Cervical Cancer
The final item of business today is a members' business debate on motion S2M-5359, in the name of Ken Macintosh, on cervical cancer and the human papilloma virus vaccine. The debate will be concluded without any question being put.
Motion debated,
That the Parliament welcomes the licensing of the first vaccine against strains of the human papilloma virus (HPV) responsible for around 70% of cases of cervical cancer; expresses its concern that, despite a 40-year history of cervical screening in the United Kingdom, almost 3,000 women are diagnosed and 1,000 women still die of cervical cancer each year in the UK; recognises that the vaccine will not prevent all cases of cervical cancer and that it is not known whether it will prevent cancer in women already infected with HPV; therefore believes that the cervical cancer screening programme should be continued and that further action should be taken to increase the take-up of screening in more deprived areas, among ethnic minority groups and among women with learning difficulties; further believes that this will improve early detection and allow earlier treatment of this disease; recognises the role of charities such as Jo's Trust, Cancerbackup and Cancer Research UK, amongst others, in supporting patients with cervical cancer and their families and in counselling the thousands more women who worry about their health following an abnormal smear result; recognises the huge potential benefits to be had through vaccination in East Renfrewshire and throughout Scotland from reducing the incidence of cervical cancer, reducing the number of colposcopies, reducing the number of abnormal smears and reducing the number of people requiring treatment for genital warts; further recognises the success of the Scottish Executive in its public health campaigns and cancer prevention strategies, and considers that ministers should put in place measures to raise awareness and to prepare for a vaccination programme.
I thank all the members who are present for the debate and the 50 or so members who have signed the motion on cervical cancer and the human papilloma virus. I also thank the many individuals, organisations and charities such as Jo's Trust and Cancer Research UK that have helped to improve our understanding of the disease and have campaigned long and hard to tackle the scourge of cervical cancer. Some of them are represented in the public gallery.
As it comes at the end of European cervical cancer prevention week, the debate in the Scottish Parliament is a timely contribution to the continuing campaign. I hope that it will lead to further action from the Executive—and throughout the United Kingdom—that could dramatically improve health outcomes for women throughout the country.
The stark facts are worrying. In 2005, 127 women in Scotland died from cervical cancer and more than 1,000 died throughout the UK. That is more than 20 women every week. They are often young women who leave behind children and families. On top of that devastation to people's lives are the misery, pain and distress of radical surgery for thousands more and the anxiety and upset that all those who have an abnormal smear result experience.
In the past two decades, the cervical cancer screening programme has made a huge impact on reducing these unnecessary deaths, but there were deeply worrying news stories just last week that the number of women, particularly young women, who attend for their smear has fallen off. In Scotland, every woman between 20 and 60 is invited to have a smear test every three years, but only four in every five women take advantage of the programme. Uptake is poorer among deprived communities and among groups that are difficult to reach or disadvantaged, such as some ethnic minority groups or women with learning difficulties. As members can imagine, those women suffer proportionately higher mortality rates as a result. I will return to screening shortly.
One of the most exciting developments in cancer treatment in recent years has been the production of a vaccine—in fact, more than one vaccine—against the human papilloma virus that causes cervical cancer. One of the vaccines—Gardasil—is on the market, and another—Cervarix—is expected to be licensed imminently.
Those of us who talk about or discuss cancer regularly know how dangerous it is to raise false expectations—to talk of breakthroughs, magic bullets or cures for cancer—but there is no doubt that the vaccine is one of the most tremendous developments of recent years. For example, Gardasil targets four human papilloma virus types that are responsible for cervical cancer, for pre-cancerous lesions of the cervix and vulva and for genital warts, and it is 100 per cent effective against two of those viruses, which are responsible for almost three quarters of all cases of cervical cancer in Europe.
The vaccines have shown themselves to be so successful that their licences have been fast-tracked, because to deny them to the wider population would be unethical. It is essential to make those vaccines available to the next generation of young women through the national health service as soon as possible.
The member will be aware that the Joint Committee on Vaccination and Immunisation—I hope that I have got the name right—will have its next meeting on 14 February. Does he agree that an opportunity exists for a decision to be made so that we can adopt a programme as speedily as possible?
I agree whole-heartedly. The member has identified one course of action on which we can press the minister.
