Sorry Mariela, but refusing to do smear tests on people over 65 is not ageism… it simply may do more harm than good

Sorry Mariela, but refusing to do smear tests on people over 65 is not ageism… it simply may do more harm than good



Do swab tests age? That’s what Mariela Frostrup claimed last week about the NHS’s cervical screening programme, which is offered to women aged 25 to 64.

It is designed to pick up changes that could indicate an increased risk of cervical cancer – a disease that can almost always be treated successfully with early intervention but still kills hundreds of women in Britain every year.

In a newspaper article, the writer and broadcaster – who is 61 and recently had her last smear test – denounced the “ageist” and “outdated” policy that means women aged 65 and over are no longer given smear tests. Routinely.

She described this as another example of “medical misogyny” by the NHS, and added that she wanted to start a campaign to see older women covered by the screening scheme.

Photo album by Mariela Frostrup, a journalist and TV presenter based in the United Kingdom
Mariela Frostrup denounced the “ageist” and “outdated” policy that means women aged 65 or over are no longer routinely given smear tests.
Dr Philippa Kay (pictured) is a GP. She believes smear tests will do more harm than good

As a GP with a particular interest in women’s health and an ambassador for the Joe Cervical Cancer Foundation, this caught my attention. I’m a huge fan of Marilla, we work together at the Women’s Wellbeing charity but I’m afraid we disagree on this – screening women over 65 may end up doing more harm than good.

My view is that if we want to eliminate cervical cancer in the UK by 2040, as the government has pledged, we need to focus our efforts on making the current program as good as possible. This means encouraging all eligible women to attend every smear test when invited – which does not happen – and doing everything we can to boost HPV vaccine uptake among 12- to 13-year-olds.

Let me explain.

What is a swab test?

A smear test detects abnormal cells in the cervix, which is the entrance to the uterus from the vagina.

Removing these cells can prevent cervical cancer.

Most test results appear clear, however, about one in 20 women show abnormal changes in cervical cells.

In some cases, these tumors must be removed or they may become cancerous.

Cervical cancer most often affects sexually active women between the ages of 30 and 45.

In the UK, the NHS Cervical Screening Program invites women aged 25 to 49 to have a smear every three years, women aged 50 to 64 every five years, and women over 65 if they have not been screened Are older than 50 years or have previously had abnormal symptoms. results.

A woman must be registered with a GP to be invited for the test.

In the United States, tests begin when a woman turns 21 and are done every three years until she reaches 65.

Changes in cervical cells are often caused by the human papillomavirus (HPV), which can be transmitted during sex.

Most cases of cervical cancer are caused by human papillomavirus, which can be transmitted sexually and is also linked to penile and anal cancer and some types of head and neck cancer. The virus is common and most people naturally develop antibodies to it, which means it is cleared by the immune system. But for about one in ten women, high-risk forms can persist and cause changes in cells in the cervix, which can become cancerous.

A screening test, which involves inserting a speculum into the vagina and taking a sample of cells from the cervix, is used to check for abnormal cells that have the potential to turn into cancer. Since 2020, she has instead researched HPV.

If the virus is found, the sample is then tested for abnormal cells, and women with it are referred for a colposcopy, which involves inserting a thin microscope into the vagina to take a closer look at the cervix and check for pre-cancerous abnormalities.

Abnormalities can be treated and sometimes removed during this or an additional procedure – so screening can prevent women from developing cancer. It is believed that around 5,000 lives have been saved through the screening programme.

Since 2008, we have also been vaccinating girls aged 12-13 years against HPV (and since 2019, boys too). The vaccine is a game changer. Data indicate that it can reduce the risk of cervical cancer by about 87 percent.

Disease rates have already fallen by 25 percent since the early 1990s. But women born before 1991 did not benefit from it, and like any vaccine, it is not 100 percent effective, so all women must undergo regular checkups.

Women are first invited when they are 25 because research has found that abnormalities detected early can resolve naturally, and treating women can expose them to unnecessary procedures.

And they stop at 64 for good reason too. In part, women are less at risk – people over 65 are half less likely to develop the disease than those in their early 30s. But it’s also because persistent HPV infection takes a long time to turn into cervical cancer.

