1 september 2011 to 31 august 2012 programme...for the period 1 september 2011 to 31 august 2012...

ISBN number: 978-1-907487-14-9

QA - CS/PR/PM-17 Rev 1

The National Cancer Screening Service is part of the Health Service Executive. It encompasses BreastCheck – The National Breast Screening Programme, CervicalCheck – The National Cervical Screening Programme, BowelScreen – The National Bowel Screening Programme and Diabetic RetinaScreen – The National Diabetic Retinal Screening Programme

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Programme Report

1 September 2011 to 31 August 2012

CervicalCheck Charter

Screening commitment:

• CervicalCheck–TheNationalCervicalScreeningProgrammeoffersafreecompletequalityassuredprogrammeofcare

• YouchooseyoursmeartakerfromawiderangeofeligibleserviceprovidersregisteredwiththeProgramme

• YoumaychangeyourpreferredproviderforsubsequentProgrammescreening

•AllProgrammestaffwillrespectyourprivacy,dignity,religion,raceandculturalbeliefs

• Yourscreeningrecordswillbetreatedinthestrictestconfidence

• Youwillalwayshavetheopportunitytomakeyourviewsknownandtohavethemtakenintoaccount

•OnceyoubecomeknowntotheProgrammeyouwillbeinvitedeverythreeyearsforscreeningwhileyouareaged25to44andeveryfiveyearswhileyouareaged45to60

• Yoursmeartestwillbescreenedinanaccreditedqualityassuredlaboratory

• YourresultandanytreatmentrecommendationwillbeprovidedtoyouandyournominatedsmeartakerbytheProgrammewithinfourweeks.

We aim:

• Toensurepleasantandcomfortablesurroundingsduringscreening.

If you require further treatment, we aim:

• Toensurethatyouwillbeofferedanappointmentataqualityassuredcolposcopyclinic(withinfourweeksforhighgradecellchangesandwithineightweeksforlowgradecellchanges).

Tell us what you think:

• Yourviewsareimportanttousinmonitoringtheeffectivenessofourservicesandinidentifyingareaswherewecanimprove

• Youhavearighttomakeyouropinionknownaboutthecareyoureceived

• IfyoufeelwehavenotmetthestandardsofthisCharter,letusknowbytellingthepeopleprovidingyourcareorinwritingtotheProgramme

•Wewouldalsoliketohearfromyouifyoufeelyouhavereceivedagoodservice.Ithelpsustoknowthatweareprovidingtherightkindofservice–onethatsatisfiesyou.

• Finally,ifyouhaveanysuggestionsonhowourservicecanbeimproved,wewouldbepleasedtoseewhetherwecanadoptthemtofurtherimprovethewaywecareforyou.

Ways you can help us:

• PleasemakeyourappointmentwitharegisteredsmeartakeronreceiptofyourinvitationletterfromtheProgramme

• PleasebringyourPPSnumberwithyoutoyourappointment

• Pleasereadanyinformationwesendyou

• Pleasetrytobewellinformedaboutyourhealth.

Let us know:

• Ifyouchangeyouraddress

•Whatyouthink–yourviewsareimportant.

Freephone 1800 45 45 55

www.cervicalcheck.ie

CervicalCheck Charter 1

Outline of The National Screening Service 3

Overview and introduction to CervicalCheck programme report 4

Updates 5

Completion of the first five years of CervicalCheck 6

Primary care 6

Smeartaker supports and training 7

Promoting regular smear test as a routine health behaviour 8

Cytology services 9

Colposcopy services 10

Histology services 12

Programme statistics 14

Glossary 35

Contents

The National Screening Service (NSS) was part of the Health Service Executive National Cancer Control Programme during the fourth year of the CervicalCheck programme 1 September 2011 to 31 August 2012. The National Screening Service has responsibility for four population-based screening programmes in Ireland:

• BreastCheck–TheNationalBreastScreeningProgrammewhichofferswomenaged50-64(over360,000women)afreemammogrameverytwoyearsandcommencedscreeningfromFebruary2000.www.breastcheck.ie

• CervicalCheck–TheNationalCervicalScreeningProgrammewhichoffersfreesmearteststowomenaged25to60(over1.1millionwomen).Regularsmeartestsatrecommendedintervalscanpreventcervicalcancer.SinceCervicalChecklaunchedinSeptember2008,almost1.65millionsmeartestshavebeenprocessedformorethan875,000women.www.cervicalcheck.ie

• BowelScreen–TheNationalBowelScreeningProgramme,fortheearlydetectionofbowelcancerinmenandwomenaged55to74(overonemillionpeople).Theprogrammeisinitiallyaimedatpeopleaged60to69years(500,000)andthefirstroundbeganinlate2012andmaytakeuptothreeyearstocomplete,afterwhicheachroundshouldbecompletedintwoyears.www.bowelscreen.ie

• DiabeticRetinaScreen–TheNationalDiabeticRetinalScreeningProgramme,fortheearlydetectionofdiabeticretinopathyisaimedatallpeoplewithType1orType2diabetesaged12andover(approximately190,000people).Theprogramme,whichcommenceditsfirstroundinearly2013,signalledtheexpansionforNSSintonon-cancerrelatedconditionsandisapopulation-basedcall,re-callscreeningprogramme.

Whenallfourpopulation-basedscreeningprogrammesarefullyoperational,overtwomillionpeopleinIrelandwillbeeligibletoparticipateinoneormoreoftheprogrammes.

TheNationalScreeningServicehasacommitmenttoimplementspecialmeasurestopromoteparticipationinitsprogrammesbyharder-to-reachindividualsandcommunitieswithinthepopulation.

TheNationalScreeningServiceisdedicatedtocontinueddeliveryofscreeningprogrammes,sharingexpertiseandlearningacrossnationalscreeningprogrammesanddrivingeffectivenessthroughstrengtheningthesinglegovernancemodelinplaceforscreening.

BackgroundNSS,formerlytheNationalCancerScreeningService(NCSS),wasestablishedinJanuary2007followingthelaunchof‘AStrategyforCancerControlinIreland2006’bytheCancerControlForumandtheDepartmentofHealth,whichadvocatedacomprehensivecancercontrolpolicyprogrammeinIreland.Thestrategysetoutrecommendationsregardingtheprevention,screening,detection,treatmentandmanagementofcancerinIreland.ItrecommendedtheestablishmentoftheNationalCancerScreeningServiceBoard,whichwaslaterdissolvedwhentheNCSSjoinedtheHealthServiceExecutiveNationalCancerControlProgramme(NCCP)in2010.

The National Screening Service

THENATIONALSCREENINGSERVICE3

THENATIONALSCREENINGSERVICE

This report contains screening statistics for the fourth year of operation (1 September 2011 to 31 August 2012) and an overview of activity and developments within CervicalCheck up to the time of publication.

CervicalCheckiscentraltocervicalcancerpreventioninIreland,workingtoreduceincidenceandmortalityfromthediseasebydetectingchangesinthecellsofthecervixbeforetheybecomecancerous.TheannualaverageincidenceofcervicalcancerinIrelandduring2008-2010was308caseswith88deathsduetothediseasein2010.1

Withaneligiblepopulationofover1.1millionwomenaged25to60,CervicalCheckhasthepotentialtoreducemortalityfromcervicalcancerbyasmuchas80percentinthescreenedpopulation.

Womenhaveachoiceofover4,700smeartakersinalmost1,450locations.Resultsareavailablequickly,withreducedwaitingtimesforcolposcopy.

Noscreeningtestis100percentaccurate.Thevalueofapopulation-basedscreeningprogramme,suchasCervicalCheck,isintherepeatnatureofscreening.

HealthprofessionalsincludingregisteredGPs,practicenursesandmedicalpractitionersworkinginprimarycareandincolposcopyservicesplayavitalroleinprovidinganeffective,qualityassuredenvironmentandexperienceinallstagesofthescreeningpathway.

ItisimportanttoalsoacknowledgetherolethateverymemberofstaffandmanagementinvolvedinrunningtheprogrammehasplayedduringthefirstfiveyearsofCervicalCheck.

