Australian Doctor 8th March issue | Page 24

PAGE 22

assessment and data col-

Specific programs are being devel-

higher risk of having cervical disease

The only validated swab for self-col-

with age , reflecting natural immu-

lation , including participation rates ,

oped to address equity of access for

than those undergoing routine screen-

lection in Australia is the red-topped

nity . Of note is the persistence of low

rates of HPV infection , and follow-up information .

The register also provides data to

Indigenous populations , particularly in rural and remote settings . 11 Programs looking at specific needs in

ing . Performing the HPV and cytology tests concurrently decreases the risk of either a false-negative HPV result or

flocked swab ( see figure 8 ). It is vital that this is the only type used , as it is the specific nature of the swab that

rates of infection with HPV 16 or 18 . The rates of HPV infection in all age groups are higher in the self-col-

the AIHW for its annual report . 5

these communities such as “ see and

false-negative cytology .

releases the viral DNA particles appro-

lection subgroup .

Participation and equity of access

Even before the 2017 renewal of Aus-

treat ” are being investigated .

Australia ’ s understanding of the significance of equity of access and barriers to screening has prompted

The sample , therefore , has to be taken from the cervix and collected into a liquid-filled jar .

If the patient is negative for HPV

priately into the test analyser .

The only collection device for clinician-collected swabs is the cervix sampler / broom / cytobrush .

Rates of detection of abnormalities

The rates of histologically-proven

tralia ’ s cervical screening program ,

the introduction of the self-collect

they return in five years for routine

Figure 7 outlines the management

high-grade lesions , stratified by year ,

it was known that participation had

screening option .

screening .

algorithms for the self-collect pathway .

appear in figure 10 .

fallen substantially from its peak in the early 2000s .

It is difficult to get an accurate current participation rate . The latest

SELF-COLLECT

THE Concept of self-collecting a cervical screening test sample has been

If the patient tests positive for HPV 16 or 18 , NCSP guidelines recommend direct referral for colposcopy , where a sample for cervical cytology will be

Outcomes of self-collection to date

The latest NCSR data since the expan-

Notably , there has been a significant increase in detection of high-grade abnormalities since the introduction of HPV testing in Aus-

figures from the AIHW assess partic-

understood for many years ; this is now

taken . Douglass Hanly Moir pathology

sion of self-collection to all eligible

tralia ’ s screening program . This

ipation at 62 % but this number also

possible because of the highly sensi-

continues to recommend cytology be

Australians shows there has been

was to be expected as it reflects the

includes people returning for repeat

tive nature of HPV DNA testing . Some

done prior to colposcopy , as many col-

a consistent increase in self-collec-

higher sensitivity of HPV testing

HPV testing after a previous positive

efforts were made to have a self-col-

poscopists prefer to have the cytology

tion uptake when analysed by age ,

result . 5

lection option for cervical cytology but

result at the time of examination .

remoteness index and socio-eco-

POSITIVE PREDICTIVE VALUE

Recruitment and participation

this was never really feasible .

If the patient tests positive for HPV

nomic status . Uptake of self-col-

An important measure in any screen-

remain a significant issue for the cer-

International studies , including

non 16 / 18 , the NCSP recommends the

lection has also increased among

ing program is the confirmation

vical program as some 70 % of cervi-

meta-analyses , have shown that a

patient returns to the clinician for a cer-

under-screened people . In March

rate of abnormalities . This shows

cal cancers occur in those who have

self-collected vaginal test is as sensi-

vical cytology sample , as management

2023 the rate was about 20 % of all

how many patients sent to colpos-

never been screened .

tive as a clinician-collected cervical

depends on the result of the cervical

samples . 14

copy will have a high-grade lesion

One of the major tasks of the pro-

HPV test . 12

cytology .

The rate of HPV positivity is sig-

detected .

gram is to ensure equity of access

A self-collection option was ini-

If the cytology is negative , or

nificantly higher in self-collected

AIHW data and work from the

and elimination of barriers to partic-

tially included in the protocol for the

shows possible or low-grade lesions , a

compared with clinician-collected

Douglass Hanly Moir laboratory

ipation . Marginalised and under-ser-

renewed program in 2017 but was

repeat HPV test is recommended in 12

samples ( 9.72 versus 8.04 , p < 0.001 ).

show this rate to be 24 %. This is well

viced groups need to be identified

restricted to under-screened women

months ’ time . If the cytology shows a

Early analysis of this information

above the internationally accepted

and targeted for attention .

older than 30 . The uptake was rela-

high-grade , glandular or possible high-

suggests this is because of a higher

level of 10 % and indicates that the

Participation rates vary significantly depending on geographic location . These rates reflect the incidence and mortality rates of cervical disease , highlighting the significance of

tively low .

