1. THE NEW CERVICAL CANCER SCREENING PROGRAM
The Renewal
THE NEW CERVICAL CANCER SCREENING PROGRAM

2. CERVICAL CANCER
4th most common cancer in women worldwide

3. CERVICAL CANCER 4th most common cancer in women worldwide
>250,000 deaths/year

4. CERVICAL CANCER 4th most common cancer in women worldwide
>250,000 deaths/year
85% of cervical cancer incidence and mortality occurs in less developed countries

5. CERVICAL CANCER 4th most common cancer in women worldwide
>250,000 deaths/year
85% of cervical cancer incidence and mortality occurs in less developed countries – limited or no screening

6. CERVICAL CANCER Incidence

7. CERVICAL CANCER Mortality

8. CERVICAL CANCER In our region
Australia:
Incidence - 5 per 100,000 women
Mortality - 2 per 100,000 women
Melanesia (PNG, Vanuatu, Fiji) :
Incidence - 33 per 100,000 women (x7)
Mortality - 20 per 100,000 women (x10)

9. FIJI – Nurse training VIA

10. Screening room

11. Sterilising equipment

12. VANUATU HPV vaccination & testing

13. Cold chain challenges

14. THE IMPORTANCE OF SCREENING
80% of women with cervical cancer are either under- screened, or have never been screened

15. CERVICAL CANCER SCREENING in AUSTRALIA
Current
National Cervical Cancer Screening Program since 1991
Women aged yrs
2 yearly Pap tests
State/Territory based Registers

16. THE PAP TEST

17. CERVICAL CANCER SCREENING in AUSTRALIA
Current
Hugely successful –
50% reduction in cervical cancer
incidence and mortality

18. SO WHY CHANGE??

19. Online petition shows women want to know more
SO WHY CHANGE??
Online petition shows women want to know more
The past week saw 70,000 people (so far) sign an online petition opposing the changes to the cervical screening program.
The person behind the petition said she was motivated by “concern and worry”, because “[she] didn’t know about it and no one seemed to know about it”, and because “[she’d] love someone to be able to get down on our level and explain the testing”.
Responses to her petition indicated widespread concern about safety of the new starting age and the wider screening interval. In addition, women perceived the renewed program as a cutback – that less screening is being driven by cost-savings rather than the availability of a better test.

20. SO WHY CHANGE?? 1. LIMITATIONS of CURRENT TESTING
Reductions in cervical cancer incidence and mortality have plateaued over the last 10 years
Current program has had no impact on certain groups – women < 25 years, subgroups of cancers (adenocarcinomas)

21. SO WHY CHANGE?? 2. INCREASED KNOWLEDGE
The role of HPV in cervical lesions and cancer (causes >99% of cancer, most HPV infections will regress within 18 months)
Pathogenesis of cervical cancer (most cancers take years to develop)

22. HPV HPV causes >99% of cervical cancer
Over 200 genotypes of HPV, 40 affect ano-genital tract
High risk HPV: 16,18,31,33,35,39,45,51,52,56,58,59,68,73,82

23. HPV Anal cancer – 90% Vaginal cancer – 70% Penile cancer – 50%
Vulvar cancer – 40%
Head and neck/orophayngeal cancers – 13 – 72%

24. HPV

25. HPV
Over 80% of HPV infections will clear within months

26. HPV
Persistent infection with high-risk HPV is the most important risk factor for cervical cancer

27. SO WHY CHANGE?? 3. NEW TECHNOLOGIES HPV DNA test
Liquid based cytology & computer-assisted image analysis

28. SO WHY CHANGE?? 3. NEW TECHNOLOGIES HPV DNA test
Much higher sensitivity compared with Pap smears (95% v 55%): better test
High negative predictive value (>99%), allowing for longer screening interval

29. SO WHY CHANGE?? 4. NATIONAL HPV VACCINATION PROGRAM
3 dose quadrivalent vaccination (Gardasil): HPV 6,11,16,18
2007 – girls (12-26yrs), 2013 – girls and boys (12-13 years)
Coverage with 3 doses: around 70-80%
86% reduction in HPV 16,18,6,11
92% reduction in genital warts
45% reduction in low grade lesions
85% reduction in high grade lesions

30. WHAT IS THE CHANGE? Renewal 5 yearly screening Based on HPV DNA test
Women 25 – 74 yrs
Option for self-collected sample (for never screened or under-screened women)
National Register

31. HPV test
Identical procedure to Pap test - sample from SC junction using cervical sampler, spatula +/- cytobrush
Then sample is placed in liquid based medium
HPV DNA testing (with partial genotyping) is performed
If positive for oncogenic HPV type, reflex liquid based cytology (LBC) is performed on the same sample

32. SCREENING PATHWAY

33. SCREENING PATHWAY

34. SCREENING PATHWAY

35. SCREENING PATHWAY

36. SCREENING PATHWAY

37. SCREENING PATHWAY

38. SCREENING PATHWAY

39. SCREENING PATHWAY

40. SCREENING PATHWAY

41. SCREENING PATHWAY

42. SCREENING PATHWAY

43. SCREENING PATHWAY

44. Self collected swab Dry flocked swab inserted into vagina
Cannot perform LBC on sample
Medicare rebate for “never or under screened women”
If +ve HPV 16/18 – refer for colposcopy
If +ve for oncogenic HPV (not 16/18) – invite back for reflex LBC under direct vision
Sensitivity 88% – better than Pap, not as good as physician collected sample

45. SPECIAL CASES Pregnancy Immune-deficient/HIV DES in utero
Symptomattic women (any age)
History childhood sexual abuse/first sexual activity <14 yrs

46. NATIONAL REGISTER Operated by Telstra Health
Bowel Cancer Screening & Cervical Cancer Screening
Legislative Framework:
- National Cancer Screening Register Act 2016
- Others: Privacy Act 1988, Cybercrimes Act 2001 etc
FAQ: Content/National-Cancer-Screening-Register

47. NATIONAL REGISTER Single electronic record
Send out invitations, reminders, and FOBT kits
Allow practitioners access to patients records/results through medical software
Upload data to Register through medical software
Allow patients to access screening record/results

48. TRANSITIONING TO THE NEW PROGRAM
Women who:
are aged 25+ years will be invited into the new program 2 years after their last Pap test
have had a Pap test below the age of 25 will be invited into the program at the routine screening age of 25 (explanatory letter to be sent by National Register)

49. TRANSITIONING TO THE NEW PROGRAM
Women who:
are in follow-up for LSIL should have co-test (HPV + LBC) at next scheduled follow-up; refer for colposcopy if + for any oncogenic HPV type; if negative return to 5- yearly screening
have been treated for HSIL (CIN2/3) in the pre-renewal program should start or continue Test of Cure (annual co-test until 2 consecutive negatives)
have been treated for adenocarcinoma in situ will have annual co-testing (HPV and LBC) indefinitely

50. TRANSITIONING TO THE NEW PROGRAM
cal_cancer/Screening

51. THE NEW SCREENING PROGRAM
We have a BETTER TEST

52. THE NEW SCREENING PROGRAM
We have a BETTER TEST

53. THE NEW SCREENING PROGRAM
We have a BETTER TEST
It will further reduce rates of cervical cancer (additional 20% reduction)
- Increased detection of adenocarcinoma

54. THE NEW SCREENING PROGRAM
The better test means we can SAFELY SCREEN LESS OFTEN
- So we allow women adequate time to clear the virus themselves (much like the common cold)

55. THANK YOU