance of the cervix. This “cures” the pre-cancer, but leaves a weakened cervix. Even though most abnormalities would resolve themselves, a few would not, so doctors treat them all.</p>
<p>The cervix, however, has an important biological role: It holds in babies until the time comes to release them. <a href="https://www.dx.doi.org/10.1002/14651858.CD012847">Women who have had a cone biopsy have a higher rate of pre-term births</a>, and some of these babies die. Having a weakened cervix may not matter for older women who are no longer having babies, but for young women who want to birth children, this is a serious potential harm.</p>
<h2>Balancing harms and benefits</h2>
<p>What this means is that cervical screening policies and guidelines must balance the potential benefits against the harms of such screening, and recognize that the probabilities change with age. </p>
<p>The Canadian Task Force on Preventive Health Care <a href="https://doi.org/10.1503/cmaj.121505">examined the evidence</a>, and in 2013 recommended that there should be no screening under age 20. Screening should start some time in a woman’s mid-20s, with an interval of every three years. Alberta and British Columbia <a href="https://doi.org/10.1503/cmaj.160636">changed their policies in accordance with the science</a>.</p>
<p>Other provinces still start at age 21, and some still screen every two years. The reasons are not clear. Too often Canadians look south to the United States, where <a href="https://www.dx.doi.org/10.3322/caac.21392">early frequent screening persists</a>. </p>
<p>We might do better to check the rest of the world, where <a href="https://www.dx.doi.org/10.1016/j.ejca.2009.07.020">few countries start before 25, and some not until age 30</a>. </p>
<h2>Women should decide</h2>
<p>If women were fully informed, how many would choose to have cervical screening so early and so often? They should have the choice, rather than being given uninformative positive encouragement of the type that’s found on many provincial websites. </p>
<p>Physicians need better information to share with their patients, and should not routinely perform cervical screening tests on young women at least until their mid-20s. </p>
<p>Women who start sexual activity later in life can wait even longer, since the earliest cancers <a href="http://cebp.aacrjournals.org/content/18/4/1070">do not develop</a> until at least four years after first sexual activity, and mostly not until 10 to 20 years later. For those who have been immunized against HPV, the probabilities will be even lower.</p>
<p><a href="http://annals.org/aim/fullarticle/2450218/screening-pelvic-examinations-adult-women-grand-rounds-discussion-from-beth">Some doctors argue</a> that women should still get regular pelvic examinations and test for sexually transmitted infections (STI). But pelvic examinations look for an enlarged uterus or ovarian disease, which mainly affect older women. And urine tests detect STIs. <a href="http://www.cfp.ca/content/62/3/211">So doing routine pelvic examinations is unnecessary</a>. </p>
<p>In provinces that do not have screening registries that remind women to get examined every three years, they may neglect to do so. So some physicians argue women should be told to come at two-year intervals to ensure they come within three years. </p>
<p>This means that compliant women will be screened more often than necessary, and subjected to extra risk of harm, but changes nothing for those who do not attend.</p>
<p>Instead, women and their doctors should follow the science, not inappropriate policies, and women should decide for themselves what is right for them.</p><img src="https://counter.theconversation.com/content/90496/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>James Dickinson was a member of the Canadian Task Force on Preventive Health Care, 2009-2016, and was the lead author on their report on cervical screening. The Task Force is funded by the Public Health Agency of Canada, and members are not paid, but receive travel funding to attend meetings. </span></em></p>Medical research suggests cervical cancer screening for women under the age of 25 has little impact. Women should therefore be screened at a later age, and less often.James Dickinson, Professor of Family Medicine, University of CalgaryLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/841852017-09-19T14:14:48Z2017-09-19T14:14:48ZThe Pap smear isn’t used to diagnose cancer – but it could be<figure><img src="https://images.theconversation.com/files/186564/original/file-20170919-22613-1i8vg9q.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Close-up of abnormal cells from Pap smear.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/download/confirm/480485131?src=pXWcLFWIh0Xead-Ch3t4oQ-1-6&size=medium_jpg">Komsan Loonprom/Shutterstock</a></span></figcaption></figure><p>Doctors can find it hard to diagnose cervical cancer in young women because the same symptoms, such as bleeding between periods or after sex, are common in women with genital infections or taking contraceptives. For decades the Pap smear has been used as a <a href="http://www.nhs.uk/conditions/Cervical-screening-test/Pages/Introduction.aspx">screening test</a> to prevent women from getting cervical cancer. It is not used as a screening test in women younger than 25 because it <a href="https://www.jostrust.org.uk/about-cervical-cancer/cervical-screening-smear-test-and-abnormal-cells/cervical-screening-under25">isn’t effective at preventing cancer in this age group</a>. But what if the Pap smear could be used to <em>diagnose</em> cervical cancer in young women?</p>
<p>In our latest research, published in the <a href="http://bjgp.org/content/early/2016/10/24/bjgp16X687937">British Journal of General Practice</a>, we found evidence that the Pap smear is an excellent test for finding cervical cancer in young women with symptoms. Currently, there isn’t a test that diagnoses cervical cancer once a woman has it. Doctors in primary care usually rely on looking at the cervix to check for cancer, but we know that this <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4758498/pdf/bjgpmar-2016-66-644-e189-p.pdf">misses most cancers</a>. Instead of just preventing cancer, this new-found role for the Pap smear could also help identify cervical cancer at an earlier, more treatable stage, which could save lives. </p>
<p>The Pap smear involves a doctor looking cells taken from the cervix under a microscope. For the purposes of cervical screening, the aim is to find abnormal cells so they can be removed before they become cervical cancer.</p>
<p>We looked at primary care medical records and cervical screening records for women aged 20 to 29. We compared Pap smear results from women with cervical cancer to results from women without cancer. We also looked at the symptoms women had using in-depth interviews and medical records. </p>
<p>Pap smear results are usually reported according to <a href="http://www.nhs.uk/Conditions/Cervical-screening-test/Pages/Results.aspx">grade of abnormality</a>. We found that over 90% of women with cervical cancer had a Pap smear result of moderate grade or worse. Using this as a cut-off point would mean that at least 90% of women with cervical cancer would be correctly identified by the Pap smear as a diagnostic test. </p>
<p>Importantly, very few women in the general population had the same test result, so women without cancer who go to their doctor with symptoms would not be unnecessarily worried by a false positive result. </p>
<h2>Needle in a haystack</h2>
<p>Cervical cancer in young women is rare – just 77 women aged under 25 are diagnosed with the disease in England each year. The main symptoms of cervical cancer are gynaecological, such as bleeding between periods or after sex, and vaginal discharge. </p>
<p>These symptoms are extremely common in young women, but for other less serious reasons, such as hormonal contraceptives and genital infections (for example, vaginal thrush or chlamydia). Unfortunately, for young women who do have cervical cancer, this means that <a href="http://metro.co.uk/2017/01/12/woman-25-dies-of-cervical-cancer-after-she-was-refused-smear-test-for-being-too-young-6376589/">doctors are very unlikely to suspect cancer</a>. </p>