Throughthecombinedeffortofthoseworkingonbehalfoftheprogramme,eligiblewomenandthewidercommunity,cervicalscreeningatrecommendedintervalsisbecomingroutinehealthbehaviour.

Majella ByrneHead, National Screening Service

Dr Gráinne FlannellyClinical Director, CervicalCheck

Overview and introduction to CervicalCheck programme report

1 CancerinIreland2013:AnnualReportoftheNationalCancerRegistry;NationalCancerRegistryIreland

2 CIN2+andadenocarcinomainsituincluded

4

In the first five years of CervicalCheck, more than 1.65 million smear tests provided

Completion of the first five years of CervicalCheck CervicalCheck completed its first five-year screening round on 31 August 2013, with over 74 per cent of women age 25-60 having at least one smear test. Over 1.65 million smear tests were provided during the first five years with more than 875,000 eligible women aged 25 to 60 having at least one CervicalCheck smear test.

CervicalCheckhastransformedtheexperienceofcervicalscreeningforeligiblewomen,strivingtomaketheprogrammeaccessibleandaseasyaspossibleforawomantoincorporatearegularsmeartestintoherroutinehealthbehaviour.

CervicalCheckusesamulti-layeredapproach,communicatingdirectlywithhealthprofessionalsandcommunitygroups,usingmediaandothercommunicationchannelstopromoteunderstandingofthevalueofregularsmeartestsamongitstargetpopulation.

Theprogrammeitselfiscomplex,involvingallaspectsofdeliveryfromregistermanagement,administration,smeartakinginprimarycare,cytology,colposcopy(diagnosisandtreatment)andhistologyservices.Everyaspectoftheprogrammeisgovernedbyqualityassurancestandards,basedonbestinternationalevidenceandreviewedbyapanelofinternationalexpertsbeforepublication.Thesecondeditionoftheseguidelines,publishedinearly2014,buildsonthelearningofthepastfiveyearsoftheprogrammeandcompletionofthefirstroundofscreening.

CervicalCheckcontinuestoinnovate,withrecentinitiativesincluding:

• Facilitatedreferralstocolposcopy

• Amoreaccessibleanduser-friendlywebsite

• Abilitytoanalyseandevaluateadditionalperformancemeasures

• IntroductionofHPVtestingpostcolposcopy

• Tailoredmanagementplansatcolposcopy

Theprogrammeisadaptingwithinachanginghealthenvironment,embracingdevelopmentswithinHPVtechnology,andmakingpreparationsfortheinclusionofHPVvaccinatedwomeninthecomingyears.Thisdiscussionissimilarlyreflectedacrossothercountrieswithavaccinationprogramme.

Primary careWomenhaveagreatdegreeofflexibilityandabroadchoiceoflocationsfortheirsmeartest.Thevastmajorityofwomenchosetohavetheirsmeartestcarriedoutinaprimarycaresetting.PrimarycaresettingsincludeGPpractices,Women’sHealth,FamilyPlanningandWellWomenClinics.

TheremainderofwomenhadtheirCervicalChecksmeartestinacolposcopyclinic,publicgynaecologyserviceorSTI/GUM(sexuallytransmittedinfection/genito-urinarymedicine)clinic.

Updates

During the fourth year of the CervicalCheck programme (1 September 2011 to 31 August 2012) over 90 per cent of women had their smear tests in a primary care setting, which is unsurprising with over 4,700 smeartakers registered with CervicalCheck across approximately 1,450 primary care settings.

UPDATES 6

Smeartaker supports and trainingAdedicatedScreeningTrainingUnitco-ordinatessmeartakereducationandtraininginitiativesforthosestartingoutinpractice,andclinicalupdatesforexperiencedsmeartakers.Theunitprovidescomprehensivetrainingandresources,developedincollaborationwithsmeartakers,toensureprovisioninaflexibleandmeaningfulway.

CervicalCheckwonBestEducationProject(GeneralPractice/Pharmacysection)attheIrishHealthCareAwards2012.CervicalCheckalsohostedasuccessfulnationalstudydayfeaturingnationalandinternationalspeakersinAutumn2012.Thestudydayprovidedaforumfordiscussingtheachievementsoftheprogrammeaswellasthefutureofcervicalscreening.

AccreditedsmeartakertrainingmodulesareprovidedthroughsuccessfulpartnershipswiththeIrishCollegeofGeneralPractitioners(ICGP),RoyalCollegeofSurgeonsinIreland(RCSI)andtheNationalUniversityofIreland,Galway(NUIG).

TherehasbeenhighlevelofengagementwithGPTrainingSchemesandatailoredtrainingprogrammewasdeliveredto316GPtraineesduring2013.AccreditedclinicalupdatesessionshavebeendeliveredtoIrishPracticeNurseAssociation(IPNA)practicenursesatregionalbranchlevel.Continuingmedicaleducation(CME)sessionswereprovidedtoclinicallyresponsibledoctors.

Over98percentofsmeartestswerereportedassatisfactoryduringtheperiodofthisreport,reflectingtheskillandprofessionalismofsmeartakersregisteredwiththeprogramme.

AneLearningportalprovidesavirtuallearningenvironment,facilitatingbusyhealthprofessionalstoadvancetheirknowledgeandskillsinanaccessible,flexibleformat.

TheeLearningportalincludesCPDaccredited‘eUpdates’,acerviximagelibrary,resourcesforGPtrainees,andeducationalmodulesonotherNCSSprogrammes(availableatwww.cervicalcheck.ie–healthprofessionalssection).

Additionaleducationalresourcesincludetherecentlyrevised‘DesktopGuideforSmeartakers’.

CervicalCheck national study day Best Education Project (General Practice/Pharmacy Section) at the Irish Health Care Awards 2012

UPDATES7

Promoting regular smear test as a routine health behaviourAcentralprincipleoftheprogrammeistheneedforeffectivecommunicationwitheligiblewomen,particularlyaroundraisingawarenessanddrivingunderstandingoftheimportanceofregularsmeartestsforcervicalhealth.Theprogrammeaimstoinform,educateandencourageeligiblewomentoparticipateintheCervicalCheckprogramme.

Maintaininghighlevelsofscreeningovertimeisakeychallengeinternationallyforpopulationscreeningprogrammes.Asthetargetaudiencechanges,withnewwomenenteringtheprogrammeandawarenessoftheprogrammegrowingacrossthewiderpopulation,CervicalCheckworkstoensureeligiblewomenareawareoftheimportanceofregularsmeartestsasaroutinehealthbehaviour,understandingthevaluefortheirhealthacrosstheirlifetime.

Somewomeninmorevulnerablesituationscanfaceanumberofbarrierstoparticipationandareidentifiedasharder-to-reach.Cuttingthroughtheimpedimentstodeliveracomplexmessageabouttheimportanceofregularsmeartestsisbestachievedusingacomprehensive,sensitivescreeningpromotionapproach.

Amulti-layeredapproachisdevisedinpartnershipbytheScreeningPromotionandCommunicationsteam,whichusestraditionalmediumssuchasadvertisingandpublicrelationsalongsidespecificinitiativestoencourageeligiblewomen,particularlythosewhoareharder-to-reach.

TheSmeartakerTrainingUnitlikewisehasakeyroleinreinforcingsimilarmessagingamongsttheserviceproviders.Inaddition,CervicalCheckprovides:

• Ascreeningpromotionteamwhoworkonanationalbasistoincreaseawarenessandunderstanding.

• AFreephoneinformationandsupportline.

• LeafletsdesignedinlinewiththeNationalAdultLiteracyAgency(NALA)PlainEnglishmark.

• Anaccessofferwhoworkstoprovideequalaccesstoscreeningforallwomen,includingthosewithdisabilities.

• Resourcesdesignedtomeetparticularneeds,suchasBraille,audioanddifferentlanguages.

