Introduction to cervical cancer and cervical screening

About cervical cancer

1 in 200
women will develop cervical cancer before the age of 75
stopwatch
4 in 10
eligible women are overdue for cervical screening
77%25 reduction in HPV

Cervical cancer can be prevented. 
Vaccination and regular screening protects from cervical cancer.
80%25
of cervical cancer occurs in women who have never screened or are not up-to-date with their cervical screening
Over 99%25
of cervical cancer is caused by human papillomavirus (HPV)

About the National Cervical Screening Program (NCSP)

  • A jointly-funded Commonwealth/State and Territory initiative, the NCSP aims to identify women at increased risk of eventually developing cervical cancer, so they can be monitored and treated appropriately.
  • The National Cancer Screening Register (NCSR) supports the operations of the NCSP by providing a secure, confidential database of screening records.
  • The NCSR invites women aged 25–74 to have a Cervical Screening Test (which replaced the Pap test*) when they are due. This new Register has replaced the Pap Test Registers within states and territories, providing a national database of screening records for cervical screening.
  • The Cervical Screening Test looks for the presence of human papillomavirus (HPV). In nearly all cases (more than 99%), an HPV infection that does not clear up is the first step in the development of cervical cancer.29
  • The Cervical Screening Test is for:
    • women aged 25 to 74 who have ever been sexually active
    • women who have had the HPV vaccination and those who have not been vaccinated.
  • The Cervical Screening Test has two parts; the first is a test for oncogenic (cancer-causing) HPV. The second test, reflex liquid-based cytology (LBC), is automatically performed on the same sample if the HPV test is positive for any oncogenic HPV type. The results of the LBC help to inform management recommendations. Both samples are reported at the same time by the laboratory and a single result with recommendations is issued.
  • For patients that may have refused to screen, an alternative method of sample self-collection is available. However, patients must meet the following eligibility criteria:
    • Aged 30 years and over, and be at least two years overdue for their screening test OR
    • Aged 30 years and over, and have never had a screening test.
  • Women are invited to take an exit screen from age 70 to 74. If the result is normal and there is no HPV, then the woman can exit the program.

The role of general practice

General practice performs around 85% of cervical screening in NSW. Your role is critical to the success of the National Cervical Screening Program and its objective to reduce the incidence of cervical cancer in NSW.

Research has shown that women are more likely to undertake cervical screening if their health professional has discussed screening with them and has recommended they screen.

It is important for practices to have processes in place to systematically remind all eligible patients to attend cervical screening.

Health professionals also play an important role in introducing and discussing cervical screening with patients, especially when engaging with women who are reluctant to screen and those who have forgotten that they are overdue for their Cervical Screening Test.

By providing a friendly, safe and sensitive environment, your support is fundamental to a woman’s decision to have a potentially life-saving Cervical Screening Test. As part of your discussions with women about cervical screening, it is important to help your patients understand important information, such as:

  • what cervical screening involves
  • why screening is important
  • why the Cervical Screening Test is relevant to them
  • what their test results mean.

The need to improve cervical cancer screening participation

  • Almost 80% of cervical cancers occur in women who have never been screened or are not up-to-date with their cervical screening.30
  • Most women with HPV infection will not have symptoms. By detecting HPV in women who aren’t aware they have the infection, cervical screening prevents the development of cervical cancer and saves lives.
Biennial cervical screening participation rate for women aged 20–69, by primary health network (PHN) (ranked), July 2014 – June 2016 and July 2015 – June 2017

Biennial cervical screening participation rate for women aged 20–69, by PHN (ranked), July 2014 – June 2016 and July 2015 – June 2017

N = Number of women aged 20 to 69 years in the population who have not had a hysterectomy, July 2015 to June 2017.

