Your browser has 'Cookies' disabled, alert boxes will continue to appear without this feature.

Clinical guidelines

National guide to a preventive health assessment for Aboriginal and Torres Strait Islander people Second edition

Prevention of cervical cancer

Author Dr Nadia Lusis
Expert reviewers  Dr Vijenti Chandra

Background

The incidence of cervical cancer in Aboriginal and Torres Strait Islander women is about 2.4–3 times greater than in non-Indigenous women.3,4 Cervical cancer is the third most common cause of death due to cancer in Aboriginal and Torres Strait Islander women, with the years of life lost due to cervical cancer being 5.7 times greater and the mortality rate being 5.6 times higher in Aboriginal and Torres Strait Islander women compared to non-Indigenous women.1,5 One study suggested that Aboriginal women in remote areas appeared to be at higher risk of cervical cancer than those in urban areas.6

Interventions

Vaccination against human papillomavirus (HPV) is recommended due to the link between cervical HPV infection and the development of cervical dysplasia. As the efficacy of vaccination in preventing HPV infection and cervical dysplasia decreases with the increasing number of previous sexual partners, vaccination should preferably be given prior to onset of sexual activity, or otherwise as early as possible. Studies in the 14–26 years age group have provided evidence for immunogenicity and prevention of high grade squamous cervical lesions, while studies in other age groups at this stage provide evidence for immunogenicity only. See the Australian Immunisation Handbook for more details.7–12 

Pap tests have been shown to reduce the risk of developing cervical cancer. In 2008–09 in Australia, 61.2% of the target population participated in screening, with the lowest participation rates in the lowest (53.3%) compared to the highest (64.3%) socioeconomic quintile.5 Cervical screening state registries do not systematically collect information on the Aboriginal and Torres Strait Islander status of women screened.5 Aboriginal and Torres Strait Islander women tend to have lower participation rates in screening programs, with studies using indirect methods to calculate their participation rates are 30–50% lower than for non-Indigenous women.13,14 

Factors that may increase participation of Aboriginal and Torres Strait Islander women in cervical cancer screening are inclusion of cervical screening programs within primary healthcare services, culturally appropriate care, appropriate staff including female staff and involvement of Aboriginal and Torres Strait Islander health workers, community participation and linkages between services.13,15–17 The Practice Incentives Program (PIP) provides financial incentives for accredited health services to provide Pap screening.

Pap testing recommendations apply to asymptomatic women. Women with symptoms, abnormalities of the cervix on examination or glandular abnormalities on smears should be referred for specialist review and treatment.

A review of the National Cervical Screening Program is planned, and once this is complete the National Health and Medical Research Council (NHMRC) guidelines18 are likely to be reviewed, which may result in changes to these recommendations. The National Cervical Screening Program recommends Pap tests be used as the primary method for population screening until there is sufficient evidence indicating the effectiveness of newer cervical screening technologies such as Thinprep and HPV tests.19 Women vaccinated against HPV should follow the same cervical screening recommendations as unvaccinated women.20 

Recommendations: Cervical cancer prevention and detection
Preventive intervention typeWho is at risk?What should be done?How often?Level/strength of evidence
Immunisation Girls aged 10–13 years Promote human papilloma virus (HPV) vaccination for the prevention of cervical cancer ideally prior to the onset of sexual activity
Recommend HPV vaccination as part of school based vaccination programs. If not accessed in a school program then offer through clinic/community services
As per National Immunisation Program Schedule (NIPS) (varies between states and territories) IIB10,21
Girls aged 14–18 years Promote HPV vaccination for the prevention of cervical cancer ideally prior to the onset of sexual activity* As per Australian Immunisation Handbook IIB10,21
Women aged 19–26 years Promote HPV vaccination for the prevention of cervical cancer for health benefit, but likely to be less effective*
Women aged 27–45 years HPV vaccination may be of some benefit depending on sexual history†
Screening Women aged 18–69 years who have ever been sexually active Offer Pap test screening from 18–20 years or 1–2 years after first sexual intercourse (whichever is later) regardless of whether HPV vaccination has been given Every 2 years IIA22,23
Women aged 70+ years who have ever been sexually active Offer Pap test screening to women who have never had a Pap test or who request a Pap test Pap test screening may cease for women aged 70 years who have had two normal Pap smears within the past 5 years IIA22,23
Women at higher risk (eg. previous cervical abnormalities, immune suppression, in utero exposure to diethylstilboestrol) Offer Pap test screening Management regimen is complex: see NHMRC guidelines GPP18
Women who have been previously treated for high grade squamous intraepithelial lesion Offer annual Pap test screening combined with cervical HPV testing for 2 or more consecutive years, if not already done following specialist treatment If both tests are negative in 2 consecutive years, screening for average risk population can recommence IIIC18,24
Behavioural All women Assess smoking status and advise on increased risks of cervical dysplasia and cervical cancer (see Chapter 1: Lifestyle, section on smoking) As part of an annual health assessment IIIB25,26
Offer a sexual health review (see Chapter 8: Sexual health and bloodborne viruses) As part of an annual health assessment
* Currently not subsidised through the NIPS
† 4-valent HPV vaccine (Gardasil®) is not registered by the Therapeutic Goods Administration for use in this age group due to lack of safety and efficacy data at the time of writing this guideline

