26 HOW TO TREAT : PREVENTING CERVICAL CANCER ausdoc . com . au
8 MARCH 2024
26 HOW TO TREAT : PREVENTING CERVICAL CANCER ausdoc . com . au
Figure 10 . High grade abnormality
same pathology laboratory as remaining non16 / 18 HPV positive . The cytology is done reflexively by the lab in these circumstances and this time shows a low-grade squamous intraepithelial lesion ( CIN 1 ). The recommendation is again a repeat test in 12 months and the GP advises Jaya accordingly .
At the next visit 12 months later , Jaya opts for a clinician-collected sample . The sample again shows HPV non16 / 18 positive with reflex cytology showing CIN 1 . As this is now the third HPV positive result , colposcopy is recommended .
Jaya attends the local colposcopy clinic where a lesion is seen and a cervical biopsy is taken . This shows a high-grade squamous intraepithelial lesion .
She undergoes a large loop excision of the transformation zone , with the lesion being completely removed .
Jaya will return at 12 months to her GP for a test-of-cure protocol , which requires a co-test ( HPV and cytology done concurrently ).)
How to Treat Quiz .
1 . Which THREE are changes introduced with the NCSP in 2017 ? a The age of starting screening increased to 25 years of age . b The recommended screening interval changed from two to five years . c Conventional cervical cytology was replaced by testing for HPV . d Vaccination against HPV was introduced .
2 . Which TWO particular oncogenic subvariants of the HPV virus are associated with cervical cancer ? a 16 . b 66 . c 39 . d 18 .
3 . Which THREE statements regarding the incidence and mortality of cervical cancer are correct ? a The condition is still a significant health burden . b This is a disease of relatively younger women . c The rate of disease has significantly declined over the past 10 years . d There are significantly higher rates among Aboriginal and Torres Strait Islander women .
4 . Which TWO statements regarding the HPV vaccination program are correct ? a A catch-up program offering a single-dose , free vaccine for those aged up to age 24 was introduced in February 2023 . b Current rates of vaccination across Australia are the same in girls and boys . c The nine-valent vaccine requires three doses to be administered over a 12-month period . d The vaccination rate is lower in the Aboriginal and Torres Strait Islander population .
5 . Which THREE are indications for a non-screening pathway under the NCSP ? a If the patient , of any age , has signs or symptoms suggestive of cervical cancer , or its precursors . b To increase the five-year interval between screening in women who have a previous negative HPV result . c If there is an abnormal-looking cervix on examination . d For the test of cure pathway undertaken after histologically proven high-grade disease has
Case study three
NAOMI , a 65 year old retiree , makes an appointment to see a GP as a new patient . She and her husband of 40 years have recently retired to the district .
She has received a reminder from the NCSR that she is due for a cervical screening test . She takes antihypertensives but is otherwise healthy . Although she is overdue for a cervical screening test , she has screened regularly during her life and , as far as she is aware , has
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been treated .
6 . Which THREE are activities of the National Cancer Screening Register ? a GP training in the NCSP . b Monitoring the program . c Call and recall of participants . d Portal to access results .
7 . Which THREE are priority populations in the recent draft Australian Cancer Plan and the draft National Strategy for the Elimination of Cervical Cancer in Australia ? a Lesbians . b Aboriginal and Torres Strait
Islander population . c Bisexual women . d Transgender men who have undergone hysterectomy .
8 . Which THREE statements regarding self-collected samples are correct ? a Self-collected samples are less sensitive for detection of HPV than clinician-collected . b Self-collection must be done with a red-topped flocked swab .
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Source : AIHW National Cervical Screening Program monitoring report 2022 5
PREVENTING CERVICAL CANCER
always had negative Pap smears . The GP explains that the Pap smear has been replaced by testing for HPV and if Naomi prefers , she can do it as a self-collect swab . Naomi is quite keen for a “ general gynaecological check-up ” and opts to have a clinician-collected sample .
The result shows she is HPV 16 positive , with negative cytology . She is somewhat concerned about this , especially as the recommendation is for a colposcopy . The GP refers her to the nearest colposcopy
c Self-collected samples cannot be used for co-testing . d If a self-collected swab is positive for HPV non16 / 18 , a cytology sample must be taken .
9 . Which TWO statements regarding the outcomes of self-collection are correct ? a Uptake of self-collection has not increased among under-screened people . b There has been a consistent increase in self-collection uptake since the expansion of self-collection to all eligible Australians . c The rates of HPV positivity were significantly higher in self-collected rather than clinician-collected samples . d Fewer than 50 % of patients returned for further investigation .
10 . Which THREE statements regarding HPV infection in self-collected samples are correct ? a The highest rate of infection is in the younger age group . b Most infections are the vaccine subtypes . c The rate of infection diminishes with age , reflecting natural immunity . d The rates of HPV infection in all age groups are higher in the self-collection subgroup . clinic . After a three-month wait she is seen and told that the examination is normal .
Naomi consults the GP again and wants to discuss what all this means . She has been married to the same person for 40 years , has never had any other partners and , as far as she knows , neither has her husband .
She asks whether she should be concerned about her husband as she has read that HPV infection is a sexually transmitted disease . She is also wondering why none of this showed up any of her previous Pap smears , which were all negative .
The GP assures Naomi that an HPV infection does not mean that she necessarily has cervical disease . The GP then views her screening record on the NCSR which is accessible from the practice software . This confirms that Naomi has had 15 normal Pap smears over her lifetime .
In this particular clinical situation with a long history of negative Pap smears in an older woman , with negative colposcopy findings and a negative cytology result , the risks of Naomi harbouring an occult cancer are negligible .
Further , it is likely that she has had the HPV infection for many years and that this is a latent viral infection .
It does mean that she requires regular follow-up with HPV testing , and the GP assures her that more radical intervention will not be necessary .
The GP also counsels her that if she develops any symptoms or signs , or any abnormal bleeding or abnormal pain , she needs to return for assessment .
CONCLUSION
GENERAL practice remains the cornerstone of the NCSP . GPs continue to play a crucial role in recruitment of women into Australia ’ s successful program , being able to identify under- and never-screened women and suggest they participate .
With the self-collection option now available , even reluctant screeners may be persuaded to take this easy test .
Management of women with HPV positivity can be complex . The resources presented in the How to Treat aim to assist GPs to stay informed and actively manage their patients .
RESOURCES
• National Cancer Screening Register ncsr . gov . au
• Getting a cervical screening test bit . ly / 492D8qM
• Self -collection for the Cervical Screening Test bit . ly / 3ubCRmo
• National Cervical Screening Program – How to collect your own vaginal sample for a Cervical Screening Test Factsheet bit . ly / 3OkL8LF
• National cancer Screen Register bit . ly / 3OjlGpT
• Draft national strategy for the elimination of cervical cancer in Australia bit . ly / 3vKvnHl
References Available on request from howtotreat @ adg . com . au