Cervical cancer: a confidential enquiry is needed

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

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

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

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.