<figure class="align-right ">
<img alt="" src="https://images.theconversation.com/files/186569/original/file-20170919-22632-5qehee.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/186569/original/file-20170919-22632-5qehee.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/186569/original/file-20170919-22632-5qehee.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/186569/original/file-20170919-22632-5qehee.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/186569/original/file-20170919-22632-5qehee.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/186569/original/file-20170919-22632-5qehee.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/186569/original/file-20170919-22632-5qehee.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Speculum – implement used in Pap smear.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/download/confirm/588003872?src=pXWcLFWIh0Xead-Ch3t4oQ-1-34&size=medium_jpg">rainbow rays/Shutterstock</a></span>
</figcaption>
</figure>
<p>Finding cervical cancer earlier is likely to have a big impact on young women. Treatment for advanced stage cervical cancer leaves women infertile. A test that diagnoses cervical cancer at an earlier stage could give women the chance to have a family in the future. </p>
<p>At the moment general practitioners (GPs) have no good way of knowing if a young woman with gynaecological symptoms has cervical cancer. The Pap smear as a diagnostic test for cancer would provide GPs with a powerful tool. GPs are likely to be enthusiastic about this repurpose of the Pap smear - a simple test that they are already familiar with. </p>
<h2>A test for all women</h2>
<p>Cervical screening doesn’t prevent all cervical cancers. Most cervical cancers are found when women go to their doctor with symptoms. Luckily it’s not just young women who could benefit from using the Pap smear as a diagnostic test. </p>
<p>In <a href="http://journals.sagepub.com/doi/abs/10.1177/0969141315598174?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%3dpubmed">two</a> <a href="http://onlinelibrary.wiley.com/doi/10.1111/cyt.12259/full">related studies</a> we showed that the Pap smear can be used to find cervical cancer in symptomatic women of all ages.</p>
<p>Despite its long-held success, the Pap smear will soon be replaced as the main cervical screening test by a new and better screening test. The new test detects the virus that causes cervical cancer - <a href="https://www.jostrust.org.uk/about-cervical-cancer/hpv">human papillomavirus</a>. Now that a new use for the Pap smear has been found, though, perhaps it won’t be retired from service just yet.</p><img src="https://counter.theconversation.com/content/84185/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Anita Lim receives funding from Cancer Research UK. This work has won a category in the Research Paper of the Year (<a href="http://www.rcgp.org.uk/researchawards">http://www.rcgp.org.uk/researchawards</a>) awards from the Royal College of General Practitioners.</span></em></p>The Pap smear test is used for screening for cancer, but it could be repurposed for diagnosing cervical cancer, according to new research.Anita Lim, Cancer epidemiologist, Queen Mary University of LondonLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/740772017-03-09T19:23:31Z2017-03-09T19:23:31ZFive myths about the new cervical screening program that refuse to die<figure><img src="https://images.theconversation.com/files/160114/original/image-20170309-21034-c9ch1o.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Women are confused about what changes to the cervical screening program will mean for their sexual health.</span> <span class="attribution"><span class="source">from shutterstock.com</span></span></figcaption></figure><p>The <a href="https://www.change.org/p/malcolm-turnbull-stop-may-1st-changes-to-pap-smears-save-women-s-lives?source_location=minibar">online petition</a> against changes to Australia’s <a href="http://www.cancerscreening.gov.au/internet/screening/publishing.nsf/Content/cervical-screening-1">cervical cancer screening program</a> has revealed more than 70,000 people (most of whom we could assume are women) are deeply concerned about what the upcoming changes mean.</p>
<p>Their comments also reveal a number of misconceptions about the new screening program, which will now be rolled out in <a href="http://www.health.gov.au/internet/main/publishing.nsf/Content/mr-yr17-dept-dept002.htm">December 2017</a>, rather than in May as planned.</p>
<p>It seems that in concentrating on the science behind shifting away from Pap smears every two years to <a href="http://www.cancerscreening.gov.au/internet/screening/publishing.nsf/content/future-changes-cervical">testing for the human papillomavirus (HPV) every five years</a>, our medical authorities have <a href="https://theconversation.com/delays-and-confusion-cloud-roll-out-of-new-cervical-cancer-screening-program-73605">failed to convince</a> many Australian women this move <a href="https://theconversation.com/recommended-cervical-screening-regime-will-save-even-more-lives-26034">will save lives</a>.</p>
<p>Convincing women to come on board is, of course, critical to the success of the new screening program, which is forecast to <a href="http://www.thelancet.com/pdfs/journals/lanpub/PIIS2468-2667%2817%2930007-5.pdf">improve cervical cancer detection rates</a> by at least 15% and is <a href="http://www.smh.com.au/comment/the-end-of-the-pap-smear-is-good-news-for-women-20170227-gum0q2.html">good news for women</a>.</p>
<p>So let’s have a look at some common misconceptions and concerns about <a href="http://www.nps.org.au/__data/assets/pdf_file/0016/310534/HPV-testing-for-primary-cervical-screening.pdf">changes</a> to the cervical cancer screening program raised by some of my patients and by the many people signing up to the <a href="https://www.change.org/p/malcolm-turnbull-stop-may-1st-changes-to-pap-smears-save-women-s-lives?source_location=minibar">change.org petition</a>.</p>
<h2>Myth #1: no more Pap tests means no more invasive examinations</h2>
<p>Quite a few of my patients have thought the new screening program means the end of invasive examinations. And I say “unfortunately not”. For most women the collection procedure will be exactly the same as before. This means you will still have to lie on a couch and a doctor or nurse will still insert the dreaded speculum. This instrument is needed to hold the vaginal walls gently apart so that the cervix at the end of the vagina can be seen. </p>
<p>Two small brushes are used to sample cells from both the outside of the cervix and from the opening which leads up to the uterus. Rather than the specimen being smeared on a slide (as with Pap smears), the two brushes are swizzled around in a preservative liquid, which separates out most of the collected cells and any HPV, the virus responsible for <a href="https://www.ncbi.nlm.nih.gov/pubmed/10451482">at least 99.7%</a> of cervical cancers.</p>
<p>But it’s not until the specimen gets to the pathology lab that the process really changes.</p>
<p>First, the specimen is checked for HPV and only if HPV is present will cells be examined for signs of pre-cancer or cancer. </p>
<p>There is also the option for women who have previously avoided having Pap tests for cultural, religious or personal reasons to collect their own HPV sample. It is estimated that even if a woman has only <a href="https://www.ncbi.nlm.nih.gov/pubmed/26985849">one self-collected test</a> at age 30 she reduces her risk of cervical cancer by about 40%.</p>
<h2>Myth #2: the new test could miss types of cervical cancer not related to HPV</h2>
<p>Almost 85% of cervical cancers are actually skin cancers, triggered not by the sun but by HPV. This type of cervical cancer usually takes about <a href="http://www.who.int/mediacentre/factsheets/fs380/en/">15-20 years</a> to develop. So, HPV testing gives us a chance to detect potential problems long before there is anything to see on a Pap test. </p>
