The role of the General Practice Nurse (GPN) within the cervical screening programme is evaluated with emphasis on abnormal cytology result. Cervical sample taking started in the 1960s however it was not until 1988 that a national screening programme was introduced in Scotland, with the aim of reducing the rates of cervical cancer. Since it’s introduction there has been an incidence drop of around 24% in the rates of cervical cancer (Cancer Research UK, 2018).
Cervical screening does not detect cancer, it detects cell changes that could develop into malignancy. At this stage changes can be easily and effectively treated (ISD Scotland, 2010). The majority of cervical sample taking is carried out by GPNs. It is important that they are adequately trained. In-depth knowledge in all areas of the screening process is vital to help inform and support women through all stages of the process. It is also necessary to have knowledge about what happens once an abnormal cytology sample has been found and the processes that follow. To ensure a minimum of discomfort and distress, sensitivity and good communication skills are needed at every stage of the process (Greenfield and Pederson, 2011).
The Importance of Cytology Screening
In 2015, cervical cancer accounted for 2% of all new, female, cases of cancer in the UK and is the 14th most common female cancer (Cancer Research UK, 2018). Worldwide, cervical cancer is the second most common female cancer (GOV.UK, 2014). 1964 saw the introduction of cervical screening but initially was opportunistic and not organised until, in 1988, a standardized call-recall system was introduced. Since the 1990s, the trend has been a reduction of 24% in the incidence rates of cervical cancer (Cancer Research UK, 2018), and it has been estimated that mortality rates dropped by about 60% between 1974 and 2004 in the UK (GOV.UK, 2014).
The aim of cervical screening is to detect changes to the cells in the cervix that could then develop into malignancy. Pre-cancerous cervical cells do not cause any symptoms and can only be detected by screening. Cell changes that are detected early can be easily and effectively treated, meaning the cells will never develop to become cancerous (ISD Scotland, 2018). The diagnostic processes are not 100% reliable and false positive or negative results are possible. If screening is carried out at regular intervals, it reduces the risk of pre-cancerous cells being missed (NICE, 2012).
In Scotland, all women aged between 25-64 and registered with a GP are invited to attend for cervical screening. Routine screening is done 3 yearly for those between 25-49 and 5 yearly for those between 50-64 (NHS Health Scotland, 2018). The screening programme changed in 2016 from 20-60-year olds being screened three yearly routinely. Evidence indicated that any cell changes in those under 25 tended to resolve on their own and that investigation led to unnecessary anxiety and treatment. Cervical cancer is rare in those under the age of 25 years. It was also decided that routine screening for women over the age of 50 should be undertaken 5 yearly as this offered good protection to women as this age group has lower risks of developing cervical changes (SCCRS, 2016).
Once a cytology sample has been taken, it is entered into a national IT database, Scottish Cervical Call/Recall system (SCCRS). All staff involved in the cervical screening process have access to and use this database. SCCRS was introduced in May 2007 to bring consistency to screening practices across Scotland. A woman’s pathway can be easily tracked throughout the screening processes. GPNs will be able to see results, when a cytology sample is next due and whether a woman is on a routine or non-routine recall for cytology. Colposcopists and family planning staff will be able to access up-to-date information about a woman’s cervical screening history ensuring a quicker, more effective treatment to those who need it (SCCRS, 2016). Around nine out of ten tests are reported as normal. Abnormal tests are categorised as borderline (CIN1), moderate (CIN2) or severe abnormal (CIN3) (Perry, 2012). CIN1 would mean a recall of six months, two consecutive negative results would return the woman to routine (3-5 yearly) recall however, three borderline result would trigger a referral to colposcopy. A result of CIN2 or CIN3 triggers a referral to colposcopy or if severe a referral to a gynaecological oncologist (Perry, 2012).
Obtaining a Sample
The room used to carry out a cytology test should be private and warm. The woman should be given the opportunity to empty her bladder and be offered a chaperone. There should be screens for privacy surrounding a height adjustable couch with an adjustable light source and disposable paper towel. The woman should be allowed to undress her lower half privately and settle onto the couch. While she is doing so, the GPN can be washing their hands, putting on disposable gloves and preparing the speculum. If needed, a water-based lubricant can be used on the sides of the speculum but not the tip as this could contaminate the sample. Once the woman is comfortable, with knees raised and heels together, she can be asked to relax her stomach muscles and allow her knees to fall to the sides. The labia and vaginal entrance should be checked prior to gently inserting the speculum with its screw facing sideways, then slowly turned until the screw facing upwards. The blades of the speculum can then be slowly opened and the cervix located (RCN, 2006). Throughout the procedure, the comfort of the woman should be checked and reassurance given. Once the cervix has been located, the sample brush should be inserted into the OS and turned through 360 degrees five times, ensuring an adequate sample of cells is taken from the transformation zone. During this process, the cervix can be observed for any sign of abnormality. The speculum can then be gently removed and the sample brush pushed vigorously into the bottom of the sample pot 10 to ensure the cells have been left in the preserving fluid (Perry, 2012).
