J R Soc Med 2003;96:318-319
doi:10.1258/jrsm.96.7.318
© 2003 Royal Society of Medicine
Cervical cancer: a confidential enquiry is needed
A R Markos FRCOG
Genitourinary Medicine and Sexual Health, Staffordshire General Hospital,
Stafford ST16 3SA, UK
 |
INTRODUCTION
|
|---|
Cervical cancer is in theory preventable yet the UK still sees
about 3200
new cases every year. We do not know the amount
of morbidity caused by this
cancer, which may even have increased
with the decline in mortality.
Pessimists say that a further
reduction in the incidence of cervical cancer is
not practically
possible. Before reaching any such conclusion, however, we
need
to look at avoidable and preventable causes; and the best way
may be by
individual case
enquiries.
1
Enquiries into medical care have helped to shape services, improve
resources and reset standards. The Confidential Enquiry into Maternal Deaths
(CEMD), begun in 1952, was a landmark in the development of maternity services
and has been imitated in several other spheres (Box 1). The aim is to
investigate areas of healthcare where trends are open to question, where
avoidable or preventable factors need identification and where improvements
are desirable.2 Some
enquiries were national, others local.
There has been a notable reduction in the incidence of cervical cancer
since the introduction of the national cervical cytology screening programme.
The guidelines and quality assurance procedures for cytology and colposcopy
provide support for service facilities, and the establishment of
gynaecological cancer networks opens the way to local audits. But the national
guidelines target the service as a whole. Even if the lessons from individual
cases are shared locally through the specialist networks they do not
necessarily filter through to other interested parties such as cytology
programme managers and primary care physicians at either local or national
level.
|
DEMOGRAPHIC AND RISK FACTORS
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|---|
In demographic terms, cervical cancer resembles a sexually transmitted
disease, with certain groups of the population at particularly
high risk. For
maternal mortality the CEMD found a correlation
with low socioeconomic status,
and a similar approach is needed
to identify the subgroups in which the
existing system for
preventing cervical cancer falls short. Identification of
these
factors (in relation to the increasingly multicultural and multiethnic
British population, with its widening social gaps) would help
us fashion local
services and direct resources to the risk
groups. The excess of cervical
cancer in socioeconomically
deprived women is likely to reflect, in part,
their low uptake
of medical
care.
10 Other
probable influences are smoking,
early onset of intercourse, multiplicity of
sexual partners,
high-risk male partners and unstable social circumstances. In
addition, health service failures might well prove important
in individual
cases—for example, failure to offer cervical
cytology, infrequent
recall, clerical and administrative mistakes,
errors in interpreting the
cytology slides, and inappropriate
colposcopic assessment and biopsy. An
illjudged surgical or
radiotherapeutic intervention can cause misery or even
death.
The identification of one or more of these factors could only
be
achieved in individual cases by confidential reviews of
clinical care at
primary, secondary and tertiary levels and
of the contributions of cytology,
pathology and administrative
services.
10
| Box 1 Examples of confidential enquiries
Postneonatal deaths (Ref.
3)
226 consecutive infant deaths (Ref.
4)
Gynaecological laparoscopy (Ref.
5)
Perioperative death (Ref.
6)
Suicide and homicide by people with mental illness (Ref.
7)
Families with two siblings with cystic fibrosis (Ref.
8)
Asthma deaths in Wales (Ref.
9)
|
|
ADVANTAGES
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|---|
The aim of the enquiry is to identify factors amenable to rectification,
to
make recommendations and to disseminate the findings. As
with previous
confidential enquiries, the publications should
avoid apportioning blame, and
should be consistent with existing
policies on good clinical practice, audit,
clinical governance,
professional self-evaluation, and adverse event
reporting.
The reports should consist of analytic reviews to assess quality
of
care, what went wrong, and what might be done to prevent
future
mishaps.
11
|
APPLICATION
|
|---|
An inquiry into 3200 cases is not an unmanageable task. If it
were not
practicable or affordable to examine every one of
the 3200 cases reported
yearly, some form of selection might
be considered.
The enquiry should be designed to engender confidence and a sense of
'ownership' in the involved professionals. Lack of confidence in the
process could lead to under-reporting, bias in the data and neglect of the
recommendations. The bad press commonly received by cervical cancer services
may tempt politicians to demand a government-led
enquiry.12 Whatever
the mechanism, a non-punitive approach is essential, acknowledging that the
healthcare professionals are themselves likely to be regretful and despondent
when a system failure has led to an unsatisfactory outcome.
|
CONCLUSION
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|---|
A wealth of lessons could emerge from a confidential enquiry
into cervical
cancer cases, in respect of the administration
of the screening programme, the
writing of guidelines, the
provision of colposcopy, cytology and histology
services, and
the clinical management of identified cancers. A presumption
that the current level of prevention cannot be surpassed fosters
a negative
approach to groups who might benefit from targeted
efforts. Through a national
confidential enquiry and the recommendations
that stem from it, there is real
chance of reducing further
the mortality and morbidity of cervical cancer.
|
REFERENCES
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|---|
- Van Wijngaarden WJ, Duncan ID, Hussain KA. Screening for cervical
neoplasia in Dundee and Angus: 10 years on. Br J Obstet
Gynaecol 1995;102: 137
-42[Medline]
- Gibb D. Confidential enquiry into maternal death. Br J
Obstet Gynaecol 1990; 97: 97
-101[Medline]
- Confidential Enquiry into Postneonatal Deaths 1964–66. Rep Publ Hlth Med Subj No. 125 London: HM Stationery
Office, 1970
- Richards IDG, McIntosh HT. Confidential inquiry into 226
consecutive infant deaths. Arch Dis Child 1972; 47: 697
-706
- Chamberlain G, Brown JC, eds. Gynaecological
Laparoscopy: Report of the Working Party of the Confidential Enquiry into
Gynaecological Laparoscopy. London: Royal College of
Obstetricians & Gynaecologists, 1978
- Devlin HB, Lunn JN. Confidential inquiry into perioperative deaths.
BMJ 1986; 292: 1622
-3
- Appleby L, Shaw J, Amos T. National confidential inquiry into
suicide and homicide by people with mental illness. Br J
Psychiatry 1997;170: 101
-2[Free Full Text]
- Lane B, Williamson P, Dodge JA, et al. Confidential
inquiry into families with two siblings with cystic fibrosis. Arch
Dis Child 1997;77: 501
-3[Abstract/Free Full Text]
- Burr ML, Davies BH, Hoare A, et al. A confidential inquiry
into asthma deaths in Wales. Thorax 1999; 54: 985
-9[Abstract/Free Full Text]
- Lawson HW, Lee NC, Thames SF, Henson R, Miller DS. Cervical cancer
screening among low-income women: results of a national screening programme,
1991–1995. Obstet Gynecol 1998; 92: 745
-52[Medline]
- Department of Health. A First Class Service: Quality in
the NHS. London: DoH, 1998
- Jones J. Government sets up inquiry into ventilation trial.
BMJ 1999; 318: 553[Free Full Text]
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INTRODUCTION
DEMOGRAPHIC AND RISK FACTORS
