The document discusses upcoming changes to Australia's National Cervical Screening Program in 2017. Key changes include replacing the pap smear with an HPV test, increasing the screening interval from 2 to 5 years, starting screening at age 25 instead of 18-20, and using self-collection methods to improve participation. The goal is to further reduce cervical cancer rates through a safer, more effective, and cost-efficient screening approach enabled by new technologies and knowledge about HPV. Clinicians will receive a single report with HPV status and reflex cytology results.

1. New Changes To Cervical
Screening Program 2017
Dr DONALD ANGSTETRA Bsc(Med) | MBBS | FRANZCOG
Obstetrician & Gynaecologist
Advanced Gynaecological Laparoscopic Surgeon | Gold Coast University Hospital
Visiting Medical Officer | Gold Coast Private Hospital
Senior Lecturer | Griffith University

2. About me…

3. ∗ National Cervical Screening Program
∗ Introduced 1991
∗ 2-yearly pap smear test
∗ Asymptomatic women who have been
sexually active
∗ Age 18-69yo
CURRENT Cervical Screening in Australia

4. Cervical Cancer in Australia
∗ Cervical cancer − last 20 years
∗ 1991-2002 − Incidence & mortality rates ↓~50%
∗ > 2002 − Rates have plateau
∗ Incidence of Cervical ca 9/100,000
∗ Mortality rate  2/100,000
Pre-NCSP
National Screening program
Introduced in 1991
National Screening program
Introduced in 1991

5. Cervical Cancer in Australia
Pre-NCSP

6. So why change??
∗ New Knowledge of HPV infection and Cervical Ca
∗ New technologies
∗ HPV DNA typing
∗ Liquid Based Cytology (LBC)
∗ Computer Assisted Image Analysis
∗ The National HPV Vaccination Program − Prevalence of HPV in community
∗ 2007 – Girls (12-13 year old)
∗ 2013 – Boys
∗ New Evidence - appropriate screening age ranges and ‘optimal’ intervals

7. Proposed New Cerical Screening Program
∗ Replace “Pap Smear” with HPV DNA test
∗ Genotyping HPV16, 18 +/- 45
∗ IF +ve HPV DNA test will undergo further triaging -> Reflex liquid based cytology
∗ Entry age of 25; Exit HPV test at age 70-74
∗ vaccinated and unvaccinated women
∗ Increases screening interval from 2yrs  5yrs
∗ HPV Self-Collection
∗ “Never screened” & “Under-Screened” population
∗ Registry – Invitation, Call & Recall

8. Patient Participation
 Will 5yr interval increase OR decrease participation?
 2008-2012 Patient participation (age 20-69)
2yr interval – 57.7%
3yr interval – 70.2%
5yr interval – 83.3%

9. Proposed NCSP Algorithm
∗ Safe
∗ More effective
∗ Aim to ↓ further Cervical ca by additional 15%
∗ More cost-effective

11. What does this mean for the Clinician?
∗ Collect sample from cervix
∗ If HPV +ve  Reflex cytology
∗ Clinician will receive a report with
∗ HPV status (+/- genotype)
∗ Cytology (if HPV +ve)
∗ Single recommendation

12. HPV and Cervical Cancer
∗ Double stranded DNA virus
∗ 100 different genotypes
∗ HPV infection is necessary, though not sufficient, for development Cervical ca
∗ HPV 16 & 18  ~70% of all Cervical ca
∗ 80% lifetime risk of acquiring HPV
∗ Majority infections are cleared within 2yrs

13. HPV and Cervical Cancer
∗ Cervical Ca - rare outcome of infection
∗ Natural progression of High Grade abnormalities over 1-25 years
 Common Diagnosis of HSIL 25-29 yo; Cervical Ca 44-49 yo
CIN2 CIN3
Regression 43% 32%
Persistence 35% 56%
Progression 5% >12%

14. HPV DNA Testing
∗ Currently use HPV DNA testing
∗ NOT a diagnostic tool
∗ “Test of cure” for post treated High Grade lesion
∗ Can be requested any times, But NO Medicare rebate ($80-$100)

15. ∗ Order of TEST is IMPORTANT
∗ Applying More sensitive test first (HPV DNA)
∗ Negative Predictive Value (NPV of >99%)
∗ Reduce number of False Negatives
∗ Applying More specific test second (LBC)
∗ Good Positive Predictive Value
∗ Reduce number of False Positives
∗ ↓↓ unnecessary referral and follow-up
WHY Combined HPV DNA Test + Reflex LBC?

16. Incidence of Cervical Cancer in <25yo
 ~2.3/100,000 (rare)
 NO effect on incidence of Cervical Ca
 Increased risk of future pregnancy
 HPV vaccination

17. HPV Vaccination & Abnormal Cervical Screening
2006 vs 2011:
Decline high grade in <20 & 20-24

18. HPV Vaccination Program & Genital Warts
women men

19. Improving Participation – SELF COLLECTION
∗ 20% did not participate in screening
∗ Victorian Cervical Cytology Register
∗ In 2009, 80% invasive Ca had never been screened OR lapsed screeners
∗ ATSI
∗ 2x incidence of Cervical Ca
∗ 4x mortality rate in comparison to non-indigenous
∗ Self-Collection  ↑participation rates

20. A Paradigm Shift? Changing Perspective
∗ By using HPV DNA as primary diagnostic tool
∗ Disease no longer cytological / histological diagnosis
∗ BUT
∗ Sexually Transmitted Infection
∗ Altered patient perception -> stigma?

21. TAKE HOME MESSAGE
∗ Procedure for collecting sample remains the same
∗ 5-year screening ONLY applies to women with negative results
∗ Women with HPV +ve will require further investigation and closer monitoring
∗ SYMPTOMATIC women (post coital bleeding, intermenstrual bleeding) need
investigation
∗ The ‘NEW’ NCSP applies only to asymptomatic women
∗ HPV vaccinated women will still require screening

22. Questions?
http://www.goldcoastwomencare.com.au