National Screening Programmes (Adult Population) Annual Report 2011-12 1
This report details the range of national screening programmes for the adult population offered by NHS Shetland and reports the latest performance and service developments in each programme (the most recent data are mostly from 2010 or 2011). Some programmes have been in place longer than others and the level of detail in each section of this report reflects this. In addition to the programmes described here, there is also a range of antenatal and neonatal screening programmes which are offered to pregnant women and their babies; and childhood screening programmes including vision testing. The three programmes reported here are all cancer screening programmes: looking at cervical cancer; breast cancer and bowel cancer. A programme is to be introduced in October 2012 to screen men for another (non-cancer) condition called abdominal aortic aneurysm (AAA). 2.1 Epidemiology of cervical cancer Each year in Scotland around 300 women are diagnosed with cervical cancer and approximately 100 women die from it. In Shetland the figures are as follows: Incidence 1 0 0 0 0 2 1 2 Mortality 0 0 0 0 0 0 1 0 Because of Shetland s small population it is difficult to interpret the small numbers of cases for individual diseases such as cervical cancer. The most recent available figures show that five women were diagnosed with cervical cancer over a three year period to the end of 2010, and one women died in that period during that time. This appears to be an increase compared to previous years, when there had been no cases diagnosed for three years. Looking at the figures as a rate over several years shows that Shetland s incidence (the number of new cases per year) and mortality (deaths) do not differ significantly from the Scottish average over time, although there may be fluctuations year on year. So in 2008 and 2010 the rate in Shetland was higher, but in 2009 it was lower. There does appear to be a gradual 2
increase in the numbers of women being diagnosed with cervical cancer across Scotland. Cervical Cancer EASR 1 Trend in Incidence (new cases) Scotland 9.2 9.7 10.2 9.9 10.1 11.0 11.3 11.3 Shetland 9.3 0.0 0.0 0.0 0.0 16.7 8.7 16.3 It should be noted that these figures are for all cases of cervical cancer not just those picked up through cervical screening (which in fact is designed to pick up pre-cancerous changes before a cancer develops). Mortality rates across Scotland do not appear to have changed over the period 2011-2010. Cervical Cancer EASR Trend in Mortality (deaths) Scotland 3.7 3.0 3.6 2.8 3.1 2.8 3.1 3.0 Shetland 0.0 0.0 0.0 0.0 0.0 0.0 7.3 0.0 2.2 The screening programme The cervical screening programme has been in place nationally for a number of years. Cervical screening is designed to detect pre-cancerous changes in the cells sampled from the cervix (the neck of the womb). This is known as cervical intraepithelial neoplasia (CIN) and can be effectively treated to prevent cervical cancer developing. The smear test is the process of sampling the cells and is usually carried out at the woman s own GP practice, by the practice nurse or GP. Cervical screening is offered to all women aged between 20 and 60 years in Shetland every three years, as in the rest of the UK, and over 1,800 women in Shetland are screened every year. The only women in this age range who are not offered screening are those who have had a total hysterectomy. This applies to about 6% of Shetland women. 2.2.1 Uptake figures 80.1% of women offered screening in the past 3.5 years (up to 2011/12) have responded. This has remained fairly stable over the past 3 years after a period of drifting downwards. The graph below shows the cervical 1 EASR: age-standardised mortality rate per 100,000 person-years at risk (European standard population) 3
screening uptake rate for Shetland over time, and demonstrates that it has mirrored the national pattern, while staying consistently well above the Scottish average. Very few women actively opt out of the screening programme in Shetland. Those that do are generally over 40 years old. The number of women opting out is decreasing. We are in the process of analysing and feeding back data at GP practice level, to try to ensure we maintain our high rate of uptake and keep opt outs to a minimum. 2.2.2 Smear taking results The quality of local smear taking is indicated by the percentage of unsatisfactory or inadequate smears. This did decrease with the introduction of a new technique for smear taking (Liquid Based Cytology LBC) a few years ago. Shetland unsatisfactory results decreased to 2.85% in 2011-12, after an increase in the previous year to just over 4%. This continues to be monitored, and smear takers have been reminded of the need to ensure they have a good technique to try and keep this as low as possible. The percentage of women with any non-negative result (non-negative results includes severe, moderate, mild or borderline changes and unsatisfactory smears) for the last 3 years is shown below. 4
