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Ministry Welcomes Cervical Cancer Audit

Ministry Welcomes Cervical Cancer Audit

The Ministry of Health welcomes the release of the cervical cancer audit report.

Deputy Director-General Public Health Dr Don Matheson says the completion of the three-year, $3 million audit, one of the most comprehensive audits of its kind, provides a further level of reassurance about New Zealand’s national cervical screening programme.

He says the most important finding is the audit reinforces that the key way for women to protect themselves against cervical cancer is for women to be regularly screened every 3 years. The audit makes recommendations about how the National Cervical Screening Programme (NCSP) can better support this.

No programme provides a 100 per cent guarantee of protection against cancer, but the audit concludes that overall, women and health professionals can have confidence in the services that are provided and should be encouraged to participate in the screening programme.

A key finding of the audit was that it did not identify evidence of systemic failings in New Zealand cytology laboratories which now provides an answer to a major recommendation of the 2001 Gisborne Cervical Screening Inquiry.

However, Dr Matheson says the audit provides no room for complacency, as the report found inadequate screening coverage and evidence of ethnic disparities in screening and follow-up.

"As the audit report says, these key findings are not new, nor are they unique to New Zealand but they do underscore the importance of ongoing efforts to increase coverage, improve the accuracy of routine data, and decrease inequalities in health for Maori women and other disadvantaged groups."

Dr Matheson says the real value of the audit is in helping to further improve the delivery of quality cervical screening services to New Zealand women. It will also serve as a baseline for future audits in New Zealand and elsewhere.

He says the overall conclusions of the audit are generally encouraging. They include:

The auditors consider that from a national perspective the NCSP operates to a generally high standard for women who are having smears.

In particular, the Audit has not found evidence of systemic issues in laboratory reading and reporting of cervical smears.

Overall, women and health professionals can have confidence in the services that are provided and should be encouraged to participate in the NCSP.

The audit reinforces the view that greater benefits from screening can be obtained with greater participation, by women, in the programme.

Five out of every ten women with invasive cervical cancer had not been screened within three years prior to diagnosis and eight out of every ten had not had regular smears.

Maori women, women with backgrounds of high deprivation, low incomes and low education are less likely to be regularly screened.

Better record keeping by all those involved in the screening pathway means more accurate monitoring to allow issues to be identified and addressed.

Dr Matheson says the audit reinforces the view that a strong partnership is required to make any screening programme work – a partnership between the National Screening Unit, health professionals and the women of New Zealand.

"The audit tells us that partnership is working and mostly working well, but like any relationship, it could be improved and it gives us a 31 step plan for doing that."

He says in particular its clear that the partnership is working less well for Maori. Two telling statistics, repeated in the audit, are that twice as many Maori are diagnosed with cervical cancer and four times as many die of it.

The Ministry will be formally responding to the recommendations of the report within the next few weeks providing advice about what actions will be taken, or have been already begun, to address the issues raised in the report.

Dr Matheson says the Ministry will be taking that time to carefully study the report. He says on first read the audit seems to be saying that we can now can have a greater level of confidence in the programme and that we should be putting more of our effort into ensuring as high a proportion of women as possible is regularly screened.

Dr Matheson says the significant changes in primary care, particularly with the increased coverage of primary health organisations, will increasingly assist in providing better tools to the NCSP and health professionals to boost coverage of the programme.

"The Ministry owes a debt of gratitude to the women in the audit, all of whom have cancer and none of whom personally benefited from participating in the audit. As the report foreword says, the quality of this report is a tribute to the willingness and cooperation from them, their families and the health professionals who cared for them."

"The best way the Ministry can begin to repay that debt, is to carefully work through the report making sure that we are able to translate as much of the learning from the audit into making the programme work as well as possible for as many women as possible."

For more information contact:

Background Information How many women die of cervical cancer each year? In 2000, 66 women died of cervical cancer, 17 of whom were Maori. The number of women dying from cervical cancer has almost halved (45%) from 1991 to 2000. New Zealand’s national cervical screening programme began in 1991.

How many women are diagnosed with cervical cancer each year? In 2002, 185 women were diagnosed with cervical cancer. The number of women diagnosed each year has declined by more than a quarter (27%) from 1990 to 1999.

Background to the National Cervical Screening Programme (Appendix 4 of the Cervical Cancer Audit report) Prior to the establishment of an organised screening programme in New Zealand in the 1990’s a number of academics, women’s groups and non-governmental organisations such as the Cancer Society advocated for the establishment of organised screening.

In 1985 in the absence of such a programme, the Cancer Society and Department of Health jointly convened a working party chaired by Professor David Skegg to review the evidence for cervical screening and to make recommendations for screening in New Zealand. However, the main impetus for establishing and organised programme came from the Cartwright Report.

