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Renewal of the National Cervical Screening Program

This page provides a summary for health professionals of information about the Renewal of the National Cervical Screening Program and where to go for more details.

Overview of the changes

From 1 December 2017, cervical screening will change:

  • The Pap test will be replaced by a new Cervical Screening Test 
  • Women should have a Cervical Screening Test every 5 years instead of a Pap test every 2 years
  • Women will be invited to start screening at age 25 and should have a final (exit) test when they are aged between 70 and 74

Women with a normal screening history will be due for their first Cervical Screening Test two years after their last Pap test.

The Cervical Screening Test detects infection with human papillomavirus (HPV), the virus that causes abnormal changes in the cells of the cervix, which if left untreated may eventually lead to cervical cancer.

If oncogenic HPV is detected, partial genotyping is used to categorise into two groups – oncogenic HPV types 16/18, or other oncogenic HPV types not 16/18 (as a pooled result).

Reflex liquid-based cytology (LBC) is applied to all HPV-positive samples to triage women into one of three risk levels and to inform clinical management.

Women whose Cervical Screening Test shows they do not have oncogenic HPV are classed as ‘Low risk’ and are advised to screen every five years.

The National Cervical Screening Program: Guidelines for the management of screen-detected abnormalities, screening in specific populations and investigation of abnormal vaginal bleeding were developed to support the renewed National Cervical Screening Program (NCSP).

Transitioning patients from the Pap test to the Cervical Screening Test

From 1 December 2017:

  • Women aged 25-74 with a normal screening history are due for their first Cervical Screening Test two years after their last Pap test. If the result is HPV-negative, they will be invited to screen again in five years.
  • For women aged less than 23 who have screened previously, if their last Pap test result was normal they will receive an invitation to screen around the time of their 25th birthday.
  • Women should have a final (or ‘exit’) test when aged between 70 and 74. If this shows no HPV infection, they can exit the screening program.

If you have women in your care who have had a previous abnormality and are undergoing investigation, treatment or follow-up, refer to this chart for ongoing management.

Results of the Cervical Screening Test

Based on the result of the HPV test and reflex LBC, healthcare providers will be provided with a risk rating and a recommendation for management, outlined in the table below.

For information about the management of oncogenic HPV test results, refer to Chapter 6 of the Guidelines.

Women should be advised of their management outcome based on their result, as indicated below:

  • Return to screen in five years
  • Repeat the test in 12 months
  • Refer to specialist
  • Unsatisfactory test

Risk rating

Based on

Management

Explaining the result – key points

Low risk

Oncogenic HPV was not detected

Return to screen in five years

  • The test shows no infection with an HPV type that causes cells to change.
  • It is safe to screen again in five years time.
  • The NCSR will send a letter to remind you when you are due to screen again.
  • Patients are classed at ‘low risk’, but not ‘no risk’ as they may subsequently acquire an HPV infection or have a latent infection that becomes active.
  • The Cervical Screening Test is different to the Pap test. It is a better test, because it looks for the infection that causes cell changes, whereas the Pap test detected the cell changes only.

Intermediate risk

Oncogenic HPV detected – not types 16 and/or 18

and

Reflex cytology found either:

  • LSIL, or
  • pLSIL or
  • was negative

Repeat HPV test in 12 months

  • The test shows infection with a type of HPV and either no changes or low grade changes to the cells of the cervix. .
  • A repeat the test in 12 months is to check that the HPV infection has cleared up naturally.
  • For most women, an HPV infection clears up within 1 or 2 years.
  • The NCSR will send a letter to remind you when you are due for this test.
  • Minor (low grade) cell changes usually clear up without needing treatment.

Higher risk

Oncogenic HPV detected type 16 and/or 18

or

Oncogenic HPV detected not types 16 or 18 and reflex cytology found either:

  • HSIL or
  • pHSIL or
  • any glandular abnormality

Refer to specialist for colposcopy

  • The test shows infection with a type of HPV that means you need further investigation by a specialist.
  • If HSIL is present – the test shows cells have changed and you need further investigation by a specialist.
  • This result does not mean cancer is present, though it is important that the referral to specialist is acted on.