2.3 Developments 2.3.1 The Test of Cure Study After treatment for CIN, women used to have several repeat smears to see if treatment has been successful. The Test of Cure pilot study showed that women who have a cervical screen that shows normal cervical cells and no Human Papilloma Virus (HPV which causes cervical cancer) six months after treatment for CIN can return to routine three yearly screening. From 30 April 2012, all women who have had treatment for CIN in Scotland are now tested for HPV at their next cervical screening test. This normally takes place six months after treatment. If they are both HPV negative and the cervical smear test is normal then they will return to the usual three yearly screening. 2.3.2 Training for smear takers A national training resource for smear takers is in development. In the meantime, we are looking at developing and running a local training session for smear takers in Shetland during 2012-13. 2.4 Further information Further information on the Scottish Cervical Cancer Screening Programme can be found at: www.nsd.scot.nhs.uk/services/screening/cervicalscreening/index.html 5
3.1 Epidemiology of breast cancer Each year in Scotland around 4000 women are diagnosed with breast cancer and approximately 1000 women die from it. Early diagnosis and advances in treatment have led to a good prognosis for most women with breast cancer nowadays. In Shetland the figures are as follows: Incidence 17 24 12 16 43 9 20 24 Mortality 4 2 3 4 5 7 6 4 Because of Shetland s small population it is difficult to interpret the small numbers of cases for individual diseases such as breast cancer. It can be seen in the table above that the number of cases diagnosed each year varies: this will in part be due to small numbers but also reflects the timing of the screening programme. In Shetland the mobile screening unit comes up every three years, and so most of the women diagnosed with breast cancer through the screening programme will be diagnosed in that year (ie 2004, 2007, 2010). However every year there will be other women who are diagnosed not because of the screening programme, but because they have developed signs or symptoms of cancer. Looking at the figures as a rate shows that over time Shetland s incidence (the number of new cases) and mortality (deaths) do not differ significantly from the Scottish average, although there are year on year fluctuations due to small numbers and the effect of three year screening. Breast Cancer EASR 2 Trend in Incidence (new cases) Scotland 60.4 61.2 61.0 61.9 61.6 63.1 64.3 64.6 Shetland 56.3 89.5 39.2 47.5 156.0 31.5 68.5 85.1 2 EASR: age-standardised mortality rate per 100,000 person-years at risk (European standard population) 6
Breast Cancer EASR Trend in Mortality (deaths) Scotland 15.5 14.4 15.1 14.3 13.6 13.0 12.6 12.4 Shetland 14.4 8.5 7.1 12.8 12.9 18.7 16.5 12.5 3.2 The breast cancer screening programme The Scottish Breast Screening Programme invites all women between 50 and 70 years old for breast screening every three years. All women should receive their first invitation by the age of 53. Women aged over 70 are not sent an invitation but are still welcome to attend for screening. The programme in Shetland is delivered in conjunction with NHS Grampian and a mobile breast screening unit comes up to Shetland every three years. The screening consists of having a mammography (like an x-ray) of the breasts. 3.2.1 Uptake figures Shetland women consistently have among the highest uptake rate for breast screening in Scotland. This is due to a combination of good processes and procedures for calling women for screening, awareness raising in the isles and a sensible attitude adopted by Shetland women towards screening. The graph below shows recent uptake rates for all Boards. Please note that uptake is now measured for women aged 50 to 70 years old, whereas previously it was only 50 to 64 year olds. 7
