A review of cervical cytology in genitourinary medicine clinics in England between 1997 and 2008

Abstract

The current cervical screening guidelines lay the duty of care of women under 25 years of age on genitourinary (GU) medicine clinics. To date there has not been an extensive review of cervical cytology results sourced from GU medicine departments. We reviewed the annual reports of the cervical screening programme, with their extensive and comparative data, including records of cervical cytology from GU medicne. There is a clear and progressive trend of rising percentages of ‘severe dyskaryosis’ in laboratory reported GU medicine cervical smears. The trend and observations indicate that GU medicine physicians should take young women's concern on cervical cancer seriously. The programme of opportunistic cervical screening in GU medicine should not be discouraged.

Keywords

cervical screening cervical cytology GU medicine STD clinics

INTRODUCTION

The current guidelines of the National Health Service (NHS) cervical screening programme state that ‘women under 25 who are concerned about their sexual health or who are at risk of developing cervical cancer should contact their general practitioner (GP) or the local genitourinary (GU) medicine clinic’. The Department of Health posts on its public website a similar statement: ‘Women under 25 who are concerned about their risk of developing cervical cancer, or experiencing any of the symptoms, should contact their GP or GU medicine clinic’. The guidelines and the screening programme lay the responsibility and duty of care of this age group on primary care practitioners and GU medicine clinics. The change in starting age for cervical screening, from 20 to 25 years of age, enforced by the 2004 guidelines, was followed with proactive efforts, led by the cancer quality assurance centres, to reduce cervical cytology in under-25 age group. The task of abolishing cervical cytology in the under-25 age group was monitored on annual and local bases, with many practitioners applying the guidelines as rules for practice.

The worried patient would relate to a family member, a friend or a celebrity figure who had had an experience with cervical cancer. The patient would reflect the experience upon herself. The patient's anxiety is a legitimate concern, and the primary care/GU medicine clinician should address this. The GU medicine physician is then faced with the dilemma of her/his duty to manage the patient's own concerns, against what is perceived as a rule of practice, that cervical cytology is prohibited in the under 25 years of age group.

We wish to objectively review the evidence, drawing from national GU medicine cervical cytology data, collected annually by the NHS cervical screening programme. We will relate to other relevant data collected by the Office of National Statistics and Cancer Research, UK. The aim is to analyse the current information in order to achieve evidence-based practice.

TREND OF CERVICAL CYTOLOGY ABNORMALITIES, FOR SAMPLES UNDERTAKEN IN GU MEDICINE CLINICS, IN ENGLAND

The cervical screening programme in England compiles a yearly report.^1,2 Analysis of the data regarding cervical cytology, from GU medicine clinics, should provide an objective basis for patterns of practice and trends on the incidence of cervical dyskaryosis between GU medicine patients. The annual report's data of samples from GP provide an objective point for comparison.

Published reports for the past 11 years indicate the following (Tables 1 and 2):

The total number of cervical smear tests, undertaken in GU medicine clinics, is persistently and progressively declining (from 72,842 samples in 1997/1998 to 18,437 in 2007/2008), a four-fold reduction. This is taking place in parallel with increasing GU medicine patients' attendance and numbers. There is a comparatively marginal decrease in the number of GP samples during the same period;

The percentages of severe dyskaryosis, in cervical cytology from GU medicine clinics, are gradually and persistently increasing during the 11-year period, from 0.64% in 1997/1998 to 1.1% in 2007/2008. There were no similar remarkable changes in samples sourced from GP clinics, which remained between 0.45% and 0.5% during the period;

The relationship of percentages of cervical cytology from GU medicine clinics, compared with cytology sourced from GP clinics, is also changing during the 11-year period. The percentages of severe dyskaryosis, reported from GU medicine clinics in the last six years, were more than double that of GP samples. For example, during 2007/2008, laboratories reported severe dyskaryosis in 1.1% for GU medicine versus 0.5% for GP samples;

The percentages of moderate dyskaryosis, from GU medicine clinics, remained similarly constant between 1997 and 2005, ranging between 1.97% and 2.2%;

In the past four reports, there was a gradual but persistent trend of decline for percentages of moderate dyskaryosis in GU medicine samples, from 2.2% in 2004/2005 to 1.2% in 2007/2008. The GP samples showed a gradual, persistent but less in percentage decline, from 0.73% in 1997/1998 to 0.5% in 2007/2008;

