Prevention of cervical cancer
Author Dr Nadia Lusis
Expert reviewers Dr Vijenti Chandra
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
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 type||Who is at risk?||What should be done?||How often?||Level/strength of evidence|
||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)
|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
|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†
||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
|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
|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
|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
||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
|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
Screening to prevent cervical cancer: guidelines for the management of asymptomatic women with screen detected abnormalities (NHMRC)
The Australian Immunisation Handbook (NHMRC): HPV chapter
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- 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.
- 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.
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- 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.
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- 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.
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