Nursing and Midwifery Council (NMC) states in its code of conduct that nurses must preserve people’s dignity, treating them with kindness and respect at all times. Nurses must listen to individual concerns and respond appropriately to anxiety and distress (Nursing and Midwifery Council, 2018). This seems rather more poignant when considered alongside a procedure that is so invasive, very personal and with potential for being distressing. The code also states that care professionals must communicate clearly and ascertain the understanding an individual has, so that informed consent can be given and the procedure can be carried out without undue delay. An older study by Chew-Graham et. al (2005) showed great variation in how care professionals involved in cervical sample taking prepared women for the procedure and what to expect afterwards. Many of the respondents to the study reported that they did not tend to discuss the reliability of the test or what would happen in the event of an abnormal result and the follow up this would entail.
It is not uncommon to receive an abnormal cytology result, and there are high levels of anxiety associated it. High anxiety often stems from poor understanding of what an abnormal result means with many thinking it is a diagnosis of cancer (Chew-Graham et. al, 2005). This highlights the necessity of giving women clear information about the screening process. The implications of possible sample outcomes should be clarified at the time of the sample being taken to avoid unnecessary anxiety when the results are obtained. Another older study carried out by Wilson and Hines (2000) found that women were far more likely to attend for colposcopy appointments when they had more information given to them explaining what the abnormal result meant and what to expect from their colposcopy appointment. This information was given in the form of a leaflet and then backed up by further verbal discussion to address any remaining concerns. Further to this, they found that a simple booklet increased knowledge and decreased anxiety whereas the more detailed booklet increased knowledge but did not alleviate anxiety. Further studies have also indicated that if a person feels they have received good levels of information about treatment, its strengths and weaknesses they feel more satisfaction from the consultation and are more likely to participate in the follow-up (Wroe et. al, 2013). However, it should be acknowledged that this study was not specific to cervical cytology and looked more generally into how information giving and involvement in decisions affected adherence to further treatment.
A disturbing fact is that nearly half of the annual new cervical cancer cases occur in women who have never had a cervical cytology test (Perry, 2012). Between 2013 and 2015, the peak rate for cervical cancer cases was in 25-29 - year old (Cancer Research UK, 2018) and yet there is evidence to show that the age group 25-34 have a lower participation in cervical screening (NHS Health Scotland, 2018). Within this age group, the highest screening uptake is from the women who have been HPV vaccinated. It is thought this may be due to the education given during the vaccination programme and the women being more aware of why screening is beneficial (ISD Scotland, 2018). This highlights a need to talk to the women in this age catchment and educate them about the purpose and benefits of the screening programme. Other factors that increase the risk of cervical cancer include; sexual activity at a young age, multiple sexual partners, smoking, multiple births, family history and HIV infection (Perry, 2012). GPNs need to engage and discuss these factors with women to help them make informed choices about whether to participate in the cervical screening programme or not and encourage compliance with follow up treatment if required. GPNs are ideally placed to be able to follow up women who do not attend screening appointments. It is possible to check the cervical screening status of women over the age of 25 years and at new patient checks. Telephone consultations can be used to discuss the benefits of screening and address any fear the woman may have about the procedure. In some cases, it may be appropriate to allocate more time to an appointment to give an anxious woman time to feel comfortable enough to consent to such an invasive procedure. Providing a service that is friendly, considerate, reassuring and empathetic, will contribute to a better experience for the woman and they will be more likely to attend to their next appointment (Richards, 2010).
However, individual choice is important and if someone decides to withdraw from the cervical screening programme, their choice must be respected and their human rights upheld (Nursing and Midwifery Council, 2018).
Human papillomavirus (HPV)
There are around 40 types of HPV that affect the genital tract. These are sexually transmitted meaning the risk increases with the number of sexual partners a woman has had. HPV infections can be classed as high or low risk depending on their association with the development of cancer. Over 99% of cervical cancers test positive to high-risk HPV types with HPV16 and 18 being responsible for over 70% of these (GOV.UK, 2014). An HPV vaccination programme began in September 2008; initially it was offered routinely to girls aged 12-13-years and a catch-up programme was offered to girls up to 18 years. The original vaccine protected against two types of HPV. In September 2012, the vaccine was changed to protect against four types of the virus (GOV.UK, 2011).
A retrospective study was devised. Data was extracted from SCCRS to document the effect of the HPV vaccination on the cervical cytology. It was found that complete vaccination with three doses correlated to a reduction in all grades of cytological cell changes, higher reduction observed for higher grade changes (Palmer etal., 2016). Continued monitoring is necessary due to the introduction of the quadrivalent HPV vaccine in 2012, the recipients of which will start to be screened in 2037. It should also be noted that some did not complete the vaccination course and some of the girls in the catch-up programme may have been sexually active prior to vaccination, reducing its effectiveness (Palmer etal., 2016). A Danish study also showed promising decreases in cervical cytology changes in women involved in their HPV vaccination programme (Thamsborg etal., 2018).
Infection with some HPV viruses has been shown to be instrumental in the development of cervical cancer. Testing for HPV in samples that show borderline cytological changes can identify women who are at high risk of developing cervical cancer. This indicates who would benefit from referral to colposcopy and who can reasonably remain on routine screening (Kelly et. al, 2011).
The GPN has a vital role to play within the cervical screening programme. It is important that all GPNs practice in a way that allows women to safely move through the screening programme with as little discomfort and anxiety as possible. Behaving in a friendly and approachable manner to encourage women to talk about their concerns, and keeping up-to-date about advances in the screening programme, ensure that GPNs are able to give sound information on which women can base informed choices about engaging with the programme. GPNs are also ideally placed to identify and engage non-attenders in a dialogue that could result in more women taking part in the programme.