Cervical cancer

Paula McGee PhD RN RNT MA BA Cert Ed
Editor, Diversity and Equality in Health and Care; Emerita Professor of Nursing, Faculty of Health, Birmingham City University, Birmingham, UK
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The term cancer refers to a group of diseases that occur worldwide and which are characterised by the development of abnormal cells which infiltrate surrounding organs and tissue. These abnormal cells may occur in any part of the body. The most common sites for men are the lungs, prostate, colorectum, stomach and liver; women are most likely to develop cancer in the breast, colorectum, lung, cervix, and stomach. An estimated 32 million people currently have a diagnosis of cancer. Each year at least 14 million new cases will be identified and 8.2 million people die from some form of cancer. Cancers are, therefore, a major cause of illness, suffering and death that affect not only those who are diagnosed with one of these diseases but also their families and the societies in which they live. Moreover, the incidence of cancers is increasing. The number of new diagnoses is projected to rise to 19.3 million per year by 2025 and to continue rising after that (World Health Authority 2015, Stewart and Wild 2014).
Cervical cancer ‘is the fourth most common cancer in women, and the seventh overall, with an estimated 528,000 new cases in 2012’ (GLOBOCAN 2012). The disease occurs mainly in young and middle aged women, aged 25-65 years. It is caused by infection by HPV viruses, a group of viruses that are spread via sexual activity and which may infect the areas around the cervix, anus, mouth and throat. Some of these viruses can cause changes in the cervix which lead to cancer. Prevalence and mortality rates are highest in developing countries, particularly sub-Saharan African nations (GLOBOCAN 2012). However, cervical cancer is both preventable and, if identified early, treatable.

Prevention of cervical cancer

There is currently no treatment to eradicate HPV infection but vaccination is now available and is currently thought to offer protection for 20 years (Cancer Research UK https://www. cancerresearchuk.org). In the UK, Gardasil HPV vaccine is offered to all girls aged 11-14 years in two doses one year apart, via schools. Girls over the age of 15 may be vaccinated with Cevarix HPV vaccine which requires three doses (British Medical Association and The Royal Pharmaceutical Society 2015). Girls who are already sexually active may be infected with an HPV virus but, as this may or may not be the type that causes changes in the cervix that lead to cancer, vaccination is still advisable. The vaccine will not cure any HPV virus already present but protection from the viruses that cause cervical changes remains a possibility.
Gardasil HPV vaccine may also be given to boys to prevent the development of anal cancers (Cancer Research UK https://www. cancerresearchuk.org).
•These vaccines do not guard against infection by all forms of HPV virus.
•Lifelong immunity cannot yet be guaranteed.
Consequently, vaccination must be combined with other strategies to reduce the spread of the disease.


The use of condoms can also help to combat cervical cancer. However, protection is only achievable if the condom is put on before any sexual activity takes place as HPV may be present already in several areas of both bodies (National Institute for Health and Care Excellence (NICE) 2014). Condoms can also reduce the spread of other sexually transmitted infections.

Cervical screening

Screening is a way of testing to determine the presence and prevalence of disease, rather than a diagnostic tool or treatment, but may detect potential cases of a disease before it becomes apparent through symptoms. The procedure in respect of cervical cancer requires the insertion of a speculum into the vagina and the collection of a small number of cells, from the surface of the cervix, for examination. These cells undergo two types of tests. A liquid-based cytology (LBC) test is used to identify changes in the cervix that may develop into cancer and cancer itself; it can also detect non-cancerous conditions such as inflammation. An HPV test may also be performed to determine whether a high risk variety of the virus is present (Department of Health, NHS England 2014). If the LBC result is positive the woman may be offered a colposcopy. A colposcopy involves using a strong light to view the cervix and record images for closer inspection to determine whether there is evidence of cancer. Further treatment may include laser therapy to destroy cancerous cells, a cone biopsy to remove the affected area or loop excision using a fine wire and electrical current. If the disease has already advanced, more radical surgical procedures may be needed as well as radiotherapy or chemotherapy. In countries such as India, and in Africa, attention is being given to a much less expensive method of screening using vinegar (the VIA test), which appear to hold promise for prevention: (https:// www.cancer.net/cervical-cancer-screening-vinegar-couldprevent- thousands-deaths-each-year-developing-countries , https://www.medscape.com/viewarticle/805181 ).
Regular cervical screening is essential to the early detection of cervical changes that may indicate the presence of cancer (NICE 2014, The American Cancer Society 2014, IARC 2008). Whilst there are some variations between the guidelines produced by different organisations there is general agreement on the following points. Cervical screening should be available to
•all women aged over 20 -49 years, every three years, including those who have been vaccinated.
• all women aged 50-64 every five years.
• transgender men (from female to male) who have retained their cervix.
• women who have undergone sub-total hysterectomy and still have their cervix.
• all women who are at high risk, for example, following organ transplant or infection with HIV, and offered more frequently than usual.
• any woman who has abnormal symptoms (table 1).
• women aged over 65 who have not previously been screened.
Screening should be postponed if a woman
• is menstruating
• is pregnant
• has given birth within the previous 12 weeks
• has an infection, such as thrush or gonorrhoea
Women who have undergone total hysterectomy and no longer have a cervix will not normally require screening. Women who are virgins may opt not to be screened as they have a low risk of developing the disease (NICE 2014, The American Cancer Society 2014).