Unsatisfactory

The sample could not be tested – either HPV or LBC

Repeat test in 6-12 weeks

  • Your sample  could not be tested by the laboratory. Another sample will need to be collected in 6-12 weeks for testing.
  • If only LBC needs to be repeated – a sample of cells should be collected from the transformation zone of the cervix, which has two types of cells. By collecting the sample from this zone, both types of cells should be collected. Because every cervix is different, sometimes it is harder to collect both types.

HPV – human papillomavirus; HSIL – high-grade squamous intraepithelial lesion; LBC – liquid-based cytology; pHSIL – possible high-grade squamous intraepithelial lesion; LSIL – low-grade squamous intraepithelial lesion; pLSIL – possible low-grade squamous intraepithelial lesion  

The four pathways are shown in the Management pathway diagram.

Resources:

National Cancer Screening Register

The National Cancer Screening Register (NCSR) is a secure and confidential database of women’s cervical screening test results. It will be established in phases. Since 1 December 2017, Cervical Screening Test results are collected and stored by the NCSR. 

  • Healthcare providers should continue to follow their existing processes for providing Cervical Screening Test results and advising women of any further testing or referral to a specialist according to the Guidelines.
    • The NCSR will not perform this function – always provide the results of a screening test to your patient.
  • Writing ‘Not for Register’ on pathology forms will no longer be a valid way of removing patients from the cervical screening register. To ‘opt-out of’ the NCSR, patients need to call 1800 627 701. If the patient is unable to call the NCSR, you as their healthcare provider, or their personal representative if they have one, can call on their behalf.
  • The National Cancer Screening Register (NCSR) will contact healthcare providers to follow-up women who have recorded a high-grade abnormality in a Pap test completed before 30 November 2017 if they have not returned for further testing.
  • Invitations and reminders will not be sent to women until the second phase of the establishment of the NCSR – which is expected to happen by mid-2018.

Accessing histories

  • A woman’s Pap test history can be requested by calling 1800 627 701

Contacting the NCSR

Healthcare providers can contact the NCSR on 1800 627 701 if you need to query a result.

Women can call the NCSR contact centre on 1800 627 701 to:

  • Provide alternative contact details
  • Check the dates of your previous and next tests
  • Change the date of your next test
  • Choose a healthcare provider to receive your results
  • Opt out of the register

NCSR in future

Once fully established, the National Cancer Screening Register (NCSR) will be a national database of cancer screening records, including Cervical Screening Test results.

The NCSR will support the National Cervical Screening Program by:

  • Inviting women to commence screening when they turn 25
  • Reminding women when they are due or overdue for cervical screening
  • Providing a woman’s cervical screening history to laboratories, which in combination with current results, will inform clinical management
  • Providing a ‘safety net’ for women who have positive HPV test results and who have not attended for further testing, by prompting them to have follow-up tests or treatment.

The renewed National Cervical Screening Program (NCSP) will collect data about Indigenous status to enable improved monitoring.

Healthcare professionals should ask all women whether they identify as Aboriginal or Torres Strait Islander, and this should be recorded on the pathology request form in accordance with ABS classification and standards.

Pathology requests and MBS items

From 1 December 2017, the Pap test is not covered under the Medicare Benefits Scheme (MBS). New Cervical and Vaginal testing MBS item numbers will replace the Pap test. From 1 December 2017, if healthcare providers write ‘Pap test’ or ‘smear’ on the pathology request form, their patient will be charged for the cost of the test.

Healthcare providers need to provide as much information on the pathology request form as possible, to avoid the wrong pathology test being performed on the sample, or the patient being charged incorrectly.

Provide the patient’s presentation and testing history on the pathology request form to correctly order the Cervical Screening Test.

