Cervical Screening Programme, England - 2020-21 [NS]

Call
Invitation for previously unscreened individuals

Recall
Invitation for subsequent screens

Screening coverage is the percentage of individuals in a population eligible for screening at a given point in time who were screened adequately¹ within a specified period.

Coverage is reported for the 25 to 49 years and 50 to 64 years age groups and is referred to as age appropriate coverage.

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

Age-appropriate coverage definition

25 to 49 = % of those eligible and registered as female aged 25 to 49 screened within the last 3.5 years on 31 March

50 to 64 = % of those eligible and registered as female aged 50 to 64 screened within the last 5.5 years on 31 March

Coverage (all ages) definition

25 to 64 = % of those eligible and registered as female aged 25 to 64 screened within the last 3.5 or 5.5 years (depending on age) on 31 March

Coverage is measured at 3.5 and 5.5 years as this allows a 6 month period for invitations to be taken up.

At 31 March 2021:

• Coverage for those registered as female aged 25 to 64 was 70.2%, a decrease of 2.0 percentage points from the previous year.
• Coverage in the lower age cohort (25 to 49) decreased to 68.0%, from 70.2% in 2020.
• Coverage in the upper age cohort (50 to 64) decreased to 74.7% from 76.1% in 2020.

At 31 March 2021, for those registered as female aged 25 to 64:

• Coverage ranged from 62.2% in London to 74.0% in the North East.
• All screening regions reported a decrease in coverage when compared with 2020.

At 31 March 2021, for those registered as female aged 25 to 64:

• No Local Authority achieved the acceptable performance level of 80%.
• 91 of 149 LAs had coverage levels of 70% and above, a decrease of 12 compared to 2020.
• Coverage ranged from 45.8% in Kensington and Chelsea (London) to 78.4% in Derbyshire (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.

KC53 coverage - historic definition

25 to 49 = % of those eligible aged 25 to 49 screened within the last 3.5 years on 31 March

50 to 64 = % of those eligible aged 50 to 64 screened within the last 5 years on 31 March

The key difference from the current coverage definition is the time since last screening for the older age cohort (50 to 64); 5 years rather than 5.5 years.  This means that the coverage rate reported for the oldest age cohort will be lower than it is in practice as an individual invited within 6 months of their 65^th birthday will not necessarily have time to attend for screening before the cut off point for the data collection.

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 2021, individuals aged 50 to 54 had the highest reported coverage at 77.6%.

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).

Links to the annual cervical screening statistics reports for Scotland, Wales and Northern Ireland are provided below.

Source for Scotland:

Source for Wales:

Source for Northern Ireland

Individuals 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 those who are registered as female and aged 25 to 64, with individuals receiving their first invitation from age 24 years and 6 months.

In 2020-21:

• 4.59 million individuals aged 25 to 64 were invited for screening, most of whom were aged 25 to 49 (3.50 million).
• The number of individuals aged 25 to 64 years invited for screening decreased compared with the previous year (4.63 million in 2019-20)

The peak in 2011-12 (see chart below) may be associated with the diagnosis and death of the high profile media personality Jade Goody³ 3 years earlier. There was an increase at that time of younger people attending for screening who would then be invited again in 3 years.

Those in the programme may receive an invitation to screen in 1 of 5 scenarios:

The table below shows a breakdown of invitation type for 2019-20 and 2020-21, for those aged 25 to 64 in England.

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

Individuals who attend a cervical screening appointment will have their sample taken and it will then be sent to a screening laboratory for assessment. They 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 2020-21, 3.03 million individuals aged 25 to 64 were tested, a decrease of 0.17 million from the previous year.

The peak in 2011-12 (see chart below), has been associated with the diagnosis and death of the high profile media personality Jade Goody³ 3 years earlier. There was an increase at that time of younger people attending for screening who would then be invited again in 3 years.

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 numbers 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

In 2020-21, 85.9% of individuals aged 25 to 64 were tested following an invitation from the screening programme.

Of all final results:

• 4.7% showed an abnormality (non-negative)
• 1.1% showed a high-grade abnormality

Where an individual 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 2020-21 (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; 1.7% for individuals aged 25 to 29 and 2.1% for those aged 30 to 34, falling to 0.4% for those aged 60 to 64.