Limitations of cervical cancer screening

Whilst screening is currently the most effective way of detecting the disease, inaccuracies can occur; 1 in 5 tests will miss cell changes (Cancer Research UK https://www.cancerresearchuk.org). A woman may be told that her cervix is healthy when it is not; treatment is not provided and the disease progresses. Similarly, a woman may be told that she has cancerous or pre-cancerous cells when her cervix is normal; subsequent unnecessary treatment may follow. Treatments such as cone biopsy and loop excision can weaken the cervix causing problems in pregnancy.

Cervical cancer screening services

The most effective approach to reducing both the incidence of and mortality from cervical cancer is to target the population as a whole. Almost any woman can develop this type of cancer and so services need to be available to everyone. Screening only those who access health services for other reasons, sometimes referred to as opportunistic screening, is inequitable and tends to benefit the better off, better educated rather than poorer or marginalised women.
However, a population-based approach for all women requires a wide range of resources; these are not cheap (Figure 1). Developing and maintaining an up to date register of women, records of those screened and those due for recall requires a sophisticated computer system and enough staff who are qualified to operate it. Providing information for women begins with educating them, and the significant people in their lives, about the importance of screening and the nature of cervical cancer. Information has to be understandable, meaningful, useful and timely. Professionals have to be able to answer questions as clearly and honestly as possible so that women can make informed decisions. Facilities for cervical screening should be easily accessible and safe. The more travelling involved, lack of parking, lack of privacy, staff attitudes, or the timing of appointments are among the many factors that may discourage attendance. Timely transport to laboratory facilities that are suitably equipped and adequately staffed by professionals able to conduct tests and interpret the outcomes are an essential part of the process. Quality assurance processes are required to ensure that high standards are maintained. Finally there has to be a clear and timely system for communicating the results to women and facilities for further investigations and treatment. Women facing a diagnosis of cervical cancer may require counselling and other support to help them as they face the future.
Developed countries are well placed to meet these requirements and provide cervical screening. The incidence and mortality rates of cervical cancer have fallen sharply in the European Union and USA (GLOBOCAN 2012). However, it is developing countries that carry the greatest burden of the disease. These nations do not have the resources to provide screening services and treatment. This situation is compounded by the population’s lack of accurate knowledge about cervical cancer and beliefs that it is ‘a contagious or a shameful disease which is rarely talked because of the body parts involved’ (Ehiwe et al. 2012). Silence, stigma, fear and fatalism all militate against seeking help even when it is available. Even in developed countries non-attendance for cervical screening remains a problem (Hammell 2014). Women may fear the outcomes, wish to avoid embarrassment or not understand why screening is so important. Education therefore requires constant reinforcement to encourage women to be screened.

The Global Initiative for Cancer Registry Development

The aim of this programme is to transfer knowledge and skills from developed to developing countries to enable them to develop sustainable approaches to the prevention and treatment of cancer generally and including those that affect women.


Cervical cancer is a major public health issue that affects the lives of women and their families worldwide. Vaccination of young girls and the regular cervical screening are currently the most effective methods available in securing prevention and early diagnosis. There is no question that these methods save lives but there is still much to be done to ensure that vaccination and screening are available to and taken up by all women irrespective of where they live. There is also a need to continue to research the development of new approaches that will improve accuracy in screening.

Further reading

Forouzanfar MH, Foreman KJ, Delossantos AM, Lozano R, Lopez AD, Murray CJL, Naghavi M (2011) Breast and cervical cancer in 187 countries between 1980 and 2010: a systematic analysis. Lancet 2011; 378: 1461–84
World Health organisation (2013) WHO guidelines for screening and treatment of precancerous lesions for cervical cancer prevention. Geneva WHO

Previously in Diversity and Equality in Health and Care

Bischoff A, Greuter U, Fontana, M, Wanner, P (2009) Cervical cancer screening among immigrants in Switzerland. Diversity in Health and Care 6 (3): 159-70
The following papers focus on other issues relating to women’s health
McGee P, Johnson M (2012) Gender inequalities in the control of fertility Diversity and Equality in Health and Care 9 (3):163-6.
McGee, P and Johnson, M. (2009) The gender lottery: maternal mortality in rich and poor nations Diversity in Health and Care 6 (1):1-62
Patel G, Harcourt D, Naqvi H, Rumsey N (2014) Black and South Asian women’s experiences of breast cancer. Diversity and Equality in Health and Care 11 (3): 135-50.
Patel-Kerai G, Harcourt D, Naqvi H, Rumsey N (2015) Exploring the lived experience of breast cancer diagnosis and treatment amongst Gujarati-speaking Indian women. Diversity and Equality in Health and Care 12 (1): 9-17