Notes:

  1. Data source: NSW Pap Test Register (population data are sourced from SAPHaRI, Centre for Epidemiology and Evidence, NSW Ministry of Health, and adjusted for hysterectomies).
  2. Data source of hysterectomy fractions: NSW Population Health Survey, NSW Ministry of Health, 2012.
  3. NSW includes de–identified tests. However, de–identified tests are excluded from LHD breakdowns as this information is not available.
  4. The NSW Pap Test Register transitioned to the National Cervical Screening Register (NCSR) in November 2017.
    Therefore, we are unable to report participation for the period ending December 2017. The biennial reporting period has been modified to end  June 2017, with all comparison periods also shifted.
Useful resources:

Useful resources:

Changes to MBS items

The Pap test is no longer covered under the Medicare Benefits Scheme (MBS) and has been replaced with the Cervical and Vaginal Testing and accompanying MBS item numbers.

Health care providers will need to know the differences between the MBS items and provide as much information on the pathology request form as possible. This will avoid the wrong pathology test being performed on the sample and may result in the patient being charged incorrectly for a test.

To assist with completing the pathology request, please refer to the Pathology test guide for cervical and vaginal testing.

The screening pathway

The Cervical Screening Test and cervical screening pathway is a risk-based approach to the management of HPV and cervical cancer, as recommended by the Medical Services Advisory Committee (MSAC). Patients are managed according to their risk of developing significant cervical abnormalities within the next five years, which is determined by their Cervical Screening Test result.

While the National Cancer Screening website provides the most up-to-date information on the cervical screening pathway, this has also been outlined below.

For clinician-collected specimens that test HPV positive, reflex liquid based cytology (LBC) is performed on the same cervical specimen (without requiring an additional request). The pathology laboratory will issue the HPV test result, LBC test result and overall screening risk rating as a combined report.

Self-collection of a vaginal sample can only be tested for HPV. A new pathology request will be required for the clinician-collected specimen for reflex LBC testing only. The pathology laboratory will then issue a combined report with the initial self-collect HPV test, LBC test result and overall screening risk rating as a combined report.

If any glandular abnormalities are detected on a screening test, health care providers should follow up according to the 2016 Guidelines.

There are four result categories:

  1. Return to screen in five years
  2. Repeat the HPV test in 12 months
  3. Refer to a specialist
  4. Unsatisfactory sample (HPV or LBC); retest within 6–12 weeks

The screening pathway

This result means oncogenic HPV was not detected. Patients with this result will be invited to screen again in five years.

These patients are at low risk of developing cervical cancer and can safely return for a Cervical Screening Test in five years.

We cannot assure patients that they are at ‘no risk’ because they may subsequently acquire an HPV infection or have a latent infection that becomes active.

This result means an HPV infection was detected. It is not associated with high-grade cell changes that require treatment.

A reflex LBC conducted on the same sample showed that the patient has negative or possible low-grade squamous intraepithelial lesion (LSIL), or LSIL abnormal cervical cells.

These patients will be invited to return for a repeat HPV test in 12 months. This is to check if the body has cleared the HPV infection.

This result means the patient has received one of two possible results:

  • HPV is detected, but not types 16 or 18
    A reflex LBC will be conducted on the same sample. If possible high-grade squamous intraepithelial lesion (HSIL) or HSIL on cytology has been detected, the patient should be recommended to a specialist to have a colposcopic assessment because they are at a higher risk of cervical cancer. A colposcopy will determine if a biopsy is needed and treatment is required.
  • HPV types 16 or 18 have been detected
    HPV types 16 and 18 are associated with approximately 70% of cervical cancers. These HPV types are more likely to progress to cervical cancer than other oncogenic HPV types. Regardless of the reflex LBC test result, the patient should be recommended to have a colposcopic assessment because they are at a higher risk of cervical cancer. The LBC will inform the colposcopic assessment.

This result means the sample collected was unsatisfactory. If the HPV test was unsatisfactory, the patient should return with 6 to 12 weeks for a repeat HPV test. If the LBC test was unsatisfactory, the patient should return with 6 to 12 weeks for a repeat LBC test. The four pathways for clinician-collected sampling are shown in the diagram below.