The Pathology test guide for Cervical and Vaginal testing provides a list of the MBS items, and the type of information healthcare providers should include.

Resources

Women under 25 

Under the renewed National Cervical Screening Program, routine cervical screening is not recommended for women under 25 years. Some women under 25 will have had previous screening and may present to you with an expectation to continue.

Medicare does not fund routine Cervical Screening Tests for women under 25.

Any tests submitted to pathology laboratories will need to be privately funded, or with the consent of the referring practitioner, it will not be processed.

Answers to common questions women may ask are provided below, including the change to start screening at 25.

  • As with women of any age, women under 25 currently under clinical management for a cervical abnormality should continue to be managed according to the guideline recommendations on transitioning patients to the renewed Program.
  • Women who experienced first sexual activity at a young age (<14 years) may be offered a single HPV test between the ages of 20-24 years. The Pathology Test Guide includes an item for this test.

Resources 

Screening women with specific needs

Screening after hysterectomy

The following information is taken from the Guidelines.

For patients who had sub-total hysterectomy (i.e. cervix was not removed) should have routine five-yearly Cervical Screening Tests, or as recommended if they have had recent cervical abnormality.

For patients who have had a total hysterectomy for documented benign reasons (e.g. menorrhagia, fibroids), no further tests are required if they were in the normal screening program prior to their hysterectomy.

Patients who have had a total hysterectomy with past history of HSIL should have co-testing (HPV and LBC from the vaginal vault) 12 months after treatment, and annually until both tests are negative on two consecutive occasions, at which time they can discontinue screening.

If a woman has completed a Test of Cure prior to the hysterectomy, and there was no cervical pathology, she does not require any follow-up.

Self-collection for HPV testing is not appropriate for patients who have had total hysterectomy with a past history of HSIL.

Resources

Screening in pregnancy

The following information is taken from the Guidelines. 

Routine antenatal care should include cervical screening when it is due or overdue.

A broom-type brush is recommended for collection of the cervical screening sample in pregnant women. The endocervical brush is not recommended.

Sample self collection for HPV testing is not recommended for pregnant women.

For some women, pregnancy may be the first opportunity for cervical screening. As cervical cancer is more likely to be diagnosed in never- or under-screened women it is particularly important to attempt to engage these women in screening.

Resources

Screening women who experienced early sexual intercourse or sexual abuse

The following information is taken from the Guidelines.

Human papillomavirus (HPV) infection often occurs shortly after first sexual activity. Women who experience first sexual activity at an early age and are subsequently infected with oncogenic HPV may have a higher risk of cancer over time if these infections persist.

For women who experienced first sexual activity at a young age (<14 years), and who had not received the HPV vaccine before sexual debut, a single HPV test between the ages of 20 and 24 may be considered on an individual basis.

Consider that some women who engaged in early sexual activity may have or be in an abusive situation. Consider referral to specialist sexual assault counselling services as appropriate.

The Pathology test guide includes an item for screening women who experienced early sexual activity.

Resources

Screening in immune-deficient women

The following information is taken from the Guidelines.

This relates to women with acquired immune deficiency due to viral infection (e.g. HIV - human immunodeficiency virus), treatment with immunosuppressant drugs to prevent transplant rejection or to control an autoimmune disease, as well as women with inherited primary immunodeficiency disorders.

The Guidelines recommend that immune-deficient women should be screened with a HPV test every 3 years. If they return a positive HPV result (any type) they will be referred for colposcopic assessment.

The Pathology test guide includes an item for screening immune-deficient women.

Resources:

Screening in DES-exposed women

The following information is taken from the Guidelines.

Diethylstilbestrol (DES) is a synthetic oestrogen, transplacental carcinogen and endocrine disrupting compound. It was prescribed from the 1940s until the early 1970s, mainly to pregnant women in the first trimester to prevent miscarriages. DES is no longer registered for human use in Australia.

