Since the abnormal result of her first smear test 32 years ago, Marie Elliott has been grateful for the cervical screening program.
"Lots of women don't like cutting back, but I've always found it massive reassurance that I don't have a potentially fatal cancer," says Marie, 69, a retired insurance worker who lives in Lincoln.
But the mother of two and grandmother of two are denied this life-saving examination only because of their age.
Cervical cancer is largely caused by the sexually transmitted infection HPV (or human papillomavirus), which affects eight in ten sexually active people – both men and women – at some point in their life.
"A lot of women don't like cutting back, but it has always been a massive reassurance to me that I don't have a potentially fatal cancer," says Marie, 69, a retired insurance worker who lives in Lincoln
According to a landmark 2007 study published in the Journal of Infectious Diseases, the infection is harmless to the majority. Nine out of ten people produce antibodies that clear HPV within two years.
It is not known why 1 in 10 people remain infected, although smoking is a risk factor. In women, however, persistent viral infection can cause changes in the cells in the cervix that can lead to cervical cancer – a process that can take up to 20 years.
The smear, in which a nurse takes a sample of cells from the cervix (cervix) with a small, soft brush inserted into a speculum, allows technicians to identify abnormal cells before they turn into cancer. They can then be easily zapped by laser or surgically removed.
Cervical cancer screening is one of the most successful programs. It prevents about 5,000 cancers annually and halves the annual deaths from the disease to around 850.
Women aged 35 to 44 – one to two decades after having sex for the first time – are at the highest risk of disease.
"This is why there is so much emphasis on getting younger women screened for cervical cancer," said Imogen Pinnell, manager of health information at Jo's Cervical Cancer Trust, a charity founded by the widower of a patient who died of the disease at the age of 40.
However, older women are still at risk of developing it, possibly due to an undetected infection at an earlier age.
And while the incidence increases faster from the age of 25 and then falls after the age of 49, it peaks again in the decade after the age of 64. Then the current screening program ends – and it was at that age that Marie was told that she would no longer be screened. In addition, half of the deaths in the UK from cervical cancer are in women over 65.
The smear, in which a nurse takes a sample of cells from the cervix (cervix) with a small, soft brush inserted into a speculum, allows technicians to identify abnormal cells before they turn into cancer
At 37, Marie was one of the first to benefit from the screening program when it was introduced in 1988, and she believes it kept her alive. She had laser therapy twice – in 1988 and again in the mid-1990s – after swabs identified abnormal cells.
On a third occasion, in 2006, she was hospitalized for loop diathermy, or LLETZ – a procedure performed under local or general anesthesia to remove abnormal cervical cells with a thin loop of electrified wire.
After each treatment, Marie was followed up every six months and then every year; then every two years when the smear has returned to normal – but always more often than the program log for women whose smears are clear again.
Currently this is every three years between the ages of 25 and 49, and then every five years until the age of 64. After that, it's only available to women who have never been screened and then choose to have their first smear.
After each treatment, Marie was followed up every six months and then every year; then every two years when the smear has returned to normal – but always more frequently than the program log for women whose smears are clear again
When she got closer and spent her 60th birthday, Marie was happy about three clear cuts. "It was good news, but I took it for granted that after five years I would be called back for further investigation." I never thought for a moment that I was not at risk of cervical cancer.
"I was listed as at risk below 64, presumably because the virus may still be active – and I have no reason to believe anything has changed now."
But should older women like Marie who have had abnormal cervical cells in the past or older women who have previously been screened be offered the test?
Currently, health leaders are forecasting a dramatic reduction in cervical cancer diagnoses and even that "cervical cancer may be eradicated for good," Health Secretary Jo Churchill said in January.
This optimism is based on two major breakthroughs. In 2008, the HPV vaccine for 12-13 year old girls was introduced nationwide.
A study in the BMJ in 2019 showed that those who were vaccinated had a 95 percent reduction in the most serious level of precancerous cellular changes caused by HPV, CIN (cervical intraepithelial neoplasia) grade 3 by the age of 20, that is Risk of getting cancer if left untreated compared to those who didn't have the vaccine.
Recently, an HPV test, which is believed to be more accurate than the smear test, has been widely used. It uses the same tissue sample taken from the cervix during the smear test, so it is only available to women aged 25 to 64 years.
While it may benefit younger women, these advances will not address the concerns of Marie – or any other woman who may wish to continue being screened after age 64.
