A lot has happened in cervical screening in Ireland in the last few years. The Covid-19 pandemic arrived just as our national cervical screening programme, CervicalCheck, was about to change to the HPV screening test - the biggest change since the programme began in 2008. And we had to implement and manage this change during the most uncertain period of the global COVID-19 pandemic: spring and summer of 2020.
Against this backdrop of change and uncertainty, a sustained public focus on cervical screening since 2018 meant we were also working hard to continue to improve the service and to regain people’s trust in screening. Implementing the new HPV screening test was an important part of this work.
The Cervical Screening Landscape
Ireland’s national cervical screening programme, CervicalCheck, was established in 2008 and is part of the HSE. Over 1.2 million women and people with a cervix are eligible for the programme and we call approximately 270,000 women per year. We have a very high uptake of cervical screening in Ireland – nearly 80% of all people who are eligible attend.
Unlike many cervical screening programmes, we provide the full pathway from looking after the register, calling and recalling people for screening, through to providing examination, diagnosis and treatment in hospital colposcopy clinics. We have the advantage of being able to take our participants through the whole screening journey from start to finish.
The programme has detected approximately 1,500 cancers since it started, treated over 60,000 women with high-grade cell changes and has reduced the incidence of cervical cancer by approximately 7% a year.
However, in 2018, the public became aware that approximately 221 women who had been included in an audit of interval cancers had not been told the results of that audit.
This led to changes in the programme, and an increased urgency to implement HPV screening, which is a better programme because it picks up more people with abnormal cells on their cervix than the old programme did.
In early 2020 screening was in the final stages of extensive planning to bring in HPV screening, which was due to begin on 30th March.
At the same time, a novel coronavirus was being reported in China. It had a high fatality rate. This led to an urgent response globally. Ireland had its first case in early March and moved to a containment phase later that month.
The impact on the HSE was significant as it moved to create more capacity quickly, and to protect staff and patients from COVID-19. Non-essential healthcare was halted. Staff were redeployed across the system and retrained in new areas of work. On public health advice, the government moved to protect the public by enforcing social distancing, shutting non-essential shops, and places where social activities took place. On 29th March the country was put into a full lockdown.
An Ethical Question
In this fast-moving emergency situation, the question for us in the National Screening Service was: should screening continue?
Cervical screening is not just a test at your GP. It is a pathway that takes in many other areas of healthcare, from GPs to hospital departments and science laboratories. Population screening is a non-urgent, preventative service. All decisions in screening programmes balance the benefits, harms and costs of screening to the population, and the benefits have to outweigh the harms. In the pandemic, we had to factor in the large risk of harm for an unvaccinated population contracting COVID-19 when attending the health services for screening.
To make the decision on whether to continue screening or not, we weighed up the possible harms to our healthy participants (who don’t have any signs or symptoms of the disease being screened for) of delaying their next screen by a number of months. This was considered against the immediate risk of those participants (and our staff) possibly contracting COVID-19 by continuing to run the programme. Also, because the health service was under such pressure we had a duty to support the national priority to keep essential services going. Most healthcare staff were now working in some ways on fighting COVID-19 and protecting essential services for people with symptoms of illness. Our staff were included in this effort. This made it vital to ensure we got the biggest return on any resources – such as GP or practice nurse appointments or radiology expertise – that we did use.
A RISK-BASED APPROACH
We analysed the risks and decided:
- On a balance of benefits and harms, the evidence was in favour of pausing the screening programme for a short period.
- To go ahead with implementing the switch to HPV primary screening from 30th March 2020.
This would enable us to complete the post-implementation testing for our laboratory and IT systems using the colposcopy samples we were continuing to receive. This would mean we could restart more quickly after the pause. - To provide ongoing care for people already on their screening journey based on their clinical need. This meant colposcopy clinics continued to see and treat people who needed to be seen. with high-grade screening results.
We paused screening on 30th March, the same day that we changed over to HPV screening. We kept working during the pause to keep all of our non-clinical systems, including our IT system and our process to send our results, working. We developed a new set of metrics (figures) to let us know how the programme was performing. We consulted regularly with the health services senior managers, public health colleagues and our international colleagues to determine an appropriate time when it would be safe to restart screening.
We had ongoing communications with GPs and the public, including engaging with government and the press. We provided monthly and sometimes weekly stakeholder updates, updated our websites and social media with new information in real time, and delivered webinars on the new HPV programme.
Ahead of restarting we invited a pilot group of people for screening, to assess whether people were willing to come for cervical screening during the pandemic.
On the basis of all this, we set a screening restart date of 06 July 2020, three months after we had paused.
Shutting down screening had been a difficult task that we had to do quickly, and restarting screening was also complex. We planned how we would release our letters inviting participants to attend – who would get letters, and when. Our strategy was to invite those women who were at higher risk first: we judged these to be those who had never had a screening test, such as new entrants to the programme, and those who were on a three-month or one-year monitoring recall for screening.
We were also grappling with the new metrics for the HPV programme and all the changes we needed to make to our IT system to get these new figures out of it. COVID-19 continued to affect how much capacity we had to deliver our screening pathway; there was a need to continue social distancing in any setting; GPs were mainly doing telephone appointments to keep them and their staff safe, and staff shortages due to COVID-19 were impacting all points in the screening pathway.
Our public communication was also affected there were many important health messages being communicated to the public at this time. On top of all that, on an international basis, some of the lab equipment needed to process our HPV tests had been diverted to COVID-19 testing. For a time this halved the number of tests we could do each week.
We began a managed return to screening on 06 July 2020, three months after we had paused. By the end of 2020 we were pleased to announce that all those who were due a screening test that year had been invited. We ran a communications campaign to let everyone know that screening was open for business, urging them to come when invited, and letting them know that when they did come, they would be receiving a new and better test.
We were disappointed but understanding when people were initially slow to book their tests. We understood the reluctance of well people to enter a healthcare environment during the height of the pandemic. We knew also that it was difficult to absorb another health message along with all the messages regarding COVID-19. Slowly, we saw confidence returning, GPs were providing space and time for screening, and by the end of 2020 we were screening a much larger number of women than in the summer.
By the end of 2021 we had completed a successful large-scale communications campaign around HPV cervical screening. And thanks to the huge commitment of our screening staff, healthcare professionals and service providers who work in the screening pathway – and from the women themselves who came for screening when invited - we had screened the same number of people in the two-year period of the pandemic as in any other two-year period.
Two years on from our decision to pause screening, we are happy to say cervical screening continues to be on track, inviting women when they are due.
We know that screening doesn’t pick up every abnormality, so we continue to emphasise that it is important to come for every screening regularly, every time you are invited. And once screened, you have the security of being personally back on your own screening journey.
What we Learned
- Communicate, communicate, communicate. We did a lot of communication but when we engaged with patients during and after the restart they told us we could have done even more.
- Relationships are key. We had good relationships within the screening programme and with all our partners in the screening pathway which made it easier to know what was possible and to make decisions accordingly.
- Monitoring is essential to know where you are and where the risks are
- A strong team always serves you well in an emergency
- Basing decisions on risk helps you make the best decisions you can when there are many competing demands. It also helps explain decisions later.
- Now we are back in ‘normal’ business we are aware of the need to attend to the inequities that will have occurred due to the emergency situation.
By Dr Caroline Mason Mohan, with thanks to Dr Noirin Russell, clinical director, CervicalCheck, Grainne Gleeson, programme manager, CervicalCheck, the CervicalCheck clinical advisory group, CervicalCheck programme team and The National Screening Service