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

NHS宫颈筛查计划(NHS CSP)自1998年在英国推出以来取得了巨大的成功。然而，2018年，筛查率处于历史最低水平，一些地区的筛查率降至50%，特别是在年轻女性和新妈妈中，尽管宫颈癌的发病率高峰出现在25-35岁这一年龄段。宫颈癌发病率的高峰期与女性生育的时间不谋而合。在怀孕和产后期间，妇女与医疗保健专业人员进行多次互动，并就一系列疾病的筛查进行讨论。怀孕为了解、教育和促进宫颈筛查提供了理想的机会。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教育包，将我们当地出生后人口的筛查接受率提高了8%。作为这项工作的一部分，我们进行了一些焦点小组，从关键利益攸关方那里寻求想法。由新妈妈、患有宫颈癌的年轻女性、全科医生和实习护士产生的一个想法是，应该在产后6周的体检时进行宫颈筛查。这次体检有很多女性参加，这意味着她们不必在几周后抽出时间在单独的预约中优先考虑自己的医疗保健。找时间参加预约是新妈妈&患有宫颈癌的女性确定的一个关键限制因素。另一个因素是不愿进行阴道检查，尿检可能会有所改善。目前，产后筛查是在出生后12周后进行的。这是基于一项传统的宫颈筛查(巴氏涂片)的研究，当时涂片者将木片上的细胞直接扩散到玻璃片上。然而，我们现在使用基于液体的细胞学(LBC)，即在宫颈筛查刷子上收集的细胞被转移到一罐特殊的收集液体中，然后使用专门的设备转移到实验室的载玻片上。这些LBC样本更清晰，更容易在显微镜下检查。这意味着，与老式的巴氏涂片相比，经期或产后出血/分泌物(称为恶露)的问题较小。我们最近还改变了在这个LBC样本上主要检测高危人乳头瘤病毒(HR HPV)，只对检测到HR HPV的人进行细胞学检查。然而，尽管缺乏证据支持目前的宫颈筛查计划，这个12周的时间点仍然存在，直到我们有数据支持将宫颈筛查与产后6周体检预约相结合。我们将提出几个问题，以帮助设计最好的未来，需要进行更大规模的研究，以确认6周体检是安全的，并提高筛查成功率。孕妇和新妈妈对6周产后检查的筛查有什么看法？2.孕妇和新妈妈对6周产后检查的自我检查有什么看法？3.在可行性研究中，女性是否会参加6周的宫颈筛查测试？如果她们参加了，她们是否愿意在12周时进行重复测试，以便进行直接比较？4.将孕妇随机分配到6周或12周的测试中是否可行，或者我们是否需要设计不同的未来研究，例如，通过全科医生或区域随机筛查时间？5.出生后妇女的尿样自我检测与LBC样本相比有多好？我们希望这些数据将提供信息，以计划如何计划一项更大的研究，以测试在NHS宫颈筛查计划中改为6周出生后检测对检测的准确性和预防宫颈癌的能力的影响，并看看这是否提高了出生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.