According to the Guidelines, women exposed to DES in utero should be offered an annual co-test and colposcopic examination of both the cervix and vagina indefinitely. 

The daughters of women exposed to DES in utero do not require additional surveillance, and should have routine screening (five-yearly Cervical Screening Tests with appropriate management of abnormalities). If these women have concerns, testing similar to that recommended for their DES-exposed mother may be considered on an individual basis.

Self-collection for HPV testing is not recommended for these women. 

The Pathology test guide includes an item for screening women exposed to DES.

Resources

Self-collection of samples

Eligibility

Before offering the option to self-collect, ensure the patient is eligible for self-collection.

Self-collection of a vaginal sample for screening is available to women based on the following eligibility criteria:

  • Women who are aged 30 years or over; AND
  • Have declined a clinician-collected sample; AND are either:
    • Overdue for cervical screening by two years or more (i.e. four years since last Pap test); OR
    • Have never screened

Self-collection is not suitable if your patient is:

  • Less than 30 years of age
  • Pregnant, or thinks she may be pregnant
  • Symptomatic or experiencing unusual bleeding, pain or discharge
  • Has had a total hysterectomy with past history of HSIL
  • Been exposed to DES in utero

Currently, COPAN FLOQswabs are the only swabs to be used for self-collected specimens. Liaise with your pathology provider to obtain these swabs.

The Pathology test guide includes an item for self-collection of a sample for screening.

Should I offer self-collection to all eligible women?

  • Self-collection is a tool to engage eligible women who otherwise refuse to participate in cervical screening
  • You should explain to a woman who is eligible and prefers self-collection, that she will collect a vaginal sample, which can be tested for HPV only. A self-collect sample will not have any cervical cells and cannot be viewed to determine whether her cervical cells have undergone any changes. If she tests positive for HPV she will either need to return for a clinician-collected sample from her cervix (if she tested HPV positive types not 16 and/or 18) or will be referred directly for a colposcopy (if she tested HPV positive types 16 and/or 18)
  • A clinician-collected sample also provides the opportunity to view the health of her cervix and genital area.
  • Screening using a self-collected vaginal sample is better than avoiding screening altogether, so use your judgment to decide based on individual conversations with your eligible patients.

Resources

Guidelines and training

The National Cervical Screening Program: Guidelines for the management of screen-detected abnormalities, screening in specific populations and investigation of abnormal vaginal bleeding were developed and published by Cancer Council Australia, in accordance with National Health and Medical Research Council (NHMRC) recommended processes. 

The Guidelines are available on a web-based wiki platform, allowing feedback and regular updating as new evidence emerges.

The guidelines have been reviewed and endorsed by:

  • The Royal Australian College of General Practitioners (RACGP)
  • The Royal College of Pathologists of Australasia (RCPA)
  • The Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG)
  • The Australian Society for Colposcopy and Cervical Pathology (ASCCP)
  • The Australian Society of Gynaecologic Oncologists (ASGO)

Cervical cancer education modules were developed to support the Guidelines, for GPs, nurses, sexual health physicians and gynaecologists. Separate modules are available for professionals providing primary colposcopy.

Modules are available at: wiki.cancer.org.au/australia/Guidelines:Cervical_cancer/Screening/E-learning

Cervical Screening Online Training Modules are available to support healthcare professionals prepare for the implementation of the renewed NCSP. They were developed by the National Prescribing Service (NPS) and are available for general practitioners and nurses:

The modules are accredited with RACGP, Australian College of Rural and Remote Medicine (ACRRM), Australian College of Nursing (ACN), Australian College of Midwives (ACM) and the Australian Primary Health Care Nurses Association (APNA).

Resources

A number of resources have been developed by the National Cervical Screening Program. These are available to download or order hard copies (free of charge).

