The document discusses changes to the National Cervical Screening Program in Australia beginning in May 2017. Key changes include replacing the Pap smear with an HPV test as the primary screening, increasing the screening interval to 5 years, and expanding the age range screened to include women ages 25-74. The goal of the changes is to make cervical cancer screening safer, more effective, and more cost-effective by reducing unnecessary tests and follow-ups through a more targeted approach focused on HPV testing.

1. Dr DONALD ANGSTETRA Bsc(Med) | MBBS|FRANZCOG
A/Clinical Lead in Gynaecology |Women’s health | Gold Coast University Hospital
Senior Lecturer | Griffith University
Visiting Medical Officer | Allamanda Hospital

3.  National Cervical Screening Program
 Introduced in 1991
 2-yearly pap smear test
 In asymptomatic women who have ever been sexually active
 Age 18-69yo

4. Pre-NCSP
National Screening program
Introduced in 1991
National Screening program
Introduced in 1991
 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

5. Pre-NCSP

7.  New Knowledge of the natural history of Cervical Ca − HPV infection
 New Evidence - appropriate screening age ranges and ‘optimal’ intervals
 New technologies
 HPV DNA typing
 Liquid Based Cytology (LBC)
 Computer Assisted Image Analysis
 The National HPV Vaccination Program − Prevalence of HPV in the community
 2007 – Girls
 2013 – Boys
 The current NCSP is intensive compared to other countries

8.  Renewal commenced in 2011
 Assess evidence for screening tests, interval and targeted age-group
 Assess and recommend a cost effective screening pathway and program
model
 Improve national data collection system and registry functions
 Assess feasibility and acceptability of the new program
 Medical Services Advisory Committee (MSAC)
 Recommendations were finalised and submitted to April 2014
 The ‘NEW’ Screening Program will begin from 1 May 2017

9.  Replace “Pap Smear” with HPV DNA test as primary screening test
 Include partial genotyping for HPV16, 18 +/- 45
 +ve HPV DNA test will undergo further triaging -> Reflex liquid based cytology
 Lifts the age of commencement to 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

10.  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%

11. more complex!!
Based on modelling, the ‘NEW’ program is:
 Safe
 More effective
 Aim to  further Cervical ca by additional 15%
 More cost-effective

13.  Collect a LBC sample from cervix
 If HPV +ve
 Reflex cytology will be carried out
 Clinician will receive a report with
 HPV status (+/- genotype)
 Cytology (if HPV +ve)
 A single recommendation of management

14.  Double stranded DNA virus
 100 different HPV genotypes
 Oncogenic HPV are acquired through sexual contact
 Strong evidence that HPV infection is necessary, though not sufficient, for
development of Cervical ca
 HPV 16 & 18 cause ~70% of all cervical cancers
 80% lifetime risk of acquiring HPV
 Majority of HPV infections are cleared within 2yrs
 CIN1  acute HPV infection and viral replication
 CIN2&3  HPV DNA incorporation into the host DNA and cell immortalisation

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

16.  Currently use HPV DNA testing
 NOT a diagnostic tool
 “Test of cure” in women who have been treated for High Grade
lesion
 Can be requested at other times, But NO Medicare rebate
($80-$100)

17.  Order of testing is important
 Applying the more sensitive test first (HPV DNA test)
 Excellent Negative Predictive Value (NPV of >99%)
 Reduce the number of False Negatives
 Applying the more specific test second (LBC)
 Good Positive Predictive Value
 Reduce the number of False Positives
  unnecessary referral and follow-up

18.  ~2.3/100,000 (rare)
 NCSP had NO effect on incidence of
Cervical Ca in this age group
 Increased risk of future pregnancy
 HPV vaccination has been shown to
reduce significant cervical abnormalities

19.  Primary prevention of HPV infection
 Commenced in 2007 at 12-13yo girls
 Catch-up program extended to women up to 26yrs of age for a
period of 2yrs
 Extended in 2013 to cover 12-13yo boys
 Uses Gardasil
 Quadrivalent vaccine (HPV types 6, 11, 16, 18)

20. 2006 vs. 2011:
A decline in high grade
abnormalities in <20 &
20-24 age groups

21. women men
% of Australians diagnosed with genital warts at first visit to a sexual
health clinic (BMJ 2013; 346:f2032)

22.  20% of Australian women did not participate in screening
in the 5yr interval b/w 2007-2011
 Victorian Cervical Cytology Register
 In 2009, ~80% of women diagnosed invasive cervical Ca had either
never been screened OR were lapsed screeners
 ATSI have
 2x incidence of Cervical Ca
 4x mortality rate in comparison to non-indigenous
 Self-Collection  participation rates

23.  By using HPV DNA testing as primary diagnostic tool
 Disease no longer cytological / histological diagnosis
 BUT
 Sexually Transmitted Infection
 Altered patient perception -> stigma?

24.  Procedure for collecting sample for HPV testing remains the same
 Sample is deposited in LBC medium rather than “slide” smear
 +ve HPV test indicate the need for more testing; however patient reassurance is important
as majority of these infections regress
 The 5 year screening interval ONLY applies to women with negative results
 Women with HPV +ve results will require further investigation and closer monitoring
 SYMPTOMATIC women (i.e. post coital bleeding, intermenstrual bleeding) need
investigation regardless of AGE
 The ‘NEW’ NCSP applies only to asymptomatic women
 HPV vaccinated women will still require screening

25. http://www.goldcoastwomencare.com.au