Cancer screening: two decades on target but still more to do

Since 1948 the "cradle-to-grave" service offered by the world's first free, universal health service has changed enormously - not just because advances in medicine have revolutionised the way we treat patients, but because we now devote a lot more time and resources to the early detection and prevention of disease.

Along with the NHS's 60th anniversary, this year also marks two decades since the NHS breast and cervical screening programmes were first introduced in England. They were key milestones in the fight against cancer. Thousands of women are alive today because routine screening has identified cancers and abnormalities which have then been treated quickly and successfully.

The anniversary is an important opportunity to pay tribute to all those involved in making such a huge difference to women's lives. It also allows us to highlight the value of screening, particularly among groups of women often less likely to accept their screening invitations, such as those from minority ethnic communities, more deprived areas, or particular age groups, so we can build on today's successes for the sake of tomorrow's lives.

The value of screening

The breast screening programme was born in the late 1980s when the government convened an expert committee chaired by surgeon Sir Patrick Forrest to report on the value of screening for breast cancer in asymptomatic women. The committee's final report concluded that screening by mammography could prolong the lives of women over 50. It found: "There is a convincing case on clinical grounds for a change in UK policy on the provision of mammographic facilities and the screening of symptom-less women."

This was the tipping point. The NHS breast screening programme was announced in March 1987 - the first of its kind in the world - and each region in England began inviting women for screening by March 1988.

The process of cervical screening was slightly different and actually began in Britain in the mid-1960s. However, it was then a largely ad hoc service which did not guarantee access for all women. The establishment of the NHS cervical screening programme in 1988 saw the introduction of a formalised, routine national programme with computerised call and recall systems for invitations.

Since then the programmes have been revolutionised. In breast screening, technological advances have brought about significantly better services for women. The non-operative diagnosis rate has improved year on year, with increasing use of core biopsy in the clinic reducing the need for open surgery.

Ever improving

The 2000 NHS cancer plan promised the extension of routine breast screening for women aged 65-70. This was rolled out everywhere by 2004. In addition all women now have two "views" of the breast taken at every screening, increasing the detection rates of smaller cancers by up to 43 per cent. Cancers detected at a less advanced stage mean more options for women and most screen-detected cancers are treated by local excision, conserving the breast.

We have changed the frequency and age range of cervical screening too, ensuring the programme is targeting those women most at risk and the old-fashioned cervical smear test has been replaced with the more accurate liquid-based cytology sample collection. Now available to every woman, this is already making a huge impact. Reporting time is much improved and tens of thousands of women are being spared the inconvenience and anxiety of repeat cervical screening due to inadequate samples.

These programmes are today internationally recognised as world class, underpinned by local quality assurance teams that regularly review guidelines, monitor standards and ensure that as technology develops better screening practices are introduced.

Screening has gained increased political and public attention. Both last year's cancer reform strategy and more recently the next stage review underlined government commitment to its future.

Cancer strategy

The cancer reform strategy foreshadowed a major reconfiguration of cancer screening as fundamental changes to existing programmes. Breast screening expansion, with a guarantee women will have their first screening by the age of 50, means over 200,000 more women will be screened annually. The programme is also hoping to invest in improved technology for detecting cancers in the breast tissue of pre-menopausal women.

By 2010 women will receive the result of their cervical screening test within two weeks. Young women are busy, sophisticated consumers who expect imaginative and personalised public services. The 14-day target will enable us to offer a more responsive and efficient service, helping to reduce the anxiety women face as they wait for their result.

In September the government will introduce a national human papillomavirus vaccination programme for young girls. Communicating messages about the virus and its relationship to cervical cancer ("high risk" types have been found to be present in close to 100 per cent of all cervical cancers) is a new and exciting challenge. It will be many years before the vaccination programme has an effect on cervical cancer incidence and older women should continue to consider invitations to participate in cervical screening seriously.

Despite the overall success of screening, however, the last couple of years have shown a small but worrying decline in the number of women accepting their invitations for cervical screening, particularly among the under-35s. Cancer of the cervix is the second most common cancer among women worldwide but in this country it is 12th. This is a remarkable tribute to the effectiveness of the programme but we must ensure we do not become victims of our own success, with young women underestimating the importance of such a vital check.

With breast screening, the opposite is true. Breast cancer risk increases with age and with an ageing population it is especially important we ensure older women understand this and continue to participate into their 70s and beyond, when they will no longer receive routine invitations but are still entitled to screening.

Access must improve

We also need to focus on the inclusion of marginalised women. These women live in deprived areas or do not have English as their first language. They may have learning or physical disabilities and may need specialist help to participate. All eligible women should have access on the same basis yet we know women with learning disabilities have a lower uptake of breast and cervical screening.

Carefully considering how we engage these women to raise awareness and encourage them to make informed choices about screening is crucial. Evidence suggests a combination of improved access and supporting individuals directly is most likely to be effective. Other studies suggest community health educators, trained GP receptionists, translated literature and photo-essays can boost uptake.

We have made a number of recent improvements, producing training packs for health professionals on how to deal with minority groups and working with people with learning disabilities to produce guidance on how they would like to be supported to take part in screening. Leaflets on breast and cervical screening are available in 19 languages, with audio versions of the leaflets in the top six most requested languages. These are not designed to promote screening but to give people the facts so they can make their own informed decision whether to attend.

Understandingethnicity

But although these initiatives have proved useful, if we are going to achieve real change, we must increase our understanding and our data on ethnicity in the NHS. This information is essential to tailor appropriate and effective education programmes to specific communities and is just the start of a long-term process.

Throughout the life of the programmes the value of cancer screening has been debated and undoubtedly will continue to be. We have weighed up the advantages and disadvantages at every stage and while there are risks involved in all screening programmes the evidence shows that at the most basic level screening saves lives: an estimated 1,400 every year through breast screening and 4,500 every year through cervical screening.

Since 1988 more than 100,000 breast cancers and 400,000 significant cervical abnormalities have been detected and more than 70 million women in England have received screening. Figures released in June 2008 showed women diagnosed through the NHS breast screening programme with early stage breast cancer who get treatment have the same life expectancy as the UK female population as a whole. It is a seismic shift in the fight against cancer.

I am proud of what we have achieved and view the challenges we face as genuine opportunities to improve the service. We have been able to draw on the experiences from both programmes to launch the NHS bowel cancer screening programme in July 2006, further reducing the cancer death toll in men as well as women. And research is already under way into whether national screening programmes for prostate, lung and ovarian cancers are worthwhile. I am confident the programmes will continue to play a central role in the prevention and early detection of cancer in England and look forward to the progress we will make over the next 20 years.