Cervical cancer: how nurses can help reverse the fall in screening uptake
Nurses need to allay peoples fears about screening and in doing so could save lives
- One in four women invited to undergo screening failed to respond in 2019-20
- Reasons include embarrassment, anxiety about pain and fear of the results
- COVID-19 pandemic is also thought likely to have increased barriers to screening
Even before the COVID-19 pandemic began, cervical cancer screening figures were failing to reach national targets, yet experts say nurses can play a key role in reversing this trend.
Nurses need to allay people’s fears about screening – and in doing so could save lives
- One in four women invited to undergo screening failed to respond in 2019-20
- Reasons include embarrassment, anxiety about pain and fear of the results
- COVID-19 pandemic is also thought likely to have increased barriers to screening
Even before the COVID-19 pandemic began, cervical cancer screening figures were failing to reach national targets, yet experts say nurses can play a key role in reversing this trend.
Data shows that around one in four eligible women or people with a cervix are not responding to invitations for screening to test for high-risk human papilloma virus (HPV), which can cause cervical cells to become abnormal. This figure rises to one in three for those aged 25 to 35.
Public Health England launched a Cervical Screening Saves Lives campaign in March 2019, in the wake of data that showed take-up rates had fallen to a 20-year low.
Key facts on cervical cancer screening
The primary cause of cervical abnormalities and cancer is persistent or chronic infection with one or more of the high-risk types of high-risk human papilloma virus (HPV), which is generally preventable. Cervical cancer accounts for 2% of all new cancer cases in women in the UK, says Cancer Research UK.
In England, around 2,600 women are diagnosed each year, with around 690 dying, says Public Health England (PHE).
In most people who become infected with HPV, infections resolve spontaneously. But for a minority of women the infection leads to abnormal changes to the cervix, which if not treated may progress to cancer ten to 20 years later.
If everyone attended screening regularly, 83% of cervical cancer cases could be prevented, according to an estimate by PHE.
Its research showed that once screened, 87% of women said they were glad they went, while 84% said they were put at ease by the healthcare professional carrying out the test.
People registered as female with a GP are invited to attend a screening appointment by letter. Those who are transgender are also eligible for screening, if they have a cervix.
Screening guidance across the UK
• In England, after a clear result, the guidance is that screening takes place every three years for those aged 25 to 49, decreasing to every five years for those aged 50 to 64
• Wales and Northern Ireland follow the same intervals
• In Scotland, the recommendation changed last year and is now every five years for women aged between 25 and 64
For more details see the RCN guidance Human Papillomavirus (HPV), Cervical Screening and Cervical Cancer
Screening programmes were paused for a while during the COVID-19 pandemic
Figures published by England’s Cervical Screening Programme for 2019-20 show that 3.2 million women were tested, down 6.8% on the previous year. This is despite 4.63 million women aged 25-64 being invited for screening, a 5% increase on the year before.
COVID-19 is likely to have impacted these figures and continues to increase barriers, says the charity Jo’s Cervical Cancer Trust, whose health information manager Imogen Pinnell acknowledges the situation is not where it should be.
‘Screening programmes were paused for a while,’ says Ms Pinnell, referring to the initial impact of the pandemic.
‘In England, we know there were delays with invitations being sent. GP surgeries and clinics are under huge amounts of pressure and weren’t able to accommodate these appointments.’
Practices should be clear with their patients about what is happening locally
Alongside dealing with a backlog from the initial surge, subsequent lockdowns are likely to be exacerbating practical difficulties.
‘After the first wave we were looking at perhaps being able to catch up with all of the missed appointments by this spring, but now we know it will be longer. It’s not a great situation,’ says Ms Pinnell.
Although screening is continuing, it is likely to be patchy and postcode-dependent, she says, with staff availability also key. The charity is urging practices to be clear with their patients about what is happening locally.
‘If they can offer appointments, they need to explain what safety measures are in place,’ says Ms Pinnell.
‘Or if they can’t carry out screening at the moment, they need to let people know when they expect to be able to start again, and what the arrangements will be.’
Tips on reassuring nervous patients
At the outset, patients should feel comfortable to talk, says Jo’s Cervical Cancer Trust health information manager Imogen Pinnell. ‘Nurses need to help patients feel they can have a conversation, establishing a rapport. Without that you can’t put support in place for what the individual needs – you’re just guessing.’
For patients with particular issues, consider offering two appointments rather than one, says Guy’s and St Thomas’ NHS Foundation Trust nurse consultant in gynaecology Debra Holloway. ‘Those who are worried or have had difficulties in the past may need someone they have confidence in to talk to first,’ she says. A conversation over the phone with the person who will be doing the procedure may also help, says Ms Pinnell.
Ask patients how they feel about screening and what their previous experience was like, Ms Pinnell suggests. ‘It helps the patient feel you are genuinely interested and want them to have a good experience,’ she says. Also clearly explain what’s happening, allowing time for questions.
Consider following up those women who don’t attend, asking what the difficulties are and how they might be helped to overcome them. Ms Holloway says: ‘For women at menopause, it’s worth checking to see if it’s been painful for them.’