The percentages of collective abnormalities (mild, moderate and severe dyskaryosis) were persistently higher in GU medicine samples as compared with samples sourced from GPs;

The percentages of mild dyskaryosis in GU medicine samples remained constant and similar, within a very narrow margin, during the 11-year period, between 7.1% and 8.1% in GU medicine as compared with 1.7% and 2.09% in general practice;

The percentages of inadequate samples sourced from GU medicine clinics are showing a decline, notable in the last two years;

The level of inadequate GU medicine samples is some 40% higher than that of GP (4.2% versus 2.9% in 2007/2008);

The percentages of negative cytology, from GU medicine clinics, are progressively increasing, which is notable in the later years. There is a similar trend in GP samples;

Samples from different strategic health authorities (SHA) indicate that the numbers of cervical cytology from GU medicine clinics had declined in some SHA more than in others. For example, GU medicine clinics in London SHA performed some 5500 smears, of a total of 621,987, as compared with East Midland SHA, 872 of a total of 266,914, during the year 2007/2008 (Table 3).

Table 1

Total number and percentage of abnormalities of smears sourced from genitourinary medicine clinics in England (1997–2008)

Year	1997/1998	1998/1999	1999/2000	2000/2001	2001/2002	2002/2003	2003/2004	2004/2005	2005/2006	2006/2007	2007/2008
Numbers total	72,842	65,665	54,766	46,694	42,290	33,962	30,211	23,837	19,331	17,753	18,437
Percentages total	100.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00
Inadequate	9.70	10.28	10.67	11.2	10.7	10.7	10.1	9.5	7.7	5.0	4.2
Negative	71.40	69.71	69.54	69.2	70.3	70.2	70.5	70.8	73.9	75.9	77.8
Borderline changes	8.67	9.14	9.44	9.3	8.9	8.1	8.5	8.6	8.2	8.8	8.5
Mild dyskaryosis	7.53	8.12	7.58	7.5	7.2	7.8	7.7	7.7	7.2	7.5	7.1
Moderate dyskaryosis	1.97	2.03	2.01	2.0	2.0	2.0	2.0	2.2	1.7	1.6	1.2
Severe dyskaryosis	0.64	0.65	0.71	0.8	0.9	1.0	1.2	1.1	1.1	1.1	1.1
?Invasive carcinoma	0.02	0.03	0.02	0	0	0	0	0.1	0.1	0.1	0.1
?Glandular neoplasia	0.07	0.04	0.03	0	0	0	0	0	0	0.1	0

Table 2

Total number and percentage of abnormalities of smears sourced from general practitioners in England (1997–2008)

Year	1997/1998	1998/1999	1999/2000	2000/2001	2001/2002	2002/2003	2003/2004	2004/2005	2005/2006	2006/2007	2007/2008
Numbers total	3,780,472	3,740,597	3,679,265	3,528,923	3,813,089	3,630,643	3,535,868	3,570,697	3,548,099	3,272.943	3,261,868
Percentages total	100.00	100.00	100.00	100.00	100.00	100.00	100.00	100.00	100.00	100.00	100.00
Inadequate	9.05	9.22	9.79	9.6	9.1	9.3	9.2	9.1	7.3	4.7	2.9
Negative	83.93	83.65	83.00	83.4	84.1	84.0	84.3	84.8	86.7	89.1	90.7
Borderline changes	3.67	3.74	3.88	3.8	3.7	3.6	3.5	3.2	3.2	3.3	3.5
Mild dyskaryosis	2.07	2.09	2.07	2.0	1.9	1.9	1.9	1.8	1.7	1.8	1.8
Moderate dyskaryosis	0.73	0.74	0.71	0.7	0.6	0.6	0.6	0.6	0.5	0.5	0.5
Severe dyskaryosis	0.45	0.47	0.46	0.5	0.5	0.4	0.4	0.4	0.4	0.5	0.5
?lnvasive carcinoma	0.03	0.03	0.02	0.0	0.0	0.0	0.0	0.0	0.0	0.0	0.0
?Glandular neoplasia	0.07	0.07	0.06	0.1	0.1	0.0	0.0	0.0	0.0	0.0	0.0