The JCVI has still to decide on the vaccination programme; I believe that that is a question not of "if" but of "when". Many are anxious about the long time that the JCVI is taking to decide on the availability of the new vaccines. With every passing month, we miss out on the opportunity to protect thousands of young women.
However, it is important that the joint committee reaches a fair and balanced decision. It should be made clear to the JCVI that there is no shortage of public or political support for a vaccination programme that is aimed at eradicating cervical cancer for the majority of women, if not all, in the next few years. As Shona Robison said, the joint committee next meets on 14 February—on Valentine's day. I ask the minister to undertake to forward a copy of today's debate to that committee so that the views of members of the Scottish Parliament and of the Scottish Executive are brought to its attention.
In the meantime, it is important that the Scottish Executive begin preparatory work. I give no credence to the scare story that making such cancer vaccines available to pre-teen girls and boys will in any way encourage sexual activity. No evidence supports that. The churches have reacted positively and by far the majority of the parents who have been surveyed have taken an eminently sensible and welcoming approach to the vaccine. There is no doubt that an education and awareness programme would need to precede introduction of the vaccine. I see no reason why the Scottish Executive could not start work on that now.
If the potential for the HPV vaccine has yet to be realised, the impact of cancer screening is already known. The Scottish Executive needs to take action now to raise awareness of the importance of having a smear test. We know that, with all cancers, early detection is the key to successful treatment. Nothing prevents us from doing more to convey that message now. Even if it is fully implemented, the HPV vaccine will not work for all women and a screening programme will be needed for at least the next 20 years, or until we create herd immunity against this deadly virus.
I began the debate by reminding members that more than 20 women die every week as a result of this preventable cancer. I will close with the words of Laura Mackay, a supporter of Jo's Trust, who spoke to members about her experience of cervical cancer at the Scottish Parliament just last week, so that we and others could learn from it. Laura said:
"I cannot emphasise enough the feeling of isolation and fear that comes with a cancer diagnosis, especially cervical cancer. I thought I was going to die. For a couple of years I was in that very dark, horrible and lonely place. I completely withdrew myself from my friends and my family and that was mainly not because it was cancer but because it was cervical cancer and I felt people didn't want to know. For you looking at me today you have absolutely no idea—no idea—of the surgery that I have had and what I have to live with for the rest of my life. By providing this vaccine for free it is giving women OF the future A future. Giving them life options—fertility. Providing this vaccine free is going to save lives."
I thank members for supporting the motion.
I congratulate Ken Macintosh on securing this very important debate and on his commitment to the cross-party group on cancer. I do not know whether Shona Robison, who has a constituency engagement, will be able to stay for the whole debate, so I shall press on.
The most recent parliamentary answer on deaths from cervical cancer reveals that, in 1975, 55 per cent of deaths were in the age group 60 and over, 44 per cent were 30 to 59, and 0.8 per cent were under 30. It is the latter group that we must consider, because the written answer went on to show that although the figures for 2004 remained fairly static for the first two groups—60 and over, and 30 to 59—the figure for the under-30s had risen to nearly 4 per cent. Ken Macintosh properly focused on that increase. I fully endorse what he said. The vaccine is not, as it were, a magic bullet—the intention is not to mislead people—but neither is it an endorsement of promiscuity. It will not accelerate promiscuity; it is an example of something that can be used to help women, indeed to prevent them dying.
The vaccine is not the complete solution. Every year, more than 500 women in Scotland are diagnosed as having cervical cancer. It must be a dreadful diagnosis, but it is not the end for all—although about 100 do die. Because of the high level of underage sex to which I have already referred, the incidence among younger women is increasing. More than 30 per cent of girls aged 15 are sexually active. The solution is a mixture of addressing the vaccine and looking at behaviour. I note what Ken Macintosh said about the vaccine and I understand that different ones are available. I do not know the technicalities but, so far, the one to which he referred has been effective.
Shona Robison mentioned delay. I understand that the JCVI first met to discuss the vaccine on 25 October. Ken Macintosh's comment that it is a question not of "if" but of "when" gives me even more concern about a delay. I hope that the minister will address that. I understand that Austria is already running the programme and that the Nordic countries have committed themselves to it. As Ken Macintosh says, delaying this any further will unnecessarily cost lives. A woman's death impacts on the entire family.
