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AMA (WA) | Louise Farrell blog

National Cervical Screening Program Update

Friday January 15, 2021

Dr Louise Farrell, Consultant Obstetrician and Gynaecologist Head of Colposcopy Services King Edward Memorial Hospital

In December 2017, the ‘renewed’ Australian National Cervical Screening Program (NCSP) commenced, with the following main features:

  • Five-yearly primary HPV screening with reflex cytology (Cervical Screening Test) replaced two-yearly cervical cytology (Pap smear).
  • Screening commences at age 25 years and finishes between 70 and 74 years.
  • Self-collection of vaginal samples for under-screened and never-screened women.
  • A National Cancer Screening Register (NCSR) that captures the entire cervical screening history, pathology, vaccination status and for the first time, colposcopy data.

It is anticipated that the new NCSP will further reduce incidence and mortality by about 30 per cent, and in combination with HPV vaccination, there are predictions of virtual elimination.

Despite disappointing major delays, the NCSR is now fully functional and responsible for invitation and recall of women, as well as data collection. This data informs Australian Institute of Health and Welfare (AIHW) screening statistics, the quality and safety of the program and potential evidence-based modifications and clinical guidelines.

Clinical management guidelines are an essential part of any program and previously these were printed and ‘set in stone’ until reviewed. The NCSP Guidelines (2015) are on an electronic Wiki platform and can be easily updated in the light of new evidence. The guidelines comprise 217 ‘pages’ advising the management of screen-detected abnormalities and the management of symptomatic women.

Initial NCSR data revealed an unexpectedly disproportionate number of ‘symptomatic’ women referred for HPV testing, largely due to misinterpretation of the term ‘symptomatic’. This led to further detailed clinical guidance, updated in the Wiki Guidelines.

Most cervical cancers in Australia occur in under-screened and never-screened women. It was hoped that the introduction of self-collection could result in improved screening rates in these women.

The uptake has been disappointingly low, mainly due to an initial paucity of laboratories providing the test and eligibility restrictions placed on self-collection. The recommendations regarding self-collection were formulated when it was considered the test sensitivity was inferior to health provider-collected samples. More recent evidence has demonstrated equal sensitivity and an expert working party is looking at significant changes to the current self-collection policy.

Another potential change to the program will be the management of the intermediate risk group (HPV not 16-18 and low-grade cytology). These women have their test repeated at 12 months and if HPV persists, they are recommended for Colposcopy. This led to a much higher-than-expected number of women being referred for Colposcopy, due to lower-than-predicted levels of HPV clearance. An expert group is considering if these women who have negative or low-grade cytology could safely wait another 12 months to see if there is viral clearance. A draft document outlining this change was distributed for public consultation in August 2020 and remains under consideration.

This highly successful screening program is reliant on participation by eligible women. The COVID situation has seen a marked reduction in women screening across Australia. This has been less pronounced in WA, but there are many women who are overdue for their screening test. It is hoped that GPs will encourage women to screen.

Another issue in WA is the low availability of public Colposcopy appointments. This has been exacerbated by the closure of the Bentley gynaecology service. King Edward Memorial Hospital’s waiting list has blown out considerably. However, this should be helped in the near future by the opening of a public Colposcopy clinic at Joondalup Health Campus.