The Victorian Cytology Service has developed a number of factsheets about the changes to cervical screening: www.vcspathology.org.au/practitioners/renewal-documents

Further information for women

NSW Factsheet for women: Information about the changes to cervical screening

Information for women about the changes to cervical screening

Family Planning NSW – Information about the changes to cervical screening

A Cancer Council website for women provides an overview of the changes to cervical screening

 

Questions women may ask

This section provides suggested responses to questions or statements you might hear from women.

How is cervical screening changing?

From 1 December 2017 the Pap test was replaced by a new Cervical Screening Test. The new Cervical Screening Test looks for the virus that causes changes in the cells of the cervix that can eventually lead to cervical cancer.

The key changes are:

  • The Cervical Screening Test  replaced the Pap test
  • Women should have a Cervical Screening Test every 5 years instead of a Pap test every 2 years
  • Women will be invited to start screening at age 25 and should have a final (‘exit’) test when they are aged between 70 and 74

Women with a normal screening history will be due for their first Cervical Screening Test two years after their last Pap test.

A National Cancer Screening Register is being established to support cervical screening. Once it is ready, it will send letters of invitation, reminders and follow-up.

Why did cervical screening change?

Since Pap tests were introduced as the method of cervical screening in 1991, science and technology has improved significantly. There is a much greater understanding of what causes cervical cancer – an infection with human papillomavirus (HPV), which doesn’t clear up.

We can now test  cervical cells for HPV types that  can lead to cancer, if the HPV infection doesn’t clear up. By finding HPV, we know which women are at more risk of developing the cell abnormalities that may eventually lead to cancer, so we can monitor and treat them (if needed) even earlier than we were able to when  cell abnormalities were found through a Pap test.

Fantastic, no more Pap smears!

The changes are great news for women – but women should be aware that the way the Cervical Screening Test is done is the same as for a Pap test/smear. Based on the increased interval, women should experience far fewer tests over their lifetime.

The Pap test was able to find cells that had begun to change or become abnormal. The Cervical Screening Test looks for HPV, the infection that causes the cells to change. 

The Cervical Screening Test is better than the Pap test at predicting how likely cervical cells are to change. Following a negative HPV test (no HPV detected), there is a very low likelihood that the cells will start to change in the next five years.

Are these changes because the government is trying to save money?

It might look like the government will save money by saying women need fewer tests, but the changes are based on science, not money. By making these changes now, the government is investing more now, which will save a lot of women from getting cervical cancer in the future.

The Cervical Screening Test will be supported by the Medicare Benefits Schedule (MBS), as the Pap test was. If the healthcare provider bulk-billed a Pap test, it should not change for the Cervical Screening Test.

What will the new test cost?

There are two costs involved in having a cervical screening test – the doctor’s consultation cost and the cost of the laboratory test. A Medicare rebate is available for both the consultation fee and the laboratory test, and some practices and pathology laboratories bulk bill, which means there are no out of pocket expenses to the woman.

The cost of the doctor’s consultation will depend on the general practice or health centre a woman attends. Women can ask what the cost will be when they make their appointment.

Is it safe to start screening at age 25?

The reason for changing the starting age to 25 for cervical screening is based on extensive research showing that it is safe to start at 25 because:

  • Cervical cancer is rare in women aged under 25
  • Most young women are protected against the main cancer-causing types of HPV by the HPV vaccine. If your patient hasn't had the vaccine themselves, 'herd immunity' provides a level of protection against HPV. Without an HPV infection, it is extremely unlikely that cervical cancer would ever develop. 
  • For those young people who do get a HPV infection, it is usually transient, meaning it is cleared up by their immune system without causing any harm. 
  • After more than 25 years of screening women under 25, the data shows there is little benefit to screening young women, and it can actually cause some harm. Treatment for minor cell changes can cause pain, bleeding and risk of infection, plus a small risk of causing problems for future pregnancies. The vast majority of cell changes in young women clear up naturally, without ever needing treatment.

Is it safe to wait five years between Cervical Screening Tests?

