Investigating the acceptability and accuracy of cervical screening and self-sampling in postnatal women to coincide with the 6-week postnatal check-up

NHS子宫颈筛查计划（NHS CSP）自1998年在英国推出以来取得了巨大成功。然而，2018年的筛查率处于历史低点，某些地区的筛查率降至50%，尤其是年轻女性和新妈妈，尽管宫颈癌的发病率高峰发生在25-35岁年龄组。宫颈癌的发病率高峰与妇女生育的时间相吻合。在怀孕和产后期间，妇女与保健专业人员进行了多次互动，并就一系列疾病的筛查进行了讨论。怀孕提供了一个理想的机会来宣传、教育和促进子宫颈检查。在之前的一项质量改进研究中，我们通过针对孕妇和助产士的一揽子教育计划，将当地产后人口的筛查吸收率提高了8%。作为这项工作的一部分，我们组织了一些焦点小组，从主要利益相关者那里寻求想法。新妈妈、患宫颈癌的年轻女性、全科医生和执业护士提出的一个想法是，应该在产后6周检查时进行宫颈筛查。这种检查有很多女性参加，这意味着她们不必在几周后找时间在单独的预约中优先考虑自己的医疗保健。新妈妈和患有宫颈癌的妇女认为，找时间参加预约是一个关键的限制因素。另一个因素是不愿进行阴道检查，尿液自检可能会改善这一点。目前，产后筛查是在产后12周后进行的。这是基于一项传统子宫颈筛查（“巴氏”涂片）的研究，当涂片接受者将来自木制载玻片的细胞直接扩散到玻璃载玻片上时。然而，我们现在使用液体细胞学（LBC），在使用专业设备将宫颈筛查刷收集的细胞转移到装有特殊收集液体的锅中，然后转移到实验室的载玻片上。这些LBC样本在显微镜下更清晰，更容易检查。这意味着，与传统的巴氏涂片检查相比，经期出血或产后出血/分泌物（称为恶露）不是什么问题。我们最近也改变了主要对LBC样本进行高风险人乳头瘤病毒（HR HPV）检测，仅对检测到HR HPV的患者进行细胞学检查。然而，尽管缺乏证据支持目前的子宫颈筛查计划，但这个12周的时间点仍然存在，直到我们有数据支持将子宫颈筛查与产后6周检查预约结合起来。我们将提出几个问题，以帮助设计最好的未来，需要更大规模的研究来确认6周的检查是安全的，并提高筛查的接受程度。孕妇和新妈妈对产后6周检查的筛查有什么看法？孕妇和新妈妈对产后6周自检有何看法？在可行性研究中，女性是否会参加为期6周的宫颈筛查测试，如果她们参加了，她们是否愿意在12周时再次进行测试，以便进行直接比较？将女性随机分配到6周或12周的测试中是否可行，或者我们是否需要以不同的方式设计未来的研究，例如按全科医生执业或地区随机分配筛查时间？产后妇女尿液样本自我检测与LBC样本比较效果如何？我们希望这些数据能告诉我们如何计划一项更大的研究，以测试在NHS子宫颈筛查计划中改为产后6周检测对检测准确性和预防宫颈癌能力的影响，并看看这是否能提高产后妇女的子宫颈筛查率。

The NHS Cervical Screening Programme (NHS CSP) has been hugely successful since introduction in 1998 in the UK. However, in 2018, screening rates were at a historical low, with screening rates down to 50% in some areas, especially in younger women & new mums, despite cervical cancer peak incidence occurring in this 25-35 year age group. The peak incidence of cervical cancer coincides with the time when women are having children. During pregnancy and the postnatal period, women have multiple interactions with healthcare professionals and discussions regarding screening for a range of conditions. Pregnancy provides an ideal opportunity to inform, educate and facilitate the uptake of cervical screening. In a previous quality improvement study, we improved the screening uptake rate in our local postnatal population by 8% with educational packages aimed at pregnant women and midwives. As part of this work we conducted a number of focus groups, seeking ideas from key stakeholders. One idea, generated by new mums, young women with cervical cancer, GPs and practice nurses, was that cervical screening should be performed at the 6-week postnatal check up. This check up is well-attended by women, & means that they do not have to find time a few weeks later to prioritise their own healthcare in a separate appointment. Finding time to attend appointments was a key limiting factor identified by new mums & women with cervical cancer. Another factor was a reluctance to have a vaginal examination, which urine self-testing might improve.Currently postnatal screening is performed after 12-weeks postnatal. This is on the basis of one study of conventional cervical screening ('Pap' smear), when cells from wooden slides were spread directly onto glass slides by the smear-taker. However, we now use liquid-based cytology (LBC), where cells collected on the cervical screening brush are transferred into a pot of special collection liquid, before being transferred to a slide in the lab, using specialist equipment. These LBC samples are much clearer and easier to examine under a microscope. This means that blood from periods or postnatal bleeding/discharge, called lochia, is less of a problem compared to old-style 'Pap' smears. We have also recently changed to primarily testing for high risk Human Papilloma Virus (HR HPV) on this LBC sample, with cytology only performed for those with HR HPV detected. However, despite the lack of evidence to support the current cervical screening schedule, this 12-week time-point remains, until we have data to support a change to combining cervical screening with the 6-week postnatal check up appointment.We will ask several questions, to help design the best future, much larger study that will be needed to confirm that a 6-week check is safe and improves screening uptake.1. What are pregnant women and new mums' views on screening at the 6-week postnatal check?2. What are pregnant women and new mums' views on self-testing at the 6-week postnatal check?3. Will women attend for a 6-week cervical screening test in a feasibility study and, if they do, would they be willing to have a repeat test at 12-weeks to allow direct comparison?4. Will it be feasible to randomise women individually to either 6- or 12-weeks tests, or would we need to design future studies differently, e.g by randomising screening times by GP practice or regionally?5. How well does self-testing with urine samples compare with LBC samples in postnatal women?We hope these data will inform how to plan a larger study to test the effect of changing to 6-week postnatal testing within the NHS Cervical Screening Programme on the accuracy of testing and ability to prevent cervical cancer, and see whether this improves cervical screening rates in postnatal women.