National Guide

Chapter 19 | Cancer prevention and early detection

Cervical cancer







National Guide to preventive healthcare for Aboriginal and <br/>Torres Strait Islander people
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      2. Cervical cancer

Cancer | Cervical cancer

Prof Lisa Whop   A/Prof Megan Smith  

Key messages

  • Elimination of cervical cancer is possible through human papillomavirus (HPV) vaccination, cervical screening and treatment of precancer and cancer.1,2
  • HPV self-collection is now universally available across Australia.
  • Self-collection is as sensitive, accurate and safe as a cervical screen conducted by a healthcare provider,3 and is highly acceptable to Aboriginal and Torres Strait Islander peoples.4
  • It is recommended that women with an oncogenic HPV-positive (type 16 or 18) result on a self-collected test are referred directly for colposcopy, with a liquid-based cytology (LBC) sample to be collected at colposcopy.3
  • It is recommended that women with an oncogenic HPV-positive (other than type 16 or 18 [non-16/18]) result on a self-collected test return to the healthcare provider for a clinician-collected cervical sample for LBC to determine the risk category and next steps in the screening pathway.3
  • Supporting Aboriginal and Torres Strait Islander women to attend for colposcopy when required is important for the prevention of cervical cancer.
  • A single dose of HPV vaccine is now the recommended schedule and is funded under the National Immunisation Program (NIP) for people aged 9–25 years, providing a great opportunity for young people who missed out at school to easily catch up.5
  • Seeing young people attending for healthcare and/or women attending at age 25 years to having their first cervical screening test is an opportunity to check whether their HPV vaccination is up to date and to give the free vaccine if there is no record of them having received it.
  • Clinicians should be aware of highly gender-sensitive cultural practices for many Aboriginal and Torres Strait Islander people and that discussions about cervical screening need to be culturally appropriate and respectful of women’s business.
Type of preventive activity - Immunisation
Who/target population What When Strength of recommendation Key source(s) and reference(s) Rationale/key considerations informing recommendation
All people aged 9–25 years, ideally aged 11–13 years and prior to onset of sexual activity Provide single dose of HPV vaccine

Check and update HPV vaccination status on the Australian Immunisation Register		 Routinely offered in early high school; catch-up available through primary care and community immunisation services Strong National program6 HPV vaccination provides protection against the cancer-causing strains of HPV
People aged 26 years and over Conduct individual risk–benefit assessment
Vaccination of adults aged 26 years and over is not routinely recommended (and not funded under the NIP)

A three-dose schedule is required if not commenced before the age of 26 years		 As clinically indicated Conditional National guideline5 Those with a history of treatment for cervical precancer (high-grade cervical intraepithelial neoplasia) are at higher risk of future disease and may wish to consider immunisation
People with significant immunocompromising conditions
No upper age limit, as per Australian Technical Advisory Group on Immunisation (ATAGI) recommendations		 A three-dose schedule of the 9vHPV vaccine
Not funded under the NIP for people aged 26 years and older		 As clinically indicated Conditional National guideline5 Requires clinical assessment
Men who have sex with men
No upper age limit, as per ATAGI recommendations		 HPV vaccine for men who have not been vaccinated

A three-dose schedule is required if not commenced before the age of 26 years

Not funded under the NIP for people aged 26 years and older		 As clinically indicated Conditional National guideline5 Should take into account the likelihood of past exposure to HPV and risk of future exposure
Type of preventive activity - Screening
Who/target population What When Strength of recommendation Key source(s) and reference(s) Rationale/key considerations informing recommendation
Asymptomatic women and people with a cervix aged 25–69 years who have ever been sexually active Offer cervical screening test (HPV based) via clinician collection or self-collection

Support patient follow-up to completion of the screening/follow-up pathway including:
  • repeating unsatisfactory tests
  • collecting cytology for those with HPV (non-16/18) detected on a self-collected sample
  • referring for colposcopy and, where needed, treatment for those with higher-risk results
 Every five years from age 25 years Strong National guideline3 Pap smears are no longer recommended as a screening test for cervical cancer
Women and people with a cervix with intermediate risk test results Repeat tests at one year for intermediate-risk results, with referral to colposcopy for Aboriginal or Torres Strait Islander people with persistent HPV at one year As clinically indicated Strong National guideline3 The risk of cervical cancer is higher among Aboriginal and Torres Strait Islander people
Pregnant asymptomatic women and people with a cervix aged 25–69 years who have ever been sexually active Review cervical screening history as part of routine care