As Ken Macintosh said, take-up of the smear test has been falling off. Perhaps familiarity breeds contempt, but it is terribly important that even with a national vaccine programme the Scottish screening programme should continue. Perhaps the minister will advise us how he will ensure people take up the invitation from their general practitioner to attend for a smear test. As we all know, the sooner cervical cancer is detected, the less invasive the treatment and the higher the chance of survival. That is important.
It is interesting that when mothers were asked whether they would allow their daughters to have the vaccine, 75 per cent said that they would. There is therefore parental consent for the vaccine, which gives the lie to the suggestion that people fear that it would encourage promiscuity.
We do not want to scare people. Most women have the virus most of the time, and most of them will never develop cancerous cells. Nevertheless, it is important that we have screening to detect the virus early and that, if it is detected, we are able to cure it. We should also be able to offer vaccination to prevent its occurrence, when that is appropriate.
I congratulate Ken Macintosh on securing the debate this evening.
I am happy to speak in this debate on an issue that I think is going to become a medical hot topic. The first paragraph of the briefing that members have received from Cancer Research UK Scotland states:
"The advent of a vaccine against Human Papilloma Virus (HPV) is a very exciting development for cancer research and cancer prevention. HPV vaccination has the potential to prevent the majority of cases of cervical cancer in the UK."
That makes it sound as though we have solved the problem of cervical cancer, does it not? Unfortunately, the situation is not quite like that. As Ken Macintosh eloquently argued, we need to continue with our screening programme because the effects of the vaccine will take many years to show because it is effective only in preventing infection in young girls who are not already affected. There is no evidence that the vaccine will be effective in eradicating the virus in those who have already acquired it.
Despite our effective screening programme, people still die of cervical cancer. Cervical cancer accounts for only 1 per cent of cancer deaths, but it is the second most common cancer in women under 35 in the United Kingdom. As Ken Macintosh said, that means that families are left without mothers and so on. That is awful, so we need to continue screening. Although people are being treated for precancerous conditions and are being treated successfully for cancers, screening will still be needed in the long term. I endorse what Ken Macintosh said about ensuring that the screening reaches groups who are traditionally hard to reach and among whom there is lower take-up of screening. The vaccine could, theoretically, prevent 70 per cent of cervical cancers that are directly due to the strains of human papilloma virus against which it will confer immunity. However, there will be some cancers that the vaccine will not prevent.
There are some practical issues on which it would be interesting to see what the JCVI has to say. For example, there is the issue of the age at which the vaccine should be given. It should be given before a girl becomes sexually active—there is no evidence that it will be effective in eradicating the virus when it has already been acquired, so it is not a treatment for people who already have the virus. There is also the question of the length of immunity and whether further doses of the vaccine will be needed. Given that the vaccine will be administered to young people, there is a question about whether the immunity will be lifelong or will need to be boosted.
Another question is whether boys should be vaccinated. Ken Macintosh talked about herd immunity, so the question arises whether we should be attempting to eradicate the virus from the population. Most immunisation programmes attempt to do that, so I think it would be more logical to vaccinate boys and girls. There is also the question of whether a catch-up campaign should be instituted and who should be part of it, given that it would probably not be effective for people who already have the virus.
Acceptability has been touched on. I am encouraged that the research so far suggests that the vaccine will be widely acceptable. In the past, there has been concern among parents groups about the number of vaccines that are being given, but that is really about baby vaccines and about many vaccines being given within a short time. I suspect that the HPV vaccine—which I imagine will be given to girls in early adolescence, who will not be being given other immunisations—should be more acceptable.
On HPV's being a sexually transmitted disease and the suggestion that vaccination would encourage unprotected sex, I do not believe that that should be any sort of objection. The goal is cancer prevention. For many years, I helped to give the rubella vaccine to 12-year-old girls, which was meant not to protect them, but to protect their unborn children. No concern was expressed that the vaccine would encourage them to get pregnant. There are probably one or two people out there who are happy to contemplate their daughters becoming pregnant at a future date, but who cannot ever contemplate their being sexually active. That is a paradox of Scottish society.
