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FROM one health professional to many others, this is a call to arms — a call to help end cervical cancer as we know it.
Alarmingly, only one in two Australian women aged 20–69 years has a Pap test every 2 years. Even more revealing is the fact that 90% of women diagnosed with cervical cancer haven’t had regular Pap tests.
Why the low uptake?
Young women in particular, and especially those from culturally and linguistically diverse communities, can experience embarrassment at the thought of a Pap test. Some may even assume that having the human papillomavirus (HPV) vaccine eliminates the need for screening, or having had only one sexual partner means that they are not at risk.
Then, of course, there are the usual assumptions around pain, discomfort, or even fear of results. The relative rarity of cervical cancer because of organised screening in Australia may also make some women think they are not at risk.
In reality, 785 women died of cervical cancer in 2012 and all of these deaths were potentially avoidable through regular Pap tests and the HPV vaccine.
So, how do we change this and end cervical cancer as we know it? Yes, women need to act, and the Cancer Institute NSW is driving the “need to screen” message through its Peace of Mind mass media campaigns. However, it is GPs who need to spearhead this campaign and help women turn knowledge into action.
GPs and practice nurses are at the coal face, armed with the knowledge and the means to inform and educate women about the essential need to screen every 2 years.
We know that GPs play a key role in a woman’s decision to participate in cancer screening. In NSW, 82% of Pap tests are performed in a general practice setting. However, formative research undertaken by the Cancer Institute NSW suggests women feel GPs don’t prompt them enough to screen, especially for first timers.
Internal analysis by the Cancer Institute NSW shows wide variation in the number of Pap tests performed in general practices across NSW with some performing none or very few. It is imperative that these practices do still initiate conversations with women about screening and refer on as appropriate, such as to women’s health nurses.
Invitations and reminders provide an important prompt for screening attendance. The most reliable reminder system provided to women in NSW is the Pap Test Register (PTR). However, the PTR can only remind women about screening when they are overdue for their next test. It cannot reach women who have never been screened. GPs are critical to prompting a first screen.
An unpublished pilot study commissioned by the Cancer Institute NSW found strong evidence that a letter of invitation sent to the patient from a GP, with an appointment date for screening, increased screening uptake.
To make such reminders feasible in the busy general practice setting, we sought to increase cervical screening rates (and increase early detection and prevention of cervical cancer) through this pilot project to test the effectiveness of sending GPs an electronic reminder to coincide with their patients receiving a reminder letter from the PTR.
The result was extremely positive with 60% more women attending for their Pap test within 2 months of receiving their letter if the GP was also sent the electronic reminder. This could mean that the GP either sent the patient a letter directly, or set up an alert to remind patients about the need to screen at their next appointment. The Cancer Institute of NSW is planning to implement this program more widely across the state in the future.
Getting women through the door to take that test requires more from GPs than simply telling women this is something they “need to do”. Ensuring reminder systems are in place and taking the time to discuss screening as part of routine care are critical general practice roles.
Women want a trusted adviser; someone who will educate them and placate their concerns (or fears) about the procedure and point out the advantages that peace of mind can bring to their overall health and wellbeing.
Professor Sanchia Aranda is the Deputy CEO of the Cancer Institute NSW — a state government agency dedicated to the control and cure of cancer through prevention, detection, innovation and information. www.cancerinstitute.org.au
Please see our published research abour our new and unique strategy to increase the performance of smear tests and of other preventive actvities in general practice:
http://www.biomedcentral.com/1471-2296/12/40
Patient acceptance and perceived utility of pre-consultation prevention summaries and reminders in general practice: pilot study
Results
Sixty patients, median age 53 years (interquartile range 40-74) years, and 58% female, were recruited. Seventy eight per cent of patients found the sheets clear and easy to understand, 75% found them very or quite useful, 72% reported they had addressed with their general practitioner all of the preventive activities that were listed on the sheets as being due to be performed. A further 13% indicated that they had addressed most or some of the activities. 78% of patients said that they would like to keep receiving the sheets. Themes emerging from interviews with patients included: patient knowledge was enhanced; patient conceptions of health and the GP consultation were broadened; the consultation was enhanced; patient pro-activity was encouraged; patients were encouraged to plan their health care; the intervention was suitable for a variety of patients.
Conclusions
Most patients reported that they found the prevention summary and reminder sheets acceptable and useful. The actual increase in performance of preventive activities that may result from this new intervention needs to be tested in randomised controlled trials.
Professor Aranda, you state that young women in particular are amongst those in the “low uptake” of pap tests, but what about those that are not sexually active? And I’m not referring to younger teens or anything, but women into their 20’s (or later), who for whatever reason (religion, belief, circumstances, illness, etc), have never been sexually active.
I’m 29 and I am one of those women. I also never got offered the HPV vaccine when it was released, despite the fact that I was regularly at my doctor. I have been asked by doctors when my last pap test was, & when I say I’ve never had one, they are often shocked for a moment, until I say that I’ve never been sexually active. Then their reaction is usually “Oh well in that case it doesn’t matter, you don’t need one.”
So when I’m being hounded by ads telling me to get a pap test, (because you can’t get away from them, they’re even in the toilets!), what am I supposed to think? What am I supposed to do? And surely I’m not the only one in this situation?
Professor Aranda and all,
I am 61 and have had annual pap smears always – I am a medical specialist now and was a private practice GP and also worked for Family Planning Qld for around 12 years so was committed to them.
My GP found a CIN 3 on my last annual routine pap smear with HPV +ve last year. I had had an abnormal pap smear and colposcopy some 5 years earlier then no other forewarning that this precancer of the cervix was developing. I presume the HPV had been there for many years if not decades. I am shocked.
May I encourage everyone to pay attention to this self-care. I wonder about the accuracy rate of each individual smear?
Thanks for being on the look out for us!
Regards
Pat