128 of 149 LAs had between 3% and 6% of tests with an abnormal result. The maximum percentage of tests with an abnormal result was 7.7% (see data table 12).

The national standard is at least 98% within 2 weeks².

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.

The change to HPV primary screening and consolidation of services did impact on turnaround times for the cervical screening programme.

In 2020-21, turnaround time improved, with 67.1% of letters received within 2 weeks, an increase of 23.1 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 chart below presents the number of result letters sent per month for 2019-20 and 2020-21 financial years, which fluctuated during 2020-21. This data represents the number of result letters sent in the month, however it does not reflect the number of tests taken in the month. Therefore, this is not an exact picture of changes in the number of individuals tested each month. However it does give a reasonable indication about which parts of the year were most affected by COVID-19.  It also shows the recovery during the second half of the year where more result letters were sent than the year before.

Regional performance, 2019-20 and 2020-21, ages 25 to 64 years

In 2020-21:

• No region met the standard of at least 98% of letters received within 14 days.
• The North West reported the highest percentage of letters received within 2 weeks at 90.7%.
• The East Midlands reported the lowest percentage of letters received within 2 weeks at 22.9%.
• Every region  increased performance compared to the previous year.

There was significant regional and local variation in turnaround times across England in 2020-21.

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

Following screening/testing, there are 3 types of recall status within the programme; normal (action code A), repeat (action code R) and suspend (action code S).

Normal (return to routine recall)

Pathway: HPV primary screening
A normal recall status will be given when the hrHPV test is negative

Repeat (requires a further test which is earlier than routine recall)

Pathway: HPV primary screening
Repeat recall required where the test result is:

• hrHPV unavailable
• hrHPV positive with inadequate cytology

An early recall of 12 months will be given if the result is hrHPV positive with negative cytology

Suspend (recall suspended due to referral to colposcopy)

Pathway: HPV primary screening
Only allowable status following a test result that is positive for hrHPV with abnormal cytology.

Also required:

• after testing positive for hrHPV and negative for cytology 3 times in a row
• after testing positive for hrHPV with inadequate cytology test results
• after a series of hrHPV unavailable results or cytology inadequate results

It can also be used when an individual remains under hospital care, regardless of test result in either screening pathway.

Of those with only a negative result:

• 87.8% were given a normal recall status.
• 11.2% were given a repeat recall status as they were under surveillance or follow up. 
• 1.0% were given a suspend recall status as they were under hospital care⁷.

90.8% of those with an inadequate screening result were given a repeat recall status.

- = recall status not applicable for this result

* Negative includes HPV Negative as well as Cytology negative.  Borderline changes or worse are all HPV positive.
**?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

HPV primary testing was fully rolled out in December 2019. In the HPV primary testing pathway those with a non-negative cytology result (following a high risk HPV result) are referred to colposcopy and given a suspend recall status.

Prior to the introduction of HPV primary, under the HPV triage protocol, only a proportion of those with borderline or low grade cytology would receive a suspend code as any patients who tested negative for high risk HPV would be returned to routine recall. This can be seen in graphs below in the years 2012-13 to 2018-19.

As HPV primary was rolled out to more laboratories in 2019-20, more patients with borderline cytology (67.6%) received suspend codes. As all laboratories had converted by the year 2020-21 then practically all borderline results (98.9%) received a suspend code.

In 2020-21, a few women (0.1%) still received repeat recall status, a decrease from the previous year (3.6% in 2019-20).

As for borderline cases, as HPV primary was rolled out to more laboratories in 2019-20, more patients with low grade cytology (89.4%) received suspend codes. As all laboratories had converted by the year 2020-21 then practically all low grade results (99.6%) receive a suspend code.

In 2020-21, a very few women still received repeat recall status, a decrease from the previous year (0.8% in 2019-20). A few (0.4) also received normal status.

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. https://www.gov.uk/government/publications/cervical-screening-programme-standards/cervical-screening-programme-standards-valid-for-data-collected-from-1-april-2018
3. An unexpected increase in those 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 those aged under 50” (Lancucki et al, 2012, p4) https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3385661/ 
4. Some individuals 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. https://phescreening.blog.gov.uk/2017/12/18/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.