Cervical Screening Programme, England - 2019-20 [NS]

Call

Invitation for previously unscreened women

Recall

Invitation for subsequent screens

Coverage

Defined as the percentage of women in a population eligible for screening at a given point in time who were screened adequately¹ within a specified period.

Acceptable performance

Defined as achieving coverage levels of 80% or greater, assessed for the 25 to 49 and 50 to 64 years age groups².

Cervical screening is available to women and people with a cervix aged 25 to 64 in England. People aged 25 to 49 years receive invitations every 3 years. People aged 50 to 64 years receive invitations every 5 years. Coverage is reported for these age groups and is referred to as age-appropriate coverage.

Coverage for all ages (25 to 64) is also reported. 

At 31 March 2020:

• Coverage for women aged 25 to 64 was 72.2%, an increase of 0.3 percentage points from the previous year.
• Coverage in the lower age cohort (25 to 49) increased to 70.2%, from 69.8% in 2019.
• Coverage in the upper age cohort (50 to 64) decreased to 76.1% from 76.2% in 2019.

At 31 March 2020, for women aged 25 to 64:

• Coverage ranged from 64.7% in London to 75.5% in the North East.
• All screening regions reported an increase in coverage when compared with 2019.
• In 2019-20, the largest increase was in the North West, 0.6 percentage points higher than the previous year.

At 31 March 2020, for women aged 25 to 64:

• One LA achieved the acceptable performance level of 80%.
• 103 of 149 LAs had coverage levels of 70% and above, an increase of two compared to 2019.
• Coverage ranged from 49.8% in Kensington and Chelsea (London) to 80.2% in Rutland (East Midlands).

This section uses data from the KC53 dataset, it uses a historic definition of coverage providing a more detailed age breakdown.

Until a more detailed breakdown of age-appropriate coverage is available, the KC53 remains a useful resource for more detailed age group comparisons.

In the 25 to 49 age cohort, coverage was lowest in the youngest age group (25 to 29) and highest in the oldest age group (45 to 49).

In the 50 to 64 age cohort, coverage was lowest in the oldest age group (60 to 64) and highest in the youngest age group (50 to 54).

In 2020, women aged 50 to 54 had the highest reported coverage at 78.5%.

Cervical screening programmes in the UK countries have different target age groups and screening frequencies. When comparing coverage among UK countries, these differences should be considered.

For England, Scotland and Wales, coverage is calculated within the past 3.5 years (age 25 to 49) or 5.5 years (age 50 to 64).

For Northern Ireland, coverage is calculated within the past 3.5 years (age 25 to 49) or 5 years (age 50 to 64).

Source for England: PHOF, Open Exeter, NHS Digital. See data tables 1 and 13.
Source for Northern Ireland
Source for Scotland
Source for Wales

Finalised data for Wales was not available at the time of publication of this report and so has not been included.

Women are invited for screening by the programme either as part of routine screening or because of a repeat screen being required. More detailed information about invitation types can be found under the 'Types of invitation' section.

The programme targets women aged 25 to 64, with women receiving their first invitation from age 24 years and 6 months.

In 2019-20:

• 4.63 million women aged 25 to 64 were invited for screening, most of whom were aged 25 to 49 (3.57 million).
• The number of women aged 25 to 64 years invited for screening increased compared with the previous year (4.41 million in 2018-19)

The peak in 2011-12 (see chart below) may be associated with the death and diagnosis of the high profile media personality Jade Goody³

Women in the programme may receive an invite to screen in 1 of 5 scenarios

The table below shows a breakdown of invites by invitation type for 2018-19 and 2019-20, for women aged 25 to 64 in England.

Sum of components may not equal 100% due to rounding.
Source: KC53, NHS Digital. See data table 4.

Women who attend a cervical screening appointment will have their sample taken and it will then be sent to a cytology screening laboratory for assessment. Women may be tested following an invitation from the programme, or screened opportunistically i.e. if a test is overdue (not prompted by the programme) when visiting a GP or other health service.

In 2019-20, 3.20 million women aged 25 to 64 were tested, a decrease of 0.23 million from the previous year.

The peak in 2011-12 (see chart below), has been associated with the death and diagnosis of the high profile media personality Jade Goody³.

The reason for the 6.8% decrease in the number tested between 2018-19 and 2019-20 are not clear. Contributory factors may include:

• Increase in the number of women tested in 2018-19. A screening awareness campaign starting in March 2019 may have contributed to this.
• Reduction in the number of tests carried out in 2019-20 may be due in part to disruption from COVID-19 at the end of 2019-20

The number of tests carried out in 2019-20 is similar to earlier years (e.g. 2016-17 and 2017-18).

In 2019-20, 83.7% of women aged 25 to 64 were tested following an invitation from the screening programme.

Of all final results:

• 4.9% showed an abnormality (non-negative)
• 1.1% showed a high-grade abnormality

Where a woman receives multiple tests, their final result will be the most severe result recorded in the year.