The Committee of Inquiry had been established to inquire into research practices at National Women’s Hospital following an article in the June 1987 edition of Metro Magazine that alleged that women who had attended that hospital with cervical abnormalities had, without their consent, been part of a research programme into the progression of Carcinoma in Situ.

As part of her report Judge Cartwright recommended that a population-based cervical screening programme be established in New Zealand as well as some recommendations as to how she considered this should occur. The government of the day accepted her recommendation and implementation of a NCSP commenced forthwith.

Early years: 1991-1997 On the basis of a review of the 1985 Skegg recommendations, the programme was directed at women from the on set of sexual activity up to 69 years inclusive.

Women commencing screening were encouraged to have two smears 12 months apart and from then on, provided their screening history was normal, to have three-yearly smears. Women with abnormal screening histories were advised to have more frequent screening. A devolved configuration was adopted.

This involved the establishment of 14 regional offices. The responsibilities of these offices were to provide local programme coordination and management of the local, stand-alone cytology register.

Smear-taking was provided by general practitioners, some practice nurses, gynaecologists and a small number of trained lay smear-takers. A majority of laboratories provided smear-reading services to the programme whilst diagnostic services were funded through the public hospital system (although women could opt for private assessment).

The cytology register acted as a back-up for smear-takers and gynaecologists, sending reminders primarily when women were overdue for their next smear test.

The Ministry of Health provided national policy, co-ordination, and cytology register help-desk functions.

It also convened technical and cytology advisory groups. Funding for the programme was administered by the various funding agencies that existed at the time. A 1993 amendment to the Health Act 1956, enshrined the cytology register (known at that time as the National Cervical Screening Register (NCS-R)) in law and changed its modus operandi from “opt-on” to “opt-off”.

This change meant that women had to actively “opt off” if they did not want their smear results included on the NCSR and lead to a rapid increase in enrolments. It also made it possible to provide more accurate measures of programme coverage as well as other statistical reporting. Kaitiaki Regulations were passed in 1995 (the Health (Cervical Screening (Kaitiaki)) Regulations 1995).

These provide for a ministerially appointed panel to protect Mäori women’s information held on the NCSP-R. The panel receives and approve applications for the analysis and reporting of Mäori women’s data. In 1996 the Ministry embarked on a process in which all the local stand-alone cytology registers were re-configured into one national database, still with local data entry.

1998 onwards In 1997 the Health Funding Authority was formed as a national operational policy and funding agency. A decision was made to transfer Ministry of Health responsibilities for the NCSP to the Health Funding Authority and with co-location of national policy, register, planning and funding activities it was theoretically possible to influence the operation and delivery of the programme at all levels.

Soon after the transfer, a woman who had developed invasive cervical cancer as a result of cervical smears allegedly having been misread came to the attention of the Health Funding Authority.

This occurred as a result of the actions of her solicitor and media attention following her taking legal action against the pathologist concerned. Concerns arising from this case (ie, that other women might also have suffered as a result of mis-read smears) lead to the Health Funding Authority seeking expert external advice and subsequently carrying out a mass re-reading of approximately 23,000 smears reported by Gisborne Pathology Laboratories during the period 1990-1996.

Initial results from the re-reading exercise suggested that there might have been significant under-reporting at the laboratory concerned.

This prompted the Government of the day to announce a Ministerial Inquiry to determine whether or not unacceptable under-reporting had occurred in the Gisborne region and if so, what factors may have lead to it.

The Inquiry Committee sat from April to September 2000 and reported to the Government in April 2001. It concluded that unacceptable under-reporting had occurred and that this was as a result both of inadequate practice at the laboratory concerned and systematic problems with the design, configuration and operation of the NCSP during the period 1990-1996.

The Inquiry made 46 recommendations all of which were accepted by the Government. As a result of the Inquiry and increased recognition of the necessary components of a high-quality screening programme, many changes have been made to the structure and operation of the NCSP. These changes relate primarily to:
• Establishment of a National Screening Unit (NSU), within which sits the national office of the NCSP, and thus a national workforce dedicated to the NCSP and the planning thereof
• Alignment of accountability for policy development, funding, planning and national quality assurance activities for both the NCSP and Breast Screening Aotearoa (BSA) all within one entity the NSU
• On-going establishment of comprehensive quality assurance processes including mandatory quality standards and until recently, on-going quantitative monitoring
• Legislative changes to clarify the Programme’s informed consent and enrolment process, improve the completeness of women’s information on the Programme register and facilitate evaluation of the Programme
• Revision of NCSP health education material
• Establishment of a screening workforce development project
• Establishment of a complaints process within the NSU
• An Audit of screening histories of women with invasive cervical cancer.

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