Table 3

Genitourinary medicine smear samples

(A) By regional office area (1997/98)
England	72,842
Northern & Yorkshire	4986
North West	9700
Trent	6510
West Midlands	5541
Anglia & Oxford	9830
North Thames	20,987
South Thames	9412
South West	5876
(B) By Strategic Health Authority (SHA) (2007–08)
England	18,437
North East SHA	233
North West SHA	2899
Yorkshire & The Humber SHA	1821
East Midlands SHA	872
West Midlands SHA	1423
East of England SHA	2032
London SHA	5500
South East Coast SHA	1268
South Central SHA	1534
South West SHA	855

CLINICAL BASIS OF PROVIDING CERVICAL CYTOLOGY IN GU MEDICINE CLINICS

Sexually transmitted oncogenic human papillomavirus (HPV) types cause virtually all cervical cancers. This leads to similarities between cervical cancer and sexually transmitted diseases (STDs), in relation to risk factors. Early age of coitarch, a high-risk male partner, multiplicity of sexual partners, smoking and contraception are associated risk factors.³ The concept of cervical cytology in STD clinics was first introduced in London in 1985. A pilot study of cervical cytology identified 73 patients with abnormal smears, eight of whom had cervical intraepithelial neoplasia Grade III, of a total of 500 new patients.⁴ The authors then concluded that they should offer cervical cytology to STD clinic attendees. Similar conclusions were reached by clinicians from Los Angeles, Georgia and Baltimore, USA. The first explored the provision of cervical cytology for low-income patients, who would not normally have access to health insurance. As these patients were likely to attend emergency centres and STD clinics, their provision with cervical cytology was then explored.⁵ Five hospitals, out of 19, had protocols for cervical cytology in their emergency centres. The authors recommended the provision of cervical opportunistic screening in public health-care settings, as a means of cancer control, in the low-income population.⁵ The same principle was later enforced by the USA Centers for Disease Control and Prevention.⁶ The third American study criticized the inconsistency of offering cervical cytology to public STD clinic attendees, and noted that 5.7% cervical cytology abnormalities were reported in their tested populations.⁷ The authors collectively concluded that cervical cytology should be integrated into public STD care, especially when the population-based programmes are not available to STD clinics' groups of patients. A similar study from the GU Medicine Department of Leicester, UK, noted a higher proportion of abnormalities in cervical smears undertaken in GU medicine clinics (155/1000 women), as compared with patients from general practice and family planning clinics (63 and 60/1000 women, respectively).⁸ The higher incidence of abnormalities was also noted in the GU medicine clinic of Bolton, UK. The authors reported higher ‘major abnormalities’ of smears performed at Bolton GU medicine clinics than the national average (37/1000 compared with 12/1000 young women at the age of 20 and above).⁹ The risk of cervical smear abnormalities was reported to be higher in women with concomitant genital infections,¹⁰ which is supported by other research on risk factors.³

The British Co-operative Clinical Group for Genitourinary Medicine explored routine and opportunistic cervical cytology, undertaken within GU medicine clinics. A national questionnaire to GU medicine clinics in 1998 identified that 12.6% of women who had cervical cytology during the period of the study were not registered with GPs. Opportunistic screening then reported fewer high-grade abnormalities than in routine smears.¹¹

DISCUSSION

The causal relationship between oncogenic high-risk HPV types and cervical cancers is well established. The sexually transmitted nature of HPV makes cervical cancer indirectly linked with the same risk factors expressed in other STIs. This suggests that GU medicine clinic attendees are at a higher risk of developing cervical cytology abnormalities. The previously published studies did not benefit from large numbers or long-term follow-ups of consistent trends.

The widespread consensus of offering cervical cytology to women who attend STI clinics is shared between practitioners across the Atlantic and extends to other parts of the world.¹² Clinicians base their conclusion on the observation that cervical cancer is the sequelae of the sexually transmitted oncogenic HPV, supported by the observation that a significant proportion of women who attend STD clinics have no registration with a GP or access to regular health care. Many young women are at a period of social, university, employment and/or relationship changes, which are bound to reflect on the consistency and continuity of their medical care. The finding of a higher proportion of cervical cytology abnormalities between STD clinic attendees enforced the concept of offering cervical cytology to GU medicine patients.