Give patients control over what happens, says Ms Pinnell. ‘It’s such a vulnerable and private test, giving back control can be very helpful for those who are struggling,’ she says. This may include asking patients if they would like to insert the speculum themselves.
Recognise that barriers may also be physical. ‘For instance, someone who has a disability may struggle to get out of their chair or onto the couch,’ says Ms Holloway. ‘There are often ways around things and solutions can be found, if you can talk it through.’
Remember that while this may be a routine part of your working day, for patients it can be a big deal, says Ms Pinnell. ‘It may be their first time or something they’ve put off for a long time because they’re frightened,’ she says. ‘Treat it as a significant experience and take time.’
Make sure all staff, including those on reception, are involved in discussions about how to make people feel more comfortable about the process, advises Ms Pinnell. ‘If the first point of contact is negative, and they are already worried about the examination, it puts people off.’
Signpost people to other sources of support or counselling, if they have particular issues, says North Wales region lead nurse specialist for cancer screening Linda Wood. ‘Know where you can direct people for extra help.’
Leaving aside the effects of COVID-19, there are various reasons why patients do not accept the offer of screening. These include embarrassment, anxieties about pain, unrealistic expectations of the perfect body and fear of the results.
‘People can also misunderstand the test and think they will be told either they have or don’t have cancer,’ says Ms Pinnell.
Past trauma can have a major influence. ‘Survivors of sexual violence can find it incredibly difficult to be in such a vulnerable position,’ says Ms Pinnell.
There can also be cultural taboos, with some seeing HPV as a sexually transmitted infection. ‘There are so many reasons why someone may not go – but there are solutions,’ she says.
Nurses should work out how to connect with people who don’t respond to screening invitations
Nurses are integral to the patient’s experience, says Ms Pinnell. Alongside focusing on the individual, they should also understand their general population.
‘You need to know the demographics you see most frequently, including whether or not they respond to screening invitations,’ she says. ‘Then you can work out what you need to do to connect with those groups, including how they like to be communicated with.’
Drop-in clinics can be a successful way of reaching women, perhaps held during the evening or weekend and tailored towards those you are trying to target, with information to take away, she says.
‘The message is you’re there primarily to talk, but nurses are on standby if someone wants to have their test there and then,’ says Ms Pinnell. ‘It takes the pressure off. They can meet the staff and it’s a gateway to them asking questions.’
Remind patients they can request who they prefer to carry out the procedure
The charity is also calling for UK cervical screening programmes to innovate and accelerate towards ‘at home’ cervical screening, saying such a move would be a game changer and help reach many more women.
Debra Holloway, nurse consultant in gynaecology and past chair of the RCN women’s health forum, says it’s important to remind patients they can request who they would prefer to carry out the procedure and also let them know they can have a chaperone.
Ms Holloway, who works for Guy’s and St Thomas’ NHS Foundation Trust, says: ‘It needn’t be a painful or stressful process.’
Nurses can play a key role in reducing people’s fears, she believes. Her advice is to ‘try to make it as least frightening as possible’.
Use the opportunity to talk about women’s health generally
Awareness campaigns and open days can help. She also suggests using the opportunity that screening presents to talk about women’s health more generally, raising contraception, sexual health and the menopause as appropriate.
Reaching communities who do not understand the purpose of cervical cancer screening is another challenge for nursing staff. ‘People who move here from countries that don’t have similar programmes may not know about it,’ says Ms Holloway.
‘Generally speaking, there can be a lack of knowledge, with people believing they’re not at risk because they’re too young, too old or have had the HPV vaccination.
‘If you don’t have symptoms, the tendency can be to put off having a test, eventually forgetting all about it.’
#LoveYourCervix campaign targets younger age group
With research showing that the lowest rates of attendance for cervical screening were among the youngest group – around one in three aged 25 to 30 not attending – Cervical Screening Wales (CSW) decided to target them directly.
Using the hashtag #LoveYourCervix, the social media campaign aimed to tackle the embarrassment and body shame that some women reported feeling.
‘It was a social media campaign designed to catch the eye of that specific age group,’ says CSW head of programme Louise Dunk. ‘This is the most common cause of cancer in women under 35.’
Based on research that showed a lack of understanding about screening and why it was important, the campaign – launched in March 2019 – used a variety of creative and light-hearted ways to generate awareness.
This included asking women ‘What do you call yours?’ followed up by the message: ‘Whatever you call yours, look after it. Go for your cervical screening and #LoveYourCervix.’
In addition, a specially made short animation directly addresses the embarrassment some feel, while another film asks beauty therapists which is more uncomfortable – a wax or a smear. ‘A wax – it’s a no-brainer’ is their response.
Discussing screening, one says: ‘It’s nowhere near as bad as you think it’s ever going to be.’ The campaign was successful, slightly increasing numbers. Post-pandemic, the service hopes to launch another campaign targeting women in the oldest age group, who are also less likely to attend appointments.
‘We’re working with the Women’s Institute, who have done a survey to try to understand the reasons why older women don’t attend,’ says Ms Dunk. ‘We know a lot feel that because they’ve had negative smears in the past they are lower risk. But there is another peak of cervical cancer in women aged 70 to 80. We also offer HPV testing now, which is much more accurate, and these women won’t have had that before as it was only introduced in 2018.’
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