Guidance

Topic 1: the NHS Cervical Screening Programme (NHSCSP)

Updated 14 September 2023

Applies to England

1. Topic 1 learning objectives

The trainee should know about:

• population screening programmes
• the aim of the NHS Cervical Screening Programme (NHSCSP)
• the history of the NHSCSP
• the current statistics and important elements in the success of the programme

The trainee should understand:

• the influences on uptake
• the barriers that prevent people from attending their cervical screening test and ways to overcome these
• the recommended routine screening intervals
• why unscheduled screening tests should not be carried out

1.1 Guidance for the trainer

Signpost the trainee to reading and resources on all topics in this section including:

• professional guidance documents for cervical screening
• current dataabout the cervical screening programme
• the research undertaken by Jo’s Cervical Cancer Trust
• Cancer Research UK Cervical cancer incidence statistics
• research by P Sasieni and others, on the benefits of cervical screening at different ages
• information about changes to the human papillomavirus (HPV) vaccine schedule in 2014 to 2015
• UK National Screening Committee (UK NSC) recommendations regarding screening age in the UK

1.2 Teaching resource

Refer to PowerPoint presentation 1 for subject areas in Topic 1 .

2. Population screening programmes

We provide information about all population screening programmes.

We also host:

• an overview of the cervical screening programme
• coverage and data information
• cervical screening information leaflets
• cervical screening professional guidance
• cervical programme standards
• cervical screening education and training information
• guidance on managing incidents
• guidance on ceasing and deferring people from cervical screening (including information on informed consent)

3. Aim of the NHS Cervical Screening Programme (NHSCSP)

The aim of the NHSCSP is to reduce the number of people who develop invasive cervical cancer (incidence) and the number of people who die from it (mortality). It does this by offering regular screening to people aged 24.5 to 64 who have a cervix.

3.1 History of the cervical screening programme

Significant milestones in the NHSCSP include:

• 1960s: cervical screening began
• 1988: the NHSCSP was set up with the introduction of computerised call and recall systems
• 2004: the introduction of liquid-based cytology (LBC), which has significantly reduced the amount of inadequate cervical screening results
• 2008: the introduction of the national HPV vaccination programme
• 2012: the introduction of HPV triage and test of cure
• 2019: the introduction of primary HPV testing in England to replace cytology as the primary screening test
• 2019: the HPV vaccine routinely offered to boys aged 12 to 13

3.2 Current statistics and success of the programme

Refer to the latest cervical screening statistics for:

• the total number of people aged 25 to 64 invited for screening in England
• the number of people aged up to 65 tested in England
• the percentage of eligible people aged 25 to 64 screened at least once in the previous 5 years

Important elements in the success of the programme

Notable accomplishments and functions in the screening programme include:

• the identification and invitation of all eligible people at appropriate screening intervals (eligible people are individuals aged between 24.5 and 64 years who have a cervix)
• the achievement of at least 80% coverage of eligible individuals
• the availability of information for people to help them make an informed choice about screening
• an operating model which describes quality assurance processes that are supported by clear administrative and clinical protocols
• acknowledging and helping to tackle barriers to screening
• being aware of the psychological aspects of intimate examinations

4. The individual’s experience of screening

The sample taker plays a crucial role in the individual’s experience. This includes:

• working together to address any anxieties and put them at ease
• addressing their individual needs both physically and psychologically
• giving accurate information to make an informed choice
• providing a positive cervical screening experience
• explaining, discussing and acting on results
• possible treatment options should the results be abnormal

A negative cervical screening experience frequently results in anxiety about the procedure itself and could potentially stop a person choosing to re-attend. Poor information can result in confusion and anxiety regarding HPV (its links to causing cervical cancer and risk factors around contracting it).

5. Barriers to cervical screening

Issues that can make it hard for people to attend cervical screening include:

• accessibility, including the availability of appointments, finding time to attend (getting an appointment at a convenient time) and choice of where to be screened ( such as a sexual health clinic or GP surgery)
• fear of having the test, due to embarrassment, fear of the test being painful, a previous bad experience at screening, post-natal concerns due to trauma during birth, or a history of sexual assault or rape
• experiencing pain or discomfort during the test (this particularly an issue for post-menopausal people)
• not understanding the relevance of screening, the role of HPV in cervical cancer, or how screening helps prevent cancer
• language barriers, cultural and religious beliefs, community or social pressure and stigma
• sexual orientation and other gender-related issues (for example lesbian women being told they do not need screening)

6. Routine screening intervals

Refer to guidance on cervical screening intervals. An overview of the primary HPV screening pathway accompanies this guidance.

