Dr Annabelle Farnsworth Director of cytopathology at Douglass Hanly Moir Pathology , and adjunct professor of pathology at the School of Medicine , University of Notre Dame , Sydney , NSW .

All images are used with the permission of Douglass Hanly Moir Pathology .

Copyright © 2024 Australian Doctor All rights reserved . No part of this publication may be reproduced , distributed or transmitted in any form or by any means without the prior written permission of the publisher . For permission requests , email : howtotreat @ adg . com . au

This information was correct at the time of publication : 8 March 2024

INTRODUCTION

CERVICAL cancer is one of the most preventable diseases yet remains a significant global health burden .

Extensive research over the past 40 years shows the disease is invariably associated with HPV infection with oncogenic subvariants 16 , 18 or non16 / 18 ( 31,33,35,39,45,51,52,56 , 59,66,68 ). 1 Much of this work was associated with screening programs using conventional cytology preparations and cells taken from the surface of the cervix . As this test , ‘ the Pap smear ’, could detect early precancerous cell changes , lesions could be removed and cancers prevented .

Viral particles were first identified within these abnormal cells and the oncogenic pathway associated with this viral infection is now well established . This new paradigm has led to both development of HPV vaccines and accurate molecular testing for the virus . 2

Australia has had a successful screening program for the prevention of cervical cancer for more than 30 years . It was one of the first countries to recognise that an effective population-based

screening program needs to be well organised , with particular attention to participation , quality management and monitoring .

The screening test of choice for most of those years was conventional cytology , which was done to a very high standard within Australian laboratories . During this time the incidence and mortality from cervical cancer fell dramatically .

Based on the new science and the understanding of the role of HPV in the pathogenesis of this disease , the Australian National Cervical Screening Program ( NCSP ) underwent major changes in December 2017 .

Reliable molecular tests for HPV showed increased sensitivity to detection of cervical precancer than conventional cytology , leading to Pap smear screening being replaced by testing for HPV .

The age for starting screening increased to 25 years and the recommended screening interval changed from two to five years .

HPV testing has a lower specificity for high-grade disease detection but this was managed by introducing cytology triage as part of the new program .

Under triage , if a test is positive for HPV , a cytology sample is prepared and examined . Management algorithms are based on the outcomes of the combined test results . 3

Prevention of cervical cancer in Australia also includes HPV vaccination , introduced as a fully-funded Australian government vaccination program in 2007 . The success of this program was also one of the drivers for the change to the NCSP .

This How to Treat covers the changes introduced in 2017 , examines how the new screening program has performed , the issues that have arisen and the way forward . It aims to facilitate optimal GP participation in the NCSP and patient management to the highest standard .

INCIDENCE AND MORTALITY

THE Australian Institute of Health

and Welfare ( AIHW ) predicted that more than 900 cases of cervical cancer would occur in 2023 , indicating this is still a significant health burden . 4

The most recent age standardised data , however , is from 2018 . This provides a population-based rate of

7.3 per 100,000 and a rate of 11.3 new cases per 100,000 women aged 25-74 ( the screening age span ). 5

This rate of disease has changed little over the past 10 years . Figure 1 shows the rates of cervical cancer by age .

As can be seen , the peak age group is between 35 and 50 , highlighting that this is a disease of relatively younger women .

Figure 2 shows the rates of disease by rural and remote , socio-economic and Indigenous status . This highlights the large variation in the incidence of this disease across Australia .

The significantly higher incidence in the Aboriginal and Torres Strait Islander population has been known for many years and is a focus of the renewed screening program .

A fall in the incidence is yet to be seen and the mortality rate is also unchanged at 4 per 100,000 head of population . Also of note is the variation in geography and socio-economic status . 5

Figure 3 shows a breakdown of mortality data for Aboriginal and Torres Strait Islander women with respect to socioeconomic and geographic status .