Cervical Cancer Elimination in Scotland Expert Group Final Report

11. Conclusion

From Scotland’s Women’s Health Champion - Professor Anna Glasier

Scotland has in place all the structures necessary to eliminate cervical cancer. It is exciting to think that we really could do it, and the Cervical Cancer Expert Group is ambitious in its efforts to ensure that Scotland succeeds.

It is clear from the mathematical modelling that eliminating cervical cancer is not going to be easy, and nor will it be quick. Success will involve significantly increasing the uptake of both HPV vaccination and cervical screening. Critically, in Scotland we want to eliminate cervical cancer not just at the population level but among all women regardless of who they are and where they live. We need to focus our efforts on the inequalities identified, including the deprivation gradients in the uptake of both HPV vaccination and cervical screening.

The decline in vaccination and screening uptake is not the result of failures of the healthcare system but rather of societal changes. However, the NHS could be doing better. Some structural changes may help improve uptake, for example offering self-taken HPV swabs to women who decline traditional screening. However, to capture the last 30% of the population for vaccination and screening, we will need to change beliefs and change behaviour and that is not easy to do.

In this final report, various time frames have been modelled for eliminating cervical cancer in Scotland as a whole, and across different deprivation groups. If levels of vaccination, screening and treatment stay as they are currently, overall elimination will not be achieved until between 2050 and 2055. The most optimistic scenario in the mathematical model shows possible elimination of cervical cancer in Scotland by 2040. Many may well think this over-ambitious but if we don’t set ambitious targets and settle for less then we will likely achieve less. That said, this would only be achievable if we reach equitable vaccine uptake of 90%; equitable screening coverage of 90%; and if we extended catch-up vaccination to cover a wider age range (15-39 an extension which would need to be approved by the JCVI) and achieved equitable coverage of 90% for catch-up vaccination. Even then it would not be until around 2045 that we would achieve success in the most deprived areas of the country – so our resolve must not weaken.

So, what do we need to do?

Vaccination

If we make a particular effort with schools with the lowest levels of vaccine uptake by improving the information we give to the schools, parents and the pupils; if we engage with teachers so that they too become enthusiastic about elimination; if we offer enhanced self-consent to HPV vaccination in all Scotland’s schools, then we really should be able to get vaccination uptake up to 90% in both girls and boys.

We will eliminate cervical cancer faster if we vaccinate as many boys as we can so that unvaccinated girls have less chance of becoming infected with HPV when they become sexually active. To eliminate cervical cancer by 2040 we will also need to vigorously pursue catch-up vaccination in every relevant setting for all women in the proposed extended age-range.

Screening

Increasing the uptake of screening will be harder and will take longer. But let us imagine that, having increased vaccination uptake to over 90%, we had a massive campaign throughout Scotland and in the course of a single week screened everyone who had never been screened or whose screen was overdue. And then, over the next week, we followed up everyone who screened positive and treated everyone who had CIN II or III - then we would eliminate cervical cancer. Of course, such a proposal is sheer fantasy, but it illustrates two important points.

Firstly, elimination could be possible. Secondly, to meaningfully increase screening uptake will take sustained and united effort across the entire healthcare system and beyond.

So if, over time, all relevant healthcare providers (in primary care, obstetrics and gynaecology and sexual health services) checked the cervical screening status of all women attending their service and offered screening if required, with self-taken sampling if need be, then, even if we did not reach 90% we would certainly screen more women. Getting the message out, particularly to young women, that screening remains essential even for those who have been vaccinated will be vital.

Information Technology and Digital Innovation

To meet the targets for both vaccination and screening we need improved IT systems. We need to enhance electronic systems for scheduling and recording vaccine uptake, including settings beyond the school, and we need to explore digital consent solutions to improve user experience and data collection. We also need Scotland’s new NHS App (mycare@scot) to be up and running nationally, with a lifelong record of vaccination and screening so that women could find out for themselves their cervical screening and vaccination status.

Making it Happen

These actions and timetables might well read today as fanciful or fantastic, but the point being made is that elimination should be possible. We must learn from the Scandinavians and adopt a ‘Faster/Even Faster’ approach^[27]. How soon cervical cancer can be eliminated in Scotland depends on how quickly the recommended interventions can be implemented and how successful they are. The Expert Group is clear that additional resources will be required to ensure that this does happen. The Group’s recommendations will be used to develop a series of required actions clearly indicating which organisations must take responsibility, and will be accountable, for these actions and what resources will be required. Finally, the Group recommends the establishment of an Implementation Group with ministerial oversight to ensure that cervical cancer will eventually be eliminated in Scotland.

We have seen HPV vaccination work, and we know what else we need to do. Doing everything that needs to be done will involve the time of a great many people, in the health service, in schools and in many other roles. Above all, it will take a national effort, supported with the money and resources needed, with everyone committed to the task, including government and the Parliament.