It is important to remember that the Cervical Screening Test is different to the Pap test – it is not the same test being offered less often. Screening every five years is for women whose Cervical Screening Test result shows they don’t have HPV. The new Cervical Screening Test is more accurate than a Pap test, and the risk of developing cervical disease within five years after a HPV-negative result is very low.  

It’s important for women to remember that if women have any signs or symptoms, such as unusual bleeding or pain – they shouldn’t wait until their Cervical Screening Test is due, but should see a doctor as soon as possible. 

What is HPV?

The human papillomavirus (HPV) is a very common virus. It is transmitted through sexual activity, by genital skin-to-skin contact.

Usually HPV causes no symptoms and is cleared by the body’s immune system.

How did I get HPV?

HPV is very common, passed on during sexual activity. It is transmitted through genital skin-to-skin contact during sexual activity. It is not only transmitted during penetrative sex.

Having HPV does not indicate promiscuity. People with only one sexual partner, or those who have had sex once may have picked up an HPV infection. 

How does HPV cause cancer?

When HPV infects the cells lining the surface of the cervix, it can disrupt the regular functions of the cells, and can cause them to become abnormal. Usually the body’s immune system recognises the virus and destroys the infected cells. When it doesn’t, a persistent infection results. If infected cells continue to grown, they can eventually become precancerous cells, and if left untreated, these cells may progress to cancer.

HPV types 16 and 18 cause over 70% of all cervical cancers in Australia. Other types of HPV cause most of the other cervical cancers. 

I had the HPV vaccine, so I don’t need cervical screening.

The HPV vaccine protects against the types of HPV that cause most cervical cancers, but not all of them, so it is important that vaccinated women participate in regular screening.

Types 16 and 18 cause about 70% of cervical cancers – the HPV vaccine protects against these types.

Is my information safe in the National Cancer Screening Register?

Data collected by the NCSR is protected by legislation and cannot be used for any other purpose other than to support the operations of the cervical screening program, inform ethics-approved research projects, and report on outcomes at a population level.

How can I opt out of the Register?

Results of Cervical Screening Tests are sent to the National Cancer Screening Register.

If a woman wishes to opt out of the Register, she (or her healthcare provider if the woman gives permission) can phone the Register’s contact centre on 1800 627 701. If a woman decides to remove her details, the Register will not send letters reminding her when to screen.

A health professional writing ‘Not for Register’ on the pathology form is no longer accepted. 

Why has a national register been set up?

For every 10 women diagnosed with cervical cancer, eight of them had either never screened or were not up-to-date with their screening. There are many reasons why women don’t screen when they are due, and for some women it is because they didn’t know they were meant to, or they forgot they were due.

The old (state-based) registers were not allowed to invite women who had never screened before, and they were only allowed to remind a woman about cervical screening once she was overdue. The new Register has different legislation, so it will send an invitation letter to a woman when she turns 25, and send letters to women letting them know they are due for a Cervical Screening Test soon, as well as reminding them if they are overdue.

It will also act as a safety net for women who have positive test results and have not attended for further tests, by prompting them to have follow-up tests. 

Will I receive my results from the register?

No. The National Cancer Screening Register (NCSR) does not provide results to women following a Cervical Screening Test. The NCSR will:

  • Invite women to commence screening when they turn 25
  • Remind women when they are due or overdue for cervical screening
  • Provide a woman’s cervical screening history to laboratories for comparison with current results
  • Provide a ‘safety net’ for women who have positive test results and who have not attended further testing, by contacting their healthcare provider and then themselves, to prompt them to have follow-up tests.

I heard that Telstra is in charge of the register. Is that true?

Telstra Health (part of Telstra) was selected to build and operate the new National Cancer Screening Register following a competitive tender process.

Information collected by the NCSR is protected by law, and can only be used to:

  • Support the operations of the screening program
  • Inform ethics-approved research projects
  • Report on outcomes at a population level

Private information will not be released to any other party.