There are other issues, such as the cost of the vaccine, which I think is within the limits that Parliament would accept, considering the savings that would be made further down the line. There are, however, costs for poorer countries where the vaccine is really needed—where there is a less-effective screening programme, where more people are dying and where the vaccine will be needed even more than it is in East Renfrewshire.
I very much welcome the debate tonight. I also welcome the on-going discussion and publicity surrounding the vaccine and the national debate that will have to take place in the lead-up to the introduction of the vaccine.
I thank Ken Macintosh for securing such an important debate.
A lot of good words have already been said, and from the practical point of view of having done cervical screening I want to emphasise that it is most important that screening continues for years to come. It is wonderful to have a vaccine, but it is not a catch-all, and even if everybody agreed to its use, certain people would always slip through the net. For years to come, we will need the important cervical screening programme, which saves lives by itself.
The fact that a cervical screening programme has been established for years is great. Parliament has also passed the smoking cessation legislation. I did not hear anybody mention it, but the harmful chemicals from smoking are found in the cervix and it could be that smoking increases the risk of cervical cancer. As the Cancer Research briefing states, it has also been accepted that smoking reduces the activity of immune cells and cuts the body's immune system.
The contraceptive pill was also mentioned, but we forget that so many people have been on the contraceptive pill. Without going into any detail, that is also something that we have to consider.
We should remember and remind people that cervical screening is better than it used to be. The techniques are better and there are more positive results. There will still be people who have to come back because their screening test has not proved anything or gives a suspicious result, and we want to ensure that people to come back for repeat smears in that situation.
Does Jean Turner agree that, although the cervical cancer screening programme has been dramatically successful in reducing the number of deaths and in reassuring women about their health, we have recently seen a gentle decline in attendance rates? Matching that, statistics that were published last week show a rise in the past four years in the number of women who have died from cervical cancer in Scotland. Does the member have any suggestions about how we could target the screening programme more effectively?
Ken Macintosh is right, and I think that it was mentioned that familiarity sometimes breeds contempt. People can just come along and get their smear, but they often believe that, unless something horrible has happened to them, it is never going to happen to them.
That is where the importance of working as a team comes in. In general practice, I depended very much on my health visitors, district nurses and others who had contact with patients. There are people whom we will have great difficulty bringing in for smear tests. Some of the more obvious groups have been mentioned—ethnic minorities and people who have language difficulties. We need to cast the net wider.
We also need to make the place where people are screened a most comfortable place, so that they feel able to speak to the doctors and have confidence in them. A lot more is done at a cervical screening than just the screening, as women can talk about women's issues as well. Money must be kept in cervical screening.
Cancer Research reminds us that it is conducting research into incorporating HPV testing into existing cervical screening programmes to try to find out who is at risk. There is a lot still to be done. It is wonderful to have a vaccine, interesting to read about how it might affect young men, and great to think that parents are willing to have their children vaccinated. However, there is a long way to go before we can say that the vaccine is safe, and there are other ways to catch more people. I thank Ken Macintosh for bringing the debate to Parliament.
I will be fairly brief because a lot of what I was going to say has already been said. I am pleased to have the opportunity to speak, and I add my congratulations to Ken Macintosh on bringing such an important health matter to the chamber.
I had involvement with cervical cancer patients for much of my professional life, initially as an anaesthetist, when they were in my care during diagnostic and therapeutic procedures, and more recently when I was involved in the Grampian oncology research project, which monitored patients' progress from histological diagnosis through treatment to survival or, sadly, on occasion to death. I also helped with trials of chemotherapy in the treatment of patients with advanced cervical cancer, so I have seen at first hand the anxiety and pain that the disease can cause when it is not picked up early.
My medical education and career were both in Aberdeen, and I am proud that the early diagnosis of cervical cancer was pioneered in that city by the late Dr Betty Macgregor, who set up the cervical cytology screening service that has saved so many lives since the 1960s. She and her colleagues were meticulous and skilled in their work, and I was privileged to know them.
We are at an extremely exciting, pioneering time in the history of cervical and related cancers. There is a prospect that they could become history in a decade or two if the vaccines that are being developed against the causative human papilloma virus are as effective as the early trials indicate. Worldwide, they could save the lives of many thousands of people who face the trauma of advanced malignancy in the middle years of their lives.