UPDATES 8

*Image removed due to copyrights

During2013atargetedcampaignaddressedtwokeyissues:

• Encouragingwomenaged50-60toparticipate.TheinternationaltrendforlowerparticipationbywomentowardstheupperendoftheagerangeisreflectedinIrelandandaconcertedeffortwasmadetoraiseawarenessoftheimportanceofparticipationacrosstheagerange.

• Targetingpopulationswithalowuptaketoencouragewomenacrosstheagerangelivinginthoseareastoparticipate.

Cytology servicesCytologyservicesareprovidedforCervicalCheckbyQuestDiagnosticsIncandMedLabPathologyLtd,twolaboratoriescontractedbytheNationalScreeningService(NSS)followingapublicprocurementprocess.

ANationalCytopathologyTrainingCentrelocatedattheCoombeCytologyDeptbeganprocessingCervicalChecksamplesfromearly2013.

Performanceisauditedagainststandardssetforcytologyaspartoftheprogrammetobestensureturn-aroundtimesandotherperformanceindicators.

TheNationalScreeningServiceiscurrentlyengagedonaprojectwithHealthlinkandthecytologylaboratoriestoprovideGPsregisteredwithHealthlinkaccesstoelectroniccytologyresults.Theprojectisaimingforcompletionin2014.

Inordertoavoidunnecessarysmeartestsforwomen,follow-upofwomenwithlowgradeabnormalitieswasmodifiedinApril2012.

During the fourth year of the CervicalCheck programme (1 September 2011 to 31 August 2012)

•Over87percentofsatisfactorysmeartestswere found to be negative or normal.

•11percentshowedlowgradeabnormalities.

•Highgradeabnormalitiesweredetectedin1.6 per cent of smear tests.

Dr Gráinne Flannelly promoting the pearl of wisdom, emblem of European Cervical Cancer Prevention Week, January 2014

UPDATES9

Colposcopy services provided at

Coombe Women and InfantsUniversity Hospital, Dublin

St Finbarr’s Hospital, Cork

The Adelaide and Meath Hospital, incorporating the National Children’s Hospital, Tallaght

Louth County Hospital, Dundalk Mayo General Hospital, Castlebar

University College Hospital, Galway

Limerick Regional Maternity Hospital

Kerry General Hospital, Tralee

South Tipperary General Hospital, Clonmel

Wexford General Hospital

Waterford Regional Hospital

Sligo General Hospital

Rotunda Hospital, Dublin

National Maternity Hospital, Dublin

Letterkenny General Hospital

UPDATES 10

Colposcopy services

Colposcopyservicesprovidedacrossfifteenlocationsarevitaltoensuringaccuratediagnosisandeffectivetreatmentofwomenwhohavehadabnormalitiesdetectedintheirsmeartest.

CervicalCheckhasgreatlyimprovedcolposcopyservicesinIreland,increasingcapacityandensuringservicesreceiveadequateinvestmentandsupport.

InSeptember2013aColposcopyforumwashostedbytheNSSwherecolleaguesfromcolposcopyservicesnationallyattendedtodiscusstheprogramme’sachievements,newdevelopmentsandqualityassuranceatcolposcopyservices.

CervicalCheckcontinuallyworkstobetteridentifythosewomenwhoneedtreatmentandfurthersurveillance.ProgresshasbeenmadeinthisareawithrevisedNSS‘GuidelinesforQualityAssuranceinCervicalScreening’issuedrecentlybytheQualityAssurancecommittee.Aclinicalguidance

documentdescribestheuseofHPVtestingforthefollow-upoftreatedwomen.Italsoupdatesclinicaladviceonmanagementandsurveillancefollowingcolposcopy.WhereappropriateacombinedsmearandHPVtestwillbeprovidedayearfollowingtreatment.

Updatedclinicalguidanceonthemanagementoflowgradeabnormalitieswasintroducedinearly2014.Thistailoredapproachwillidentifyatanearlierstagethosewomenwhoneedtreatment.AnumberofITchangesandinformationsourceswereintroducedinordertofacilitatethis.WomenwhoattendaninitialcolposcopywherenoCINisidentifiedwillbeplacedundersurveillanceandreceiveacombinedsmearandHPVtestinayear’stime.

Performanceismonitoredagainststandardssetforcolposcopyaspartoftheprogrammeandinformationgatheredcentrallyisanalysedtoproducetheresultsinthisreport.ColposcopyservicesareprovidedbyclinicianscertifiedbytheBritishSocietyforColposcopyandCervicalPathology(BSCCP).

CervicalCheckcommitstoofferingcolposcopyappointments:

• Urgentreferralswithintwoweeksofsmeartestresults

• Highgradecellchangeswithinfourweeksofsmeartestresults

• Lowgradecellchangeswithineightweeksofsmeartestresults.

Participants at recent colposcopy forum hosted at King’s Inns House

UPDATES11

*Image removed due to copyrights

Theprogrammecontinuestoworktowardsachievingandsurpassingstandardstoavoidanxietyandmaximiseefficiencyindiagnosisandtreatmentforthewoman.

Facilitated referral process for colposcopy services

Thefacilitatedreferralprocess,recommendingaspecificcolposcopyserviceforawomanrequiringreferral,hasbeenofbenefitbothintermsofcapacitymanagementandensuringappointmentsaregivenwithinprogrammetargets.Thisensuresthatwomenarereferredtocolposcopyserviceswithavailablecapacitywithinagreedtargetsforofferinganappointment.

Thefacilitatedreferralprocesshasalsoseenparticularbenefitintemporarilydivertingreferralsfromacolposcopyservicethatbecomesunavailableduetounforeseencircumstances.DuringfloodingatLetterkennyGeneralHospitalinAugust2013,referralswerequicklydivertedtoSligoGeneralHospitaluntilthehospitalreinstateditsserviceareas.Thisminimiseddisturbancetowomenandensuredreferralsoccurredinatimelyfashion.

Histopathology services

Biopsysamplestakenatcolposcopyareanalysedinhistopathologylaboratoriestodeterminethedegreeofabnormalityfound.Treatmentdecisionsarebasedonhistopathologyoutcomes.

In2013NSSextendedthescopeofitsagreementswithhospitalsprovidingcolposcopytoincludehistopathology.

Positive predictive value for CervicalCheck programme smear tests

Oneofthemostimportantqualitymeasuresforascreeningprogrammeisthepositivepredictivevalue(PPV)asitreflectstheprobabilitythatapositivetesthasdetectedtheunderlyingconditionbeingtested.

Thepositivepredictivevalueisameasureofthelikelihoodthatawomanwithapositivesmeartestactuallyhasapre-cancerouscervicalabnormalityoracancerdiagnosis.

Cervicalscreeningprogrammesaimforearlydetectionofhighgradeabnormalitieswhileminimisingunnecessaryinvestigations,anxietyandpossibleovertreatment.Thevalueofcytologyasatesttakesintoaccountboththesensitivity(abilitytodetectaproblemandavoidanceoffalsenegatives)andspecificity(avoidanceoffalsepositives).

During the fourth year of the CervicalCheck programme (1 September 2011 to 31 August 2012) the programme exceeded the standard set at 90 per cent for urgent and low grade referrals, with over 93 per cent of women being offered an appointment within eight weeks of the date the letter was received in the clinic.

During the fourth year of the CervicalCheck programme (1 September 2011 to 31 August 2012) the positive predictive value of Colposcopic impression was 75.3 per cent, above the programme standard of 65 per cent.

UPDATES 12

women screened from September 2011 - August 2012

328,000+

Introduction to the statistics 2011/2012CervicalCheck became a national screening programme on 1 September 2008. The figures reported in this section relate to the fourth year of operation (1 September 2011 to 31 August 2012). During this period the programme operated both an invitation entry system whereby eligible women received an invitation letter to screening and ‘direct entry’ whereby a woman could be screened by a smeartaker who could check her eligibility using an on-line facility.

Theresponsetotheprogrammehasbeenverypositivewith328,161womenattendingforscreeningduringthereportingperiod.QualityassuranceunderpinseveryaspectoftheCervicalCheckprogramme.Theprogramme’sperformanceismeasuredagainstKeyPerformanceIndicators(KPIs)asoutlinedinGuidelinesforQualityAssuranceinCervicalScreeningFirstEdition2009.

