Cervical Cancer Elimination Expert Group minutes: December 2024

Attendees and apologies

• Professor Anna Glasier (Chair)
• Dr Kirsty Roy
• Dr Tim Palmer
• Dr Calum Robertson
• Dr Kimberley Kavanagh
• Dr Sharon Hanley
• Dr Cheryl Gibbons
• Professor Sir Lewis Ritchie
• Dr Victoria Flanagan    
• Blair Harrison
• Caroline French
• Rona Watters
• Rona Tatler
• Dr Tasmin Sommerfield
• Nicola Barnstaple
• Dr Carolyn Sunners 
• Kirsty Stewart
• Professor Maggie Cruickshank

Apologies

• Dr Claire Cameron 
• Dr Lorna Willocks
• Felicity Sung
• Dr Azmat Sadozye
• Laura McGlynn
• Alexander Cruickshank
• Julie Hoey
• Heidi Douglas
• Gareth Brown

Items and actions

Minutes (sign off) of the last meeting and actions update

The group noted that minutes of Cervical Cancer Elimination (CCE) Expert Group are to be published online. Members were therefore encouraged to ensure that the minutes of the previous meeting are accurate and complete. 

Members reviewed the action log and provided updates on any open actions. 

It was noted that representation on the group from deep-end general practice (GP) services would be beneficial.

Updates from Chairs of the Vaccination, Screening and Treatment Subgroups

As all three subgroups have held a number of meetings already, the Chair invited the Chairs of the three subgroups to provide updates on their initial discussions and preliminary work. 

Vaccination Subgroup

The human papillomavirus (HPV) Vaccination Subgroup has met three times, with the fourth meeting scheduled for early 2025. The Chair has also been meeting with individual members of the subgroup to tap into their expertise and gain broader input in a way that may not be possible in standing meetings. 

The introductory meetings have sought to map out the vaccination landscape, looking at trends in uptake and the levers for change within the vaccination pathway. 

Key issues examined by the subgroup thus far include:

• consent (consent forms, self-consent, digital consent, opt-out vaccination)
• digital vaccination records
• the role of education and schools
• communications opportunities to raise the profile of the HPV vaccine
• Scottish 5 Year Vaccination and Immunisation Framework and Delivery Plan

With regards to next steps, it has been agreed in principal that HPV vaccination could be utilised as an exemplar of how the Scottish Vaccination and Immunisation Programme (SVIP) framework is implemented in Scotland. While this aims to improve HPV programme uptake, successes here will bring improvements to other vaccination programmes as well, as there are common features across these programmes. 

The subgroup will also examine vaccination outside of the school programme. This may include encouraging HPV vaccination through other channels, such as sexual health clinics and dental clinics. 

In discussion, the following points were raised by the group:

• opt-out vaccination would be bold and potentially controversial, but it merits examination. The group must consider whether secondary school children are sufficiently knowledgeable to be exercising consent in their own right. This happens to a degree already, although parental consent is sought first 
• health boards vary in their approaches to vaccinating on the day via self-consent.  It would be helpful to consider a standard approach to self-consent and supporting health boards in delivering this. More training around self-consent for staff to build confidence would be welcomed
• work around digital consent is ongoing as part of the wider digital transformation work. This would reduce the burden of paperwork endured by health boards and would enable improved analysis on vaccination consent. However, there are also concerns that digital consent could widen some inequalities due to digital exclusion

Screening Subgroup

The Cervical Screening Subgroup has met twice, with the third meeting scheduled for early 2025. The first meeting focused mainly on available statistics. Unfortunately, up-to-date cervical screening uptake is not currently available due to an IT issue in extracting the data. However, historical data demonstrates both declining uptake and a marked deprivation gap.

The second meeting examined the cervical screening pathway from end to end, identifying a number of key issues:

• use of paper letters to contact patients
  • for younger people (who move more frequently) around 5000 invitation letters per year are returned to sender. This highlights the need to build on existing work to explore text message invitations as a priority
• barriers to the sample taking process
  • difficulty in getting a GP appointment or attending a GP surgery
  • IT issues, including with Scottish Cervical Call Recall System (SCCRS) inhibiting opportunistic screening at sexual health clinics
• potential tests of change
  • moving screening services from GP surgeries to primary care-led clinics with greater flexibility of appointment times and additional equipment for people with disabilities
• self-sampling
  • UK National Screening Committee (UKNSC) are currently leading a consultation on the use of self-sampling in under-screened populations. It should be noted that self-sampling is not as sensitive as a clinician taking a sample
• communication materials (letter and leaflets) 
  • although there are links within these to different formats, it would be beneficial to be able to better target communication in the right format from the outset. While the new community health index (CHI) system will help with this, accessing the necessary data will still be challenging. A business case has been submitted to Scottish Government to progress this
• provision of specialised screening service (e.g. for sexual trauma and homelessness 
  • while some great services are already available in some areas, they are not widely available across Scotland 

Next steps will be to more specifically identify the priority areas for the group to work on. This may involve mapping what work is already being progressed as part of the Scottish Equity and Screening Strategy.

