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Cervical Cancer (Minimum Age for Screening)

Volume 497: debated on Wednesday 14 October 2009

Motion for leave to introduce a Bill (Standing Order No. 23)

I beg to move,

That leave be given to bring in a Bill to require NHS bodies in England to provide cervical screening for women aged 20 and over.

The Bill would bring England in line with Wales, Scotland and Northern Ireland, which all begin screening at the age of 20. Cervical cancer is the second most common cancer in women under 35 in the UK. Every year, more than 2,800 women in Britain are diagnosed with cervical cancer, and every year 1,000 women die from the disease. Thankfully, regular cervical screening can detect and treat early the abnormalities that, if left untreated, could lead to cervical cancer. Since the launch of the NHS cervical screening programme in 1988, early detection and treatment has had an excellent success rate. More than 90 per cent. of screening results come back normal, but for the few whose results do not, the test can, quite simply, make the difference between life and death.

The new human papillomavirus vaccination programme—HPV—was also introduced last year for girls aged between 12 and 15, and this autumn it will be extended up to the age of 18. So, we have a vaccination programme that ends at the age of 18 and a screening programme that begins at the age of 25. That leaves young women between the ages of 18 and 25 caught in a medical limbo, eligible for neither vaccination nor screening.

My Bill seeks to narrow that gap. By making cervical screening available to any woman aged 20 and above, an extra 1.3 million women would have the choice of cervical screening. The support for lowering the screening age to 20 comes from organisations that range from Marie Stopes International and Jo’s Trust to The Sun newspaper, which ran a petition with over 108,000 signatures. In addition, recent polling by Harris for the Metro newspaper showed that 82 per cent. of 16 to 24-year olds in England agree with lowering the screening age.

In 2004, the Government raised the age from which cervical screening can begin from 20 to 25. Their justifications were that cervical cancer is rare in women under 25, that the anxiety and stress of unnecessary investigation and the treatment for abnormal cells is proportionally excessive, and that the age limit is now in line with World Health Organisation recommendations.

Cervical cancer may be rare in women under 25, but it is inexcusable to dismiss the cases that occur as negligible statistics. Unnecessary investigation and treatment when an abnormal test is proved wrong may be stressful, but it is not for the Government to presume to know best what young women want. If a young woman knows the risks associated with treatment, the decision about whether to proceed with screening and any further treatment should, by rights, be hers alone.

Although the Government claim that raising the screening age to 25 brings it into line with World Health Organisation recommendations, the age at which screening can begin varies across the world. Oddly, England has chosen to raise its screening age and be out of step with even its closest neighbours. When England raised its screening age in 2004, Scotland, Northern Ireland and Wales all kept screening from the age of 20. In America, screening also begins at 20, or within three years of first sexual contact, whichever is earlier. In Australia, screening begins even earlier, at the age of 18. England’s screening age of 25 looks out of step by comparison.

So why do our Government have a blind spot when it comes to this critical health issue? I fear that it may be down to Budget restrictions: this Government’s mismanagement of the country’s finances over the past 12 years has forced them to cut critical health care services—an observation clearly supported by many 16 to 24-year olds in England, according to a recent poll by Harris.

The Government are concerned about funding, yet the numbers attending for cervical screening are actually falling. In 2007-08, a quarter of those invited did not attend. Alarmingly, the biggest drop was in the 25 to 29 age bracket, with attendance numbers falling from 79 per cent. in 1998 to 66 per cent. in 2008. Although I understand that demand for screening may have increased in 2009 due to the Jade Goody effect, we cannot rely on those numbers being sustained.

The Government’s health policy needs to move with the times and be realistic about changing lifestyles. Young women are now more at risk from cervical cancer than ever before, as the contributory causes of unprotected sex and smoking are on the rise. At some point in their lifetimes, 75 per cent. of sexually active men and women come into contact with the HPV virus that causes cervical cancer. With British teenagers now becoming sexually active earlier, the chance of a young woman developing serious cell changes and early-stage cancer before the age of 25 is increasing.