Table1showsthenumberofwomenscreenedbyagegroup.Womenbetweentheagesof25and60areinvitedtoscreening,butasmallnumberofwomenunder25mayattendunderspecificcriteria.Thosewomenaged61orovermayhavepresentedforthefirsttimeatthisageandsowereeligibleforafirstsmeartest,mayhavereceivedtheirinvitationtoscreeningatage60butdelayedsometimebeforepresentingforscreening,ormayreflectwomenhavingfollow-upsmeartestsperformed.

Programme statistics

Table 1: Number of women screened by age group

Age group Number of women screened %

<25* 1,812 0.6

25-29 55,083 16.8

30-34 60,128 18.3

35-39 54,378 16.6

40-44 47,254 14.4

45-49 38,936 11.9

50-54 30,840 9.4

55-59 23,599 7.2

60 3,659 1.1

≥61 12,472 3.8

Total: 328,161 100

* Basedonevidencetodate,thereisnoadditionalpublichealthbenefitinstartingpopulationscreeningbelowtheageof25.Screeninginwomenundertheageof25mayleadtomanywomenreceivingunnecessarytreatmentforlesionsthatwouldneverhavedevelopedintoinvasivecancer.Certainexemptionsapplywheresomewomenovertheageof60andundertheageof25areconsideredeligible.Suchexemptionsmayincludewomenofanyagewhoarepostcolposcopy,womenovertheageof60whohaveneverhadasmeartestandwomenaged20andoverwhoareonrenaldialysis,haveHIVinfection,arepostorgantransplantorwhohavehadapreviousabnormalsmeartestresultandarewithintherecommendedfollow-upperiod.

PROGRAMMESTATISTICS 14

Figure 1: Percentage of eligible women screened based on county of residence* from 1 September 2008 to 31 August 2012

* PopulationbasedonCSO2011Censusextrapolatedto2012

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PROGRAMMESTATISTICS

Programme coverageCoverageisdefinedastheproportionofuniquewomenwhohavehadatleastonesatisfactorysmeartesttakenwithinthedefinedperiod,expressedasapercentageofthetotalnumberofeligiblewomeninthepopulation.Itisameasureofhowwelltheprogrammeisreachingthetargetpopulation.

Theoverallpercentageoftheeligiblepopulationscreenedinthefirstfouryearsofthenationalprogrammewas67.9percentnationwide.ThisdemonstratesthatCervicalCheckcontinuestoimprovecoverage,followingsuccessfulachievementofitstargetcoverageduringthefirstscreeninground(inyearsonetothreeofthenationalprogrammecoveragewas60.9percent).

ThegeographicalspreadofscreeningcoveragebasedontheeligiblepopulationofeachcountyisshowninFigures1and2.

15

PROGRAMMESTATISTICS

70km40mls

>=70%

65%-69%

<65%

Coverage

Figure 2: Map showing percentage of eligible women screened by county of residence* from 1 September 2008 to 31 August 2012

* DataanalysedusingHealthAtlasIreland.

PopulationbasedonCSO2011Censusextrapolatedto2012

Eligible Women ScreenedSeptember 2008 – August 2012

16

100%

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70%

60%

50%

40%

30%

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0%25-29 30-34 35-39

Agegroup

%cov

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40-44 45-49 50-54 55-59 60

Figure 3: Coverage of women by age group

Mostwomen(90.8percent)hadtheirsmeartestscarriedoutinaprimarycaresetting;93.2percentoftheseattendedaGPpractice.Fortheremainderofwomen,thefirstCervicalChecksmeartestoccurredinacolposcopyclinic,publicgynaecologyserviceorSTI/GUMclinic.

CoverageoftheprogrammebyagerangeforthefirstfouryearsisshowninFigure3.ThesefiguresrepresentthenumberofwomenscreenedcomparedtoeligiblewomenasoutlinedinCensus2011extrapolatedto2012.

Aconsistentpatternhasbeenevidentsincetheinceptionoftheprogramme,withthehighestcoverageseeninyoungeragegroupsandcoveragegraduallydecreasingwithincreasingage.

PROGRAMMESTATISTICS17

Table 3: Percentage of women sent results letter within four weeks of smear test date

Time from smear test to results letter printed date 2011/12 Target

Within4weeks 74.8% >90%

Table 2: Laboratory turnaround time - time from receipt of sample at laboratory to results returned to the programme

Performance parameter 2011/12 Target

%resultsreturnedwithintwoweeksof 88.2% >90%receiptofsampleatlaboratory.

Laboratory turnaround time Oneofthecriteriafortheselectionoflaboratoriesfortheprovisionofcytologyserviceswasthecapacityandabilitytoprocesssmeartestswithin10daystofacilitatetheprovisionofresultstowomenwithinfourweeksfromthedateofthesmeartest.Table2showshowthelaboratoriesperformedoverthefourthyearoftheprogramme.Overallforthereportingperiod88.2percentoftestresultswerereceivedbytheprogrammewithintwoweeks,slightlybelowthetargetset.

Thelaboratories’performancemetricsareauditedandmonitoredonanongoingbasistoensureadherencetotheguidelinesforqualityassuranceincervicalscreening.

CervicalCheck women’s charterTheCervicalCheckwomen’scharterincludesthecommitmentthat“yourresultandanytreatmentrecommendationwillbeprovidedtoyouandyournominatedsmeartakerbytheprogrammewithinfourweeks”.Laboratoriestypicallyprovidewrittenresultstodoctorswithinthreeweeksofreceiptofsamples.Theprogrammeisnotifiedthattheresultisavailable,andwomenareissuedaletterfromtheprogrammeoutliningthenextstepandanyrecommendationfollowingtheirsmeartest.

BytheendofAugust2012almost75percentofwomenreceivedaresultsletterfromtheprogrammewithinfourweeks(over91percentwithinfiveweeks)oftheirsmeartestdate(Table3&Figure4).Overthefirstfouryearsofthenationalprogrammetherehasbeensustainedimprovement.Thenumberofwomensentresultsletterswithinfourweeksincreasedfrom40.5percentin2008-2009to74.8percentin2011-2012.Ongoingmonitoringandactionsaretakentoprogressivelyimprovethisresponsetime,workingwithsmeartakersonsamplesubmissionaswellasprocessimprovements.


Upto4weeks

4-5weeks

5-6weeks

Over6weeks

Figure 4: Time in weeks for results letter sent to women (%)

Table 4: Cytology findings for smear test results

Smear tests Cytology findings

Total number of smear Unsatisfactory/ Satisfactory/ tests processed inadequate smear test adequate smear test

N N % N %

364,213 4,554 1.3 359,659 98.7

CytologyCytologyfindingsreportedinTables4and5arebasedonsmeartestresultsreceivedbytheprogrammeintheperiod1September2011to31August2012,ratherthanthesmeartestdate.Ofthe364,213smearteststaken,asmallnumberwereunsatisfactory(Table4).Theoutcomesoftheremaining359,659satisfactorysmearsarereportedinTable5.

17.1%

3.6%4.4%

74.9%


Table 5: Cytology results excluding unsatisfactory smear tests

Cytology results N %

NAD(noabnormalitydetected) 314,476 87.4

Low Grade

ASCUS 25,497 7.1

AGC(AtypicalGlandularCells) 1,211 0.3

LSIL 12,860 3.6

High Grade

ASC-H 2,026 0.6

HSIL(Moderate) 1,683 0.5

HSIL(Severe) 1,870 0.5

QuerySquamousCellCarcinoma 10 0.0

QueryGlandularNeoplasiaorAIS 26 0.0

Total 359,659 100

Ofsmeartestsperformedoutsideofcolposcopyclinics14,194(4.2%)resultedinareferraltocolposcopy.

