Cervical Cancer Smear Tests

Helen Jones Excerpts

Monday 28th January 2019 Westminster Hall

[Helen Jones (Warrington North) (Lab)]

I beg to move,

That this House has considered e-petition 225767 relating to lowering the age for smear tests for cervical cancer from 25 to 18.

It is a great pleasure to serve under your chairmanship, Sir Roger. Before I move to the substance of the debate, I want to say a little about the woman who started the petition, Natasha Sale. She died on 28 December last year. She was 31 and left four children. I have spoken to her friends this afternoon, and I think Natasha must have been a remarkable person, because it takes a remarkable person to decide, when they have a terminal diagnosis, that they will use their time to help others rather than to bemoan their fate. That is what Natasha did. In her petition, she said that

“it’s too late for me but it’s not too late for the next generation”.

I thank her family and friends, who encouraged people to sign the petition to get the debate today. I particularly thank Natasha’s family, who have kindly said they are happy with the debate going ahead. That, too, takes courage, and I am grateful to them.

Cervical cancer is something that all women fear. Like breast cancer, it strikes at the heart of how we see ourselves and how we define ourselves as women. Because of that, screening programmes have been introduced in this country. In fact, screening is changing so that women will be tested for the human papillomavirus before they get cervical screening, because most but not all cervical cancers are caused by HPV. Screening is currently on offer only to women between the ages of 25 and 64. Those between 25 and 49 are called every three years and those from 50 upwards are called every five years, yet the reasoning behind that offer is perhaps not often understood. Before the age of 25, not only is such cancer very rare, but changes in the cervix are very common. A test can produce false positives and lead to unnecessary treatment and anxiety for women.

Nevertheless, there have been repeated calls to lower the age of screening, not only in this petition, but in others, including one we received previously. In response, the Government would rightly say that the UK National Screening Committee has looked at the evidence and decided that there is no real evidence to support reducing the age of screening. Their reasoning, which is valid, is that one in three tests below that age will produce a false positive; and that, when people are given unnecessary treatment, there is a risk to future pregnancies. I hope the Government will publish the evidence on the risks of getting cervical cancer at that age and the risks from screening so that women can make an informed decision. They should publish that in a way that can be understood by people who, like me, are not doctors or scientists. The evidence is often couched in scientific jargon, which conveys very little to most of us. That is the first important thing that we want to do.

Even with that evidence published, there will always be some cases, and cases in young women can be very tragic. They can lead to the loss of a young life, and often leave children without their mother. Because the disease can be so devastating, in 2008 the then Labour Government introduced a programme of vaccination against the most virulent forms of HPV for all girls from the age of 12. In fact, for that first cohort, we vaccinated up to the age of 18 to catch up. Those who were 18 at the time will now be undergoing their first screening. If as expected the rate of cervical cancer in that age group drops, it will have been well worth while.

When the programme was introduced, I well remember MPs getting a lot of letters from parents saying they did not want their daughters vaccinated—it still happens—because they somehow saw it as encouraging promiscuity. That is not what vaccination is about. It is about vaccinating girls before they become sexually active. I hope parents will think about the risk they are putting their daughters through if they do not have the vaccinations.

[Jim Shannon (Strangford) (DUP)]

I thank the hon. Lady for presenting the case in the petition. While the vaccine has been shown to lower incidence of cervical cancer, does she agree that cervical screening should take place as a matter of urgency, initially for those who are sexually active? The average age when sexual activity begins is 15.6 years across the United Kingdom of Great Britain and Northern Ireland. Does she agree that people cannot be allowed to wait 10 years for a first cervical smear? It must be addressed immediately.

[Helen Jones]

I will answer that point in a moment, because it is important that we look at the evidence. There will always be some cases, even among women under 25. We can never eliminate the risk completely. When that happens, it is important they get the right treatment. That is why in 2010 guidelines were published for GPs to ensure that young women who presented with abnormal symptoms were offered screening and referred on to a consultant if necessary. That does not always happen—I will come on to that in a moment.

[Louise Haigh (Sheffield, Heeley) (Lab)]

I apologise that I cannot stay for the whole debate. What monitoring is done of GPs providing that screening, including for women over the age of 25? I had a smear that presented as abnormal. I had HPV. I went to my local GP and asked for my smear test that I was required to have and was told that they did not do smear tests. What monitoring is being done to ensure that all GPs are adhering to the guidance and their duties under the legislation?