Resources

Screening to prevent cervical cancer: guidelines for the management of asymptomatic women with screen detected abnormalities (NHMRC)
www.nhmrc.gov.au/publications/synopses/wh39syn.htm

The Australian Immunisation Handbook (NHMRC): HPV chapter
www.immunise.health.gov.au/internet/immunise/publishing.nsf/Content/Handbook-hpv.

References

  1. Vos T, Barker B, Stanley L, Lopez AD. The burden of disease and injury in Aboriginal and Torres Strait Islander peoples 2003. Brisbane: School of Population Health, The University of Queensland, 2007.
  2. Cunningham J, Rumbold AR, Zhang X, Condon JR. Incidence, aetiology, and outcomes of cancer in Indigenous peoples in Australia. Lancet Oncology 2008;9(6):585–95.
  3. Australian Bureau of Statistics & Australian Institute of Health and Welfare. The health and welfare of Australia’s Aboriginal and Torres Strait Islander peoples 2008, ABS cat no. 4704.0. Canberra: ABS, 2008. Cited October 2011. Available at www.aihw.gov.au/publications/index.cfm/title/10583.
  4. Australian Institute of Health and Welfare & Australasian Association of Cancer Registries. Cancer in Australia: an overview,2010. Cat. no. CAN 56. Canberra: AIHW,2010 cited 2011 October 10. Available at www.aihw.gov.au/publications/can/ca08/ca08.pdf.
  5. Australian Institute of Health and Welfare. Cervical screening in Australia 2008–2009. Cat. no. CAN 57. Canberra: AIHW, 2011.
  6. O’Brien ED, Bailie RS, Jelfs PL. Cervical cancer mortality in Australia: contrasting risk by Aboriginality, age and rurality. Int J Epidemiol 2000;29(5):813–6.
  7. Villa LL, Costa RLR, Petta CA, Andrade RP, Paavonen J, Iversen OE, et al. High sustained efficacy of a prophylactic quadrivalent human papillomavirus types 6/11/16/18 L1 virus-like particle vaccine through 5 years of follow-up. Br J Cancer 2006;95(11):1459–66.
  8. Harper DM, Franco EL, Wheeler CM, et al. Sustained efficacy up to 4.5 years of a bivalent L1 virus-like particle vaccine against human papillomavirus types 16 and 18: follow-up from a randomised control trial. Lancet 2006;367(9518):1247–55.
  9. Ault KA. Effect of prophylactic human papillomavirus L1 virus-like-particle vaccine on risk of cervical intraepithelial neoplasia grade 2, grade 3, and adenocarcinoma in situ: a combined analysis of four randomised clinical trials. Lancet 2007;369(9576):1861–8.
  10. National Health and Medical Research Council. The Australian immunisation handbook, 9th edn. Canberra: Commonwealth of Australia, 2008. Cited October 2011. Available at www.health.gov.au/internet/immunise/publishing.nsf/content/handbook-home.
  11. Dillner J, Kjaer SK, Wheeler CM, et al. Four year efficacy of prophylactic human papillomavirus quadrivalent vaccine against low grade cervical, vulvar, and vaginal intraepithelial neoplasia and anogenital warts: randomised controlled trial. BMJ 2010;340:c3493-c.
  12. Kjaer SK, Sigurdsson K, Iversen O-E, et al. A pooled analysis of continued prophylactic efficacy of quadrivalent human papillomavirus (Types 6/11/16/18) vaccine against high-grade cervical and external genital lesions. Cancer Prev Res (Phila) 2009;2(10):868–78.
  13. Coory MD, Fagan PS, Muller JM, Dunn NAM. Participation in cervical cancer screening by women in rural and remote Aboriginal and Torres Strait Islander communities in Queensland. Med J Aust 2002;177(10):544–7.
  14. Binns PL, Condon JR. Participation in cervical screening by Indigenous women in the Northern Territory: a longitudinal study. Med J Aust 2006;185(9):490–5.
  15. Gilles M, Crewe S, Granites I, Coppola A. A community-based cervical screening program in a remote Aboriginal community in the Northern Territory. Aust J Public Health 1995;19(5):477–81.