Over87percentofsatisfactorysmeartestresultsintheperiodwerefoundtobenegativeornormal.Oftheremainder,11percentshowedlowgradeabnormalitiesand1.6percentshowedhighgradeabnormalities(HSIL(moderateorsevere),ASC-H,queryinvasivesquamouscarcinomaorqueryglandularneoplasia).

Thehighrateoflowgradeabnormalitiesremainedaninterestingfeatureoftheprogrammeduringthisyear.Thisisbecausesomewererepeatsmearsthatwererecommendedfollowingapreviouslowgradesmeartestresult.


Table 6: Outcome of appointments at colposcopy clinics

First visits Follow-ups Total

N % N % N %

Attended 16,621 72.6 43,202 53.7 59,823 57.9

Cancelled 5,056 22.1 28,609 35.6 33,665 32.6

Didnotattend(DNA) 1,172 5.1 8,531 10.6 9,703 9.4

Notrecorded 54 0.2 60 0.1 114 0.2

Total 22,903 100 80,402 100 103,305 100

50,00035,00020,000 45,00030,00015,0005,000 40,00025,00010,0000

Numberoffirstvisits Numberoffollow-upvisits

Sep2011–Aug2012

Sep2010–Aug2011

Sep2009–Aug2010

Sep2008–Aug2009

Figure 5: Attendance at colposcopy services from 1 September 2008 – 31 August 2012

Diagnosis and treatmentTheprovisionofhighqualitycolposcopyserviceswithtimelydiagnosisandtreatmentisacrucialcomponentofsuccessfulcervicalscreeningprogrammesandremainsakeypriorityfortheCervicalCheckprogramme.FifteencolposcopyservicesnationwideworkwiththeProgramme,eachwithagreedindividualisedserviceplansdeliveredbydedicatedmultidisciplinaryteams.Informationiscollectedelectronicallyandacentraldataextractionperformed.Thesedataformthebasisforthissectionofthereport.

Duringtheyear16,621womenattendedcolposcopyforthefirsttime.Thisrepresentsaslightdroponthepreviousyear.Thesustainedincreaseinreferralsseeninpreviousyearsisreflectedinadoublingofthenumbersofwomenattendingforfollowupappointments(43,202in2012comparedto20,769in2011).

Itisimportanttonotethenumberofwomenreferredandthenumberofnewreferralsattendedwillnotbethesameinanygiventimeperiod.Thisisbecauseoftheleadtimebetweenthecolposcopyreferralandthedateofthefirstcolposcopyvisitaswellasadditionalreferralsforclinicalreasons.


Women who default from attendance at colposcopy services according to CervicalCheck standards


Thepercentageofwomenwhodonotattendand 9.4% <15%whodonotnotifytheclinicshouldbemaintained atalowleveltomaximisetheefficiencyoftheclinic andtoavoidthelossofwomentofollow-up.

Table 7: DNA rates for appointments offered to women by age group

Age in years at Number of First Number of Follow-up first offered first visit DNA follow-up visit DNA appointments appointments rate (%) appointments rate (%)

<25 946 12.6 5,798 15.5

25–29 6,224 5.5 23,412 12.0

30–34 5,011 5.5 17,952 11.2

35–39 3,420 5.1 11,470 9.7

40–44 2,596 4.0 8,381 8.5

45–49 1,927 2.9 5,897 7.5

50–54 1,310 2.7 3,592 6.7

55–59 684 3.1 1,893 6.1

60 77 2.6 248 3.6

≥61 355 1.7 654 5.2

Notrecorded 353 9.3 1,105 12.8

Ofthe16,621newattendancesatcolposcopy,informationontheageofthewomanwasavailablefor16,488(99.2%).Themeanageatreferralwas36years.Themajorityofwomenwereagedbetween25-45yearswith3.8percentagedunder25yearsand11.3percentover50years.

AccordingtothestandardsforcolposcopyfortheCervicalCheckprogrammetherateofdefaultedappointmentswherenopriornoticewasgiven(DNA)shouldbekepttoaminimumandmaintainedbelow15percent.

TherateofDNAappointmentsispresentedaccordingtothetypeofvisitandtheageofthewoman(Table7).TheDNArateishigherforreturnvisitsthanforfirstvisits.Asreflectedinlastyear’sreport,youngerwomenweremorelikelytodefaultthanolderwomen.Thismayreflecthigherlevelsofmobilitywithinthispopulationofwomen.


Table 8: Reason for referral to colposcopy

New referrals for whom consent is available

Reason for referral to colposcopy N %

Abnormalsmeartestresult 13,728 82.8

Clinicalindication–nonurgent 1,531 9.2

Clinicalindication–urgent 1,316 7.9

Total* 16,575 100

* 15womenhadnoreasonentered

Figure 6: Reason for referral for women attending colposcopy services from 1 September 2008 – 31 August 2012

6,000

5,000

4,000

3,000

2,000

1,000

0

Sep2008–Feb2009

Lowgrade Highgrade Clinicalindication–nonurgent Clinicalindication–urgent

Mar2009–Aug2009

Sep2009–Feb2010

Mar2010–Aug2010

Sep2010–Feb2011

Sep2011–Feb2012

Mar2011–Aug2011

Mar2012–Aug2012

Num

ber

Reasons for referralOfthe16,621newreferralswhoattendedcolposcopyservices,consentinformationwasavailablefortheCervicalCheckprogrammefor16,590women(99percent).Fortheremainingonepercenttheconsentinformationwasnotrecorded.Thereasonsforreferraltocolposcopyforthesewomenwere:

• 83percentwerereferredonthebasisofanabnormalsmear

• 17percentforclinicalreasons

Anumberofwomenwerereferredtocolposcopyfromoutsideoftheprogrammeforclinicalreasonssuchasanabnormalsmeartestresultorforclinicalreasonssuchassymptomsofabnormalvaginalbleedingorasuspicionofananatomicalabnormalityofthecervix(Table8).

Therelativeincreaseinclinicalreferralsisfacilitatedbyanincreaseincapacityforthesereferralsatcolposcopywhichpreviouslywouldhavebeenseeninoutpatientgynaecologyservices(Figure6).


Ofthe13,728womenwhopresentedwithanabnormalsmear,4,092(30%)werereferredfollowingdetectionofahigh-gradeabnormality(Table9).Thedetectionofalow-gradesmeartestresult(LSILorASCUS)wasthereasonforreferralin8,690(63%)womenandasmeartestshowingAGC(borderlineglandularcells)wasthereasonforreferralin883cases(6.4%).Thenumbersofwomenreferredwithpersistentlyunsatisfactoryorinadequateresults(63;0.5%)remainedconsistentlylow.

Table 9: Reason for referral to colposcopy as a result of an abnormal smear test result

New referrals for whom consent is available

Referral smear abnormality N %

Unsatisfactory/inadequate 63 0.5

Low Grade

ASCUS 4,334 31.6

AGC(borderlineglandular) 883 6.4

LSIL 4,356 31.7

High Grade

ASC-H 1,410 10.3

HSIL(moderate) 1,272 9.3

HSIL(severe) 1,377 10.0

Queryinvasivesquamouscarcinoma 11 0.01

QueryglandularneoplasiaAIS/adenocarcinoma 22 0.2

Total 13,728 100


Figure 7: Waiting time for colposcopy services over first four years of the programme – measured against CervicalCheck standards over time

100%

80%

60%

40%

20%

0%

Sep2008–Aug2009

Sep2009–Aug2010

Sep2010–Aug2011

Sep2011–Aug2012

Allwomenreferredtocolposcopyshouldbeofferedanappointmentwithineightweeksofthedatetheletterwasreceivedintheclinic

Allwomenreferredtocolposcopywithasuspicionofinvasivecanceronasmearshouldbeofferedanappointmentwithintwoweeksofthedatetheletterwasreceivedintheclinic

AllwomenreferredtocolposcopywithasmearsuggestiveofCIN2orCIN3shouldbeofferedanappointmentwithinfourweeksofthedatetheletterwasreceivedintheclinic

Allwomenreferredtocolposcopywithasmearsuggestiveofglandularneoplasiashouldbeofferedanappointmentwithinfourweeksofthedatetheletterwasreceivedintheclinic

Waiting timesOneofthekeychallengesfacedbytheCervicalCheckprogrammeinthefirstfouryearswastheprovisionofaccesstocolposcopyinatimelyfashionforwomen.Sincethestartoftheprogramme,serviceshavebeenactivelyengagedinaprocesstoincreasecapacityandthishasresultedinsustainedimprovementsyearonyear.