[Helen Jones]

My hon. Friend makes a very good point and I will be asking the Minister to look at that. Our first problem is getting people through the door. If there is something wrong with us, it is natural to think either that it will somehow go away or that it might be cancer—we kid ourselves that, if we do not get a diagnosis, it is somehow not happening. We need to have much more publicity to encourage young women to report to their GP if they have abnormal symptoms. After all, it might not be cancer and they might be reassured. Equally, if it is cancer, the sooner someone gets treated, the better their chances of survival. I do not think that that message is always getting through, particularly to younger women.

The other problem is that the rates of people attending screening, even among those who are eligible, are falling. In the last year for which I have figures, only 69.1% of eligible women attended their screening appointments. That is down from 73.7% in 2011. In practice, that means that 3.5 million women in this country have not been screened in the past three and a half years. That is very worrying. Even more worrying is the fact that 1.7 million have never had a test. Some 345,000 have not had a test in the past 10 years. What is more, there are significant regional variations in the rates of screening. For instance, for those aged between 25 and 49, the rate of screening in London is 61.6%. In the north-east, it is 72.9%. Among over-50s, the rate in London is 74% and in the east midlands 78%. We need to look closely at those figures and find out why women do not attend. It is no use getting into the blame culture. We need to ask the right questions. Are they frightened, for example? Are appointments not at convenient times? Are there particular groups of women who do not turn up for screening? It is probably a mixture of all three.

I was sent some very interesting information from Jo’s Trust, who asked a group of young women in a survey why they did not attend for their screening. Seventy-one per cent. said they were frightened of the test and 75% said they felt vulnerable. A whopping 81% said they were embarrassed, which is a particular factor for young women who are constantly bombarded with air-brushed photos of what they should look like and what their bodies should be like, so they suffer from a lot of body consciousness. Despite the fact that doctors and nurses keep repeating, “We don’t care what you look like, we are not interested in what you are wearing, we do hundreds of these tests”, the message is not getting through. It is therefore important that tests are conducted in a supportive environment.

Interestingly, in the same survey, 67% of the women said they had felt they were not in control of the test and 68% said they would not discuss their fears with a doctor or a nurse. That particular problem applies to survivors of sexual assault: 72% are put off going for their screening or do not go at all. It is vital that women are screened in a supportive environment where they get the chance to discuss any fears they have with a practitioner beforehand.

[Anna McMorrin (Cardiff North) (Lab)]

My hon. Friend is making an excellent speech. I apologise for not being able to be here for the whole of this absolutely critical debate. Cervical screening uptake in Wales is at an all-time low. More than a quarter of women did not attend their cervical screening in the past year. Importantly, last September, Wales became the first nation in the UK to provide high-risk HPV testing as the primary cervical screening test across Wales. It leads to more sensitive and specific tests, more certainty for patients and more appropriate referrals to colposcopy services, faster treatment and then faster discharge times. Does my hon. Friend agree?

[Helen Jones]

Yes, and I hope those tests will be rolled out across the rest of Britain.

On the problem of women getting access to screening services, time and again they report that they ring their GP for an appointment that is then weeks ahead. Someone I met recently told me that, in her case, it is months ahead. It can be as much as 10 weeks. All are offered appointments at times they cannot attend, perhaps because they work shifts—that applies particularly to younger women who are more likely to be in insecure employment and therefore not eager to ask for time off.

I do not know why we persist in this, but very often the comments on screening give the impression that someone is saying, “These stupid women are not going for their screening.” Actually, there is a problem of access. I remember when we had mobile breast cancer screening units that came to a place of work. I got my blood pressure tested in the middle of Warrington shopping centre because the hospital had a programme to encourage people to go for testing in case they were at risk of vascular disease. Why can we not do more to take cervical screening to places where women are? Why can they not be screened in the workplace, for example, where groups of women are much more likely to say, “Come on! We will all go together”? It is not beyond the wit of man to arrange that.

[Jim Shannon]

Will the hon. Lady give way?

[Helen Jones]

I will give way one more time and then I must make some progress.