Those who are due or overdue for screening should be offered screening via either clinician collection (correct sampling equipment must be used) or self-collection		 Routine antenatal and postpartum care Strong National guideline3 Screening is safe during pregnancy

An endocervical brush should not be inserted into the cervical canal because of the risk of associated bleeding, which may distress women
Asymptomatic women aged 70–74 years who have ever been sexually active Offer HPV cervical screening test by either clinician collection or self-collection

Support patient follow-up to completion of the screening/follow-up pathway including:
  • repeating unsatisfactory tests
  • referring for colposcopy and, where needed, treatment for those with higher-risk results (HPV detected, any type)
 Between ages 70 and 74 years Strong National guideline3 People can be discharged from the National Cervical Screening

Program (NCSP) if oncogenic HPV is not detected at their exit test between the ages of 70 and 74 years
Women with recent screen-detected abnormalities, previously treated for high-grade cervical abnormalities or at high risk of cervical abnormalities (eg immune suppression, in utero exposure to diethylstilbestrol) Screening and management refer to NCSP Guidelines (refer to Useful resources) As per clinical guidelines, follow-up intervals vary by condition Strong National guideline3 Screening and management recommendations are more complex
Type of preventive activity - Behavioural
Who/target population What When Strength of recommendation Key source(s) and reference(s) Rationale/key considerations informing recommendation
All women Assess smoking status and advise that smoking increases risks of cervical dysplasia and cervical cancer. (refer to Chapter 2: Healthy living & health risks, ‘Smoking’) Opportunistically Strong Single studies7,8 Addresses risk factors for cervical dysplasia
All people undergoing cervical screening, especially women aged 30 years and younger (34 years and younger in remote areas) and people at risk of sexually transmissible infections and blood-borne viruses and/or anyone who requests screening Consider offering a sexual health check as appropriate to age and context (see Chapter 13: Sexually transmissible infections and blood-borne viruses Opportunistically Good practice point National guidelines9,10 Cervical screening offers easy opportunity for sexually transmissible infection screening
  • Always check whether a young person has had their dose of HPV vaccine (using the Australian Immunisation Register); only needing a single dose makes it much simpler to provide protection to everyone.
  • Have regular recall and reminder mechanisms for cervical screening tailored to the local community (eg SMS reminder).
  • Ensure Aboriginal and Torres Strait Islander status is recorded on pathology forms and in the National Cancer Screening Register.
  • Increase staff awareness and education about the availability of HPV self-collection.
  • Run locally tailored activities to increase participation in screening, such as community day events.
  • Provide education about the signs and symptoms of cervical cancer.
  • Ensure access to cervical screening and follow-up pathways, including through development of locally appropriate information.
  • Consider the follow-up process to support people in whom HPV was detected.
  • Spread the message about the elimination of cervical cancer. Communities can take up the challenge by supporting all their young people to get vaccinated and their mums, sisters and aunties to get screened once every five years.

Clinical guidelines

General

Patient resources

Background

The incidence of cervical cancer among Aboriginal and Torres Strait Islander women is 13.4 per 100,000 women.11 This is 2.2-fold higher than among non-Indigenous Australian women (6.2 per 100,000 non-Indigenous women).11 Cervical cancer mortality among Aboriginal and Torres Strait Islander women is 5.8 per 100,000 women, which is four-fold higher than among non-Indigenous Australian women (1.4 per 100,000 non-Indigenous women).11

Cervical cancer is almost entirely preventable. It can be eliminated as a public health problem not only by ensuring that those diagnosed with cervical cancer receive timely and effective treatment, but also by using available and highly effective forms of primary prevention (HPV vaccination) and secondary prevention (cervical screening with a high-performance test, such as an HPV-based test, and pre-cancer treatment where indicated).2 Cervical cancer is highly treatable in its early stages. In 2020, the World Health Organization released a global strategy to accelerate the elimination of cervical cancer as a public health problem, with the threshold for elimination set at four per 100,000 women.2 The strategy identifies three scale-up targets to be achieved by 2030 in order to place all countries on track to reach this threshold over the next century:

