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Practice Nurse

Screening Part 1

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Several screening tests are carried out in general practice which general practice nurses (GPNs) might be involved in. Screening is the process of identifying people who are at increased risk of a disease despite appearing to be in good health. Screening tests offer an indication of risk and may help to highlight those who need further investigations or interventions. However, there are moral, ethical and practical considerations that should be borne in mind when patients are offered screening tests.

This resource, consisting of five assessment questions at intermediate level, tests your knowledge of the use of screening tests in general practice. A further module will test your knowledge of health screening questionnaires in primary care.

Complete this resource, including the further reading and some or all of the suggested activities to obtain a certificate for one hour of continuing professional development to include in your revalidation portfolio. Write up your reflections, considering how the activities reflect the NMC Code, and add to your revalidation portfolio.

On completion of this resource, you should have an understanding of:

The benefits and limitations of a range of screening tests

The need to counsel people about why and how we screen for certain conditions

The actions that might be taken if a screening test is positive

The GPN’s responsibilities when reviewing the results of screening tests

Public Health England has produced guidance on screening tests (PHE 2015). The guidance explains the criteria that must be fulfilled to meet the requirements of a screening test and can be accessed at 

https://www.gov.uk/government/publications/evidence-review-criteria-national-screening-programmes/criteria-for-appraising-the-viability-effectiveness-and-appropriateness-of-a-screening-programme

National Cancer Screening Programmes, Risks Benefits and Concerns

Focus on women’s health: best practice in cervical screening

What practice nurses need to know about prostate disease

Abby is 26 and was eligible for her first cervical smear test last year. She attends for an asthma review where you notice that she has not yet booked in for her smear test. When you mention this to Abby she says that her friend described it as being ‘awful – painful and embarrassing’ and another friend said she didn’t need them anyway as she had had the HPV jab. Abby asks to be taken off the recall system. You take time to explain the process and attempt to reassure Abby. When discussing all of this with Abby, which of these statements is true?

More than 3,000 women are diagnosed with cervical cancer every year in the UK and it is the most common cancer in women aged 35 or under. In the vast majority of cases, it is due to a persistent infection with human papillomavirus (HPV). Most people will be exposed to HPV during their lives but their immune systems will eliminate it. Persistent infection will increase the risk of developing changes in the cells of the cervix and if these are not identified through a smear test the risk of cervical cancer will increase significantly. The HPV vaccine offers good protection against some but not all types of HPV so it is important to attend for smear tests even after having the HPV injections.

Signs of abnormal changes in the cervix include bleeding, discharge and dyspareunia but these do not provide the early warning that a smear test can provide. By the time these symptoms occur changes may already be underway.

Cervical screening is used to identify early changes in the cervix before they become more serious. Up to 75% of cervical cancers can be prevented this way. Non-attendance is an important risk factor for developing cervical cancer.

Immunisation Scotland. HPV vaccination, 2015 

http://www.immunisationscotland.org.uk/vaccines-and-diseases/hpv.aspx

There is often some debate about when cervical screening should start. Different countries within the UK have different cut off points and Scotland is changing its starting age from 2016. Have a look on the Jo’s Trust website to see how and why Scotland is changing its approach. Does this help you to explain your own country’s position to your patients?

http://www.jostrust.org.uk/about-cervical-cancer/cervical-screening-smear-test-and-abnormal-cells/cervical-screening-under25

Question 1

Betty’s mum died of breast cancer in her native Poland at the age of 45. Betty is 38 years old and is anxious about her own risks. She also wants to know if her 13-year-old daughter might also be at risk. She has heard that gene testing for the BRCA breast cancer genes is possible and she wants to know if she is eligible. Which one of these statements about BRCA gene testing is true?

Breast cancer affects over 50,000 people per year, almost all of whom are women. It is the most common female cancer with 1 in 8 women being diagnosed with the condition at some point in their lifetime. Almost 8 out of 10 women survive 10 years post diagnosis. Around 1 in 4 breast cancer cases is preventable. Screening for this condition is important in ensuring early detection and intervention. Mammography has a key role in this respect but only genetic testing can identify people at risk of breast cancer before they develop it. NICE recommends screening for the BRCA1 and BRCA2 genes in women whose family history suggests that they might benefit from this test. The test is available on the NHS and if it is positive the chance of developing breast cancer in the future is between 45-90%. Although bilateral mastectomy (and possibly bilateral oophorectomy) may be advised, there is some evidence that drug treatments such as tamoxifen may help prevent breast cancer.

Cancer research UK – breast cancer, 2015 

http://www.cancerresearchuk.org/about-cancer/type/breast-cancer/?ds_kids=p3752151809&adc=cpc&gclid=CIHc3f7r8ssCFbQV0wodusYIeg&dclid=CNWF6f7r8ssCFYxy2wodCXwI6w

Cancer Research UK – breast cancer genes, 2014 

http://www.cancerresearchuk.org/about-cancer/type/breast-cancer/about/risks/breast-cancer-genes

NICE CG164. Familial breast cancer, 2013 

NICE guidance on familial breast cancer (2013) is currently awaiting an update but it recommends that primary care clinicians should take a careful history in terms of particular risk factors for breast cancer. Are you aware of what these are? Does the OPERA self-assessment tool feature in the advice you offer? Do you feel confident about how to refer people for genetic counselling?

 to see the advice on taking a family history and the advice in the 

 on identifying factors known to increase risk.

