Cervical Cancer Elimination Expert Group minutes: March 2025

Attendees and apologies

• Professor Anna Glasier (Chair)
• Sir Lewis Ritchie
• Dr Tasmin Sommerfield
• Professor Maggie Cruickshank
• Dr Claire Cameron
• Dr Tim Palmer
• Dr Lorna Willocks
• Rona Tatler
• Dr Sharon Hanley

• Caroline French
• Dr Carolyn Sunners
• Dr Douglas Rigg
• Dr Calum Robertson
• Heidi Douglas
• Alexander Cruickshank
• Dr Kirsty Roy
• Dr Kimberley Kavanagh
• Nicola Barnstaple
• Blair Harrison

Apologies

• Dr Azmat Sadozye
• Dr Cheryl Gibbons
• Felicity Sung
• Gareth Brown
• Julie Hoey
• Dr Kate Cushieri
• Kirsty Stewart
• Laura McGlynn
• Dr Victoria Flanagan

Items and actions

Minutes of previous meeting (sign off) and actions update

Members approved the minutes of the previous meeting with no amendments raised.  

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

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

The purpose of this interim meeting is to cover the agenda item on the World Health Organisation (WHO) 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, this item was not covered at the previous Expert Group meeting as planned. 

A presentation was delivered on the WHO Framework to open discussion. The framework document provides more detail on the key areas of the WHO strategy. There are three pillars of the WHO elimination strategy:

• primary prevention with a focus on HPV vaccination and health promotion
• secondary prevention with a focus on cervical cancer screening and pre-cancer treatment
• and tertiary prevention with a focus on treatment and supportive care for those with cervical cancer

The Framework highlights specific indicators related to these pillars which can be used to help track progress and to drive improvement. It is important to note that the WHO strategy has a global focus (i.e. both developing and developed countries) and that the group must consider which indicators would be most appropriate for Scotland in measuring progress towards the WHO targets. 

For example, HPV prevalence would be very costly to monitor in Scotland as it is very low and would necessitate a large study. This indicator is of greater relevance to countries without an established vaccination programme. The group must determine how we make best use of the data and tools we have available in Scotland to improve outcomes for all and achieve elimination. 

There are three main types of indicators which can be used to track progress:

• Impact Indicators - these measure the ultimate outcomes of the strategy, particularly in terms of reducing cervical cancer cases, deaths, and associated burden
• Programmatic Indicators - these monitor the implementation of specific interventions and the extent to which key targets in vaccination, screening and treatment are met
• Health System Indicators - these evaluate the enabling environment, infrastructure and system-wide capacities needed to implement the strategy effectively, as well as providing indication of how well they are integrated into national policies

As part of the Cervical Cancer Elimination (CCE) work, it was suggested that a monitoring and evaluation framework sit alongside the action plan. These two frameworks will enable the use of data to guide decisions-making and embed a continuous process of learning and improvement, aligning with the Plan, Do, Study, Act method of evaluation.

Plan: This will entail using the data currently available to inform recommendations and interventions. From these, objectives and key performance indicators (KPIs) can be identified (some objectives and KPIs have already been developed for screening and immunisation).

Do: Implement interventions.

Study: Evaluation to measure the effectiveness of interventions and consider whether any changes are required.

Act: Act on conclusions of evaluation to adapt interventions and improve outcomes.

Next steps

The group must identify which indicators should be measured and why, mapping the data indicators currently available against WHO indicators and assessing whether they are appropriate/relevant. It will also be essential to consider indicators which relate to equity, in order to ensure that efforts are inclusive and effective across diverse populations and context. 

Considerations include, but are not limited to:

• whether the targets and indicators all suitable for Scotland
• whether there are additional targets and indicators needed (e.g. around reduction in inequalities)
• whether the systems are in place to track indicators and report on the three targets
• current levels of vaccination, screening, incidence, mortality and service provision
• whether any recommendations will require new data/indicators to be developed

It was also noted that the United Kingdom (UK), rather than the devolved administrations, will report regularly to the WHO through a standardised template to facilitate global analysis of targets and indicators. A report is expected in 2025. 

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

Following the presentation, the following points were raised in discussion:

• resource constraints should be considered when weighing up the need for a new indicator 
• there may be some indicators for which a baseline is not presently established in Scotland
• the approach to data collection for HPV Immunisation Surveillance differs across the four UK nations, in part due to differences in system linkages, therefore the data produced by the other nations may well compliment that of Scotland and increase the value of collaboration
• for example, HPV prevalence is monitored within the population of England and Wales through the chlamydia screening programme, whereas Scotland is now reliant on samples taken from age 25. 
• Public Health Scotland (PHS) have already been in touch with UK Health Security Agency (UKHSA) colleagues to discuss progress on elimination work in their respective areas and are in agreement that the four nations should align in so far as possible 
• HPV prevalence in the wider female population (in England) was measured between 2010 and 2020 by UKHSA using residual vulvovaginal swabs from women attending sexual health services (a link to this study can be found here)
• HPV prevalence is likely to be similarly low in Scotland which would therefore necessitate a very large sample size to be of value in Scotland
• while this indicator is unlikely to be helpful in Scotland, HPV prevalence is an important indicator for some countries, where prevalence can be as high as 20%+
• a potential alternative is to use HPV prevalence within screening populations, which was done historically using residual liquid based cytology (LBC) samples, given that high-risk human papillomavirus (hrHPV) prevalence has become routinely available
• whether or not HPV prevalence within the screening population is representative of the wider population depends on how they compare with women who do not take up the offer of screening (for example, unvaccinated women are also less likely to be screened) as well as the impact of age and herd immunity
• preliminary discussions have begun around how the impact of hrHPV testing can by analysed at the national level - it may be possible to analyse this data by age, SIMD and ethnicity 
• as a developed country, targets set for Scotland should perhaps be more challenging overall, for example, by including specific targets for areas of deprivation

Next steps – preparing update for Ministers (end April 2025)

The Minister for Public Health and Women’s Health has requested an interim report which outlined the groups’ progress and includes any recommendations that groups are ready to make. The group aims to draft and collate this report ahead of the next Expert Group meeting and ensure that all members have the chance to shape and develop it. A further meeting of the full Expert Group will be scheduled in April to finalise the draft report ahead of submission. 

Subgroup chairs provided a brief verbal update on the progress and key conclusions so far, which may be suitable for inclusion in the interim report. 

Vaccination Subgroup: The recommendations of the subgroup will likely take the form of Scotland’s 5-year Vaccination and Immunisation Framework and Delivery plan, which will be adapted to utilise HPV vaccination as an exemplar of the plan in action. 

Screening Subgroup: The subgroup has worked through the cervical screening pathway to identify interventions to improve uptake and quality of testing. The subgroup is also considering which interventions will be implemented under business as usual (BAU) and which are new developments, which may require additional resources. 

Treatment Subgroup: Work has focussed on the definition of the WHO targets and assessing whether the data presently available in Scotland confirms that the target is already being met. There are particular groups for whom the targets are not being met, therefore the subgroup must consider recommendations as to what action is required to address health inequalities. 

Date of next meeting and any other business

The Expert Group will next meet on 17 April 2025 to finalise the interim report. Subgroup Chairs will be expected to present on their respective elements of the report. 

Another meeting of the Expert Group, following submission of the interim report, will then follow shortly afterwards.