<p>In the new program, women who carry the highest risk HPV types will then have their cells examined using a more sensitive test known as liquid-based cytology. They will also be automatically referred to a gynaecologist for further tests. If other kinds of HPV are found, a check whether the cells show any changes will guide whether the woman is referred for other tests or simply monitored more closely. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/159912/original/image-20170308-27341-1f9p2dt.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/159912/original/image-20170308-27341-1f9p2dt.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/159912/original/image-20170308-27341-1f9p2dt.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/159912/original/image-20170308-27341-1f9p2dt.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/159912/original/image-20170308-27341-1f9p2dt.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/159912/original/image-20170308-27341-1f9p2dt.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/159912/original/image-20170308-27341-1f9p2dt.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">The new screening program relies on detecting human papillomavirus (HPV), which cause the vast majorities of cervical cancers.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/download/confirm/391299166?src=JfnpCIQhNAVe0XK5cR8iCQ-2-64&size=medium_jpg">from www.shutterstock.com</a></span>
</figcaption>
</figure>
<p>Some 15% of cervical cancers start in glandular cells. HPV also triggers these cancers but they are often beyond the reach of the little brushes used to collect cells in a Pap test. They can hide away quietly, growing and spreading for many years before they are detected. </p>
<p>When you hear of someone diagnosed with cervical cancer after previously normal Pap tests it is almost always a <a href="https://www.jostrust.org.uk/forum/cervical-cancer-newly-diagnosed/smear-missed-my-cancer-anyone-else-out-there-same">glandular-type cancer</a>. </p>
<p>The good news is that HPV testing should pick up this kind of cancer earlier and more reliably than a regular Pap test.</p>
<p>There are also some very rare cervical cancers (less than 1%) that start off from muscle, nerve or pigment cells deep within the cervix and are not related to HPV infection. It is true that the new screening program is not designed to detect these types of cancer but then they were also almost impossible to detect on a traditional Pap test as well.</p>
<h2>Myth #3: young women will miss out on early detection if screening starts at 25</h2>
<p>There are many online testimonies from women signing the change.org petition saying they had cervical cancer before the age of 25. It is more likely that most of these were pre-cancerous changes because cervical cancer in this age group is really rare – around <a href="https://cervical-cancer.canceraustralia.gov.au/statistics">1.7 in 100,000</a> Australian women under 25.</p>
<p>Unfortunately, in the nearly 30 years our present screening program has been running there has been <a href="https://www.mja.com.au/journal/2016/205/8/impact-australian-national-cervical-screening-program-women-different-ages">no significant impact</a> on the numbers of cervical cancers reported in Australian women under 25. </p>
<p>Another complication in this younger age group is that cellular changes may look worse than they actually are because of a robust immune reaction to the HPV infection. Unfortunately this can lead to well-meaning advice to treat changes that are very likely to get better on their own.</p>
<h2>Myth #4: less cervical testing reduces the chances of picking up other cancers such as ovarian and uterine cancer</h2>
<p>Pap tests were designed to pick up pre-cancerous changes in the cells of the cervix. They are absolutely useless at detecting endometriosis, polyps, ovarian cancer or sexually transmitted infections other than HPV. They occasionally pick up uterine cancer if it is advanced enough for the cells to be shedding through the cervix that day. </p>
<p>The important point here is that screening tests are only for women with no symptoms. If a woman develops symptoms, such as irregular bleeding, pain or abnormal vaginal discharge, she needs to see her doctor for advice regardless of when she had her last cervical screening test. </p>
<h2>Myth #5: the government is motivated by a cheaper option and will shift the costs of the test to the woman herself</h2>
<p>The new tests are more expensive than a traditional Pap test, but because they are so much more sensitive there is no need to do them as frequently. </p>
<p>They will be funded under Medicare just as the Pap test is now. Any out-of-pocket costs depend on whether health care providers bulk bill (as they often do with screening tests) or charge the scheduled fee.</p><img src="https://counter.theconversation.com/content/74077/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Terri Foran does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>There is a lot of misinformation about the government’s new cervical cancer screening program that involves less frequent tests. Here are the facts.Terri Foran, Lecturer in the School of Women's and Children's Health, UNSW SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/736052017-02-28T01:28:42Z2017-02-28T01:28:42ZDelays and confusion cloud roll-out of new cervical cancer screening program<figure><img src="https://images.theconversation.com/files/158464/original/image-20170227-27378-19j2afc.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Women are confused about how the new test for human papillomavirus (HPV), pictured here, will help them prevent cervical cancer. Let's fix that.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/download/confirm/384228760?src=xBaqrpZc9AFre8W2uFNr6g-1-67&size=medium_jpg">from www.shutterstock.com</a></span></figcaption></figure><p>Australia’s new <a href="http://www.cancerscreening.gov.au/internet/screening/publishing.nsf/Content/cervical-screening-1">national cervical cancer screening program</a> has had a bad week.</p>
<p>The government <a href="http://www.health.gov.au/internet/main/publishing.nsf/Content/mr-yr17-dept-dept001.htm">announced it would delay</a> the May 1 roll-out of its new program until <a href="http://www.health.gov.au/internet/main/publishing.nsf/Content/mr-yr17-dept-dept002.htm">Dec 1, 2017</a>. And a <a href="https://www.change.org/p/malcolm-turnbull-stop-may-1st-changes-to-pap-smears-save-women-s-lives?recruiter=9728543&utm_source=share_petition&utm_medium=facebook&utm_campaign=autopublish&utm_term=mob-xs-share_petition-reason_msg">petition</a> opposing the new program swept social media.</p>
<p>But it’s not all bad news. The delay gives the <a href="http://www.cancerscreening.gov.au/internet/screening/publishing.nsf/Content/standing-committee-on-screening">Standing Committee on Screening</a>, which is responsible for implementing the <a href="http://www.cancerscreening.gov.au/internet/screening/publishing.nsf/Content/E6A211A6FFC29E2CCA257CED007FB678/$File/Executive%20Summary%20notated%2013.6.14.pdf">new program</a>, the chance to engage with the public and communicate why the changes are being made and what they mean.</p>
<p>If the online petition is anything to go by, this is badly needed to counter the widespread misunderstanding of the <a href="https://theconversation.com/recommended-cervical-screening-regime-will-save-even-more-lives-26034">new cervical screening program</a> and the role of human papillomavirus (HPV) in causing cervical cancer.</p>
<h2>How did we get here?</h2>
<p>In 2014 the <a href="http://www.msac.gov.au/">Medical Services Advisory Committee</a> recommended the national cervical screening program be “<a href="http://www.cancerscreening.gov.au/internet/screening/publishing.nsf/Content/overview-of-the-renewal">renewed</a>” to provide better protection against cervical cancer.</p>