If a vaccination programme is set up within the next 12 months for all girls who are about to enter their sexually active lives, the incidence of cervical cancer could be cut to almost zero in 20 years or so. As Christine Grahame said, it is encouraging that parental surveys show that there is ready support for such a programme. However, it will be vital to continue with the screening programme in the intervening years and to stress to women that it is important that they attend for cervical smear tests regularly. It is worrying that attendance in Scotland has fallen off in recent years, particularly among young women, most of whom are sexually active from an early age nowadays.
Tonight's debate will help to raise awareness of what is a fairly common disease that is readily curable provided that it is picked up early—ideally, in the pre-cancerous phase. We must continue to keep it in the public eye.
I fully endorse the motion's praise for the charities Jo's Trust, Cancerbackup and Cancer Research UK, which play a vital role in flagging up the importance of early diagnosis during the pre-malignant and totally curable phase of the disease. I also commend the charities' work to support patients who have clinical cervical cancer and their families.
It is important that a vaccination programme is put in place at the earliest opportunity. I hope that the Deputy Minister for Health and Community Care will be able to tell us when that is likely to happen, assuming that the JCVI gives approval on 14 February. I hope that he will do all that he can to keep cervical cancer in the public eye and to encourage young women to take part in the potentially life-saving screening programme that is readily available to them.
I will be brief, because most of what I wanted to say has already been said. I, too, thank Ken Macintosh for bringing the debate to the chamber. As others have said, it is timely, because a decision on the vaccine will be made soon.
It is great that advances in medical science have detected the reasons for cervical cancer and genital warts. The cause seems to be viral, and given that at least one vaccine has been found to prevent cervical cancer, we should take forward the advances in medical science and put them to good use.
As others have said, in the UK three people die from cervical cancer each day. One in three of those who are identified with the disease die from it. If that were the case with flu, an epidemic would be declared and Government ministers would do something about it.
Screening will still be necessary if the vaccine is successful, but we hope that it will be done at longer intervals. Last week, Nanette Milne and I were in talks with Grampian NHS Board, which confirmed that there has been a decline in the take-up of cervical screening. It is not difficult to identify the reasons for that. Someone may make an appointment and then find out that it is not convenient, so they cancel it and make another appointment at another time. The matter slips off the agenda of busy women's lives.
I, too, recently met representatives of Jo's Trust, including a young woman who had recently been diagnosed with and treated for cervical cancer. She spoke movingly about the trauma caused by being told that she had an abnormal smear, the examinations, the invasive surgery and the disruption to her life and that of her wider family. If there is a way of preventing that, surely we should introduce it.
I, too, take on the people who say that the introduction of the vaccine is likely to lead to an increase in sexual activity. I do not believe that that is the case. As part of the sexual health programme, we have to make clear the possibility of picking up STDs. Education on sexual health will still be necessary. My 14-year-old daughter, who is involved in the peer education programme, has been talking to me about this issue and about the talks that she is giving to others.
It would be remiss of us not to take up the innovation and research that has been done in this area. As others have said, the vaccine is being introduced in other places. In New Hampshire, nine to 26-year-olds are getting it. It should not be left to the well-off, many hundreds of whom are now paying £450 for three doses of the vaccine. The people who need the vaccine most must get access to it. I hope that the minister will give us good news.
I, too, thank Ken Macintosh for his opening remarks and for bringing this debate to the chamber, and I thank members for their constructive contributions on this important issue.
I am happy to agree to Ken Macintosh's request to draw this debate to the attention of the JCVI before its next meeting and to ensure that it is aware of members' views on this important issue.
As we have heard, cervical cancer is the second most common cancer that affects women. In almost all cases it is caused by a family of viruses called human papilloma viruses. HPV infection happens, as a matter of course, as a result of sexual activity. In most women, HPV causes no long-term harm, but some women are at risk of developing cancer without showing any physical signs of infection.