[Jim Shannon]

Constituents have expressed concerns to me on two issues: first, that it is very painful; and secondly that it is embarrassing. When it comes to giving peace of mind to ladies going for cervical cancer screening at whatever age, it is very important that the doctors and GPs are involved at an early stage to put their minds at rest. The importance of cervical cancer screening cannot be underlined enough, but the ladies need to be assured of not having the pain and embarrassment, which is a big task for the NHS.

[Helen Jones]

The hon. Gentleman is right. Women need to be assured that they will be treated sympathetically, whatever their age. All of us who have been to screening know that sometimes it is fine, but sometimes someone is a bit ham-fisted and it is not fine. It is better than getting cancer.

Another issue needs tackling: when women under 25 present with abnormal symptoms such as abnormal vaginal bleeding, they are not always treated according to the guidelines. In fact, they are frequently not treated according to guidelines. There are plenty of examples of younger women going to their GP with symptoms and being told they are too young for cervical screening, and plenty of examples of women going time and again and, as one lady told me earlier, being fobbed off. The problem is that GPs do not see a lot of cases and cervical cancer is therefore not the first thing they think of. The Government must do more to alert GPs to the possibility of cancer to get early diagnosis and ensure that people are referred to consultants where necessary.

[Emma Little Pengelly (Belfast South) (DUP)]

I absolutely agree with the hon. Lady that GPs and others must take the concerns of young people under 25 seriously. I recently attended a pensioners’ parliament in Northern Ireland and many women over 64 spoke of the difficulty of being taken seriously when they go to the doctor. The vast majority of deaths from cervical cancer happen to those over 50 and many of those over 64. Is that not also an issue that needs to be addressed? Those women feel that they are being left behind.

[Helen Jones]

The hon. Lady makes a good point. We need people to realise that women know their own bodies and know if something is wrong, so people must listen to what they say. There are too many examples of women having to pay for a private test before finding out they have cervical cancer. If it is not diagnosed early, there is a chance it will become terminal. If it is diagnosed early, the chances of survival are much greater, so we need to ensure that people are diagnosed early.

On the question of whether the age for screening should be reduced, I am not convinced at the moment. The scientific evidence does not support it, but I hope that the Government will keep it under review. If the evidence changes, we need to change what we do. Sir Mike Richards is undertaking a review of cancer screening and is due to report by Easter. I hope he looks at the issue. Ministers must ensure that they get the best advice and they have to proceed on that advice. We have to remember that, rare as it is, in 2016, 15% of women diagnosed with cervical cancer were under 30, and last year, 12 of those who died were under 30. We can and should do much more to prevent such deaths by ensuring that women are screened where necessary, even if they are under 25. If they have indications that require them to be screened, they should be. We must ensure that we promote the HPV vaccination programme, which is one of the best things that has been done in recent years. I say to parents who worry about it, “Don’t put your daughters at risk. Get them vaccinated.” We have to do much more to convince them that vaccination is the right thing. We have to do much more to make screening accessible and easily available to women, and it must be done in a supportive environment. Let us be honest: it is a bit like a sausage machine when we go to the GP, precisely because health workers are screening all the time. To them it is not at all unusual, but it is to the people who attend; that is the difference.

[John Howell (Henley) (Con)]

I hope that, like me, the hon. Lady will support the Public Health England awareness campaign that is about to start, which will try to tackle all the misunderstandings about screenings, and to overcome the feelings of fear and embarrassment that she described so well.

[Helen Jones]

The hon. Gentleman is right, and it is not before time to have such an awareness campaign. However, it is no good having one unless we ensure that screening is easily available and that people are treated well when they go. That is vital, because one bad experience can put a woman off ever going again, which is not what any of us want.

Natasha started the petition because she wanted to raise awareness of the symptoms of cervical cancer, and to ensure that other women did not suffer as she had suffered. That was a remarkable thing to do, and I hope that today’s debate, which I know her MP, the hon. Member for Newton Abbot (Anne Marie Morris), would have liked to have attended—unfortunately, she has to be in Committee elsewhere—will go some way towards doing that. I hope the debate will open up the dialogue on how best to get women screened, and when they should be screened, and I hope that the Minister will commit to keeping the age of screening under review, so that, if the scientific evidence supports screening earlier, that is acted on.