<p>Key <a href="http://www.cancerscreening.gov.au/internet/screening/publishing.nsf/Content/MSAC-recommendations">changes</a> included raising the screening age to 25 and replacing Pap tests every two years with HPV tests every five years. The HPV test is more accurate than the existing Pap test, which looks for abnormal cells on the cervix rather than HPV, and its accuracy means <a href="https://theconversation.com/recommended-cervical-screening-regime-will-save-even-more-lives-26034">it is safer</a> for women to go longer between tests. </p>
<p>Another important change is setting up a national cancer screening <a href="http://www.health.gov.au/internet/main/publishing.nsf/Content/National-Cancer-Screening-Register">register</a> to record people’s cervical cancer screening histories.</p>
<p>But last week, Commonwealth Chief Medical Officer Brendan Murphy <a href="http://www.health.gov.au/internet/main/publishing.nsf/Content/mr-yr17-dept-dept001.htm">announced</a> the <a href="https://theconversation.com/telstra-health-will-hold-australians-cancer-details-so-we-need-to-ensure-their-privacy-is-protected-60104">Telstra Health-managed register</a> would not be ready for May.</p>
<p>As a result, the new cervical screening test will not be made available on the Medicare Benefits Schedule from May 1; instead, the health department advised women continue to be screened using the existing Pap test.</p>
<h2>Online petition shows women want to know more</h2>
<p>The past week saw 70,000 people (so far) sign an <a href="https://www.change.org/p/malcolm-turnbull-stop-may-1st-changes-to-pap-smears-save-women-s-lives?recruiter=9728543&utm_source=share_petition&utm_medium=facebook&utm_campaign=autopublish&utm_term=mob-xs-share_petition-reason_msg">online petition</a> opposing the changes to the cervical screening program.</p>
<p>The letter accompanying the petition, since removed, unfortunately misrepresented the effectiveness of screening women <a href="https://theconversation.com/cervical-cancer-screening-shouldnt-start-until-25-11314">under the age of 25</a>, the <a href="https://www.cancer.gov/about-cancer/causes-prevention/risk/infectious-agents/hpv-fact-sheet">role of HPV</a> as the cause of cervical cancer and the rationale behind the new screening program.</p>
<p>The petition struck a chord and quickly gathered steam.</p>
<p>In an <a href="http://www.smh.com.au/national/health/petition-against-cervical-screening-changes-woefully-misinformed-says-ama-20170223-gujtda.html">interview</a>, the person behind the petition said she was motivated by “concern and worry”, because “[she] didn’t know about it and no one seemed to know about it”, and because “[she’d] love someone to be able to get down on our level and explain the testing”.</p>
<p>Responses to her petition indicated widespread concern about safety of the new starting age and the wider screening interval. In addition, women perceived the renewed program as a cutback – that less screening is being driven by cost-savings rather than the availability of a <a href="https://theconversation.com/recommended-cervical-screening-regime-will-save-even-more-lives-26034">better test</a>. </p>
<p>A <a href="https://ama.com.au/ausmed/cervical-cancer-screening">response</a> from Michael Gannon for the Australian Medical Association provided a large number of facts.</p>
<p>It also portrayed the petitioners as “well-intentioned […] but woefully misinformed and misguided”, but did not respond to the factors motivating the anger in many petition comments.</p>
<h2>How to handle concerns?</h2>
<p>Petitioners’ concerns <a href="https://theconversation.com/how-to-cut-through-when-talking-to-anti-vaxxers-and-anti-fluoriders-72504">should not be dismissed</a>. If the public is “misinformed and misguided” about changes to cervical screening, it is the result of a failure to effectively communicate the changes and their rationale. </p>
<p>An implementation phase was to be undertaken that included engaging with the public to assess acceptability and educating clinicians and women about the changes. No public information has been released about this phase, so it is not clear what has been done or who may have been consulted.</p>
<p>Other countries that have introduced HPV testing to their cervical screening programs have noted the importance of <a href="http://jfprhc.bmj.com/content/41/2/134">responding to women’s concerns</a> around screening changes, especially when and how they receive information about HPV. Research also
highlights some people’s <a href="http://www.amjmed.com/article/S0002-9343(04)00668-0/abstract">reluctance</a> to accept less-frequent screening.</p>
<h2>How do we communicate change?</h2>
<p>Screening programs generally change because the evidence about screening changes. It’s a good thing for screening programs to be responsive, to make adjustments when it becomes apparent harms may be occurring, or that benefits can be retained with less burden on participants and the health system. </p>
<p>Now, with the delay to the cancer screening register, there is an opportunity to take seriously the responsibilities of a screening program to communicate well with the population it serves. </p>
<p>The epidemiology that guides screening is complex, but its simple communication is a vital part of any public health program. Good communication and understanding what matters to stakeholders are as important as the scientific evidence that programs are based on. </p>
<p>In this case, a reasonable message to take from the petition opposing the renewal is that communication and consultation have not been sufficient or effective.</p>
<p>Unfortunately, this seems to have become a feature of Australian health policy. For instance, last year people were confused about <a href="https://theconversation.com/true-blood-cutting-through-confusion-about-pathology-cuts-55140">pathology rebates</a> and <a href="https://theconversation.com/confused-about-the-medicare-rebate-freeze-heres-what-you-need-to-know-59661">GP rebate freezes</a>.</p>
<p>Meaningful public engagement and communication are neither easy nor cheap, but shying away from them is not an acceptable response.</p><img src="https://counter.theconversation.com/content/73605/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Sally Wortley was part of the evaluation team that conducted the review of the clinical effectiveness evidence for the National Cervical Cancer Screening Renewal.</span></em></p><p class="fine-print"><em><span>Jane Williams does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>The roll-out of a new screening program for cervical cancer has been delayed, leaving Australian women understandably confused about if or when they need Pap smears. Here’s what they need to know.Jane Williams, Researcher at the Centre for Values, Ethics and the Law in Medicine (VELiM), University of SydneySally Wortley, Research Fellow and PhD candidate School of Public Health, University of SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/613602016-06-27T23:53:29Z2016-06-27T23:53:29ZElection FactCheck: has the Coalition cut bulk-billing for pathology and scans ‘to make patients pay more’?<blockquote>
<p>In their first term in office the Liberals … cut bulk-billing payments for pathology and diagnostic imaging to make patients pay more. – <strong>Shadow health minister Catherine King, <a href="http://www.catherineking.com.au/media/malcolm-cannot-be-trusted-on-medicare/">media release</a>, June 20, 2016.</strong></p>
</blockquote>
<p>The opposition has released political ads accusing the government of planning to privatise Medicare and warning of higher health costs in future – a campaign Prime Minister Malcolm Turnbull has <a href="http://www.news.com.au/national/federal-election/scare-campaign-could-hamper-attempts-to-boost-medicares-efficiency/news-story/fe9e1ae2b30ee2e2f8ec9aa817448579">called</a> “extraordinarily dishonest.” </p>
<p>As part of Labor’s Medicare campaign, shadow health minister Catherine King said that the government has “cut bulk-billing payments for pathology and diagnostic imaging to make patients pay more”. Incentives worth between $1.40 to $3.40 are paid direct to pathology service providers to encourage them to bulk-bill. </p>
