Cervical Cancer Elimination Expert Group minutes: April 2024

Attendees and apologies

• Professor Anna Glasier, Women’s Health Champion and Chair of Expert Group
• Professor Maggie Cruickshank, University of Aberdeen
• Dr Sharon Hanley, University of Aberdeen
• Dr Kimberley Kavanagh, University of Strathclyde
• Dr Kate Cuschieri, HPV Reference Lab and University of Edinburgh
• Martin Hunt, Jo’s Cervical Cancer Trust
• Bridget Little , Jo’s Cervical Cancer Trust
• Dr Kirsty Roy, Public Health Scotland
• Dr Tasmin Sommerfield, NHS National Services Scotland           
• Heidi Douglas , NHS Tayside
• Dr Calum Robertson , NHS Forth Valley
• Kirsty Stewart , Public Health Scotland
• Ruth Burns, Public Health Scotland
• Dr Ross Cameron, Public Health Scotland
• Laura McDonald, Public Health Scotland
• Dr Tim Palmer, Public Health Scotland and University of Edinburgh
• Dr Carolyn Sunners, Scottish Government
• Louise Watson, Scottish Government
• Rona Watters, Scottish Government
• Dr Lorna Willocks, Scottish Government
• Blair Harrison, Scottish Government

Apologies

• Gareth Brown, NHS National Services Scotland
• Dr Claire Cameron, Public Health Scotland
• Jonathan Brannan, Scottish Government
• Laura McGlynn, Scottish Government
• Dr Azmat Sadozye, Scottish Government
• Felicity Sung, Scottish Government

Items and actions

Welcome and introductions 

The Chair welcomed members to the first meeting of the expert group and noted that the aim of the group should be to outline the steps required to work towards the elimination of cervical cancer in Scotland within the context of the targets set by the World Health Organisation (WHO). The Chair explained that the Minister for Public Health and Women’s Health had asked for the expert group to be established to ensure that progress is made in Scotland. 

Membership and terms of reference 

It was noted that the draft Terms of Reference was circulated ahead of the meeting. Members were invited to consider and make any comments via correspondence. 

Our starting point

The presentation set the scene in terms of where Scotland currently is on the pathway to elimination of cervical cancer. An overview was provided of:

• the WHO strategy for the elimination of cervical cancer
• cervical cancer incidence and mortality
• human papillomavirus (HPV) vaccine uptake and evidence of vaccine impact
• cervical screening uptake 
• summary of progress towards WHO targets

Estimation of the time to cervical cancer elimination in Scotland

The presentation gave an overview of an age-period-cohort modelling approach, based on observed vaccine uptake, screening uptake and cervical cancer incidence rate, to estimate when cervical cancer rates in Scotland are likely to fall below the WHO threshold for cervical cancer elimination.

Questions

Following both presentations, the group was invited to ask questions and discuss. In discussion, the following points were made:

• there was interest in exploring the data illustrating the impact of moving to a single dose of HPV vaccine on uptake rates
• there are still some gaps in the available data on cancer. The National Colposcopy Clinical Information and Audit (NCCIAS) system may provide treatment rates and the National Cervical Cancer Audit was identified as a valuable source of data, for example around delay in presentation.
• herd immunity was identified as an issue to explore further. There is likely existing data which might quantify herd immunity stratified by Scottish Index of Multiple Deprivation (SIMD).

The group discussed the Age-Period-Cohort model and noted some of its limitations, such as:

• the assumption that all vaccines confer same impact on cervical disease
• the model cannot simulate any hypothetical changes made to the screening programme
• the model does not include coverage within the boys’ immunisation programme 

Targets for higher income countries should be more robust than lower/middle income countries. For example, aiming for 80% uptake instead of the WHO target of 70%. More nuanced targets, which specifically address uptake by deprivation should also be considered. 

Policy updates: vaccinations 

It was highlighted that the Minister for Public Health and Women’s Health values this work and is keen to see it progress. It was noted that, despite the challenging financial circumstances that the Scottish Government was currently facing,  recommendations that the group outlines as key will be considered. 

Policy updates: screening 

It was highlighted that there has now been a validated test for self-sampling in the UK, with a number of kits now approved for use. Research around the expansion of self-sampling is ongoing, although it was noted that opportunistic screening has been more effective than sending self-sampling kits to everyone. 

An additional, written update provided ahead of the meeting noted that the validation of a test for cervical self-sampling has concluded and is now with the United Kingdom National Screening Committee (UK NSC). Scottish Government colleagues also met with colleagues from Screening Oversight and Assurance Scotland (SOAS) to begin discussions around what considerations will be required prior to, and what actions will be required once this recommendation is received. 

