Many women’s health groups are understandably anxious at the thought of the NSU making changes to New Zealand’s excellent screening programme, and question whether the HPV test will actually be of much benefit to those women who are currently not being regularly screened.
New Zealand currently has one of the best cervical screening programmes in the world. It was established in 1990 in the wake of the Cartwright Inquiry into the treatment of cervical cancer at National Women’s Hospital. Since then the numbers of women who get cervical cancer and the number of women who die from it have reduced by 60%.3 MOH statistics reveal that there are now 150 – 160 women who are diagnosed with cervical cancer each year, and about 50 women who die from it.
espite the serious reservations that continue to be raised about the NSU’s (National Screening Unit) plan to change the primary cervical screening test from the current liquid-based cytology test to primary HPV (human papillomavirus) screening, the NSU recently announced that it will make the switch to HPV primary screening in 2018.1, 2
Women who are unscreened and under-screened feature highly in those diagnosed with cervical cancer, and Maori women are disproportionately represented in these statistics. Maori women have a registration rate for cervical cancer twice that of non-Maori women, and a mortality rate about 2.5 times that of non-Maori.4
The most efficient and effective way of increasing the rate of regular cervical screening for Maori women and for other under-screened women is to introduce free cervical screening. The AWHC has been actively lobbying for this for some years as we are often contacted by women who do not understand why breast cancer screening is publicly funded, but cervical screening is not.
Need for adequate information
There are in fact several issues that give cause for concern. One of the most important ones is the information the NSU produces for people about its screening programmes. The AWHC and others have protested for some years about the changes needed to the pamphlets and booklets about breast cancer screening. Women need to know about the risks associated with breast cancer screening which include over-diagnosis and over treatment. The NSU has been extremely reluctant to include such information and when it does it is unacceptably brief and downplays the risks...
Use of international statistics
Likewise, when discussing cervical screening the Ministry of Health and the NSU usually begin by announcing that around 275,000 women die from cervical cancer each year and continue to provide international statistics, but do not mention what the actual figures are for women living in New Zealand. Of course, NZ health agencies are not alone in doing this, but that does not make it acceptable to set the scene for discussions about proposed changes to cervical screening by overdramatising the incidence of cervical cancer in this way.
The facts are that over 85% of cervical cancer cases are found in low-resource countries, with the incidence and death rates being the highest in sub-Saharan Africa, Central America, South-Central Asia and Melanesia.5 Most of these countries do not have organised cervical screening programmes, nor do they have the necessary follow-up diagnostic and treatment services.
While the information about cervical screening, and HPV and cervical cancer that is on the NSU website states that:
“It is estimated that about 80 percent of sexually active women will become infected with HPV at some point in their lives. Most HPV infections have no symptoms, and in nearly all cases (especially in women under 30) the infection will clear on its own in 6-24 months, without the woman even knowing she had it,”6 the information in the pamphlets on cervical screening does not mention this important fact.7
Benefits and risks of the HPV test
Hopefully these resources will all be updated prior to the introduction of primary HPV screening and the important facts emphasised, eg how the body nearly always clears HPV infections without the need for colposcopy or treatment. Women who are identified as having one of the high-risk types of HPV are particularly vulnerable in terms of making informed decisions about the risks and benefits of further investigations.
The March issue of the NSU newsletter features an article about the new consumer-friendly website that the NSU is developing on cervical and breast screening which is due to be rolled out in mid-2016.8
The article states that “the website will also be accompanied by a social marketing campaign and new consumer resources to help increase screening rates especially for under-screened and unscreened women. The new website, social media and consumer resources are being designed with the help of advertising agency FCB.”
This is not good news. The experience of women’s health groups is that advertising agencies are often not good at producing health information for consumers, as they do not understand the Code of Consumers’ Rights or the need for informed decision-making. They see their brief as being promotional resources rather than providing evidence-based information on the benefits and risks of cervical and breast cancer screening.
The elephant in the room
The elephant in the room is the influence of big pharma. At the NSU/MOH consultation meeting the AWHC attended in October last year there were more representatives from Roche in the room than consumer representatives.
It was also obvious from a careful read of some of the 87 submissions the NSU received that the drug company was behind some of the statements that when the switch to HPV screening is made New Zealand women must have access to Roche’s FDA-approved HPV test, as other tests were inferior, or not FDA-approved. For example, one submitter, who of course wished to remain anonymous, wrote:
“I strongly recommend that the Cobas® HPV test is considered for use in New Zealand because it is the only clinically validated, FDA-approved and CE-IVD marked assay for first-line, primary screening of cervical cancer.”9
Another anonymous submitter even described women’s right to have access to Roche’s test as an equity issue.
It is difficult to know exactly who or what is behind the NSU’s rushed move to adopt an HPV test as the primary cervical screening test. And only time will tell whether it will save money and/or save lives.