<p>Is King right?</p>
<h2>Checking the source</h2>
<p>The Conversation asked Labor campaign media for sources to support Catherine King’s statement but did not hear back before deadline. </p>
<p>Health Minister Sussan Ley has <a href="http://www.health.gov.au/internet/ministers/publishing.nsf/Content/health-mediarel-yr2016-ley001.htm">argued</a> that bulk-billing incentives are not meant to be used to cross-subsidise other costs of doing business for <a href="https://theconversation.com/true-blood-cutting-through-confusion-about-pathology-cuts-55140">large companies</a> – some of which are owned by private equity firms – at a time when health care costs are growing.</p>
<h2>From ‘Don’t Kill Bulk Bill’ to a deal on rent</h2>
<p>In its December 2015 <a href="http://www.budget.gov.au/2015-16/content/myefo/download/MYEFO_2015-16_Final.pdf">Mid-Year Economic Fiscal Outlook</a>, the Coalition government announced a suite of bulk-billing changes aimed at saving $650 million over four years. It proposed removing bulk-billing incentives for pathology and diagnostic imaging services.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/127652/original/image-20160622-19786-1usxxbd.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/127652/original/image-20160622-19786-1usxxbd.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/127652/original/image-20160622-19786-1usxxbd.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=440&fit=crop&dpr=1 600w, https://images.theconversation.com/files/127652/original/image-20160622-19786-1usxxbd.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=440&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/127652/original/image-20160622-19786-1usxxbd.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=440&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/127652/original/image-20160622-19786-1usxxbd.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=553&fit=crop&dpr=1 754w, https://images.theconversation.com/files/127652/original/image-20160622-19786-1usxxbd.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=553&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/127652/original/image-20160622-19786-1usxxbd.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=553&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption"></span>
<span class="attribution"><a class="source" href="http://www.budget.gov.au/2015-16/content/myefo/download/MYEFO_2015-16_Final.pdf">MYEFO 2015-16</a></span>
</figcaption>
</figure>
<p>Pathology Australia, which includes big players such as Genea and Sonic Healthcare Group among its members, has been central to how this issue has unfolded. Pathology Australia says its member organisations perform a majority of pathology testing within the private sector.</p>
<p>Pathology Australia collected nearly 600,000 signatures for its “<a href="http://www.dontkillbulkbill.com/">Don’t Kill Bulk Bill</a>” campaign, which warned that patients would face expensive pap smears and other costly tests due to government’s removal of the bulk-billing incentive for pathology services.</p>
<p>In May, Pathology Australia <a href="http://www.pathologyaustralia.com.au/2016/05/13/patients-win-in-pathology-announcements/">closed</a> its Don’t Kill Bulk Bill campaign after striking a <a href="https://www.liberal.org.au/latest-news/2016/05/13/coalitions-plan-access-affordable-pathology-all-australians">deal</a> with the government, aimed at ensuring pathology service providers who co-located their collection rooms inside a GP’s building were charged “fair market value” rents.</p>
<p>The bulk-bill incentive removal is still going ahead, but the idea is that many pathology service providers may now be better able to absorb the cost if they’re getting a cheaper deal on rent – instead of passing the extra cost onto patients. </p>
<p>Nick Musgrave, president of Pathology Australia, told The Conversation that:</p>
<blockquote>
<p>Decisions regarding billing practices are made by individual pathology providers … The regulatory changes announced by the Coalition to control excessive rents for pathology collection rooms will enable providers to more readily maintain current billing practices as would the maintenance of current funding. In the absence of either of these measures, providers had indicated they would not have been able to maintain current high levels of bulk-billing.</p>
</blockquote>
<p>Musgrave said the deal to regulate rents for collection rooms will “more readily enable pathologists to maintain current billing practices” whether or not they are members of Pathology Australia. (You can read his full response <a href="http://theconversation.com/full-response-from-pathology-australia-61438">here</a>.)</p>
<p>But some other pathology service providers have said the deal with the government doesn’t take them into account.</p>
<h2>Not all pathologists</h2>
<p>Pathology is no longer a small industry, with the Sonic group reporting annual revenue of about <a href="http://www.sonichealthcare.com/about-us/corporate-overview/">$4 billion</a> – but not all businesses are on this scale.</p>
<p>Catholic Health Australia is one of the service providers that says the deal doesn’t take them into account. This group also represents pathology service providers, including many in regional and rural areas.</p>
<p>According to its spokesman:</p>
<blockquote>
<p>Independent and not-for-profit pathology providers may have to adopt co-payments simply in order for their services to remain viable … Turnbull’s deal with ‘the pathology sector’ was made without taking not-for-profit providers into account.</p>
</blockquote>
<p>The group said that the rents deal will:</p>
<blockquote>
<p>disproportionately assist the larger corporate providers and will not be sufficient to adequately offset the cuts imposed on smaller providers by removing the bulk-billing incentives.</p>
</blockquote>
<p>You can read Catholic Health Australia’s full comment <a href="http://theconversation.com/full-response-from-catholic-health-australia-61439">here</a>.</p>
<p>So, whether or not you’ll pay more for pathology tests after July 1 depends mostly on who owns that practice or pathology service provider, and whether they can afford to absorb the cost of the changes themselves or choose to pass on these costs to patients.</p>
<p>Labor has <a href="http://www.smh.com.au/federal-politics/federal-election-2016/federal-election-labor-promises-to-continue-funding-bulkbilling-incentives-for-pathology-radiology-20160618-gpmd3m.html">pledged</a> to reverse cuts to the Medicare Benefits Schedule pathology bulk-billing incentives – which it believes will improve access to bulk-billed pathology services, but would also drive up the cost to taxpayers. </p>
<p>Others, such as the Grattan Institute, <a href="http://grattan.edu.au/wp-content/uploads/2016/02/935-blood-money.pdf">argue that</a> there are ways save money in pathology, saying that:</p>
<blockquote>
<p>patient co-payments for tests should be abolished. Patients aren’t the real consumers of pathology tests – the doctors who order and use them are. </p>
</blockquote>
<h2>What about scans?</h2>
<p>The rents deal struck between the government and Pathology Australia doesn’t cover scans.</p>
<p>Australian Diagnostic Imaging Association (ADIA), which represents private providers of radiology services, <a href="http://www.adia.asn.au/public/3/system/newsAttachments/ADIA%20Pathology%20Deal%20Response%20May16.pdf">said</a> the rents deal was “cold comfort for the millions of patients needing vital radiology services”. </p>
<p>The government plans to remove bulk-billing incentive payments for radiology services in January 2017. However, ADIA has <a href="http://www.adia.asn.au/public/3/system/newsAttachments/050616_FINAL_ADIA%20welcomes%20Coalition%20commitment%20on%20access%20to%20diagnostic%20i%20....pdf">secured</a> a commitment from the government to “work with the diagnostic imaging sector on structural reforms to provide patients with certainty on affordable access to services”.</p>
<p>The review will happen before January 2017.</p>