Standardsfortheprogrammestatethat90percentofwomenwithhighgradecytologicalabnormalitiesshouldwaitlessthanfourweeksand90percentofallwomenshouldwaitlessthaneightweeksforanappointment.

Fortheperiod1September2011to31August2012informationonwaitingtimeswasavailablefor15,115ofthe16,590newattendances(Table10,Figure7).

ForwomenreferredtocolposcopywithasmeartestsuggestiveofCIN2/CIN3,81.6percentwereseenwithinfourweeks.

Overallhowever,onlysevenpercentofwomenexperiencedwaitingtimesoflongerthaneightweeksandinonlyonepercentofcasesthewaitwaslongerthan12weeks.Thisrepresentsaconsiderableimprovementinthefourthyearoftheprogramme(duringthepreviousyearthewaitwaslongerthan12weeksin15.8percentofcases).


Waiting times for colposcopy measured against colposcopy standards


Allwomenreferredtocolposcopyshouldbeoffered 93.4% > 90%anappointmentwithineightweeksofdatetheletterwasreceivedintheclinic.

Allwomenreferredtocolposcopywithasmear 81.6% > 90%suggestiveofCIN2orCIN3shouldbeofferedanappointmentwithinfourweeksofdatetheletterwasreceivedintheclinic.

Allwomenreferredtocolposcopywithasuspicion 100% > 90%ofinvasivecanceronasmearshouldbeofferedanappointmentwithintwoweeksofdatetheletterwasreceivedintheclinic.

Allwomenreferredtocolposcopywithasmear 95.5% > 90%suggestiveofglandularneoplasiashouldbeofferedanappointmentwithinfourweeksofthedatetheletterwasreceivedintheclinic

Table 10: Waiting times for women referred to colposcopy grouped by grade of referral smear test

High grade Low grade Total

N % N % N %

Lessthan2weeks 1,411 35.1 1,639 17.4 3,050 22.7

Between2and4weeks 1,848 45.9 2,274 24.1 4,122 30.6

Between4and8weeks 689 17.1 4,695 49.7 5,384 40.0

Between8and12weeks 42 1.0 703 7.4 745 5.5

Greaterthan12weeks 12 0.3 129 1.4 141 1.0


Figure 8: Number of women undergoing biopsy at colposcopy services

12,000

10,000

8,000

6,000

4,000

2,000

0

Num

ber

Sep2008–Feb2009

Mar2009–Aug2009

Sep2009–Feb2010

Mar2010–Aug2010

Sep2010–Feb2011

Sep2011–Feb2012

Mar2011–Aug2011

Mar2012–Aug2012

Allappointments Firstappointments

Biopsy rates measured against colposcopy standards


Abiopsyshouldbeperformedinthepresenceofan 88.0% >95%atypicalTransformationZoneandasmeartestwhichsuggestsunderlyingCIN.

Ifthereisasuspicionofinvasivediseaseabiopsy 93.9% >90%mustbeperformedimmediately.

Theroleofcolposcopyistofacilitatediagnosisandtreatmentofwomenwithabnormalsmeartestresults.Whereanabnormalityissuspectedatcolposcopyitisgoodpracticetoperformabiopsytoconfirmthediagnosis.Therearetwomaintypesofbiopsyperformed–adiagnosticbiopsy,whichinvolvessamplingaportionoftheabnormalareaonly,andanexcisionalbiopsywhichremovestheabnormalareainitsentirety.

Duringthereportingperiod13,373diagnosticbiopsies,7,375excisionalbiopsiesand40otherbiopsieswereperformed.TheinitialcolposcopyvisitdeterminesthepresenceorabsenceofanatypicalTransformationZone.Abiopsywasperformedin88percentofcaseswherethetransformationzonewasdocumentedasatypicalandover93percentofcaseswhereaninvasivecancerwassuspected.


Table 11: Biopsies performed during the first visit to colposcopy according to referral smear grade

Biopsy performed

Excisional Diagnostic No biopsy Total biopsy biopsy taken

Grade of cytology result of referral smear N % N % N % N %

AGC(borderlineglandular) 145 16.4 468 53.0 270 30.6 883 100

HighGrade 1,193 29.2 2,283 55.8 616 15.1 4,092 100

LowGrade 360 4.1 4,821 55.5 3,509 40.4 8,690 100

Unsatisfactory/inadequate 2 3.2 19 30.2 42 66.7 63 100

Total 1,700 12.4 7,591 55.3 4,437 32.3 13,728 100

ThebiopsyratesaccordingtothegradeofthereferralsmeartestandreasonsforreferralarepresentedinTable11.Eightyfivepercentofwomenpresentingwithahighgradecytologicalabnormalityhadabiopsyperformedatthefirstvisitcomparedwith60percentofwomenpresentingwithalowgradecytologicalabnormality.Over69percentofwomenpresentingwithAGC(borderlineglandularcells)hadabiopsyatthefirstvisitwhichincludedanexcisionalbiopsyin16.4percent.Thisreflectsthecontinueddifficultyofmanagingthisrelativelynewgroupofwomenparticularlyifthecolposcopicappearanceisnormalorunsatisfactory.


The outcome of use of local anaesthetic measured against colposcopy standards


Themajorityofwomenshouldhavetreatment 94.0 >80%performedasanoutpatientunderlocalanaesthetic.

Treatment at colposcopyEffectivetreatmentofhighgradeCINandadenocarcinomainsituwithsubsequentreductionoftheriskofinvasivecancerisvitaltothesuccessofanycervicalscreeningprogramme.Thistreatmentshouldbeeffective,safeandacceptable.ItshouldaimtoeradicateallCINfromthecervixandshouldbetailoredtothecircumstancesoftheindividualwoman.

ThestandardsfortheCervicalCheckprogrammestatethattreatmentsbeperformedasanoutpatientprocedureunderlocalanaestheticmorethan80percentofthetime.Duringthefourthyearoftheprogrammetreatmentwasperformedasanoutpatientusinglocalanaesthetic94percentofthetime,surpassingthistarget.

Duringthereportingperiod,8,109treatmentswererecordedatcolposcopy.LargeloopexcisionoftheTransformationZone(LLETZ)wasperformedin7,236(89.2%)andablativetreatmentwasusedin758(9.3%)cases.Fortyconebiopsies(0.5%),74hysterectomies(0.9%)andonetrachalectomy(0.01%)wereperformed(Figures9and10).Ofthetotaltreatments,7,545wereperformedfollowinganabnormalsmeartest.

Ablation

ConeBiopsy

LLETZ

Hysterectomy

Trachalectomy

Figure 9: Treatment at colposcopy

89.2%

9.3%

0.5%

0.01%0.9%


Table 12: Treatment at first visit to colposcopy

Reason for referral No treatment Treatment on Total number of to colposcopy on first visit first visit women attended

N % N % N %

Clinicalindication 1,472 96.1 59 3.9 1,531 100– nonurgent

Clinicalindication 1,282 97.4 34 2.6 1,316 100– urgent

AGC 737 83.5 146 16.5 883 100(borderlineglandular)

Highgrade 2,901 70.9 1,191 29.1 4,092 100

Lowgrade 8,330 95.9 360 4.1 8,690 100

Unsatisfactory 61 96.8 2 3.2 63 100/inadequate

Total 14,783 89.2 1,792 10.8 16,575 100

4,500

4,000

3,500

3,000

2,500

2,000

1,500

1,000

500

0

Num

ber

Allappointments Firstappointments

Sep2008–Feb2009

Mar2009–Aug2009

Sep2009–Feb2010

Mar2010–Aug2010

Sep2010–Feb2011

Sep2011–Feb2012

Mar2011–Aug2011

Mar2012–Aug2012

Figure 10: Number of women undergoing treatment at colposcopy


The performance of colposcopy treatment parameters measured against colposcopy standards


Treatmentatfirstvisitshouldnotbeperformed 4.1% <10%onwomenwhopresentwithlowgradecytologicalchangeevenifthereisaColposcopicsuspicionofhighgradedisease(exceptinspecialcircumstances).