"It may seem arbitrary," says Peter Sasieni, Professor of Cancer Prevention at King & # 39; s College London and Consultant Gynecologist at Guy & # 39; s Hospital in London, "especially because a woman can apply for breast cancer screening all her life."
"But the evidence suggests that women aged 55 and over are rarely infected with HPV, and even if they do, it is unlikely that there will be enough time to progress to invasive cancer in their lives."
In 2014, Professor Sasieni published a study that showed that only eight out of 10,000 women who are regularly screened up to the age of 65 and had at least three significant smears in the years up to age limit continue to develop cervical cancer – compared to 49 out of 10,000 women who were not examined.
It is this evidence that explains why Marie was denied a smear test in November 2018, five years after her previous one.
But Marie's general practitioner had agreed – based on her history – that she should continue to take regular smears.
"But when I showed up at the clinic for my appointment, they said there was no point in having the smear because it wouldn't be checked because of my age."
Now, more and more experts are voicing concerns that the upper age limit for screening could put a generation of baby boomers at risk.
According to 2018 statistics from Cancer Research UK, women over 65 account for a fifth of new cases of cervical cancer. These showed that the death rate from cervical cancer is highest in women aged 85 to 89 years.
Emma Crosbie, Professor of Gynecologic Oncology at the University of Manchester's NHS Foundation Trust, says that “The highest peak for developing cervical cancer occurs between the ages of 30 and 34, but a second high peak occurs in women between the ages of 70 and 74 – and that is ignored in the current guidelines.
A Canadian modeling study published in The Lancet Oncology in 2018 predicted that older women would be at a reduced risk of cervical cancer if screening continued to be 75 years old in developed countries, including the UK (although the risk would be less more dramatic than in younger women).
There are good reasons women continue to be at risk for an abnormal smear, which indicates a risk of cancer beyond 64 years of age.
First of all, the suggestion that women over 55 are unlikely to get a sexually transmitted infection is controversial.
A woman can "easily become infected or re-infected in her fifties or sixties, possibly after a divorce," says Dr. Sue Sherman, a health psychologist at Keele University who specializes in the psychological effects of cervical cancer.
And there's another "million dollar question," says Imogen Pinnell of Jo & # 39; s Cervical Cancer Trust: How long can HPV infection go invisibly if the body's immune system doesn't clear it? "The textbooks say up to 30 years, but there's no actual evidence that it can't be longer," she adds.
Dr. Sherman agrees, "It is entirely possible that the virus could lie dormant for years or even decades and only turn into cancer when the immune system becomes less effective with aging."
“Whatever the reason, the threshold for screening at age 64 is undeniably arbitrary, as the data show that one in two deaths from cervical cancer occurs in women over that age. It is completely wrong for the NHS to claim that because of his age, he has a lower risk of developing cervical cancer. "
Patti Gravitt, a professor of public health at George Washington University in the United States, shares the same view. Research published in 2012 in the Journal of Infectious Diseases suggests that the peak of cervical cancer diagnosis in women in their 60s and 70s may be due to "risk of age-related reactivation of hidden long-term HPV infection."
Today, Professor Gravitt says that further analysis of the data from the study, which examines the causes of reactivation, suggests that "Age or changes in hormones during menopause may trigger the recurrence of abnormal cells."
She adds, "If HPV persists for more than a year or two, there is always a risk that reactivated infections will not be brought back under control, and this is a good reason to continue screening."
Cancer Research UK is also looking into whether women over 64 should be offered cervical screening routinely. "We may need to rethink the age limit for smearings," said Jess Kirby, the charity's health information officer.
One reason older women may be prevented from having a smear is the risk of increased discomfort when inserting a speculum, "as the tissue becomes less stretchy after menopause," says Imogen Pinnell. "But that shouldn't be a reason not to screen: if necessary, a topical estrogen cream can be applied a few weeks before a smear to moisturize the tissue."
In either case, she says, the general practitioner is the "doorman" and "a woman at risk of cervical cancer should be eligible for a smear regardless of her age, provided the general practitioner agrees."
Marie thinks she may still have HPV. "I may have had a series of clear smears, but this has happened before and an abnormal smear followed."
Marie admits that she could be tested privately at a relatively low cost – a smear test costs around £ 105.
"But," she says, "I am concerned that if I am diagnosed with cervical cancer in the private sector, I will find it difficult to get expensive treatment at the NHS." What's so crazy is that women can ask for a mammogram for their entire life, but that is not possible for cervical screening. "
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