--- Later in debate ---

[The Parliamentary Under-Secretary of State for Health and Social Care (Steve Brine)]

It is a pleasure to serve under your chairmanship, Sir Roger—I shall refer to you again in a moment. I feel somewhat outnumbered, along with the hon. Member for City of Chester (Christian Matheson) and my hon. Friend the Member for Henley (John Howell), but I am rather used to that, having chaired the all-party parliamentary group on breast cancer for five years with the shadow Minister, the hon. Member for Washington and Sunderland West (Mrs Hodgson). We were often referred to as “Steve and the girls”.

I completely endorse the point by the hon. Member for Lanark and Hamilton East (Angela Crawley) that this is not a women’s issue. Natasha, whom I will come to in a moment, had four children—two of each. It is very much a boys’ issue for them, as it is across the board. [Interruption.] We may have heard the B-word only once during the debate, but I could have sworn I just heard something from outside. I must be imagining things.

It has been a privilege to be part of this debate. It is only right that I start by expressing my sincerest condolences to the family and friends of Natasha Sale, who tragically passed away in December. I know I speak on behalf of all Members present when I say that our thoughts are with her family and friends. Anybody who has lost a loved one to cancer knows the pain and anguish that the family are experiencing due to Natasha’s loss. As somebody who has fought and lost more than I have won, I am one of those people. In some of the coverage of Natasha’s death, I saw a quote from Amanda Scott, her best friend, who said:

“God only takes the best”.

I thought that was a lovely quote. We have heard that many times before, but I was interested in how that was reported.

As the Minister responsible for public health and cancer, cancer prevention and early diagnosis are vital priorities for me. I am delighted to see Natasha’s army here today. I saw the pictures on the bus on social media this morning, with some interesting hand signals—I must ask them about that. It is very good to see them all here. I hope they know, as Members know, that I will continue wholeheartedly to support the efforts of the NHS and Public Health England, which I hold to account, and of all our excellent cancer charities, which work as part of team cancer to prevent cancer and reduce the number of families who have to go through what Natasha’s family is going through.

There have been so many interesting speeches. Luckily, for once I have time to touch on a number of them, if not all of them. I was very interested in the point made by the hon. Member for Darlington (Jenny Chapman) about the data showing that take-up is better in the north-east than almost anywhere else. I was interested in what she had to say about the reasons behind that. The NHS as a system too infrequently talks to Members of Parliament, who know their areas better than most. I will ask Sir Mike Richards to contact her, perhaps along with the hon. Member for City of Chester, who is obviously still waiting for an introduction. I am very happy to facilitate that. Her other point was about access, which many Members mentioned. I will ensure that her very good point about disabled women is fed into Sir Mike Richards’s review, and I encourage her to raise that with him when she sees him.

[Ian Austin in the Chair]

I will come to the hon. Member for Warrington North (Helen Jones), who introduced the debate on behalf of the Petitions Committee, because many of the points she raised will come up in my speech. I was pleased that my hon. Friend the Member for Henley talked about the “Be Clear on Cancer” campaign and the new Public Health England campaign that will be rolled out next month. He mentioned the role of GPs in those campaigns. “Be Clear on Cancer” is a public-facing campaign, but elements of it relate to GP education, which I will come to. He often makes very good points in our debates, and I thank him for raising that topic. The hon. Member for Rotherham (Sarah Champion) also mentioned GP understanding, which I will touch on.

The hon. Member for Livingston (Hannah Bardell) made a very personal speech. She said she is awaiting results, and I think I speak for everyone when I say we wish her well. We will be thinking of her, and our fingers are crossed for her. She made a point about the trans community, which I had not heard mentioned in this context. NHS England has published clear guidance for trans men—people who have changed from female to male. Trans men who still have a cervix and have not had a hysterectomy remain entitled to screening. If a trans man is still registered with their GP as a female, they will continue to receive invitations for screening. If they are registered as a male, they remain eligible for screening but will not automatically be invited. The guidance makes clear that trans men need to request screening from their GP. I thank her for raising that point, which is another that I want to feed into Sir Mike’s screening review.

The hon. Member for Kingston upon Hull West and Hessle (Emma Hardy) made a brilliant speech, as always. She should be on the stage. The rather unconventional advice surgery she talked about may not catch on, but I enjoyed hearing about it. We constituency MPs all dread somebody saying, “I’m sure I know you from somewhere.” She talked about education, particularly in schools. Public Health England has a range of materials aimed at providing teenagers and their parents with information about things such as the HPV vaccination programme. She will know that the Department for Education is also working on new relationships and sex education guidance. Its consultation closed in November. That guidance, which will include input from Health Education England, will be published in the first half of this year.

