Screening the cancer screeners

Women are about to find out what is being done to ensure there is no repeat of the Gisborne cervical cancer scandal. ARNOLD PICKMERE reports.

Six months after the Gisborne cervical cancer report, Health Minister Annette King will face the women of the city tomorrow night with an update.

Her audience is likely to ask tough questions.

One of the many remarkable aspects of the cervical cancer screening saga is that it has taken until now for the scale of the system's failings to become apparent.

The slides which led to the inquiry were read by Dr Michael Bottrill between 1990 and his retirement in 1996.

This week it became known that Dr Bottrill picked up only 32 per cent of seriously abnormal smears, compared with 96 per cent discovered by the Sydney laboratory that retested his slides.

The Sydney lab reread 22,976 smears from 12,099 women. It found that about 10 per cent (2244) that Dr Bottrill had read as normal were abnormal.

Tomorrow night in Gisborne, Mrs King will speak at a public meeting where she will give a summary of six months of progress in acting on the 46 recommendations from the ministerial inquiry.

The report to October shows eight of these recommendations are complete. They include such things as minimum standards for cytology laboratories analysing smear tests and guidelines to ethics committees regarding privacy issues.

The Government has also promised legislation allowing researchers access to women's medical records, which experts told the inquiry was essential to check whether similar under-reporting had occurred elsewhere.

But the report shows most of the other recommendations are still "under way". There are "reporting milestones" such as "cabinet paper submitted" or "no reporting milestones this period".

Why is cervical screening seen as so important?

Unlike most cancers, the most common type of cervical cancer - squamous cell carcinoma - is largely preventable. Cells in a woman's cervix go through changes which, if not detected and treated, may develop into cervical cancer in some women.

Cervical cancer takes between 10 and 15 years on average to develop. A cervical smear test can detect changes in the cells of the cervix.

Who should be screened?

The Ministry of Health's National Screening Unit suggests it should include all women between 20 and 69 who have ever been sexually active. For women with normal smear results that means an interval between screenings of three years. The women most likely to develop cervical cancer are those not regularly screened.

The three-year interval is said to be important because there is a "small chance" that some abnormalities may not be detected at a single screening.

The success rate for the treatment of abnormal cervical cells (also called pre-cancerous changes) is said to be 98 per cent.

Do many women get cervical cancer?

It is estimated that one in 97 women in New Zealand can expect to develop cancer of the cervix before the age of 75. Independent experts have estimated that without an organised screening programme, there would be about 340 new cases and 116 deaths a year.

Since the screening programme began, the rates of the disease and deaths from cervical cancer have fallen significantly. From 1987 to 1996, the incidence of cervical cancer dropped by 22 per cent and the death rate by 43 per cent.

At the beginning of December last year, 978,586 New Zealand women aged 20 to 69 were enrolled on the national screening programme. That represented 90.17 per cent of eligible women.

Who provides the smear service and how does it work?

Doctors, gynaecologists, nurses, lay smear-takers, family planning centres, midwives and laboratories. Cervical smears are sent to laboratories for analysis. The laboratory reports the result back to the person who took the smear and also sends it to the National Cervical Screening Register. It is a stand-alone system that records and provides information to assist individual women and their medical advisers with appropriate follow-up if needed.

The system also provides data for monitoring and evaluation. This means that unless a woman opts to leave the register it will contain her complete smear history, which is available to her, her medical adviser and cytology laboratories.

Have New Zealand women been getting a reliable service?

We don't know because privacy rules make it impossible for researchers to check whether Dr Bottrill's failures have been repeated elsewhere. The ministerial inquiry report, by Ailsa Duffy, QC, found fault with Dr Bottrill.

But it also placed the responsibility for the mass under-reporting of smears with the Health Ministry, which had not properly designed and developed a safe and effective programme for a decade.

"Ultimately, it was the flaws in the National Cervical Screening Programme that permitted Dr Bottrill to practise as he did," the report said.

The final version of the interim Health Funding Authority report, issued on Monday, concludes that a screening programme needs high levels of enrolment and coverage, high-quality screening and follow-up services. It adds: "It must also be properly organised and co-ordinated."

Issuing the report, Director-General of Health Dr Karen Poutasi said 18 per cent of the 22,976 smears carried out by Dr Bottrill were found to be abnormal on rereading. Nine of the 304 women involved in the rereading have since died of cancer.

"Whilst a good quality screening programme cannot prevent cervical cancer, it's vitally important that we do better," the report says.

What checks are being made now to see women get accurate results?

The cervical cancer inquiry pointed out concerns that Dr Bottrill worked alone, had no checks to ensure work was competent, his laboratory was not accredited and he had no refresher training.

As a result of this case, changes started even before the findings of the inquiry were known. In October last year, for example, operational policy and quality standards were introduced after 18 months of consultation. They included 21 laboratory standards covering areas such as staffing, training of staff and minimum volumes of work for laboratories, pathologists and cytotechnologists.

From July 1, laboratories have been required to process a minimum of 15,000 cytology smears a year. This is seen as an important factor in ensuring quality care of women in the screening programme.

Such minimum standards are among the inquiry's recommendations listed as complete.

How did the ministry fail women?

Herald health (now political) reporter Fran Mold covered most of the five-month Gisborne inquiry.

After the report was issued in April, this is how she described the Ministry of Health's performance over the cervical screening programme.

"It consistently ignored advice from cancer experts who were driven by a desire to make the programme safe for women.

"The ministry developed policies which it lacked the power to enforce.

"It paid taxpayers' dollars to laboratories which could not prove they had quality checks in place or even that they were skilled at reading cervical smears.

"It made little attempt to do its own evaluation of the programme's success.

"Its measure of success was the number of women having smears - not whether screening was reducing cancer deaths."