Policy updates: cancer 

It was noted that the 10 year Cancer Strategy and 3 year Action Plan were published in June 2023. A  monitoring and evaluation framework was also published last year, with quarterly reports from these contributing to ongoing actions and the first annual report is currently being drafted. 

Cancer services are currently under considerable pressure, which affects a range of services including diagnosis through to treatment. Quality performance indicators are used for a number of cancer types. For cervical cancer, the most recent report from 2021 showed targets were met for 5/8 indicators, indicating clinical standards were generally being met. 

Discussions on future work and activity 

In discussion, the following points were made:

• the deprivation gradient in screening is currently the biggest impediment towards elimination of cervical cancer
• the group agreed that it would be helpful to collate learning from any completed initiatives undertaken by local Health Boards to increase uptake of vaccination and screening. The Screening Equity Network for Scotland was also identified as a valuable source of information and evidence
• deep-end general practices (GP) have also looked at how to engage with those who do not attend appointments for cervical smears, this may be valuable to review. It may also be valuable to seek deep-end GP representation on any subgroups 
• the group noted that there is already considerable lived experience of vaccination/screening etc. across the membership, although it may be valuable to set up discussion groups with lived experience groups at a later date to discuss any potential actions
• a pilot project running in National Health Servicve (NHS) Shetland and NHS Lothian, whereby young people being vaccinated were given information to take home to prompt family members to attend screening appointments, was noted for its multi-pronged approach to messaging
• there may be value in pursuing messages outside of cervical cancer elimination, such as emphasising the protection of children and future generations through vaccination/screening
• although vaccination staff are trained to assist those with a phobia of needles, this is a growing problem in line with greater health-related anxiety in younger age groups which may be affecting vaccination uptake
• a catch-up programme in Sweden, whereby vaccination and screening is performed concurrently in the same health centre and focussed around at-risk groups, has contributed to their cervical cancer elimination target being brought forward
• Scottish Cervical Call Recall System (SCCRS) was noted as both a barrier and a valuable data source. Issues with user friendliness (such as practitioners forgetting log-in information) inhibit its use for opportunistic screening. However, SCCRS also offers screening, immunisation and disease data by demographic and postcode
• it is important to consider how to bring a trusted voice to vaccination and screening, for example by working with community leaders and being mindful of cultural attitudes. While general practitioners (GPs) are often a trusted voice, issues with accessing GP services have a knock-on effect on screening 
• self-sampling may have the advantage of circumventing some of these issues with difficult systems accessing services. Self-sampling may also be more acceptable to women who find cervical smears distasteful, such as survivors of sexual abuse. However, more evidence is required on this point  
• public messaging and appointment booking systems for cervical smears should be as straightforward as possible. The new, online booking portal for winter vaccinations was noted as a good example of this
• a national screening contact centre should be considered as this may help to alleviate the barrier to accessing appointments, as well as alternative methods of issuing invitations (e.g. via text message rather than letters)
• in the Republic of Ireland, a higher uptake of screening in younger people was achieved by taking the screening to them
• if the uptake of screening does improve, we will inevitably increase the demand for colposcopy and eventually oncology clinics
• many within the health workforce already have concerns around their workloads, there may be concern that a drive to eliminate cervical cancer and increase opportunistic screening would add to already considerable workloads. However, once elimination is achieved, there will perhaps not be a sustained requirement for as much opportunistic screening in setting such as sexual health or family planning services
• it is important that tackling inequalities is at the heart of considerations with regard to elimination targets

Next steps 

The group agreed that three subgroups should be established, focussing on vaccination, screening and cancer treatment. The group can consider what additional representation may be valuable on these groups, which could also include representatives brought in on a more ad-hoc basis.

The group noted that, while it seems that there is sufficient data to draw on, there would be value in linking data from screenings/vaccination systems to wider social/healthcare data sets within NHS Scotland.  For example, looking at the characteristics of those not receiving the vaccine by linking to ethnicity, postcode or maternity data.

There are a number of options which are logistically and operationally feasible within current systems to improve screening and vaccination uptake. Much of the work will be around building on what is already being done. The screening and vaccination subgroups would likely be the initial focus, moving onto the third subgroup around cancer treatment at a later date. 

Any other business (AOB) 

It was noted that the invitation to express interest/join subgroups would be issued in due course. 

Subgroup meetings will likely take place before the next meeting of the group, with dates being scheduled in due course.