The current review provides objective evidence of the consistent trends of high-grade abnormalities in cervical cytology undertaken in GU medicine clinics, as compared with samples from GPs. The concurrent relative increase in percentages of negative cytology reports, on GU medicine samples, suggests that there is no internal bias in the selection of patients who are offered cytology within the GU medicine settings. The observation of higher percentages of reports of inadequate cytology could be a reflection of a higher incidence of vaginal/cervical infections in GU medicine patients than in those from GPs. There is a clear decline in the overall number of smears taken in GU medicine clinics. This could be a result of the directions to reduce cervical cytology in the under 25 years of age, the disproportionate pressure exerted by HIV care and/or the escalating demand on GU medicine services. The remarkable increase in the percentage of severe dyskaryosis is difficult to ignore.

The reports of some 40–50 patients developing cervical cancer, in the under 25s, annually (Table 4) is a cause of concern to many young women. The records of 3000–4000 cases of carcinomas in situ, in the same age group, on an annual basis, is alarming, for the significant number of patients that are affected.^13–15

Table 4

Registered cervical cancer, for 20–24 and 24–29 years of age, from 1999 to 2006 (Office of National Statistics)

Year	1992	1993	1994	1995	1996	1997	1998	1999	2000	2001	2002	2003	2004	2005	2006
Age group
20–24	34	32	55	33	38	42	33	23	48	38	36	56	46	39	54
25–29	191	164	190	183	194	188	164	171	164	151	147	168	149	193	207

Undiagnosed carcinoma in situ, in those under 25 years of age, may progress to invasive disease and reflect on cervical cancer numbers for the later age groups. This could be the underlying cause of the constant numbers of diagnosed invasive disease in the 25–29 years of age group. This age group, contrary to the others, does not show a similar decline in cervical cancer, but an increase, especially in the last three reports (Table 4).

CONCLUSION

The current guidelines of the NHS cervical screening programme lay the responsibility of cervical conditions, in the under 25 years of age, on GU medicine clinics. GU medicine physicians should be aware of the clinical risks and the medicolegal pitfalls of refusing to offer cytology to patients who are worried about cervical cancer or have symptoms that are similar to those of cervical cancer. We should also be aware of the trend of increasing percentages of laboratory reports of severe dyskaryotic abnormalities between our GU medicine patients, many of whom do not access regular health care.

Opportunistic cervical screening in GU medicine continues to identify an increasing percentage of patients with cervical severe dyskaryosis, and should not be discouraged. The percentage of severe dyskaryosis in GU medicine samples is twice that in general practice, in a rising yearly trend. These findings call for a revisit of the provisions of cervical screening in GU medicine.

References

Lyttle

, Platts

, MacLean

. Pilot study of cervical screening in a sexually transmitted diseases clinic. Genitourin Med 1985;61:330–4

Marcus

, Crane

, Kaplan

, Screening for cervical cancer in emergency centres and sexually transmitted disease clinics. Obstet Gynecol 1990;75 (3 Pt 1):453–5

Kamb

. Cervical cancer screening of women attending sexually transmitted disease clinics. Clin Infect Dis 1995;20(Suppl. 1):S98–103

Kanno

, Nguyen

, Lee

, The prevalence of abnormal cervical cytology in a sexually transmitted diseases clinic. Int J STD AIDS 2005;16:549–52

Young

, Malet

. A study comparing cervical cytology results from a genitourinary medicine department with those of two other local populations. Int J STD AIDS 1993;4:297–9

Acladious

, Mandal

. Cervical cytology screening for sexually-active teenagers. Int J STD AIDS 2000;11:648–50

10.

Foley

, Harindra

. Cervical cytology: are national guidelines adequate for women attending genitourinary medicine clinics? Sex Transm Infect 1999;75:349–51

11.

Wilson

, Parsons

, British Co-operative Clinical Group. Cervical cytology smears in sexually transmitted infection clinics in the United Kingdom. Sex Transm Infect 2001;77:107–10

12.

Abeyewickreme

. Cervical cytology screening in a sexually transmitted diseases clinic for the first time in Sri Lanka. Genitourin Med 1989;65:98–102

13.

Office of National Statistics; Cancer registration statistics 1992–2006. www.statistics.gov.uk

14.

Herbert

. Cervical screening: Why young women should be encouraged to be screened. www.ingertaconnect.com

15.

Herbert

, Smith

JHF

. Women under 25 should be offered screening. BMJ 2007;334:273