Womentreatedbyexcisionaltreatmentsatfirst 91.8% >90%visitshouldhaveCINonhistology.

Womentreatedbyexcisionaltreatmentsatany 91.0% >80%visitshouldhaveCINonhistology.

The positive predictive value of colposcopy measured against colposcopy standards


CompliancebetweenColposcopicimpressionof 75.3% >65%highgradediseaseandhistologicallyprovenhighgradeCIN.

Oneofthekeychallengesofscreeningistheavoidanceofovertreatment.Thisisofparticularrelevancetocervicalscreeningbecausetreatmenthasthepotentialtohaveanadverseeffectonfuturefertility.Inthisregardtreatmentatthefirstvisitforwomenwhopresentwithlowgradeabnormalitiesshouldbeavoidedandkeptbelow10percent.Duringthefourthyearoftheprogrammethisfigurewaswithinthetargetat4.1percent.

ItisgenerallyacceptedthatmostofthewomenwhoundergoexcisionalproceduresshouldhaveCINonhistologyontheexcisedspecimen.Thisisparticularlytrueiftheprocedureisperformedatthefirstvisittocolposcopy.DuringthefourthyearoftheCervicalCheckprogrammethistargetwasreachedwithnearly92percentofwomentreatedatthefirstvisithavingCINonhistology.

Colposcopyplaysanimportantroleintheevaluationofwomenwithsuspectedcervicalabnormalities.Itallowstheidentificationofthesiteoftheabnormalityaswellasanestimationofthegradeofabnormalityincludingthepresenceorabsenceoffeaturessuggestiveofinvasivecancer.Thecorrelationbetweenthecolposcopicimpressionandhistologicaldiagnosisisausefulmarkerofthequalityofcolposcopy.Duringtheyearthepositivepredictivevalueofacolposcopicimpressionofhighgradediseasewas75percentwhichexceedstheCervicalCheckstandard(>65%).


7,000

6,000

5,000

4,000

3,000

2,000

1,000

0

Num

ber

Figure 11: Detection of CIN and cancer

Sep2008-Aug2009

NoCIN LowgradeCIN HighgradeCIN Cancer

Sep2009-Aug2010 Sep2010-Aug2011 Sep2011-Aug2012


Biopsyspecimensshouldbesuitablefor 98.7% >95%histologicaldiagnosis

HistologyTheobjectiveofacervicalscreeningprogrammeisthedetectionandtreatmentofhighgradeCINandtheyieldoftheseabnormalitiesisoneofthehallmarksofasuccessfulprogramme.ThehistologyispresentedbyyearinFigure11.TheyieldofhighgradeabnormalitiesremainedconsistentlyhighandillustratestheprogrammeisachievingitsobjectiveofdetectionandtreatmentofhighgradeCIN.Thisreflectsthesustainedhighlevelsofactivityinthecolposcopyservices.


Tabl

e 13

: H

isto

logy

resu

lts fo

r wom

en w

ho h

ad a

sat

isfa

ctor

y bi

opsy

in c

olpo

scop

y fr

om 1

Sep

tem

ber 2

011

to 3

1 A

ugus

t 201

2

N

o CI

N/N

o H

PV

HPV

/ Ce

rvit

is

CIN

1

CIN

2

CIN

3

Ade

noca

rcin

oma

Canc

er

(n

orm

al)

only

in s

itu

/ CG

IN

(incl

udin

g

m

icro

inva

sive

)

Gra

de o

f cyt

olog

y

resu

lt o

f ref

erra

l sm

ear

N

%

N

%

N

%

N

%

N

%

N

%

N

%

ASC

US

723

20.9

448

12.9

1,43

141

.3

517

14.9

331

9.6

10

0.3

40.1

AGC

249

29.2

85

10.0

244

28.6

88

10.3

124

14.5

52

6.1

12

1.4

(borde

rline

gland

ular)

LSIL

654

15.0

435

10.0

1,73

239

.7

925

21.2

603

13.8

14

0.3

10.02

ASC

-H

144

9.7

103

7.0

324

21.9

272

18.4

610

41.2

12

0.8

16

1.1

HSIL

211

6.0

147

4.2

501

14.2

560

15.9

2,00

756

.9

29

0.8

71

2.0

(mod

erateorsevere)

Que

ryinvasive

110

.0

00.0

00.0

00.0

110

.0

110

.0

770

.0

squa

mou

scarcinom

a

Que

rygland

ular

620

.7

13.4

310

.3

13.4

931

.0

517

.2

413

.8

neop

lasiaAIS/

ad

enocarcino

ma

Unsatisfactory/

11

40.7

518

.5

829

.6

00.0

311

.1

00.0

00.0

Inad

equa

te

Total

1,99

914

.5

1,22

48.9

4,24

330

.8

2,36

317

.2

3,68

826

.8

123

0.9

115

0.8


Measures of the performance of cytology

PPV 75.6%

APV 28.7%

TPV 45.8%

RV 2.18

Performance measures for CervicalCheck programme smear testsCervicalscreeningprogrammeshavetobalancetheearlydetectionofhighgradeabnormalitieswithavoidingunnecessaryinvestigationsandpossibleovertreatment.Performancemeasureshavebeendevelopedwhichlookathowvalidthescreeningtestsarewithinorganisedprogrammes.Theseincludethepositivepredictivevalue(PPV),abnormalpredictivevalue(APV),totalpredictivevalue(TPV)andreferralvalue(RV).

Thepositivepredictivevalue(PPV)isreportedasthepercentageofwomenreferredwithhigh-gradecytologicalabnormalitywhohaveahistologicaldiagnosisofCIN2orhigher.DuringthecurrentreportingyearthePPVwas75.6percent.

Theabnormalpredictivevalue(APV)calculatesthepercentageofsamplesreportedasborderlineorlow-gradethatledtoreferraltocolposcopyandsubsequenthistologicaldiagnosisofCIN2orhigher.DuringthecurrentreportingyeartheAPVwas28.7percent.

Thetotalpredictivevalue(TPV)examinesthepercentageofallwomenreferredtocolposcopyonthebasisofanabnormalsmearwhohaveahistologicaloutcomeofCIN2orworse.Duringthereportingyear45.8percentofwomenreferredtocolposcopyhadCIN2orhigherdemonstratedonhistology.

Thereferralvalue(RV)looksatthisinanotherwayandexaminesthenumberofwomenreferredtocolposcopyforthedetectionofonecaseofCIN2orworse.Duringthecurrentreportingyear,forevery2.18womenreferredtocolposcopyonehadCIN2orhigherdetected(forevery218womenreferredtocolposcopy100hadCIN2orhigherdetected).


AblationTreatmentwhichinvolvesthedestructionofthecervicalabnormalitiesusingavarietyoftechniques.Itdoesnotallowforhistologicalexaminationofthewholeabnormalareaandstrictcriteriamustbefollowedthereforetominimisetheriskofinadvertenttreatmentofhiddenmicroinvasivecancer.

Abnormal/not normal smear test Asmeartestwhichshowscellswhicharenottypicallynormalorwherepre-cancerousorcancerouscellsareidentified.

AdenocarcinomaAcanceraffectingthecervix,butinvolvingthecolumnar(endocervical)cellsratherthanthesquamouscells.Thecolumnarcellsareinvolvedinglandularactivity.

Adenocarcinoma in situApre-canceraffectingthecervix,butinvolvingthecolumnar(endocervical)cellsratherthanthesquamouscells.

Adequate smear test resultAsmeartestwhichisdeemedsatisfactoryforevaluationbythelaboratory.

AGCAtypicalglandularcells.