Reflective exercises

1. SE and her sisters are traveller women who are living on a legal site in your area. What practical steps could be taken to encourage them to attend cervical screening?
Points to consider:
• Limited education and low levels of literacy often prevent Travellers and Gypsies from accessing information and services. Constant moves may mean that some are not registered with a doctor. Many live in poverty.
• There is still a lot of prejudice against Travellers and Gypsies. Past experience of racism and discrimination may cause members of these groups to distrust outsiders.
• Travellers and Gypsies have very poor health and low life expectancy. Lack of education means that they may know little about how their bodies work.
Sources that may be helpful
NHS England (2014) National Health Visiting Service Specification 2014/15
Pavee Point https://www.paveepoint.ie/ provides a series of programmes in Ireland and other resources all of which focus on Traveller and Gypsy health.
Parry G, van Cleemput P, Peters J et al. P (2004) The Health Status of Gypsies & Travellers in England. Report of Department of Health Inequalities in Health Research Initiative. Project 121/7500. Sheffield, the University of Sheffield. Available at https://www.shef.ac.uk/polopoly_fs/1.43714!/file/GT-final-report-for-web.pdf
2. You have been asked to give a talk to parents at a local school about the benefits of vaccination against HPV. Some parents see this vaccination as encouraging promiscuity. How would you explain the benefits of vaccination? How would you respond to parents’ concerns?
Points to consider:
Parents may vary considerably in their knowledge about HPV and cervical cancer. It is important not to make the talk too technical or too simple.
Plan your talk – what are the important points you need to cover? Visual images and uncluttered PowerPoint slides will help to emphasise the important points.
There is no evidence that vaccinating girls against HPV encourages them to be sexually active nor is it related to any increase in promiscuity.
Sources that may help you
Brabin L, Roberts S, Farzaneh F, Kitchener H (2006) Future acceptance of adolescent human papillomavirus vaccination: A survey of parental attitudes. Vaccine 24 (16): 3087–3094
Friedman A, Shepeard H (2007) Exploring the Knowledge, Attitudes, Beliefs, and Communication Preferences of the General Public Regarding HPV. Findings from CDC Focus Group Research and Implications for Practice, Health Educ Behav June 34 (3): 471-485
Waller J, Marlow L, Wardle J (2006) Mothers' Attitudes towards Preventing Cervical Cancer through Human Papillomavirus Vaccination: A Qualitative Study. Cancer Epidemiol Biomarkers Prev 15(7):1257–61)

Other Useful Resources concerned with minority ‘at risk groups’

• NCAT Cancer Awareness newspapers targeted at African and African–Caribbean, South Asian and Irish communities, along with guidelines for Wellbeing Boards and GP Commissioners have been uploaded and published through their website (https://www.ncat.nhs.uk/our- work/improvement/equality)
Other NCAT campaign materials developed as part of the ‘Cancer Does Not Discriminate’ programme can be found on the websites of partner agencies such as:
Other NCAT campaign materials developed as part of the ‘Cancer Does Not Discriminate’ programme can be found on the websites of partner agencies such as:
• the RAFFA site working with faith communities (https://www.raffa.org.uk/health-and-wellbeing/)
• Stonewall (https://www.stonewall.org.uk for LGBT groups)
•Cancer Research UK (https://www.cancerresearchuk.org/)

Tables at a glance

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Table 1

Figures at a glance

Figure 1
Figure 1


The American Cancer Society https://www.cancer.org/cancer/news/new-screening-guidelines-for-cervical-cancer (accessed 27.5.5)

Arbyn M, Anttila A, Jordan, et al. (eds) (2008) European guidelines for quality assurance in cancer screening. Second edition. Luxembourg: Office for Official Publications of the European Communities,

British Medical Association, The Royal Pharmaceutical Society (2015) British National Formulary No 68. London, BMJ and Pharmaceutical Press

Department of Health, NHS England (2014) Service specification no. NHS public health functions agreement 2015 -16. 25 Cervical screening. NHS England Publications Gateway Reference 02598

Döbr?ssy L, Kovács A, Budai A, (2015) Inequalities in cervical screening practices in Europe. Diversity and Equality in Health and Care 12 (2)

Ehiwe E, McGee P, Filby M, Thompson M, (2012),"Black African migrants' perceptions of cancer: are they different from those of other ethnicities, cultures and races?" Ethnicity and Inequalities in Health and Social Care, Vol. 5 (1) pp. 5 - 11

GLOBOCAN Cervical Cancer (2012) Estimated Incidence, Mortality and Prevalence Worldwide in 2012 https://globocan.iarc.fr/old/FactSheets/cancers/cervix-new.asp (accessed 21.5.15)

Hammell L (2014) Opting-out women from the Scottish Cervical Screening Programme. Guidance paper for healthcare professionals. Scotland, NHS Forth Valley.

National Institute for Health and Care Excellence (NICE) (2014) Clinical Knowledge Summaries. Cervical cancer and HPV https://cks.nice.org.uk/cervical-cancer-and-hpv#!scenario (accessed 21.5.15)

Stewart B, Wild CP (2014) World Cancer Report 2014. Lyon, International Agency for Research on Cancer

World Health Organisation (2015) Cancer Fact sheet N°297. WHO available https://www.who.int/mediacentre/factsheets/fs297/en/
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