For detailed explanations of the different types of cytology see Appendix D.
*?invasive carcinoma means ‘suspected invasive carcinoma’
**?glandular neoplasia means ‘suspected glandular neoplasia of endocervical type’
Source: KC53, NHS Digital. See data table 8.

The decrease in the number of borderline results in 2019-20 (see table above) may be due to the change to the HPV primary screening. HPV primary screening is a more sensitive test with an increased negative predictive value and reduced false negative rates.  The impact of the introduction of HPV primary screening will continue to be monitored

The percentage of results showing a high-grade abnormality decreased with age; 1.8% for women aged 25 to 29 and 1.9% for women aged 30 to 34, falling to 0.4% for women aged 60 to 64.

121 of 149 LAs had between 3% and 6% of tests with an abnormal result. The maximum percentage of tests with an abnormal result was 8.6% (see data table 12).

The national standard is 98% within 2 weeks².

In 2019-20, 44.0% of letters were received within 2 weeks, a decrease of 4.4 percentage points from the previous year. There was significant regional and local variation across England depending on the status of laboratories and the stage of HPV primary screening implementation.

The implementation of HPV primary screening across England was completed in December 2019 and resulted in a consolidation of cytology service to 8 sites from the previous 48. This impacted on cytology workforce and reduced cytology screening capacity in some areas during the implementation.

This has lead to an increase in the turnaround times of cervical screening samples since 2016-17⁵ ( see Appendix J for more information). Actions to address increases in turnaround-time have been put in place⁶. 

Regional performance, 2018-19 and 2019-20, ages 25 to 64 years

In 2019-20:

• No region met the KPI value of 98% of letters returned within 14 days.
• The East of England reported the highest percentage of letters received within 2 weeks at 63.7%.
• The East Midlands reported the lowest percentage of letters received within 2 weeks at 9.8%.
• 4 regions had increased performance compared to the previous year (Yorkshire and the Humber, East of England, London and the South East).

There was significant regional and local variation in turnaround times across England in 2019-20, depending on the status of laboratories and the stage of HPV primary screening implementation.

An LA breakdown of this output is available both in the data tables and the interactive visualisation tool.

Following screening/testing, there are three types of recall status within the programme; normal (action code A), repeat (action code R) and suspend (action code S).

Click on a recall status below to see the screening pathways that lead to that outcome.

Of women with only a negative result:

• 91.3% were given a normal recall status.
• 7.8% were given a repeat recall status as they were under surveillance or follow up. 
• 0.9% were given a suspend recall status as they were under hospital care⁷.

96.6% of women with an inadequate screening result were given a repeat recall status.

- = recall status not applicable for this result
*?invasive carcinoma means ‘suspected invasive carcinoma’, ?glandular neoplasia (endocervical) means ‘suspected glandular neoplasia of endocervical type’ NB. The sum of components may not equal totals due to rounding.
Source: KC53, NHS Digital. See data table 10.

Borderline and low-grade results

Prior to HPV testing as triage and test of cure (from March 2012), most women with a first borderline screening result would have been assigned a repeat recall status.

Where HPV triage testing has been implemented, women with a borderline result are tested for high risk HPV and depending on the result either returned to normal routine recall or referred to colposcopy and given a suspend recall status.

In 2019-20, comparatively few women (3.6%) were given repeat recall status.

HPV primary testing was fully rolled out in December 2019. Where HPV primary testing has been implemented, women with a non-negative cytology result (following a high risk HPV result) are referred to colposcopy and given a suspend recall status.

Between 2018-19 and 2019-20 the percentage of women given a suspend recall status following a borderline result, rose from 49.0% to 67.6%.  The change to HPV primary testing is likely to have contributed to this change.

The change following the introduction of HPV triage testing in March 2012, is less noticeable for women with low-grade dyskaryosis screening results. However, the increase in the proportion of women with a normal recall status and the fall in the proportion with a repeat recall status is still evident.

For low-grade screening results, there is an increase in the percentage of ‘suspend’ recall status outcomes. These changes may be associated with the full implementation of HPV primary testing (December 2019).

1. In a small proportion of cases the laboratory result may be either HPV unavailable or cytology inadequate and the test is considered inadequate.
2. Cervical screening standards valid for data collected from 1 April 2020
3. An unexpected increase in women tested in 2008-09 has been associated with the diagnosis and death from cervical cancer of the high profile media personality, Jade Goody (Lancucki et al, 2012). Research published in the Journal of Medical Screening reported that her diagnosis and death, which were well publicised, “……were marked by a substantial increase in attendances in the cervical screening programme in England…..(Although the) increase in screening attendances was observed at all ages…..the magnitude was greater for women aged under 50” (Lancucki et al, 2012, p4) https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3385661/ 
4. Some women may receive multiple tests in a year for clinical reasons such as a previous inadequate sample or the need for a repeat test due to a previous abnormality (with or without treatment). See data table 7.
5. NHS public health function agreement 2019-20. Service specification no. 25 NHS Cervical Screening Programme 
6. New guidance to help cervical screening providers reduce cytology backlogs
7. Those with a negative result and suspend recall status could include some who were referred to colposcopy for symptoms noted at the time of testing.