AGUSAtypicalglandularcellsofundeterminedsignificance.

ASC-HAtypicalsquamouscellsforwhichahigh-gradelesioncannotbeexcluded.

ASC-USAtypicalsquamouscellsofundeterminedsignificance.

Atypical Transformation ZoneThetermusedwhenchangesaredetectedbycolposcopyintheTransformationZone.Thesechangescanincludeavarietyofpatternsincluding:leukoplakia,acetowhiteepitheliumandabnormalvascularpatterns.

BiopsyTheremovalofasampleoftissuefromthebodyforexaminationusingamicroscope.

Cervical cancerCancerofthecervix.Cancercellshavespreadbeyondthenaturalbasementmembraneboundaryofthecervicalskin.Cervicalcancercanbeofsquamousorigin(approximately85%)orglandularorigin(approximately15%).

Cervical intraepithelial neoplasia (CIN)CINisnotcancerbutisthehistologicaltermreferringtotheabnormalgrowthofpre-cancerouscellsinthesurfacelayersofthecervix.Itdescribesvaryingdegreesofabnormalityofthecellswithinandconfinedtotheepithelium.TherearethreegradesofCIN:CIN1,CIN2orCIN3.

Cervical screeningAprocesswhichinvolvestheapplicationofascreeningtestatregularintervalstoadefinedpopulationofwomentodetectpre-cancerouschanges.

Cervical cytologyAmicroscopicexaminationofasinglelayerofcellsscrapedfromthesurfaceofthecervix.

ColposcopyAnexaminationofthecervixusingaspecialisedopticinstrument(colposcope)thatprovidesmagnificationtoallowdirectobservationandstudyofvaginalandcervicalepithelium.Itidentifieslesionsonthecervixwhichcanbebiopsiedandtreated.

Cone biopsy Asurgicalremovalofacone-shapedsectionofthecervixtoremoveabnormalcells.

CoverageTheproportionofwomenaged25-60yearswhohavehadascreeningresultrecordedonthescreeningregisteroveracompletescreeninground.

DiagnosisAprocessaimedattheclarificationofcervicalabnormalitiestoinformdecision-makingregardingtreatment.

DyskaryosisTermusedincytologytodescribenuclearabnormalitiesincervicalcells.

Glossary

GLOSSARY35

Eligible for screeningWomanaged25to60wholiveinIrelandareeligibletohaveafreesmeartest.

Excisional treatmentTreatmentwhichinvolvestheremovaloftheabnormalityinitsentiretytherebyallowinghistologicalexaminationoftheentireTransformationZone.

HSILHighgradesquamousintraepithelial(moderateandsevere)lesionencompassingmoderate(CIN2)andseveredysplasia(CIN3/CIS).

HistologyThemicroscopicstudyofthestructureandcompositionofbodytissue.

Human papillomavirus (HPV)Agroupofwartvirusesofwhichahighproportionaresexuallytransmitted.Over100differenttypesofHPVhavebeenidentifiedandeachisknownbynumber.Types6and11areassociatedwithgenitalwartsandtypes16and18areassociatedwithhighgradelesions.

HysterectomyThesurgicalremovaloftheuterus(womb)–calledtotalifitincludesthecervixorsubtotal/partialifthecervixisnotentirelyremoved.

IncidenceThenumberofnewcasesofadiseaseorhappeningthatoccursinagivenperiodinaspecifiedpopulation

Informed consentThegivingofallthenecessaryinformationbythesmeartakertothewomaninorderthatshefullyunderstandsthesmeartestprocedureandpossibleresultssothatshecanmakeaneducateddecisiontoparticipateintheprogramme.FortheCervicalCheckinformedconsentprocess,thenecessaryinformationcoversparticipationintheprogramme,thetransferofdatatothirdparties,limitationsofscreening,results,associatedtestsandtreatment.

Invasive cancerAbnormalcells,notlimitedtotheouterlayeroftheepithelialbutwhichbreachthebasementmembranetoinvadetheunderlyingstroma(layeroftissue).

Key performance indicators (KPIs)Ametricusedtohelpanorganisationdefineandmeasureprogresstowardorganisationalgoalsorstandards.

Large loop excision of the Transformation Zone (LLETZ)LargeloopexcisionoftheTransformationZoneisadiagnosticand/ortreatmentmethodtoremovethecervicalareasofabnormality.TheprocedureinvolvesremovaloftheentireTransformationZoneusingathinwireelectrodechargedwithelectriccurrenttoprovideasampleforexaminationbythepathologist.

LesionsAzoneoftissuewithimpairedfunctionasaresultofdamagebydiseaseorwounding.

Liquid based cytology (LBC)Theplacementofharvestedcellsintoaspecialtransportsolutionforsendingtothelaboratory,wheretheslideismadereadyforexamination.

LSILLowgradesquamousintraepitheliallesionencompassingHPVinfectionormilddysplasia(CIN1).

Microinvasive cancerThisrepresentsearlystagecervicalcancerwheretheabnormalcellsbreachthebasementmembraneandinvadetonotgreaterthan5mmindepthandnotmorethan7mminwidth.

MortalityThenumberofdeathsfromaspecifieddiseaseduringadefinedperiodoftimeinagivenpopulation.

NADNoabnormalitydetected(normal).

Positive predictive value (PPV)Theproportionoftest-positivewomenwhoaretrulypositive.Itcanbeconsideredameasureofthelikelihoodthatawomanwithapositivetesttrulyhasapre-cancerouscervicalabnormality.

GLOSSARY 36

Primary care settingFirstcontactcarethatisnothospitalorspecialistcare-generalpractice,WellWomanandFamilyPlanningClinics.

Quality assuranceAprogrammeforthesystematicmonitoringandevaluationofthevariousaspectsoftheNationalCervicalScreeningProgrammetoensurethatstandardsofqualityarebeingmet.

Screening programmeAnorganisedapproachtoscreeningadefinedpopulationtodeterminethelikelihoodofaspecificdiseasewithinthepopulationwiththeaimofreducingtheriskofthediseaseandimprovingthequalityoflifethroughearlydiagnosis.

Select and treatAprocesswherebywomenwithsuspectedhighgradediseaseareselectivelytreatedatthefirstvisittocolposcopy.

Smear testAscreeningtestwherecellsfromthesurfaceofthecervixaresampled,preservedimmediatelyandsenttothelaboratoryforcytologicalanalysis.

SmeartakersAdoctorornursewhotakessmeartests.

SpecimenAsampleoftissueremovedfromthebodyformicroscopicexamination.

Squamous Atypeofmulti-layerscells,whichlinethevaginaandouterlayerofthecervix.

Squamous cell carcinoma/cancer Themostcommonformofcervicalcancerinvolvingthesquamouscells.

StandardAminimumrequirementagainstwhichperformancecanbemeasured.

Transformation Zone (TZ)Theregionofthecervixwherethecolumnarcellsoftheinnercervixhaveorarechangingtooutersquamouscells.Theprocessofchangeiscalledmetaplasia.Itistheareamostatriskofabnormalchange.

TreatmentAprocessaimedattheeradicationofcervicalabnormalitiesthusrestoringnormalcytologyandreducingthechanceofsubsequentcancerby90percent.

Unsatisfactory colposcopyAtermusedtodescribetheinabilitytovisualisethewholeoftheTransformationZonecolposcopically.

Unsatisfactory/inadequate smear test resultAn‘inadequate’or‘unsatisfactory’smeartestthatcannotbeassessedbythecytologylaboratory.

GLOSSARY37

ISBN number: 978-1-907487-14-9

QA - CS/PR/PM-17 Rev 1

The National Cancer Screening Service is part of the Health Service Executive. It encompasses BreastCheck – The National Breast Screening Programme, CervicalCheck – The National Cervical Screening Programme, BowelScreen – The National Bowel Screening Programme and Diabetic RetinaScreen – The National Diabetic Retinal Screening Programme

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Programme Report

1 September 2011 to 31 August 2012

1 september 2011 to 31 august 2012 programme...for the period 1 september 2011 to 31 august 2012...

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