Ever since the abnormal result from her first smear test 32 years ago, Marie Elliott has been grateful for the cervical screening programme.
‘Many women dislike having smears but for me it’s always been a massive reassurance, putting me at my ease that I don’t have a potentially fatal cancer,’ says Marie, 69, a retired insurance clerk who lives in Lincoln.
Yet the mother-of-two and grandmother-of-two is now being denied this life-saving screening purely on the grounds of her age.
Cervical cancer is largely caused by the sexually transmitted infection HPV (or human papillomavirus), which affects eight out of ten sexually active people — both men and women — at some point in their lives.
‘Many women dislike having smears but for me it’s always been a massive reassurance, putting me at my ease that I don’t have a potentially fatal cancer,’ says Marie, 69, a retired insurance clerk who lives in Lincoln
For the majority, the infection is harmless, with nine out of ten people producing antibodies that clear HPV within two years, according to a landmark 2007 study reported in the Journal of Infectious Diseases.
It’s not known why one in ten people remains infected, although smoking is a risk factor. But, in women, a persistent viral infection can bring about changes in cells in the neck of the womb that can then lead to cervical cancer — a process that may take up to 20 years.
The smear test, in which a nurse removes a sample of cells from the neck of the womb (the cervix) using a small, soft brush inserted into a speculum, enables technicians to identify any abnormal cells before these turn into cancer. They can then be easily zapped by laser or surgically removed.
Cervical cancer screening is one of the most successful programmes, preventing some 5,000 cancers each year and halving annual deaths from the disease to around 850.
Women aged 35 to 44 — one to two decades after they first have sex — have the highest risk of the disease.
‘It is why there is so much emphasis on younger women having cervical screening,’ says Imogen Pinnell, health information manager at Jo’s Cervical Cancer Trust, a charity set up by the widower of a patient who died of the disease at the age of 40.
But older women are still at risk of developing it, perhaps as a result of undetected infection at an earlier age.
And while incidence increases more rapidly from age 25 and then dips after age 49, it peaks again in the decade after the age of 64, which is when the current screening programme ends — and is precisely the age at which Marie was told she’d no longer be screened. Furthermore, half the UK deaths from cervical cancer are in women over 65.
The smear test, in which a nurse removes a sample of cells from the neck of the womb (the cervix) using a small, soft brush inserted into a speculum, enables technicians to identify any abnormal cells before these turn into cancer
At the age of 37, Marie was one of the first to benefit from the screening programme when it was introduced in 1988, and she believes it has kept her alive. Twice, she has had laser therapy — in 1988 and again in the mid-1990s — after smears identified abnormal cells.
On a third occasion, in 2006, she was admitted to hospital for a loop diathermy, or LLETZ — a procedure done under local or general anaesthetic to remove abnormal cervical cells using a thin loop of electrified wire.
After each treatment, Marie was followed up with every six months and then every year; then every two years when the smear came back normal — but always more frequently than the programme’s protocol for women whose smears come back clear.
Currently, this is every three years between the ages of 25 and 49, and then every five years up to the age of 64. Thereafter it is available only to women who have never been screened and who then decide to have their first smear.
After each treatment, Marie was followed up with every six months and then every year; then every two years when the smear came back normal — but always more frequently than the programme’s protocol for women whose smears come back clear
As she approached and passed her 60th birthday, Marie was pleased to have three clear smears. ‘It was good news, but I took it for granted that I’d be recalled after five years for a further check-up. I never thought for a moment that I wasn’t at risk of cervical cancer.
‘I was considered to be at risk under 64, presumably because the virus might still be active — and I’ve no reason to think anything has changed now.’
But should older women such as Marie, who have had abnormal cervical cells in the past, or older women who have been screened before, be offered the test?
Currently, health chiefs are predicting a dramatic reduction in cervical cancer diagnoses, and even that ‘cervical cancer could be eradicated for good’, as public health minister Jo Churchill said in January.
That optimism is based on two major breakthroughs. In 2008, the HPV vaccine was introduced for 12 to 13-year-old girls nationwide.
A study in the BMJ in 2019 showed those who were vaccinated had, at the age of 20, a 95 per cent reduction in the most serious degree of pre-cancerous cell change caused by HPV, CIN (cervical intraepithelial neoplasia) grade 3, which is at risk of becoming cancer if left untreated, compared to those who hadn’t had the vaccine.
More recently, a test for HPV that is considered to be more accurate than the smear test, is now widely available. It uses the same sample of tissue collected from the cervix during the smear test and is therefore available only for women aged 25 to 64.
So while younger women may benefit, these advances will not address the concerns of Marie — or of other women who would like to continue to be screened after the age 64 cut-off.