3.2.2 Trends over time As can be seen from the graph above, the Shetland and Orkney uptake rates have been consistently the highest in Scotland over the past six years. Island Boards perform extremely well, and are consistently among the best performing areas and well ahead of the national average. Encouragingly, the national rate has been showing a steady increase over recent years and is now at 75%. Historical data shows that this has increased steadily from around 70% over the last 20 years. 3.3 Developments 3.3.1 Review of the breast screening programme The breast screening programme has been running for 22 years and although there have been significant developments and changes to the programme in that time, there has not yet been a review of the whole programme. The National Services Division of NHS Scotland therefore commenced a major review of the programme in 2011 which is due to run until June 2012. This has included consultation with all key stakeholders, including the public. The review is considering what is the most cost and clinically effective structure and delivery for the service, consistent with the needs of the population and of the NHS Scotland Quality Strategy. It is also looking at whether or not the Scottish Breast Screening Programme should continue to be designated and co-ordinated as a national service; and if not how it should be funded, planned and managed. As the Breast Screening Programme remains central to Scottish Government policy, this review does not include the rationale behind screening, the methods used, the eligible age range, or any resulting treatments. Further information can be found at: www.nsd.scot.nhs.uk/services/screening/breastscreening/breastreview.html 3.4 Further information Further information on the Scottish Breast Cancer Screening Programme can be found at: www.nsd.scot.nhs.uk/services/screening/breastscreening/breastfaqs.html 8
4.1 Epidemiology of bowel cancer Bowel cancer (or colorectal cancer) is a major public health problem in Scotland, which has a higher rate of bowel cancer than most other countries in the Western world. In Scotland it is the third most commonly diagnosed cancer in both men and women with approximately 3,400 new cases diagnosed each year. It is the second most common cause of cancer death for men and the third for women with around 1,600 people dying of the disease in Scotland each year, although the death rate is falling. 95% of cases occur in people aged over 50 years. Bowel cancer screening can identify pre-cancerous signs in men and women who otherwise have no symptoms and treatment of these abnormalities at this stage is usually very effective. In Shetland the figures for numbers of new cases diagnosed and deaths due to colorectal cancer are as follows: Incidence 15 22 16 14 11 19 15 18 Mortality 6 12 5 5 6 6 8 7 Looking at the figures as a rate shows that over time Shetland s incidence (the number of new cases per year) and mortality (deaths) do not differ significantly from the Scottish average. EASR 3 Trend in Incidence (new cases) Scotland 52.2 52.1 50.7 50.8 52.8 55.2 55.2 54.5 Shetland 55.7 72.6 55.9 52.5 40.5 54.8 52.4 50.3 EASR Trend in Mortality (deaths) Scotland 22.8 21.9 21.9 21.4 20.7 21.1 20.4 19.1 Shetland 18.5 43.2 18.9 17.2 22.0 19.2 24.8 21.4 3 EASR: age-standardised mortality rate per 100,000 person-years at risk (European standard population) 9
4.2 The National Colorectal (Bowel) Cancer Screening Programme This programme was introduced in Scotland in 2007 and rolled out by NHS Board, with NHS Shetland starting in October 2009. Men and women aged 50-74 are invited every two years to take part in the screening using a test kit that is posted out, completed at home and returned to the National Screening Centre in Dundee. The test (called the FOB test) looks for evidence of blood in the faeces, which can be a sign of bowel cancer. If blood is found then the patient is invited to attend for a further investigation, a colonoscopy, at the Gilbert Bain Hospital. 4.2.1 Uptake figures for home testing kit The uptake figures for the bowel screening programme for 2009-11 are shown in the graph below. These figures are for people invited between November 2009 and October 2011 and so include all the Shetland patients invited during the first two year round of invitations, nearly 7,500 people. The figures do show that Shetland has one of the highest uptake rates, but as noted they need to be interpreted with caution. Notes: 1. Due to small numbers of positive test results recorded for NHS Orkney, NHS Western Isles and NHS Shetland any comparison of figures with these NHS Boards should be treated with caution. 2. NHS Fife unable to produce data. The uptake rates for bowel cancer screening are lower than that those for cervical and breast cancer screening. This is likely to be because this is a 10