<p>ADIA has also said that patient rebates for diagnostic imaging have been frozen since 1998, with patient gaps now averaging <a href="http://www.adia.asn.au/public/3/files/ADIA%20Rebate%20Response%2031May16.pdf">$100</a>, and has voiced concern that Labor’s pledge to reverse the decision to remove the bulk-billing incentive does not go far enough. Labor has said it will restore indexation in January 2017 to all services provided by GPs, allied health and other health practitioners and medical specialists – but that scans are not included.</p>
<p>ADIA has <a href="http://www.adia.asn.au/public/3/system/newsAttachments/100616%20ADIA%20calls%20Labor%20failure%20to%20index%20DI%20a%20broken%20promise%20on%20Medicare....pdf">called</a> on Labor to expand its indexation election promise to include diagnostic imaging service providers too.</p>
<h2>Verdict</h2>
<p>Catherine King was right to say that in its first term of office, the Coalition government cut bulk-billing payments for pathology and diagnostic imaging. That is scheduled to come into effect on July 1, 2016, for pathology services and in January 2017 for radiology services.</p>
<p>But the second part of her statement – “to make patients pay more” – didn’t tell the whole story. Pathology Australia’s deal with the government on rent regulation means some pathologists may be able to keep bulk-billing. Others, however, may not. </p>
<p>Whether or not patients will pay more as a result of the bulk-billing incentive removal depends on whether your pathology or radiology service provider passes on the cost to customers. <strong>– Helen Dickinson</strong></p>
<hr>
<h2>Review</h2>
<p>This is a sound FactCheck. I would further note that the Grattan Institute <a href="http://grattan.edu.au/wp-content/uploads/2016/02/935-blood-money.pdf">reports</a> that almost 99% of pathology tests for out-of-hospital patients are bulk-billed, an increase from 93% a decade ago.</p>
<p>St John of God, a large not-for-profit health group, is <a href="http://www.clinicallabs.com.au/media/1037/australian-clinical-labs-media-statement-22nd-june-2016.pdf">selling</a> its pathology operations to Clinical Labs. The removal of the bulk-billing incentive payment may have put them in a position where they would have passed increased costs onto patients. </p>
<p>The unmentioned driver behind the rising cost to the health budget of pathology bulk-billing is clinicians practising <a href="http://www.racgp.org.au/afp/2014/may/we-live-in-testing-times/">defensive medicine</a> – GPs and specialists reasonably ordering tests “to be sure” or “safe”, even where it may not be needed.<strong>– Bruce Baer Arnold</strong></p>
<hr>
<p><div class="callout"> Have you ever seen a “fact” worth checking? The Conversation’s FactCheck asks academic experts to test claims and see how true they are. We then ask a second academic to review an anonymous copy of the article. You can request a check at checkit@theconversation.edu.au. Please include the statement you would like us to check, the date it was made, and a link if possible.</div></p><img src="https://counter.theconversation.com/content/61360/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Helen Dickinson receives funding from the federal Department of Health.
</span></em></p><p class="fine-print"><em><span>Bruce Baer Arnold does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Labor’s shadow health minister Catherine King, said that the government has “cut bulk-billing payments for pathology and diagnostic imaging to make patients pay more”. Is that right?Helen Dickinson, Associate Professor, Public Governance, The University of MelbourneLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/590212016-05-16T09:07:54Z2016-05-16T09:07:54ZHere’s a new way to look at your vagina – it might just save your life<figure><img src="https://images.theconversation.com/files/121576/original/image-20160506-32040-rwy5du.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Wearable tech is heading between women's legs.</span> <span class="attribution"><span class="source">Ko-Le Chen/TeresaAlmeida</span>, <span class="license">Author provided</span></span></figcaption></figure><p>Oh vagina, how do I name thee? Let me count the ways. From private parts to lady bits, clunge to chuff, fanny to minge, yoni to yum yum, the list of names given to female genitalia is <a href="http://www.theguardian.com/world/2015/aug/01/sweden-girls-genitals-feminist-invention-snippa-vagina">seemingly endless</a> and often verging on the ridiculous. </p>
<p>With vaginal metaphors and euphemisms depicting female genitalia as scary, ugly or off limits, it’s not surprising a large number of women and girls struggle to identify parts of their own genitalia – with just <a href="http://www.dailymail.co.uk/health/article-2739552/Just-HALF-women-locate-vagina-diagram-female-reproductive-system.html">half of women surveyed able to correctly locate the vagina</a> on a diagram of the female reproductive system.</p>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/121577/original/image-20160506-32047-1dxli9e.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/121577/original/image-20160506-32047-1dxli9e.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/121577/original/image-20160506-32047-1dxli9e.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=856&fit=crop&dpr=1 600w, https://images.theconversation.com/files/121577/original/image-20160506-32047-1dxli9e.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=856&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/121577/original/image-20160506-32047-1dxli9e.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=856&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/121577/original/image-20160506-32047-1dxli9e.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1076&fit=crop&dpr=1 754w, https://images.theconversation.com/files/121577/original/image-20160506-32047-1dxli9e.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1076&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/121577/original/image-20160506-32047-1dxli9e.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1076&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Labella in action.</span>
<span class="attribution"><span class="license">Author provided</span></span>
</figcaption>
</figure>
<p>But <a href="http://dl.acm.org/citation.cfm?id=2858187&CFID=784022429&CFTOKEN=33468873">our recent research</a> is hoping to change all this. We have designed a phone app called <a href="http://dl.acm.org/citation.cfm?id=2858119&CFID=784022429&CFTOKEN=33468873">Labella</a>, which combines a piece of underwear and a mobile phone – allowing the user to get to know their own anatomy through the medium of a smart phone.</p>
<p>Initially designed with a wide range of women in mind, future developments will be aimed at young women, providing them with an educational tool which will enable them to get to know their bodies in a way that feels comfortable and knowledge driven.</p>
<h2>Knowing what’s normal</h2>
<p>Being inadequately informed about the appearance and function of female anatomy, along with the social taboo surrounding female genitalia has led to many women feeling uncomfortable when it comes to <a href="http://www.nhs.uk/Livewell/vagina-health/Pages/vagina-health.aspx">caring for</a> and being aware of their intimate parts. Because realistically how can women understand these parts of their bodies when we don’t even know how to name them properly?</p>
<p>Given this attitude towards female genitalia, it’s unsurprising then that we know so little about the clitoris given it’s not in textbooks or even <a href="http://femmagazine.com/2014/11/29/sex-ed-in-schools-and-the-mysterious-down-there/">covered in sex education</a>. And with <a href="http://www.independent.co.uk/news/world/americas/teen-labiaplasty-surgery-is-on-the-rise-as-adolescents-worry-about-appearance-and-symmetry-a7006081.html">labia surgery now the latest trend among teenage girls</a>, it’s clear the worlds of <a href="http://www.dailymail.co.uk/news/article-3562856/The-number-teenage-girls-getting-surgery-designer-vaginas-DOUBLES-year-doctors-blame-porn-poor-sex-education.html">porn and advertising</a> have collided, leaving women with yet more insecurities about their bodies – this time focused on the vagina.</p>
