Cervical Cancer Elimination in Scotland Expert Group Final Report

10. Cancer Treatment Subgroup

Background

This report presents an assessment of the progress made toward achieving the third pillar of the WHO elimination strategy target in 2021, based on data from the National Cancer Registry.

As noted previously, cervical screening is primarily delivered within GP practices by practice nurses and samples are analysed in two nationally commissioned laboratories. Where the result is abnormal, SCCRS automatically refers the patient for colposcopic assessment when appropriate. Colposcopy services are delivered by the 14 territorial Health Boards. Patients with pre-cancer are treated within the colposcopy service, whereas those with invasive cancer will be referred to gynaecology oncology services for ongoing management. Treatment will depend on the stage and grade of the cancer. A percentage of women will present too late for curative treatment and will require palliative care. The combined screening and treatment pathways can be seen under Figure 6:

Definitions of the treatment targets

Precancer: Precancer is considered to be a histological diagnosis of cervical intraepithelial neoplasia 2/3 (CIN2/3).

Management of cervical cancer: Management decisions for women with invasive cervical cancer are made at one of three regional multi-disciplinary teams (MDTs) (West of Scotland, East of Scotland and North of Scotland). Therapeutic options are mainly surgery, chemotherapy and radiotherapy and will include palliative care for advanced or recurrent disease.

Pathway for precancer

Women who screen positive are referred directly to local colposcopy services via the Scottish Cervical Call Recall System (SCCRS). All territorial Health Boards (except NHS Orkney, whose patients are referred to colposcopy in NHS Grampian), provide colposcopy clinics. All colposcopists are British Society for Colposcopy and Cervical Pathology (BSCCP) certificated, which requires structured training and assessment and 3 yearly re-accreditation, with audit of clinical practice and evidence of recognised Continuing Medical Education (CME). All Health Boards have a lead colposcopist, responsible for quality assurance (QA) of colposcopy practice and service, are members of the national QA group under the auspices of the Scottish Cervical Screening Programme and participate in the National Invasive Cancer Audit. Regular multi-disciplinary teams (MDTs) are held by each Health Board, with local pathology and regional HPV/cytology laboratories. Colposcopists may also diagnose and treat microinvasive cancer and link with the Gynaecology Oncology MDT when necessary.

Progress in Treating Precancerous Lesions: To prevent the progression of cervical intraepithelial neoplasia (CIN) to invasive cancer, timely diagnosis and treatment at colposcopy are essential. The National Cancer Registry data for 2021 indicates significant success in this area:

• 92.5% of CIN2 cases were treated
• 98.9% of CIN3 cases were treated

These high treatment rates reflect the effectiveness of the national cervical screening programme and colposcopy services in identifying and managing precancerous lesions promptly, and with failsafe procedures to minimise default. This includes direct referrals from SCCRS and non-SCCRS pathways, which trigger further recall if the woman does not have a colposcopy episode recorded after referral. It is recognised that CIN2 has a reasonable rate of spontaneous regression in younger women and so active monitoring may be offered as an alternative to immediate treatment following suitable discussion. Treatment of CIN will also generally be deferred during pregnancy. Such scenarios are covered by evidence-based colposcopy guidelines.

While treatment rates of CIN2 and CIN3 are high, wait times for colposcopy vary (sometimes significantly) between Health Boards. Additional work is required to understand and address these differences so that treatment across the country is consistent and effective.

Invasive Cancer pathway

Women with red flag symptoms (bleeding after sex, post-menopausal bleeding, other abnormal vaginal bleeding) are referred on Urgent Suspicion of Cancer (USC) pathway to secondary care following the Scottish Referral Guidelines for Suspected Cancer. Some women will be asymptomatic and diagnosed at colposcopy either as a result of an abnormal screening test, or due to the smear taker recognising a cervical cancer when preparing to take a smear test. Other women may be diagnosed in general gynaecology services, other specialities or as an emergency admission due to symptoms. All cases are discussed at one of the three regional MDTs to plan staging and treatment based on British Gynaecological Cancer Society (BGCS) guidelines.

Progress in Treating Cervical Cancer

Management of cervical cancer involves a multidisciplinary approach, including surgery (fertility sparing and non-fertility sparing), chemotherapy, radiotherapy and bio-immune therapies. According to the National Cancer Registry:

• 95% of women diagnosed with cervical cancer in 2021 received treatment

This achieves the WHO target of 90% treatment coverage. However, it is important to recognise that palliative care, while a vital component of comprehensive cancer management, is not included in these registry figures. With the high treatment rates and approximately 15 cancers per year not receiving active treatment an association with specific groups (e.g. ethnicity) has a low risk of being identified. While inequality by deprivation exists within cancer incidence, it is unlikely that a disparity of this scale exists within women not receiving treatment with curative intent.

Recommendations

To maintain and further improve the treatment coverage for cervical cancer and its precursors, the following good practice points are recommended:

Optimise Treatment Pathways

• minimise delays in the diagnosis and treatment initiation – this has been a challenge with the introduction of primary HPV screening in 2020 predicted to increase colposcopy referrals by 80% over a 5-year screening cycle
• increase monitoring of colposcopy referrals and CIN2/3 diagnosis – as the 2^nd HPV screening round began in September 2025, the effect of clearing prevalent disease in the first round may reduce colposcopy demand, however, this will also be impacted by the age range and frequency of screening, as well as the criteria for onward investigation at colposcopy by the screening programme

*To note – there will be more women within the screening age targeted population who will have received at least one dose of the HPV vaccine, which should reduce the incidence of pre-cancer and cancer and thereby reduce the volume of treatments required.

Comprehensive Data Collection

• use data collected on vaccination, screening (SCCRS), colposcopy and treatment (NCCIAS) Cancer Registry and the national invasive cancer audit (NICA) to model the demand on colposcopy and cancer services across Scotland – this data is currently used to ensure quality standards of treatment of precancer and cancer

Enhance Public and Professional Awareness

• promote education campaigns to ensure women understand the importance of early detection and treatment and follow up after treatment
• ensure equity of access to colposcopy appointments
• review and develop information materials in a range of accessible formats to explain the treatment process and the importance of attending after a positive screening test

Conclusion

The progress made towards the third pillar of the WHO elimination strategy is commendable, with high treatment rates for both CIN (precancer) and cervical cancer. Continued investment in colposcopy services, treatment accessibility, and data collection will be crucial to sustaining and surpassing these achievements.