Fast track cervical cancer testing and save lives

Opinion piece featured in the NZ Herald on 8 Sep 2020

By Kate Moodabe
GM, Total Healthcare PHO

Professor Peter Davis wrote a recent column (NZ Herald, August 31) about the failings of the NHI register and the National Immunisation Register. These are not the only IT tools holding back improvements in health delivery to New Zealanders.

We now have an accurate test for markers of cervical cancer that Kiwi women can use themselves to help lower our national mortality rate from the disease, but health providers are being told a national rollout could be three to five years away.

Holding up its introduction is the overhaul of a national cervical screening register of women aged 25–69 years. The current register is no longer fit for purpose; it cannot be easily updated to manage a new primary HPV programme and larger volume of results.

Updating the register for the new test and for all eligible women is dependent on funding, but I suspect that funding is readily available within current screening coffers.

While this issue is being addressed, we continue to grapple with the limitations of our current national screening programme that, quite simply, is failing women. Years of underscreening among women and, in particular, Māori and Pasifika women, has meant the mortality rate for cervical cancer – a preventable cancer – among Māori is 2.5 times higher than non-Māori.

Put even more simply – we are falling far short of even our current screening targets. The holy grail of cancer screening is 80 per cent participation (screening three-yearly). In 2018, within our PHO region our overall screening rate was 64 per cent and 59 per cent for Māori women.

With the measles outbreak in 2019 and the Covid-19 pandemic this year – and subsequent fear of infection if presenting at a clinic - these rates have dropped to 51 per cent coverage overall and only 44 per cent for Māori women.

Nationally, for the first six months of 2020, there have been 55,000 fewer cytology screens compared to the same period last year. Half of these were lost during the Covid-19 lockdown when virtual health consultations increased and GP visits were down, which meant that in-practice opportunistic screening fell too.

Existing socio-economic factors also leading to limited cervical screening. Women in full-time employment find it difficult to get time off work for a medical appointment for reasons other than illness; and many medical clinics are closed in the evening or at weekends when women are free to visit.

Cervical screening is the only national programme in which it is not free to participate. At Total Healthcare, we have tried to address these issues with after hours, including weekend, clinics and the availability of free smear-testing, and even incentivising women to have them done.

However, these measures have not been enough to tackle major contributors to non-attendance, that is, distress and embarrassment with the invasive nature of a cervical smear test in a clinical setting, and negative past experiences.

Two years ago, Total Healthcare participated in a study of 200 previously unscreened or under-screened women at three of its medical centres in West Auckland to assess a new vaginal swab test that is self-administered. The study aimed to specifically engage women who had shied away from having the standard cervical smear in a clinic.

Women were encouraged to use the swab-test, either in their home or in privacy at the clinic, to test for the human papilloma virus (HPV) which can develop into cervical cancer.

The trial picked up HPV in four women who had never presented for a smear, thus demonstrating an HPV selfswab is acceptable and women will take it up, and it can improve equity.

An important difference is the new test checks for the presence of HPV, whereas the current smear test picks up abnormalities in cells that the virus has already produced.

Furthermore, the enhanced accuracy of primary HPV testing over the current test means mortality could be reduced by a further 15–17 per cent.

Nationally there are plans to implement HPV as a primary test for cervical screening but there appears to be delays in implementation.

At the very least, we want to see this swab test funded and offered as soon as possible to our high needs Māori women who are not presenting for screening – either regularly or at all – and hopefully provide a proof of concept that will see its uptake throughout New Zealand.

To this end, we are already working with 21 other PHOs, through General Practice New Zealand (GPNZ) and the Auckland Primary Leadership Group (which together represent over 4 million New Zealanders). We all agree with the need to fast-track the development of a national register of women, which could be achieved with the diversion of funds from the present screening programme.

Lack of data shouldn't leave Kiwi women to die with this preventable cancer.

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