Background – Cervical Screening

Australian rates of cervical cancer incidence and mortality are among the lowest in the world. This is largely attributed to the successful introduction in 1991 of the National Cervical Screening Program (NCSP). The NSCP is an organised approach to cervical screening that operates as a joint program of the Australian Government and the state and territory governments.

Opportunistic cervical screening began in Australia in the 1960s, with some women having regular Pap smears while others remained unscreened. In 1982 cervical cancer was the sixth most common cancer in Australian women and by 1991 it had fallen to eighth ranking, presumably related to increased opportunistic screening. Following the introduction of the NCSP in 1991 there was a steady fall in the incidence of cervical cancer, and by 2009 it ranked the twelfth most common cancer in Australian women.

The national policy established in 1991 stated:

  • Routine screening with Pap smears should be carried out every two years for women who have no symptoms or history suggestive of cervical cancer.
  • All women who have ever been sexually active should start having Pap smears between the ages of 18 and 20, or one or two years after first having sexual intercourse, whichever is later.
  • Pap smears may cease at the age of 70 for women who have had two normal Pap smears within the past five years. Women over 70 who have never had a Pap smear, or who request a Pap smear, should be screened.

The establishment of state-based cervical screening registers was an important contributor to the organised approach to cervical screening, providing the mechanism for following up abnormal results and issuing reminders for rescreening.

The first registry to be established, the Victorian Cervical Cytology Registry was formed in 1989. This was followed in subsequent years by the establishment of individual registries in all Australian states and territories.

The National HPV Vaccination Program commenced for girls in 2007 and for boys in 2013, using a quadrivalent vaccine against HPV types 6, 11, 16 and 18 (Gardasil). This vaccine is effective in preventing infection with the oncogenic HPV types (16 and 18) that cause 70–80% of cervical cancer in Australia. In 2018, Australia will commence using the new 9 valent HPV vaccine, replacing the 4 valent HPV vaccine and protecting against an additional 5 strains of HPV.

In July 2009, the Australian Health Ministers' Advisory Council (AHMAC) agreed to the renewal of the NCSP.

The renewal of the NCSP commenced in late 2011, to ensure the continuing success of the program and to ensure that that all Australian women – HPV vaccinated and unvaccinated – have access to a cervical screening program that is based on current evidence and best practice.

Factors stimulating the renewal included:

  • a plateau in the incidence of cervical squamous cell carcinoma since 2002
  • lack of significant reduction in glandular carcinomas since the introduction of the NCSP
  • new knowledge about the natural history of cervical cancer
  • new evidence about the optimal screening age range and interval
  • new tests, such as liquid based cytology (LBC) and HPV testing
  • the National Human Papillomavirus Vaccination Program, which commenced in 2007 for girls and in 2013 for boys.

After a rigorous and independent process, the Medical Services Advisory Committee (MSAC) considered a systematic literature review and modeled evaluation and made their recommendations in April 2014:

  • Five yearly cervical screening using a primary HPV test with partial HPV genotyping and reflex liquid based cytology (LBC) triage, for HPV vaccinated and unvaccinated women 25 to 69 years of age, with exit testing of women up to 74 years of age;
  • Self-collection of an HPV sample, for an under-screened or never-screened woman, which has been facilitated by a medical or nurse practitioner (or on behalf of a medical practitioner) who also offers mainstream cervical screening;
  • Invitations and reminders to be sent to women 25 to 69 years of age, and exit communications to be sent to women 70 to 74 years of age, to ensure the effectiveness of the program; and
  • Delisting of the existing cervical screening test MBS items over a 6 to 12 month transition period.

In September 2014, MSAC’s recommendation was accepted by the Australian Government and AHMAC endorsed the Interim Renewal Implementation Plan. There are five main areas of activity for implementation included:

  • MBS changes;
  • register capability;
  • workforce and practice change;
  • safety and quality; and
  • communication and information.

A Steering Committee for the Renewal Implementation Project (SCRIP) was established and identified three key priorities for implementation including:

  1. the development of clinical management guidelines for positive screening results;
  2. development of pathology performance measures and standards for HPV testing and reflex cytology; and
  3. register capability.

As part of the 2015-16 Commonwealth Budget, the Australian Government committed funds to implement a renewed National Cervical Screening Program and National Cancer Screening Register.

Due to the complexity of this project, including register and legislative changes, a long lead time was required for implementation with the renewed NCSP commencing on 1 December 2017.

Chapter 1 of the NCSP Guidelines for the management of screen detected abnormalities, screening in specific populations and investigation of abnormal vaginal bleeding contains a comprehensive review of the history of cervical screening in Australia and the factors leading to the renewal of the NCSP. It includes analysis of the impact of cervical screening upon the incidence of and mortality from cervical cancer and the justification for the renewal of the NCSP.

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07-Sep-2018
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