Google the OPERA self-assessment tool for calculating the risk of inheriting breast and/or ovarian cancers and see if you think you would recommend this for use.

Question 2

Jack is 59 years old and has noticed some nocturia and hesitancy. He has read a lot about prostate cancer and the PSA test and he has come to see you for a form so he can get this done. You counsel Jack about the pros and cons of PSA testing. Which of these factors will result in an artificially raised PSA level?

The PSA levels in blood increase when the prostate gland enlarges. This enlargement may be due to benign or malignant causes but the most common cause of a raised PSA is benign prostatic hyperplasia (BPH). Two out of three men with a raised PSA level will have no cancer cells detected on biopsy and around 20% of men with prostate cancer will have a normal PSA. GPNs should be able to advise men about factors which might give a falsely elevated PSA. These include:

Prolonged exercise (long-distance running or cycling)

Some drugs (such as the prostate drug finasteride)

Ejaculation (which may raise the PSA for 2-3 days)

The subject of PSA testing is a difficult one as there are several considerations to bear in mind before recommending it. Do you have any guidance in place in your place of work? Is this mainly for the clinical staff or is there information for patients too? Have a look at these publications and see if they would help you to support someone to decide whether or not to have the PSA test.

https://www.gov.uk/guidance/prostate-cancer-risk-management-programme-overview

http://www.nhs.uk/livewell/prostatehealth/pages/psa-test.aspx

Question 3

Tamas age 67, has been offered abdominal aortic aneurysm (AAA) screening but has no idea what it is and whether he should go for it or not. What would you say to Tamas?

A ruptured abdominal aortic aneurysm is almost always fatal but is often preventable. AAA screening offers the opportunity to identify an aneurysm when it is small and before it becomes life-threatening. The test is carried out by a simple, painless ultrasound scan and takes around 10 minutes. The AAA screening programme is now available throughout the UK to the highest risk group – men over the age of 65. If a man over 65 has a normal sized aorta no further screening is needed as AAAs do not develop after the age of 65. If it is slightly enlarged, further screening will be advised. Only men with large AAAs will be advised to consider surgery as the risk of rupture is higher than the risk of surgical intervention.

NHS Choices (2014) Abdominal aortic aneurysm screening 

http://www.nhs.uk/conditions/abdominal-aortic-aneurysm-screening/pages/introduction.aspx

http://sdm.rightcare.nhs.uk/pda/aaa-screening/

AAA surgical repair information leaflet available from 

http://www.circulationfoundation.org.uk/downloads/Circulation_Foundation_Aaa_Repair_Op_Leaflet.pdf

Carry out an audit of 20 male patients over the age of 65 and see if you can find a record of whether or not they have been offered and/or accepted an invitation for AAA screening. Do you have a system in place to support men to decide about the test? If you find someone who has not attended, try to find out why they didn’t attend – was it accessibility? Was it a lack of information about the test? Were there other reasons? Discuss your findings with the practice team, and record your reflections in your portfolio to prepare for revalidation.

Question 4

Peter is 62 and has recently received an invitation to take part in the NHS bowel cancer screening programme. However, Peter is concerned about what might happen if the test is positive and whether he has to have further tests. What advice would you give to Peter?

The NHS bowel cancer screening programme is available to people age 60–74 years. People eligible for screening receive an invitation letter and an information leaflet explaining the benefits and risks of bowel cancer screening. The screening test looks for hidden blood in the stools (faecal occult blood, [FOB]) The home testing kit contains all that’s need to collect a sample and send it to the laboratory for analysis. Results are sent back within 2 weeks. Screening is carried out every two years. WhileIt is true that GP practices are perhaps less involved in this screening test than some of the other mentioned above; however, patients may well seek support and advice from people they know such as GPs and nurses in the practice. As a result, GPNs should have some understanding of the process along with its aims and objectives. Although it is unlikely that Peter will need further investigations, he needs to be clear that they may be suggested and he needs to decide how he feels about that prospect. Having a positive FOB test and then deciding not to attend for further investigations is entirely his choice but may create a great deal of anxiety. In some areas of the country people over 55 are being offered a screening colonoscopy, so GPNs should be aware if they are in an area where this is happening and have an understanding of what the scheme involves.

http://www.cancerresearchuk.org/about-cancer/type/bowel-cancer/about/screening/who-is-screened-for-bowel-cancer

https://www.gov.uk/guidance/bowel-cancer-screening-programme-overview

GP practices have limited involvement in this programme but will get copies of the results or will be told if people did not take part. What process does the practice have in place for following up on these individuals? Do you know if they declined to join the screening programme and if so why? What about people who perhaps didn’t fully understand what to do because of communication difficulties (language barriers, learning disability etc.) or couldn’t be sure about the implications of screening? Can we be sure this is informed dissent? See if you can obtain a copy of the letter sent out to people who are eligible. What do you think? Reflect on your findings and consider whether the practice should follow up on non-attenders. Discuss your views with colleagues.

Screening Part 1

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