As I mentioned earlier, there is another weapon in the fight against cervical cancer—vaccination. It is not my intention in this speech to examine the rights or wrongs of that vaccination, as my hon. Friend the Member for Reigate (Mr. Blunt) has already highlighted that in a previous Adjournment debate. However, the vaccination programme has implications for the Bill that I am proposing today.

I am concerned that some young women could see vaccination as a “silver bullet” solution, leading them to assume that it has protected them from all risk and that there is now no need for them to attend their screening appointment. Screening and vaccination share a common purpose, yet Government policy seems contradictory. Even by their own admission, the Government do not yet know the full risks of the HPV vaccine Cervarix, but nevertheless they are pressing ahead with the programme. Yet the same lack of certainty exists in the risks outlined in the Government’s argument against reducing the screening age to 20. That just does not stack up. One cannot use the same rationale in support of one cervical cancer prevention scheme and in denial of another. What is so frustrating is that there was, until 2004, a good, sound policy in place. The Government requested a further review earlier this year but, unfortunately, they have decided to stick with the latest guidelines.

I hope that the argument that I have presented today will convince the Minister that there is still a strong case to be made for lowering the age of cervical screening back down to 20. With this Bill, we have the opportunity to try and beat one of the deadliest cancers in this country; we must take it. I commend the Bill to the House.

I rise briefly to oppose this Bill. I do not do so out of any personal animosity towards the hon. Member for Braintree (Mr. Newmark), whom I know well from our work on the Health Committee, but because I think that the premise on which it is based is entirely flawed. I was not sure what the hon. Gentleman was going to say, but what he said made me more convinced of the need to put on record the scientific evidence for the approach taken by the Government.

I do not lightly defend what the Government are doing, but I think that they have been absolutely right about both the screening programme and the introduction of a vaccination programme. I want the House to consider the nature of a screening programme, and to show hon. Members that the way in which it is being done in England is appropriate. In addition, I want to show that the reference that the hon. Member for Braintree made to the vaccination programme was flawed.

A good screening test must be both sensitive and specific—“sensitive” in the sense that it must pick up as many as possible of the things that is designed to find, and “specific” in the sense that it should not pick up what it is not supposed to find. The problem of false positives leading to treatment is a real one, and there are two difficulties with screening at a young age. First, the condition being sought is rarer in the young, and there is good evidence that the lesions that are suffered do not progress as quickly as is the case when the person is older. Secondly, early screening can lead to over-treatment, the risks of which—especially given the possible impact on fertility—are greater among younger women.

When talking about the use of public money, it is not good enough to say that a non-evidence-based screening programme that is neither sensitive enough nor specific enough will be introduced, and then to leave it to people to make the choice. The funding spent on such a programme could be spent on other interventions to treat established disease or to screen in other areas of ill health where the evidence is better. It is not good enough to say that the matter can be left to individuals to make the choice, because the spending decisions involved have to be made responsibly.

It is certainly not logical—I am afraid that it is totally illogical—to talk about the existence of a gap between the ages of 18 and 25. The hon. Member for Braintree said that the catch-up programme ended at 18 and that the screening programme started at 25, but it is not an either/or matter. People who are vaccinated will go on to get screened. The fact that the catch-up programme ends at 18 makes it an independent variable, and there will be no more catch-up after the programme has taken place. The gap will widen as more people are vaccinated, but the hon. Gentleman’s statement was both meaningless and misleading.

When we look at whom to trust on these matters, it is important not to listen to politicians or even—dare I say it?—to journalists. The hon. Member for Braintree cited evidence from The Sun, so I want to refer to a recent edition of the British Medical Journal, which I mentioned to him earlier in the summer.

In the BMJ edition of 8 August 2009, a study by Sasieni and colleagues asked:

“Does the association between cervical screening and a subsequent decrease in the incidence of cervical cancer vary with age?”