new programme and it will take a while for people get used to the idea of screening for this particular cancer, and especially using home testing kits. Also, this programme includes both men and women and whereas women have been used to attending for breast and cervical cancer screening, men have not been invited for cancer screening before on a population level. 4.2.2 Uptake figures for colonoscopy All people who have a positive result on the home testing kit should be invited to attend for a pre-assessment with a view to having a colonoscopy. Most people with a positive FOB test will be advised to have a colonoscopy, but some will not be able to for medical reasons or may decide to decline. The percentage of people with a positive FOB going on to have a colonoscopy in Shetland is slightly higher than the average for Scotland, but again these are small numbers. Notes: 1. Due to small numbers of positive test results recorded for NHS Orkney, NHS Western Isles and NHS Shetland any comparison of figures with these NHS Boards should be treated with caution. 2. NHS Fife unable to produce data. 4.2.3 Cancer detection rate The crude cancer detection rate varied across NHS Boards from 0.15% to 0.31% in men and 0.05% to 0.19% in women (excluding NHS Orkney and NHS Shetland). NHS Orkney had very low rates, and NHS Shetland higher rates, although due to small numbers of positive test results recorded for 11
the Island Boards, any comparison of figures with these NHS Boards should be treated with caution. Screening detected around twice as many cancers in men. The crude cancer detection rates for Shetland and Scotland are shown below: Males Females All NHS Shetland 0.33 0.29 0.31 Scotland 0.20 0.09 0.14 4.2.4 Overall adenoma detection rate This is the percentage of people with adenomas detected out of those who completed a screening test. Adenomas can be a precursor to cancer and can be classed as high, medium or low risk depending on size and number. Screening detected more than twice as many adenomas in men as in women. The overall adenoma detection rate varied across NHS Boards from 0.42% to 1.46% in men and 0.12% to 0.62% in women. The adenoma detection rates for Shetland and Scotland are shown below: Males Females All NHS Shetland 1.44 0.49 0.94 Scotland 0.94 0.34 0.61 4.2.5 Positive predictive value (PPV) of current bowel screening test to bowel cancer This is the percentage of screen detected colorectal cancers found in people who had a positive test and went on for further investigation (normally a colonoscopy). Across Scotland, 7.9% of men and 5.7% of women who had a positive screening test result (and who went on for further investigations) had either polyp cancer or invasive colorectal cancer. In Shetland the PPV was 11.9 for men and 18.4 for women, however again due to the small numbers involved it is difficult to interpret these figures. 4.2.6 Complications arising from colonoscopy Colonoscopy is an invasive procedure and there is the risk of complications, which sometime require hospital admission to manage. The overall rate of complications (requiring admission) across Scotland was 0.6%. In Shetland the rate was 4.1%. However, because the number of colonoscopies performed in Shetland is small, then a very small number of complications makes a big difference to the complication rate. The rate of complications will continue to be monitored closely. 12
4.3 Further information Further information on the Scottish Bowel Cancer Screening Programme can be found at: www.bowelscreening.scot.nhs.uk. This programme is to be introduced in Scotland from 2012. AAA is a cardiovascular condition that can lead to death if the aneurysm gets very big and ruptures. It is more common in older men. Often there are no signs and symptoms of an AAA, but it can be picked up on an ultrasound scan. The screening programme will aim to identify men who have an AAA by inviting them to have an ultrasound scan at the age of 65. If the scan shows evidence of a small AAA then the man may be followed up to see if it grows any bigger. If the scan identifies a large AAA then elective surgery may be offered to prevent it rupturing. NHS Shetland will be delivering this programme in conjunction with NHS Grampian and NHS Orkney. The Grampian, Orkney and Shetland collaborative will commence the programme in late October 2012. The ultrasound scans will be carried out in a number of locations across the collaborative with the main administrative Screening Centre being in Aberdeen. In Shetland, the scans will be done by our own ultrasonographers at clinics in the Lerwick Health Centre. 5.1 Further Information Further information on the AAA Screening programme can be found at: www.scotland.gov.uk/topics/health/health/screening/aaascreening Dr Susan Laidlaw Screening Co-ordinator NHS Shetland October 2012 13