Smear tests can detect cervical cancer as well as pre-cancerous conditions. Fergus Bescoby explains the underwriting implications of abnormal cells and different cancer stages
The recent publicity of cervical cancer has raised awareness of the disease and the number of women attending regular screening for this sometimes deadly form of cancer has increased dramatically.
As the name implies, this type of cancer attacks the cervix uteri or cervical area and develops if the cells of the cervix (neck of the womb) become abnormal and grow out of control.
There are two main types of cervical cancer: squamous cell cancer, which is the most common, and adenocarcinoma - although they are often mixed. They are named after the types of cell that become cancerous. Squamous cells are flat cells covering the cervix; adenomatous cells are found in the passageway from the cervix to the womb.
Other rarer cancers of the cervix include small cell cancer.
Cervical cancer develops from cells lining the cervix, the canal that connects the uterus to the vagina. There is usually a period when some of the cells lining the cervix develop abnormal changes but are not yet cancerous - these can give rise to cervical cancer at a later point. Doctors can pick up these changes through screening, and simple treatment can prevent the development of cancer.
As a result of these regular screenings, death from cervical cancer in the UK has fallen over the last two decades. The screening programmes detect changes in the cells of the cervix at a pre-cancerous stage and if abnormal cells are caught early, cancer can be prevented or treated. The changes can be detected by a laboratory test on a small sample of cells. The latter are taken from an area called the transformation zone on the surface of the cervix, and preserved using a procedure called liquid-based cytology.
Each year, there are around 2,700 new cases of cervical cancer in the UK and although there is a higher chance of developing cervical cancer later in life, it is the second most common cancer in women under the age of 35.
Woman aged between 25 and 60 in the UK will be invited for a cervical screening test at least every five years. The exact age groups for screening vary between the different counties of the UK. Almost 90% of women who attend their invitation for a smear test in the UK will receive a normal result but between 7% and 10% will receive an inadequate or abnormal result. Receiving an inadequate or abnormal smear result can upset and cause distress to many women. The majority of abnormal smear results will indicate a grade of cervical intra-epithelial neoplasia (CIN), which is a pre-cancerous condition and is not cancer. More information pertaining to the various CIN grades is covered later.
The higher reported incidence rate of cervical cancer and lower mortality rate highlight the fact that women are more aware of the dangers surrounding cervical cancer and are prepared to engage in the NHS Cervical Screening Programme and have regular screening carried out. As previously mentioned, if the disease can be detected at an early stage it is more than often treatable. When left, it has the potential to become a killer.
Diagnosis
If there has been an abnormal screening result or symptoms of cervical cancer, the GP will recommend a colposcopy. This is simply a close examination of the cervix by a specially trained doctor or nurse using a lighted magnifying instrument called a colposcope.
A small sample of tissue called a biopsy may be taken from the cervix and sent to a laboratory for testing. This will show if abnormal cells have spread from the skin covering the cervix to the tissue underneath.
As with many other types of cancer, the outcome depends on how advanced the cancer is when it is diagnosed. Since the 1970s, the number of deaths from cervical cancer in the UK has been falling. The main reason for this is the introduction of cervical screening in the 1960s and the launch of the National Screening Programme in the 1980s.
Regular screening has meant that pre-cancerous changes and early stage cervical cancers have been picked up and treated early. Figures suggest cervical screening saves 5,000 lives each year in the UK.
Grades of CIN
In the UK, women who receive an abnormal smear result are usually informed that they have a grade of cervical dyskaryosis or dysplasia. If a biopsy is taken, CIN can be found to be present.
Dyskaryosis or dysplasia is a term used to describe the abnormality noted by cytological analysis on a smear test. CIN is divided into three grades that describe how far the abnormal cells have gone into the surface layer of the cervix. Borderline smear indicates slight abnormality.
CIN 1 - a third of the thickness of the surface layer of the cervix is affected.
CIN 2 - two-thirds of the thickness of the surface layer of the cervix is affected.
CIN 3 - the full thickness of the surface layer of the cervix is affected.
With all three grades of CIN, often only a small part of the cervix is affected by abnormal changes.
CIN 3 is also known as carcinoma-in-situ. Although this may sound like cancer, CIN 3 is not cancer of the cervix. It is only if the deeper layers of the cervix have been affected by abnormal cells that a cancer has developed. However, it is important that CIN 3 is treated as soon as possible.
A screening test can show that CIN is present, but it cannot always show how deeply the abnormal cells go into the cervix. In order to find the grade of the CIN, further tests may need to be carried out. During the further tests, samples of the abnormal areas of the cervix may be taken. The biopsies are looked at under a microscope to find the grade of the CIN. This makes it easier for the doctor to decide on the most appropriate type of treatment.
Statistics
- In 2005, 2,803 women in the UK were diagnosed with cervical cancer.
- Cervical cancer caused 949 deaths in the UK in 2006.
- The NHS Cervical Screening Programme has meant that the occurrence of cervical cancer has reduced by 40% in the UK.
- Of all those women diagnosed with cancer of the cervix, about 68% will live for at least five years. About 66 women out of every 100 will live for more than 10 years after diagnosis. Younger women have a better survival rate than older women. This is at least partly because, in younger women, the disease tends to be diagnosed at an earlier stage.
The majority of smear tests are normal.
- Approximately 7% to 10% of cervical smears are diagnosed as having atypical or abnormal cells.
- Fergus Bescoby is underwriting manager at PruProtect
SOURCES
Cancer research UK at www.cancerresearchuk.org
Hannover Re underwriting guidelines
UNDERWRITING IMPLICATIONS
Abnormal smears - CIN 1 and 2 are standard rates for all benefits and CIN 3 is standard rates after appropriate treatment. For serious or critical illness (CI), confirmation would be required that the follow-up smear was normal. This is usually carried out six months after treatment. This information can usually be obtained via a telephone interview with the customer.
Cervical cancer - terms are dependent on the time since treatment was completed and the stage of the cancer: the further the cancer has spread, the harsher the terms. If a customer has had stage 1 cancer, which is the earliest stage, standard rates will normally be offered for life cover after a period of four years has elapsed. If the customer applies during the four years after treatment, a temporary extra premium will be charged. A stage 2 cancer has a worse prognosis so terms would not be offered until four years have elapsed, then an extra premium will be charged until 11 years after completion of treatment when standard rates can be accepted. Terms are rarely offered after stage 3 or 4. Serious or CI will either be declined or a cancer exclusion imposed. The information required is usually obtained via a GP report.