The summary answer was:

“Cervical screening at ages 35-64 is effective at preventing cervical cancer. It is less effective at ages 25-34 and has no effect at ages 20-24.”

That is a pretty clear judgment, so it is not as if there is a benefit to be set against the risks; on the basis of the study, there does not appear to be a benefit.

I always caution hon. Members against listening to the results of one study, because one study may not be representative of the field. Usefully for us, the BMJ commissioned an editorial commenting on that study and a number of others. The editorial, by Guglielmo Ronco of Turin, summarised the study and said that, according to the study, screening is effective only from the age of 35. It said that

“effectiveness in preventing cancers in the five years after screening is limited below age 25”.

It commented:

“The large sample size allowed analysis of the cancers by stage”,

and there was no finding, when the cancers were stratified by stage, that undermined the conclusions made. The editorial went on to say:

“The question is whether to screen younger women, and if so, how? In many developed countries the low incidence of invasive cervical cancer and the lack of effectiveness of screening in young women indicate that screening should not start before the age of 25. For women aged 25-34, screening with HPV testing alone is much more sensitive than screening with cytology, but it is also less specific.”

That is a reference to another technique that could be used for screening, which it would be useful to debate. We might debate whether we should test for the presence of the human papillomavirus, because that test has greater sensitivity. However, one would find people with the virus who did not have any lesions and were therefore clearly not likely to develop cancer at that point. There is an argument that we should look into that, and I hope that the Government will continue to examine that area.

The hon. Gentleman mentioned the cervical cancer or HPV vaccination programme, and it is important to say a word in defence of it. There is very good evidence that it will save lives, because of the very high effectiveness of the vaccine at preventing infection with HPV, which has been demonstrated to be the cause of many cervical cancers. There is clear evidence of benefit, and I urge parents—as do the Government and, more importantly, medical experts—to ensure that their children are vaccinated.

Of course, it is impossible to say that any vaccine is entirely safe. That is not something that should be said, or that can be said. However, it is a matter of balancing benefits against risks. There is great known benefit to the programme, and if there is a risk, it is known to be small. I very much regret, as I hope that the hon. Gentleman does, the coverage of the issue in The Sunday Times two weeks ago. In an article asking, “What has cervical cancer drug done to our girls?” it cited the case of Natalie Mort, who died after having the vaccine, but who, post mortem, was found to have a tumour in her chest. The pathologist said that it was

“so severe that death could have arisen at any point”.

It is extremely disappointing that the article went on to quote a parent—

Order. The hon. Gentleman is straying from the proposed Bill. Perhaps he could return to it.

I take your point, Mr. Deputy Speaker. Clearly, the issues are interlinked, but I think that I have made the point about coverage. I urge the House to consider, when thinking about the Bill, the role of evidence-based policy making. Given that there are different screening ages across the world, it may well be, certainly on the basis of the reviews that I have read of the evidence, that this country has got it correct, not only with regard to cost-effectiveness, which is always controversial, but with regard to actual effectiveness. That is not to understate the upset that can be caused when young women develop cancer prior to screening. Such cases occur, rarely; we know of such cases, including one that was mentioned by the hon. Member for Braintree. I recognise his commitment to the important and devastating condition that we are discussing, where it occurs, but such feelings are not a substitute for proper, evidence-based policy making, and I urge the House not to support the legislation.

Question put and agreed to.


That Mr. Brooks Newmark, Mr. Fraser Kemp, Angela Watkinson, Mr. John Baron, Simon Hughes, Ms Sally Keeble, Susan Kramer, Mrs. Eleanor Laing, John McFall, Mrs. Ann Cryer and Mr. Nick Hurd present the Bill.

Mr. Brooks Newmark accordingly presented the Bill.

Bill read the First time; to be read a Second time on Friday 16 October and to be printed (Bill 149).