‘It might seem arbitrary,’ says Peter Sasieni, a professor of cancer prevention at King’s College London and a consultant gynaecologist at Guy’s Hospital in London, ‘especially as a woman can request screening for breast cancer throughout her life.
‘But the evidence suggests that it’s rare for women aged 55 or older to be infected with HPV, and even if they are, there is unlikely to be sufficient time for it to progress to invasive cancer in her lifetime.’
In 2014, Professor Sasieni published research that showed that only eight in every 10,000 women who are regularly screened until the age of 65, and who have had at least three clear smears in the years running up to the age limit, go on to develop cervical cancer — compared with 49 in every 10,000 women who were not screened.
It is this evidence that explains why Marie was refused a smear in November 2018, five years after her previous one.
Yet Marie’s GP had agreed — based on her history — that she should continue having regular smears.
‘But when I turned up for my appointment at the clinic, they said there was no point in me having the smear as it wouldn’t be checked because of my age.’
Now, a growing number of experts express concern that the upper age limit for screening could be putting a generation of baby boomers at risk.
Indeed, women over 65 account for a fifth of new cases of cervical cancer, according to 2018 Cancer Research UK statistics. These showed that the mortality rate from cervical cancer is highest in women aged 85 to 89.
Emma Crosbie, a professor of gynaecological oncology at Manchester University NHS Foundation Trust, says that while ‘the highest peak for developing cervical cancer occurs between the ages of 30 and 34, there’s a second high peak that occurs in women aged 70 to 74 — and that’s ignored in current guidelines’.
A Canadian ‘modelling’ study published in the journal The Lancet Oncology in 2018 predicted that older women would face a reduced risk of cervical cancer if screening in developed countries, including the UK, continued to age 75 (though the reduction in the risk would be less dramatic than for younger women).
There are good reasons why women remain at risk of having an abnormal smear indicating a risk of cancer over the age of 64.
For a start, the suggestion that women over 55 are unlikely to get a sexually transmitted infection is in dispute.
A woman may ‘easily be infected or re-infected in their 50s or 60s, perhaps after a divorce,’ says Dr Sue Sherman, a health psychologist at Keele University, who specialises in the psychological impact of cervical cancer.
And there’s a further ‘million-dollar question’, says Imogen Pinnell, of Jo’s Cervical Cancer Trust: how long is the HPV infection able to persist, possibly invisibly, if the body’s immune system fails to clear it? ‘The textbooks say up to 30 years, but there’s no actual evidence that shows it can’t last longer than that,’ she adds.
Dr Sherman agrees: ‘It’s perfectly possible that the virus may be dormant for years, even decades, and only turns into cancer perhaps as the immune system becomes less effective due to ageing.
‘Whatever the reason, the age 64 cut-off point for screening is indisputably arbitrary as the data shows that one in two deaths from cervical cancer occurs in women over this age. It is entirely wrong for the NHS to suggest they are at reduced risk of cervical cancer because of their age.’
Patti Gravitt, a professor of public health at George Washington University in the U.S., takes the same view. Research she published in 2012 in The Journal of Infectious Diseases suggests that the peak in cervical cancer diagnosis in women in their 60s and 70s could be down to a ‘risk of age-related reactivation of hidden long-term HPV infection’.
Today, Professor Gravitt says that further analyses of the data from the study, looking into the causes of reactivation, suggest that ‘age or changing hormones at menopause may trigger recurrence of abnormal cells’.
She adds: ‘If HPV persists for more than one to two years, there is always a risk that reactivated infection may not be brought back under control, and that is a good reason to keep screening.’
Cancer Research UK is also looking at whether cervical screening should be routinely offered to women over 64. ‘We may need to start reconsidering the upper age limit for smears,’ says Jess Kirby, the charity’s health information officer.
One reason why older women might be discouraged from having a smear test is the risk of increased discomfort when a speculum is inserted, ‘as tissues become less stretchy after menopause’, says Imogen Pinnell. ‘But that shouldn’t be a reason not to screen: if necessary, a local oestrogen cream can be applied a couple of weeks before a smear to moisten the tissues.’
In any case, she says, the GP is the ‘gatekeeper’, and ‘a woman who feels she is at risk of cervical cancer should be entitled to a smear whatever her age, provided the GP agrees’.
Marie believes she may still have HPV. ‘I may have had a series of clear smears, but that’s happened before and it was followed by an abnormal smear.’
Marie acknowledges that she could get tested privately at relatively little cost — a smear is priced at around £105.
‘But,’ she says, ‘I worry that if I was diagnosed with cervical cancer in the private sector, I may find it hard to get expensive treatment on the NHS. What’s so crazy is that women can ask to have a mammogram throughout their lives but that’s not possible for cervical screening.’