6.1 First and subsequent invitations

We send out a first invitation for routine screening 6 months before the person turns 25. This gives them time to consider attending, and book an appointment by the age of 25.

We send out all subsequent invitations (either 3 yearly or 5 yearly) around 6 weeks before the person’s next test due date.

A delay of several months may occur between the issuing of invitations to people and the date of their screening test. Sending invitations well before test due dates reduces possible delays.

6.2 Transgender (trans) men

Trans men who still have a cervix are eligible for screening. Trans men registered with their GP as female will receive automatic screening invitations. Trans men registered as male do not receive an invitation, but remain entitled to screening and should arrange an appointment with their GP practice every 3 to 5 years (depending on their age).

6.3 People under the age of 24.5

We do not invite people under the age of 24.5 for cervical screening because:

• cervical cancer is very rare in people under 25
• infection with high risk human papillomavirus (hrHPV) is very common in people under 25 and may cause abnormal cell changes of the cervix (for most people these cervical abnormalities will regress as the immune system clears the HPV infection)
• an abnormal screening result and treatment for cervical abnormalities can cause anxiety for many people
• the International Agency for Research on Cancer (IARC) recommends that people should not start cervical screening before the age of 25
• in 2012, the UK NSC advised the NHSCSP that screening under 25 does more harm than good and recommended a consistent screening age across the whole of the UK (from June 2016 all 4 nations screen from age 25)
• the number of younger people diagnosed with cervical cancer is likely to reduce due to the NHS HPV vaccination programme introduced in 2008

6.4 People over age 64

We do not invite people over the age of 64 for cervical screening because:

• the natural history and progression of cervical cancer means that it is highly unlikely that such people will go on to develop the disease; those aged 65 and over who have had 3 consecutive negative tests are taken out of the call and recall system
• people aged 65 and over who have never been screened or have an incomplete screening record are entitled to a test if they request one

6.5 People who are not sexually active

The NHSCSP invites all eligible people between the ages of 24.5 and 64 for cervical screening. If a person has never had sexual contact with a male or female, research evidence shows that their chance of developing cervical cancer is very low. This is not ‘no risk’, only very low risk. In these circumstances, an individual might choose to decline their invitation for cervical screening.

The term ‘sexual contact’ includes:

• vaginal, oral or anal sex
• any skin-to-skin contact that includes the genital area
• sharing sex toys

If a person is not currently sexually active but has had sexual partners in the past, we recommend that they continue to attend for screening.

7. People under age 24 with abnormal vaginal bleeding

Guidance from the Department of Health and Social Care (DHSC) on management of women below screening age who have symptoms of cervical cancer states that people experiencing vaginal bleeding after sex and or in between periods require a pelvic examination.

A trained nurse, doctor or registered physician associate can perform a speculum examination. A trained GP can perform a pelvic examination.

Vaginal bleeding is extremely common and can have a range of causes including normal conditions such as:

• cervical ectropion
• hormonal changes due to the contraceptive pill
• benign cervical polyps
• sexually transmitted infections such as chlamydia

The DHSC guidance explains the types of questions that sample takers need to ask people to establish if their symptoms relate to cervical cancer.

8. Non-NHS cervical screening tests

People who have a sample taken privately remain eligible for screening under the NHS at the standard intervals. As the NHS cannot quality assure private tests, the results of non-NHS tests are not recorded in a person’s NHS screening record.

9. Unscheduled cervical screening tests

Do not carry out additional tests if a person is in the screening age group and has had a test in the previous routine screening interval (3 to 5 years).

Additional tests should not be carried out for someone because they:

• are attending for contraceptive advice or services
• are attending for advice on hormone replacement therapy
• are pregnant or attending for postnatal services
• have genital warts
• have vaginal discharge
• have an infection
• have had multiple sexual partners
• are heavy cigarette smokers
• have a family history of cervical cancer

The laboratory will not accept unscheduled samples, and will reject the test in accordance with the national guidance on sample acceptance. The sample taker should explore the reason(s) for the individual requesting screening and if appropriate, examine and refer accordingly.