I took the Teenage Cancer Trust and CoppaFeel!—a breast cancer charity with possibly the best name of any cancer charity—to see my right hon. Friend the Minister for School Standards at the end of last year. We were very keen to make the point to them that we must improve awareness in schools of health, bodies and particularly cancers, but in a balanced way that educates children about warning signs without frightening the life out of them. I think we have struck that balance, and I think Members will be pleased when they see that guidance rolled out in the first half of 2019.

[Helen Jones]

Will the Minister tell us whether that guidance includes educating young girls about the need to go for smear tests? Some of Natasha’s friends have forcefully made the point to me that if we do that, it may encourage girls to go for smear tests when they reach the age for screening.

[Steve Brine]

I cannot tell the hon. Lady that, but I will find out and write to her and other Members who in the debate. It is not my policy area—obviously I am not the Minister of State for School Standards—but it is a good point and it would seem logical that that is done in consultation with the Department of Health and Social Care and with Health Education England.

To go to the heart of where I want to start, the hon. Member for City of Chester talked about a constituent being refused a smear test. He said that it would be simple for a Minister to change the regulations and said that this was an example of the system not doing what we direct it to do. As the shadow Minster said, the system should already do that. It would not be appropriate to go into individual instances, but it is important to understand that cervical screening is a screening test and not a diagnostic test. It aims to detect abnormalities of the cervix that if left undetected may develop into cancer, so it is preventative. Cervical screening is not appropriate for women with symptoms, but if women of any age, including under-25s, have unusual symptoms or abnormal bleeding, they should consult their GP immediately and they should be treated under the NHS and initially offered a speculum examination in accordance with the National Institute for Health and Care Excellence guidance for primary care. If that is not happening and if that were one of my constituents, I would be taking that up through the procedures that the hon. Gentleman will know about as an experienced constituency MP. I think that is clear.

The hon. Gentleman also touched on the petition. To be clear, the petition is entitled:

“Lower the age for smear tests from 25 to 18 to prevent cervical cancer.”

He is right to raise the point about women requesting that. We do not often hear about “Liberating the NHS: No decision about me, without me” in the House these days, but it is still very much alive. I would encourage him to take that case up, as I would encourage any other Member who runs into that issue to do.

--- Later in debate ---

[Helen Jones]

I thank the hon. Members who have participated in this debate. I have learned more about some of my colleagues than I ever thought I would. I cannot compete with their stories of recognition; the only thing that happened to me was after I had had a smear test, which did not show abnormal cells but was a bit dodgy for various reasons. I was waiting in hospital for an exploratory op, and everyone was being very, very careful about not saying who I was, until the porter came in to take me to theatre and proclaimed loudly across the ward: “You the MP then, love?” God bless Warringtonians.

We have heard a lot of useful comments in this debate about the need to look at variations in the take–up of screening, including variations between regions; about the need to find out what is going right and what is not; and about the need to be careful how we communicate with women. I had a letter following a mammogram that began, “Do not be alarmed.” As I told the person in charge of screening, who happened to be someone I had gone to primary school with, that is immediately very alarming. People often do not think about what they are sending out in letters.

We have also heard about the need to ensure that the guidance on young women presenting with abnormal symptoms and how they should be screened and treated is put into effect. I hope the Minister recognises the concern around the Chamber that that guidance is not always being followed; when it is not, it can have disastrous results. We have heard about the need to review the evidence on what should be the best age for screening and to keep that evidence continually under review.

We have heard about the need to counter any resistance to the HPV vaccination programme. There is now a lot of false information about vaccination programmes going around on social media and the internet, and it needs to be countered, not by us as politicians, but by doctors and clinicians who really understand the value of vaccination. Like the Minister, I will probably get a lot of angry tweets and emails after this debate, but we must ensure that the evidence, not false information, is what leads us. I am glad to hear that the Minister takes this matter seriously—I am confident that he does—and I hope we will make further progress in the coming years.

Question put and agreed to.

Resolved,

That this House has considered e-petition 225767 relating to lowering the age for smear tests for cervical cancer from 25 to 18.