<p><a href="https://nursingclio.org/2016/01/21/clio-reads-a-review-of-it-hurts-down-there-the-bodily-imaginaries-of-female-genital-pain/">Research</a> shows that women tend to avoid “contact” with their genitalia unless they are experiencing pain. With further research showing that women still <a href="https://www.questia.com/library/journal/1G1-154816846/talking-about-down-there-the-politics-of-publicizing">avoid talking about their “private parts”</a> even among other women. What this essentially means is that women are not talking about their genitals because of society’s views of vaginas – mainly as something sexualised and shrouded in mystery.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/121579/original/image-20160506-32044-meqkjb.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/121579/original/image-20160506-32044-meqkjb.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/121579/original/image-20160506-32044-meqkjb.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=153&fit=crop&dpr=1 600w, https://images.theconversation.com/files/121579/original/image-20160506-32044-meqkjb.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=153&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/121579/original/image-20160506-32044-meqkjb.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=153&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/121579/original/image-20160506-32044-meqkjb.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=192&fit=crop&dpr=1 754w, https://images.theconversation.com/files/121579/original/image-20160506-32044-meqkjb.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=192&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/121579/original/image-20160506-32044-meqkjb.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=192&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">How Labella looks on the screen.</span>
<span class="attribution"><span class="license">Author provided</span></span>
</figcaption>
</figure>
<p>Take urinary incontinence, the involuntary loss of urine that is <a href="http://www.bbc.co.uk/programmes/p00v1279">estimated to affect up to a third of women in the UK alone</a>. Incontinence is generally accepted as a consequence of childbirth and or ageing. It is regarded as “<a href="https://www.caring.com/questions/adult-incontinence">normal</a>”, just as menstruation is once a month and menopause once in every lifetime, and yet no one really talks about it. </p>
<h2>Tech to the rescue?</h2>
<p>Clinical health care has seen few technological breakthroughs in either its interventions or devices, which can be seen in the use of <a href="http://dspace.lafayette.edu/xmlui/bitstream/handle/10385/589/Rossmann-Ambidextrous-vol10-2008.pdf?sequence=1">the Graves and Pederson “duckbill” specula</a>. This device was originally designed in 1878 and it remains in use today. Cervical screenings or smear tests use <a href="http://www.theatlantic.com/health/archive/2014/11/why-no-one-can-design-a-better-speculum/382534/">this vaginal speculum</a> to dilate the vaginal walls to enable inspection of the cervix – which are meant to be quick and easy tests to carry out. </p>
<figure class="align-left ">
<img alt="" src="https://images.theconversation.com/files/121581/original/image-20160506-32047-alu7vz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/121581/original/image-20160506-32047-alu7vz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=553&fit=crop&dpr=1 600w, https://images.theconversation.com/files/121581/original/image-20160506-32047-alu7vz.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=553&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/121581/original/image-20160506-32047-alu7vz.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=553&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/121581/original/image-20160506-32047-alu7vz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=695&fit=crop&dpr=1 754w, https://images.theconversation.com/files/121581/original/image-20160506-32047-alu7vz.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=695&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/121581/original/image-20160506-32047-alu7vz.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=695&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Up close and personal.</span>
<span class="attribution"><span class="license">Author provided</span></span>
</figcaption>
</figure>
<p>But it is often considered to be <a href="http://www.telegraph.co.uk/women/sex/theres-something-wrong-with-my-vagina-but-im-too-scared-to-see-the-doctor/">unpleasant, embarrassing, fearful and even painful</a> by a lot of women. These are probably some of the reasons why so many women are skipping smear tests – with <a href="http://www.dailymail.co.uk/health/article-2926486/Cervical-cancer-rates-35s-soar-60-number-having-smear-tests-falls-time-low.html">millions of British women failing to attend their screenings</a> every year.</p>
<p>The vagina persists as an “uncomfortable” social and personal topic, perpetuating a culture of shame, secrecy, and lack of awareness, which can be (broadly) damaging to <a href="https://theconversation.com/vulvas-periods-and-leaks-women-need-the-right-words-to-seek-help-for-conditions-down-there-53638">genital integrity and health</a>. </p>
<p>While this discomfort might contribute to the estrangement between women and their genitalia, <a href="https://www.academia.edu/6962248/Vulnerable_Vulvas_Female_Genital_Integrity_in_Health_and_Disease">“having the knowledge and ability to make bodily and verbal distinctions”</a> is critical to women’s reproductive health and sexual well-being. </p>
<p>We hope that Labella will have a role to play in helping to break this cycle of bodily taboos that are barriers to knowledge and self care, while also improving women’s comfort and esteem within a clinical environment – such as at their next smear test.</p>
<p>This development could help to break some of the societal shame that surrounds the female anatomy and could even lead to a decline in the number of women getting diagnosed with cervical cancer. It is the most <a href="http://www.huffingtonpost.co.uk/2016/01/27/cervical-cancer-cases-increase-in-the-uk-_n_9086202.html">common cancer among young women</a>, and is thought to be on the rise due to the number of women missing their smear appointments where early signs of pre-cancerous cells can often be found and treated.</p><img src="https://counter.theconversation.com/content/59021/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Teresa Almeida does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Developers are using wearable tech to help women and girls better understand their bodies.Teresa Almeida, PHD candidate, Newcastle UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/499952015-11-12T03:31:18Z2015-11-12T03:31:18ZWhat’s stopping Nigerian women from being screened for cancer?<figure><img src="https://images.theconversation.com/files/101600/original/image-20151111-9379-v77oko.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Young women in Kano, northern Nigeria. Access to cancer screening in the region is particularly problematic.</span> <span class="attribution"><span class="source">Reuters/Goran Tomasevic </span></span></figcaption></figure><p>Screening for both cervical and breast cancer can save lives. Although many women in northern Nigeria know this, there is still reluctance to undergo these important screenings.</p>
<p>There are a combination of <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3883231/">reasons</a> that explain this. These include the high cost of screening procedures, too few facilities, not enough female healthcare workers to conduct the screenings and a host of sociocultural reasons. </p>
<p>Without Nigeria’s policymakers putting in effort to improve cancer education and change the attitude to screening, women will remain reluctant.</p>