As previously outlined , increasing the participation rate and providing equity of access to all eligible participants in the screening program is of

grade lesions , then a referral directly to colposcopy is indicated .

There has been much discussion as to whether self-testing could be done via mail-out or whether a swab could

positivity among under- and never-screened people compared with those previously screened . Unsatisfactory sample rates were higher with self-collection than clini-

screening program is working well . 15

CASE STUDIES

Case study one

ROMA , a 36-year-old woman , pre-

equity of access ( see figure 6 ).

utmost importance .

be given to the patient to undertake the

cian-collection ( 1.98 % versus 0.13 %,

sents to the GP requesting a sexually

Consideration of equity of access

In July 2022 the self-collection

test at home .

p < 0.001 ). 14

transmitted infection ( STI ) check .

needs to be given to Indigenous , cul-

option became available for all people

For the self-collected test to be as

Importantly , patients have been

She is new to the practice . Roma has

turally and linguistically diverse , and LGBTIQ + communities .

Any patient with , or who has had ,

eligible for cervical screening . This option is suitable for both primary screening and as 12-month fol-

sensitive as the clinician-collected sample , the sampling needs to be done under well-controlled circumstances ,

returning for further investigation at a reasonable rate .

There was about a 70 % rate of

recently entered a new relationship with a female partner . She identifies as lesbian and uses the pronoun

a cervix should have access to and be

low-up HPV testing where the patient

with validated swabs , transport and

colposcopy after a self-collect posi-

‘ her ’.

encouraged to participate in cervical

has tested positive to non 16 / 18 with

testing .

tive test for HPV 16 or 18 and about

Her past medical history is unre-

screening services .

negative or low-grade cytology .

Recently published data from the

70 % of people returned for a liq-

markable . She keeps fit and healthy

Lesbian women report almost half

It is important to note that a

Netherlands cervical screening pro-

uid-base cytology within six months

with exercise and diet . She has no

the rates of cervical screening of het-

self-collected sample cannot be used

gram - which also offered a self-collect

of a self-collected non16 / 18 HPV pos-

symptoms or signs of any STI but ,

erosexual women and account for a

where a co-test ( simultaneous HPV

option - showed an uptake of around

itive result . 14

given this is a new relationship ,

much higher proportion of individuals who have never been screened compared with their heterosexual counterparts . 9 , 10

and cytology ) is the recommended investigation . The two major clinical situations where this applies are for a symptomatic patient ( potential symp-

7 % of all samples . 13

Notably , self-collected samples had a significantly lower rate of detection of both HPV and high-grade lesions than

Rates of detection of HPV related to age

Recent AIHW data provides an indi-

would like to be screened for chlamydia and gonorrhoea .

When the GP asks whether she has ever had any cervical screening tests ,

Lesbian and bisexual women

toms or signs of cervical cancer ) and

clinician-collected samples , a finding

cation of the rates of detection of HPV

Roma advises she had a Pap smear

and transgender men who have not

when a patient is undergoing a test of

contrary to previous studies .

by subtype ( see figure 9 ).

10 years ago . She cannot remember

undergone hysterectomy have been

cure .

Detailed analysis shows that the

The figure is stratified by age and

the result but found the whole expe-

specifically included as priority pop-

A clinician-collected sample is

collection methodology was causing

clearly shows the highest rate of

rience unpleasant and embarrassing

ulations in both the recent draft Aus-

needed in each of these cases so that

the lower sensitivity , highlighting the

infection is in the younger age group ,

and has not been tested since . Roma

tralian Cancer Plan and the draft

an HPV and cytology test can be done

importance of the collection proce-

with most infections being the

has also been told that gay women do

National Strategy for the Elimination

concurrently .

dure . The Netherlands subsequently

non-vaccine subtypes .

not need screening .

of Cervical Cancer in Australia .

These patients are at significantly

changed their protocols .

The rate of infection diminishes

The GP orders the appropriate