“It can take 10 to 20 years for HPV to turn into cancer,” explains obstetrician-gynecologist Adeola Olitan, a trustee of the Joe Cervical Cancer Fund. This means that if women regularly undergo smear tests, especially if their results are negative after the age of 50, they are less likely to end up with cervical cancer that will cause them problems or need treatment during their lifetime. Another critical consideration, according to Theresa Freeman Wang, one of the country’s leading experts on colposcopy and cervical cancer, is weighing the benefit against the potential harm and recognizing that screening older women could cause them unnecessary surgical procedures.

“As women get older, screening becomes more uncomfortable because estrogen deficiency causes vaginal dryness, so it can be difficult to get a good sample,” she says. “And when you do get one, it can be more difficult to evaluate technically — if the woman isn’t You are taking hormone replacement therapy, your cells may look abnormal even if they are not.

Women are first invited when they turn 25 because research has found that abnormalities detected early can resolve naturally (stock image)
About 3,200 women are diagnosed with cervical cancer each year in the UK, often between the ages of 30 and 34 (stock image)

This means that doctors may perform a colposcopy to check for signs of abnormalities, which can cause significant stress. But these procedures are also more difficult to perform in older women because the area in the cervix where the abnormalities are found recedes with age, making vision more difficult.

“You may end up in a situation where you can’t evaluate the area,” says Ms. Freeman Wang. “That woman may then be offered further treatment, such as a more invasive surgical biopsy, to make sure we haven’t missed anything.

“Then, if the woman is post-menopausal, there is a possibility that the cervix will heal, preventing further evaluations. In this case we may need to talk about a hysterectomy that the woman would not have needed if we had not started this.” The Road.

For Ms Freeman Wang, more evidence is needed to assess whether screening for over-65s would do more good than harm, especially if they have regularly attended cervical screening. “The concern I have is that we may be over-treating women who would never be at any significant risk,” she adds. “It’s not about misogyny or ageism.”

I do not know the answer. “We need to find cervical cancer in older women, but we are not yet at the point where we can recommend expanding the threshold for screening.” So what about the women who are diagnosed with cervical cancer every year after the age of 65?

In the absence of screening, it will be discovered after symptoms appear that include unexpected bleeding, changes in vaginal discharge, pain during sex, or unexplained pelvic or lower back pain. These issues should never be ignored, no matter how old you are, and should be checked by your GP.

About 3,200 women are diagnosed with cervical cancer each year in the UK, often aged between 30 and 34 years.

Read more: More doctors are convinced that almost every diet ends in failure… Because obesity is a disease, writes frontline GP, Dr Philippa Kay

Rates decline after this point until women reach age 65 — right after screening stops — when there is a slight rise. Cancer Research UK figures show 580 cases a year affect women over the age of 65.

Some of these women, especially those in their 80s, have only been screened for 15 years (the program began in 1988) and may have never been tested for HPV, leading to a diagnosis of HPV infection later in the year. life.

Some cases may be associated with women living longer, so there is a greater chance that undetected HPV will turn into cancer.

High divorce rates could also play a role, as women may have new sexual partners later in life, exposing them to infection.

In 2018, in a report to the National Screening Committee, the GO Cervical Cancer Foundation noted this, adding: “Continued clinical research is needed to fully ascertain the risks and benefits to determine the ideal course of action for those over 64 years of age.”

The charity continues to support this call for further research, as do I.

But these cases in older women may also be linked to their failure to attend final examinations.

Some do not attend because they mistakenly believe that menopause means they are no longer at risk. Others stop coming because changes in their genitals and reproductive system mean they find it increasingly uncomfortable. We can help by prescribing estrogen gel in the weeks before the smear test, using a smaller speculum during the examination or by allowing you to insert the speculum yourself.

One trial is also looking at whether self-testing – using a simple swab kit at home – might help boost participant numbers. This is crucial as data shows that screening rates are declining – with only two-thirds of women attending regularly, and in the most deprived areas this proportion is less than 50 per cent.

We must also encourage uptake of the HPV vaccine, which, like other childhood vaccines, remains well below pre-pandemic levels.

Therefore, rather than extending the screening program as Mariela Frostrup suggests, the priority should be to improve the current programme.

This means encouraging women to keep up to date on smear tests, and making sure parents understand the benefits of vaccinating their children against HPV. These things will protect all women – not just now, but in the decades to come.

As Athena Lamnisos, of the charity Eve Abell, says: “There is no strong evidence for screening after the age of 65, but there is evidence that regular screening from your 20s to your mid-60s will protect you.”

For advice and support, visit jostrust.org.uk or call the charity’s helpline on 0808 802 8000.

(marks for translation) Smear

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