In that context, the first thing to say about protecting women's health is that the cervical cancer screening programme offers the best protection available to women. We know that if cervical cancer is identified early, treatment can be delivered quickly and survival rates will continue to improve. That is why, although it is important to have a debate about vaccination, it is also important to encourage every woman to take up her invitation to attend for screening. I am grateful to Nanette Milne for reminding us of the pioneering work that was done by Betty Macgregor and her colleagues in Aberdeen. We want to maintain that reputation for leading the way in this area, so we will continue to build on the success of the cervical cancer screening programme in Scotland.
Although Ken Macintosh and other members rightly drew attention to some negative trends, it is also important to recognise as part of the big picture that deaths from cervical cancer declined by 30 per cent between 1995 and 2005, and that the incidence of the disease between 1986 and 2003 fell by 45 per cent. Those trends are significant and positive. The five-year survival rate for cervical cancer is now 70 per cent, compared with only 54 per cent in 1981. All those positive trends reflect clearly the benefits of early diagnosis through cervical screening, which is key to our continuing approach to dealing with the disease.
NHS Quality Improvement Scotland reviewed the cervical screening programme last year and praised it for delivering "extremely high quality care." The national uptake target was set at 80 per cent. The level of uptake is still above that target but, equally, as members have said, there has been a slight decline in recent years. That concerns us, and we recognise that action is required. A number of members have asked us to take and support such action.
We have in place a national advisory group on cervical screening, which is closely monitoring uptake rates and will provide advice as appropriate to the Executive and NHS boards on strategies for increasing uptake. NHS boards have a duty continually to assess the needs of their local communities and to target groups in their areas where that is appropriate to increase uptake, particularly, as has been said, among younger women, certain ethnic minority groups and women with learning disabilities.
There are some good examples of local initiatives to tackle low uptake. For example, NHS Lanarkshire is piloting a community health education programme that is focused on deprived areas, and is also working with local learning disability services to improve the uptake of cervical screening. In Fife, women who do not attend screening are issued with leaflets that provide information on their choices as to where they might attend for treatment. The healthy women's project in Lothian is doing similar work. There are other examples throughout Scotland.
Are any programmes specifically designed for women from ethnic minorities? I know that they find it particularly difficult.
Yes. I recognise, as has been said by a couple of members, that among certain groups that is an issue. Boards recognise that and deal with it on a case-by-case basis. We continue to expect them and encourage them to do that.
It is worth saying that the approach to dealing with cervical cancer is in the context of dealing with cancer as a whole, and that we are making significant progress in reducing death rates from cancer in Scotland. We are on course to reach our target of reducing the rate for people under the age of 75 by 20 per cent by 2010.
However, we always want to do more and to be more effective. For example, we recognise the importance of providing information to patients who have cancer and other diseases. We have approved a national framework, which was developed by Citizens Advice Scotland in partnership with the NHS, for the provision of independent advice and support to NHS users, their carers and their families.
Of course, the key proposition in Ken Macintosh's motion relates to the introduction of vaccination. It is worth saying that the United Kingdom has one of the most successful vaccination and immunisation programmes in the world, and advice is provided on a UK basis by the JCVI.
We are currently seeking expert advice from the JCVI on the efficacy and safety of the new vaccines against HPV and the benefits that they may offer. Of course, we do not expect decisions to be taken on introducing those vaccines until the JCVI has fully considered all the evidence and has presented its advice to ministers. We expect it to do that, and we do not wish to press it to make a decision or a recommendation until it has satisfied itself in scientific and medical terms that it has considered all the relevant information. However, we look forward to measures being put in place. In advance of that, work is already being done by, for example, Health Protection Scotland to prepare the way for a positive decision, so that people and NHS systems are ready to act on it at the appropriate time.
It is important that the JCVI carefully considers all the available evidence on HPV vaccines and makes recommendations. However, I reiterate the point that such a development will in no way diminish the central role of the screening programme. I do not want anybody to go away with the impression that the introduction of vaccination would reduce the significance of screening—far from it. Vaccination has no direct relevance for women and girls who are or have been sexually active, therefore detection by the screening programme will remain essential for them.
We will be advised by the JCVI on the potential benefits of vaccination for those who have not been sexually active. I share the view that it can make a real difference to future patterns of risk, disease and mortality. However, the screening programme will continue to be at the centre of everything that we do in reducing the impact of cervical cancer, and we should all ensure that that message is heard loud and clear by women throughout Scotland.
Meeting closed at 17:44.