<h2>A global killer</h2>
<p>The mainly rural northern Nigeria, which takes up 79% of the country’s landmass, is home to just under 85 million of the country’s 140 million <a href="http://www.population.gov.ng/index.php/state-population">population</a>. Its 19 states are split between Christian and Muslim majorities, but the north is generally considered more traditional than the south, which has several more<a href="http://dhsprogram.com/pubs/pdf/FR293/FR293.pdf"> densely populated</a> states. </p>
<p>In some states in the north, literacy rates for women are as low as <a href="http://dhsprogram.com/pubs/pdf/FR293/FR293.pdf">5%</a>, compared to the national rate of 51% for women. </p>
<p>Health care in many parts of the north is a challenge. There is a critical <a href="http://healthpartners-int.co.uk/our-projects/women-for-health-nigeria/">shortage</a> of female health workers in several states. Additionally, the country’s northeast zone has the <a href="http://dhsprogram.com/pubs/pdf/FR293/FR293.pdf">highest</a> maternal mortality and morbidity rates in the country. </p>
<p>Cervical cancer, which is the number-one cancer killer in developing countries, is the second most common cancer in <a href="http://link.springer.com/article/10.1007/s12558-012-0212-2">Nigeria</a>. And recent <a href="http://www.cancerepidemiology.net/article/S1877-7821(12)00060-4/abstract">statistics</a> show that Nigeria has a breast cancer incidence of about 54.3 per 100,000 people. This is higher than the expected global estimate of 38.7 per 100,000.</p>
<p>Breast cancer is the most common cancer in women globally, accounting for 16% of all cases. In sub-Saharan Africa, one in four people diagnosed with cancer has breast cancer. And it is responsible for one of the five people cancer <a href="http://globocan.iarc.fr/Pages/fact_sheets_cancer.aspx">deaths</a>. </p>
<h2>The importance of screening</h2>
<p>Detecting cancer early on is important for a better prognosis and survival through timely treatment. Cervical cancer is highly preventable due to its slow progression. Its screening procedures include:</p>
<figure class="align-right ">
<img alt="" src="https://images.theconversation.com/files/101576/original/image-20151111-9366-1kep0mz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/101576/original/image-20151111-9366-1kep0mz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/101576/original/image-20151111-9366-1kep0mz.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/101576/original/image-20151111-9366-1kep0mz.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/101576/original/image-20151111-9366-1kep0mz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/101576/original/image-20151111-9366-1kep0mz.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/101576/original/image-20151111-9366-1kep0mz.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">A pap smear test kit.</span>
<span class="attribution"><span class="source">shutterstock</span></span>
</figcaption>
</figure>
<ul>
<li><p>pap smears;</p></li>
<li><p>visual inspections with acetic acid; </p></li>
<li><p>visual inspection with Lugol’s iodine; and </p></li>
<li><p>human papilloma virus DNA <a href="http://www.ajol.info/index.php/njcp/article/view/75782">testing</a>.</p></li>
</ul>
<p>Similarly, if breast cancer is detected at an early stage, there is a much higher chance of a patient surviving. Screening techniques include:</p>
<ul>
<li><p>clinical breast examination;</p></li>
<li><p>breast self-examinations;</p></li>
<li><p>magnetic resonance imaging; and</p></li>
<li><p><a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4518334/">mammograms</a>.</p></li>
</ul>
<p>Regardless of this, Nigeria has no national policy or organised programmes that promote cancer prevention and encourage cancer screenings for women. Only a few federal hospitals and private clinics have facilities for these screenings.</p>
<p>In some parts of the country, human papilloma virus screening is offered as part of the national program to control sexually transmitted infections and <a href="http://www.seer.ufrgs.br/hcpa/article/view/52764/0">HIV/AIDS</a>. Free periodic screening services are also offered by some private hospitals and NGOs like the <a href="http://www.sfhnigeria.org/projects/ccs-a-pt">Society for Family Health</a> and <a href="http://www.medicaidradiology.com/services.html">Medicaid</a>.</p>
<p>As a result of this, many cancer cases are <a href="http://www.ajol.info/index.php/pamj/article/view/82069/72222">diagnosed</a> at very late stages and women have little to no chance of survival.</p>
<h2>Religion and culture affect screenings</h2>
<p><a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3883231/">Research</a> shows that in northern Nigeria, women are aware of cancer. They get their information from family, friends, the media and hospitals. </p>
<p>But they also have misconceptions about the causes of breast and cervical cancer. These include wearing “iron bras”, holding money in their bras and inserting herbs into their genitals. </p>
<p>Most do not go for screenings. This includes those who are aware of the benefits screenings have in preventing cancer, such as medical students and health professionals. </p>
<p>The women surveyed had a multitude of reasons that prevented them from going for screenings. Aside from the cost of screening, many said there are shortages of facilities and trained female healthcare workers. </p>
<p>This is exacerbated by sociocultural factors. In various cultures and religions, particularly Islam and Christianity, a woman’s body is considered sacred and should only be seen or touched by her spouse. In the absence of female health workers, few women get screened.</p>
<p>Others believed that cancers are punishment from God and that prayer is the only <a href="http://www.omicsonline.org/awareness-attitude-and-practice-of-rural-women-regarding-breast-cancer-in-northeast-nigeria-2161-0711.1000148.php?aid=6491">cure</a>. In addition, the availability of traditional medicine also discouraged access and acceptability of cancer screening.</p>
<p>There were also some that feared positive test results, accusations that they were unfaithful or that their husbands would abandon them. </p>
<h2>Changing the mindset</h2>
<p>In the African tradition, particularly rural areas, people only visit hospitals when they have disease symptoms. Regular health check-ups are very uncommon.</p>
<p>Women are more likely to have cancer screening if they believe they are at risk and getting screened would reduce this <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4518334/">risk</a>. But negative attitudes, such as anxiety, hopelessness and denial of cancer significantly decreases the chances of women having pap smears, regardless of their educational <a href="http://www.seer.ufrgs.br/hcpa/article/view/52764/0">status</a>.</p>
<p>For uptake of cancer screening to be improved, services and trained health professionals are required in primary healthcare centres in <a href="http://file.scirp.org/Html/4-8202297_36318.htm">northern Nigeria</a>.</p>
<p>Accurate information on breast and cervical cancer is also needed in this population. Cultural misconceptions and practices should be addressed appropriately. Campaigns should emphasise and encourage male contribution towards improving cancer screening in northern Nigeria.</p>
<p>Community and religious leaders should also be involved in designing programs specifically tailored for improving practice of breast and cervical cancer <a href="http://leadership.ng/news/377079/woman-die-cervical-cancer">screening</a>.</p><img src="https://counter.theconversation.com/content/49995/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Aisha Mukhtar Dodo does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Women in northern Nigeria are not going for cancer screenings early enough. There are myriad social, cultural and economic reasons for this. But early detection would save their lives.Aisha Mukhtar Dodo, PhD Student, Cardiff Metropolitan UniversityLicensed as Creative Commons – attribution, no derivatives.