In discussion, the following points were raised:

• it would be helpful to have up-to-date data on the rates of cervical intraepithelial neoplasia (CIN) 2 and CIN3. In particular, data around the number of vaccinated people getting cancer and which HPV genotype(s) are being recorded would help to understand what percentage of cancers would be covered by vaccination

Cancer Treatment Subgroup

The Cancer Treatment Subgroup has also met twice, with the third meeting planned for early 2025. Initial meetings have focused on the definition of the third pillar World Health Organisation (WHO) targets:

“90% of women with precancer treated and 90% of women with invasive cancer managed”

• “precancer” to be defined as CIN2 and CIN3.
• whether “treatment” should be defined as ablation or excision of abnormal transformation zone (TZ) only, or whether this should include any decision for active surveillance, as per British Society for Colposcopy and Cervical Pathology (BSCCP) guidance
• “management of invasive cancer” to mean active treatment and palliative care.

The subgroup has also explored available data sources, including:

• precancer:
  • SCCRS
  • National Colposcopy Clinical Information and Audit System (NCCIAS)
• cancer:
  • National Invasive Cancer Audit (NICA)
  • Cancer Registry

It is possible that Scotland is already meeting these WHO treatment targets. 

Ahead of consideration by the main group, the subgroup has also begun to consider the WHO Monitoring Framework and what indicators may be most relevant to Scotland. 

Next steps for the group will involve reviewing the cancer registry data and considering data stratification by Scottish Index of Multiple Deprivation (SIMD), rural/urban, socio-economic status etc.

In discussion, the following points were raised: 

• perhaps surprisingly, women in rural areas can often access treatment more easily
• getting women to attend their appointments is more of a challenge than appointment availability. Any increase in screening uptake therefore may not be a concern in terms of appointment availability
• did not attend (DNA) rates have declined since the introduction of SCCRS as it is now possible to see which patients have attended appointments in other parts of the country.
• on data stratification, rurality is derivable from postcode. It may be possible to enhance  SIMD data based on new census results

Policy and communications update

Policy and finance

All subgroups have noted that the work would benefit from budget availability for enhanced communications and improved digital solutions. A business case highlighting the public health benefits of digital modernisation has been submitted to Scottish Government.

Officials are in discussion with Public Health Scotland (PHS) and SVIP colleagues to seek representation from the Expert Group on the SVIP Delivery Board. This will ensure that the Expert Group can more easily link in with SVIP to move the work forward at pace and ensure alignment with SVIP governance. 

While public finances are facing unprecedented challenges, Ministers and senior SG officials are aware of the importance of this work and are happy to consider any funding requests that may deliver improvements and results within cervical cancer elimination. Once the Expert Group reaches the stage of generating proposals, officials will be happy to consider these.

Communications update

SG and PHS colleagues are developing a suite of documents, including a work plan and a communications plan, to help map out and progress the cervical cancer elimination work. These documents will be shared with the group in due course. 

The Chat.Sign.Protect marketing campaign is going live in health boards across Scotland to coincide with the issuing of consent forms. The award-winning campaign aims to encourage students to discuss vaccination with their parents and return their signed consent forms to receive the benefits of vaccination. PHS have also released an HPV information pack for educational establishments, which is live in all health boards.  

A new communications initiative has been launched at vaccination sessions, whereby vaccination teams will issue vaccinated pupils with a postcard to take home. The postcard advises that the pupil is now protected against HPV, but reminds anyone else in household to ensure they’re up to date with their cervical screening. This initiative is a cost-effective solution to get the message out to parents and carers at home.
In discussion, the following points were raised:

• given the challenges in improving vaccination and screening uptake, it would be useful to invite Scottish Government Health Marketing colleagues to a future meeting in order to consider possibilities around public health campaign(s) around vaccination, screening and cancer
• future campaigns must seek to link vaccination and screening, as there is perhaps lack of public understanding around the importance of this link at present
• it is already clear that certain groups are at greater risk (particularly deprived, under-screened and unvaccinated people). It may therefore be worth concentrating national marketing campaigns on these vulnerable groups first
• members are exploring how celebrity/influencer champions may get involved in promoting this work, particularly on social media
• while PHS and Scottish Government messages cannot appear on TikTok, other organisations use it (such as Young Women’s Movement and Young Scot)
• there are a number of groups supporting local champions across Scotland. It would be helpful to arrange a meeting with these groups to explore whether they are able to support screening and cervical cancer elimination messaging on TikTok

Discussion of Framework for Monitoring the Implementation of the WHO Global Strategy to Accelerate the Elimination of Cervical Cancer as a Public Health Problem

Due to time constraints, it was agreed to hold an interim meeting in the coming months (before April) to cover this item and any other urgent business. 

Date of next meeting and any other business

The Chair noted that the Expert Group have been asked to provide a progress report in April. Members should therefore expect to be contacted to provide advice and input to the report.  

It was agreed that there should be a shorter, interim meeting before April to cover the WHO Monitoring Framework and any other urgent business.