By Kate Moodabe
GM, Total Healthcare PHO
Good news: 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.
Bad news: health providers are being told its 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 believe that funding is readily available within current screening coffers.
For 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 Pacific Island women, has meant the mortality rate for cervical cancer – a preventable cancer – among Māori is 2.5 times higher than non-Māori.
Falling short of screening targets
Put even more simply – we are falling far short of even our current screening targets. The holy grail of cancer screening is 80% participation (screening three-yearly). In 2018, within our PHO region our overall screening rate was 64% and 59% for Maori women. With the measles outbreak in 2019 and the Covid pandemic this year - and subsequent fear of infection if presenting at a clinic - these rates have dropped to 51% coverage overall and only 44% for Maori 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.
We are continuing to see fewer clinic visits as women continue to fear the risk of infection as we gradually recover post-lockdown.
Those obstacles are compounded by existing socio-economic factors that are 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’ clinics and the availability of free smear testing.
However, these measures have not been enough to tackle major contributors to non attendance, ie, women’s distress and embarrassment about the invasive nature of a cervical smear test in a clinical setting, and negative experiences of having smears taken in the past.
West Auckland study found HPV detected in unscreened women
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) that can develop into cervical cancer. Special care was taken to ensure clear information was provided and the process itself was easy to follow, and clinic nursing staff also received training as part of the study. During the trial, the swab test picked up HPV in four women who had never presented for a smear. New Zealand studies like this one have demonstrated that using an HPV self swab is acceptable and women will take it up, and it can improve equity.
Another important difference is that the new test targets 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%.
Nationally there are plans to implement HPV as a primary test for cervical screening but there appears to be delays in implementation.
Lobbying with GPNZ to fast-track register
To this end, we are already working with GPNZ to lobby for the fast-tracking of the development of a national register of women, which could be achieved with the diversion of funding from the present screening programme.
Lack of data should not be the reason we don’t save Kiwi women from death from this preventable cancer.
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.
Contact me for more information and to give your support.