  16. Hunt JM, Gless GL, Straton JA. Pap smear screening at an urban aboriginal health service: report of a practice audit and an evaluation of recruitment strategies. Aust N Z J Public Health 1998;22(6):720–5.
  17. Reath J, Carey M. Breast and cervical cancer in indigenous women-overcoming barriers to early detection. Aust Fam Physician 2008;37(3):178–82.
  18. National Health and Medical Research Council. Screening to prevent cervical cancer: guidelines for the management of asymptomatic women with screen detected abnormalities. Canberra: Commonwealth of Australia, 2005. Cited October 2011. Available at www.nhmrc.gov.au/publications/synopses/wh39syn.htm.
  19. Department of Health and Ageing. New technologies for cervical screening. Canberra: Commonwealth of Australia, 2009. Available at www.health.gov.au/internet/screening/publishing.nsf/Content/new-technology-policy.
  20. Department of Health and Ageing. Policy for screening women vaccinated against HPV. Canberra: Commonwealth of Australia, 2007. Available at www.health.gov.au/internet/screening/publishing.nsf/Content/hpv-vaccinated-policy.
  21. Australian Technical Advisory Group on Immunisation. Systematic review of the safety, immunogenicity and efficacy of HPV vaccines. Canberra: DoHA, 2007. Cited October 2011. Available at www.health.gov.au/internet/immunise/publishing.nsf/Content/A812080FEADF9486CA25728A001213C3/$File/part-1.pdf.
  22. Department of Health and Ageing. National Cervical Screening Program Policies. Canberra: Commonwealth of Australia, 2009. Available at www.health.gov.au/internet/screening/publishing.nsf/Content/NCSP-Policies-1#topic.
  23. International Collaboration of Epidemiological Studies of Cervical Cancer. Comparison of risk factors for invasive squamous cell carcinoma and adenocarcinoma of the cervix: collaborative reanalysis of individual data on 8,097 women with squamous cell carcinoma and 1,374 women with adenocarcinoma from 12 epidemiological studies. Int J Cancer 2007;120(4):885–91.
  24. Medical Services Advisory Committee. The use of human papillomavirus testing to monitor effectiveness of treatment of high-grade intraepithelial abnormalities of the cervix, 2004. Cited October 2011. Available at www.health.gov.au/internet/msac/publishing.nsf/Content/8FD1D98FE64C8A2FCA2575AD0082FD8F/$File/Ref%2012e%20-%20HPV%20testing%20Report.pdf.
  25. Appleby P, Beral V, Berrington de González A, et al. Carcinoma of the cervix and tobacco smoking: collaborative reanalysis of individual data on 13,541 women with carcinoma of the cervix and 23,017 women without carcinoma of the cervix from 23 epidemiological studies. Int J Cancer 2006;118(6):1481–95.
  26. Collins S, Rollason TP, Young LS, Woodman CBJ. Cigarette smoking is an independent risk factor for cervical intraepithelial neoplasia in young women: a longitudinal study. Eur J Cancer 2010;46(2):405–11.
Advertisement loading...

Advertisement

The Royal Australian College of General Practitioners

Contact Us

General Inquiries

General Enquiries

Opening hours 8:00 am-8:00 pm AEST

1800 4RACGP

1800 472 247 | +61 (3) 8699 0300 (international)

Payments

Payments

Pay invoices online

RACGP automated payment service: 1800 198 586

Follow us on

Follow RACGP on Twitter Follow RACGP on Facebook Follow RACGP on LinkedIn


Healthy Profession. Healthy Australia Logo

The Royal Australian College of General Practitioners (RACGP) ABN 34 000 223 807
RACGP House, 100 Wellington Parade, East Melbourne, Victoria 3002 Australia

Terms and conditions | Privacy statement
Sponsor conditions | Delegate conditions