  • 90% of girls fully vaccinated with HPV vaccine by age 15 years
  • 70% of women screened with a high-performance test by age 35 years and again by age 45 years
  • 90% of women identified with cervical disease receive treatment (90% of women with precancer treated, and 90% of women with invasive cancer managed).2

Australia has been identified as likely to be the first country in the world to reach the elimination threshold, potentially as soon as 2030,12 but this will not be achieved for Aboriginal and Torres Strait Islander women.13,14 Key initiatives have been outlined in the draft national strategy to achieve equitable elimination, particularly for Aboriginal and Torres Strait Islander people. To reach the elimination target of four per 100,000, a 67% reduction in the incidence of cervical cancer is required for the Aboriginal and Torres Strait population.15

Please note that throughout this topic the term ‘women’ is generally used to refer to people eligible for or attending cervical screening or experiencing cervical cancer. However, we respectfully acknowledge that some people with a cervix do not identify as women and are equally impacted by the risk of cervical cancer.

Vaccination against HPV

Vaccinations against HPV are given because infection with oncogenic types of HPV is the underlying cause of almost all cervical cancers, as well as contributing to other anogenital and oropharyngeal cancers. Because the vaccine works by preventing HPV infection (and thus the development of cervical dysplasia and sometimes cancer), and cannot treat existing HPV infection or disease, vaccination is ideally given prior to the onset of sexual activity, or otherwise as early as possible. The HPV vaccine is provided free in schools to all girls and boys aged 12–13 years, with free catch-up vaccination available in primary care settings up to and including age 25 years,5,16 as part of the NIP. From 2023, the vaccine is given as a single dose, with the exception of cases of significant immunocompromise or vaccination at age 26 years or older, when three doses are required. Some older women and men at higher risk of HPV-related cancers may also benefit from HPV vaccination. See the Australian immunisation handbook for more details.5

Cervical screening

Cervical screening has been shown to reduce the risk of developing cervical cancer due to the detection and treatment of cervical changes before they develop into invasive cancer, with 80% of cervical cancers occurring in women who have never been screened or who have not had timely screening.3 The NCSP commenced in 1991, and changed on 1 December 2017, replacing the Pap smear test with a new HPV cervical screening test (and reflex LBC for samples with oncogenic HPV detected). Evidence shows that HPV-based cervical screening prevents more cervical cancers17 and Australia’s updated NCSP is expected to prevent around 30% more cervical cancers compared with the Pap smear screening program.18 HPV-based screening is more sensitive and will detect high-grade cervical lesions earlier than Pap smear screening, so can safely be done less frequently. Consequently, the program has changed from two-yearly Pap smear screening to five-yearly HPV screening from age 25 years, with an explicit exit test for women between the ages of 70 and 74 years. For women with previously normal Pap smears, their first HPV test was due two years after the last Pap smear test. Guidelines are available online with details of further screening and follow-up recommendations (see Useful resources).3

Cervical screening providers and other relevant health service staff should discuss HPV in terms of being the most common sexually transmissible infection that affects most sexually active people at some point in their life, explain that the renewed cervical screening program uses the HPV test rather than collecting cells (Pap smear) and answer questions that patients may have about the test. Specific educational information for Aboriginal and Torres Strait Islander women is available19 (see Useful resources) and many communities develop resources that are locally tailored and appropriate.

Screening participation in women in the age range eligible for screening declined steadily from 63.7% in 1998–99 to 56.0% in 2015–16, with even greater declines in women aged less than 35 years.20 The change from a two- to five-year interval (meaning that women remain adequately screened for longer once they have had an HPV test) has led to an increase in participation among women aged 25–69 years from 57.9% as at the end of 2016 to 71.9% by the end of 2021.1,20 Participation rates tend to be lower in lower socioeconomic groups and remote areas.1,11 Participation rates for Aboriginal and Torres Strait women have never been routinely reported. State-based cervical screening registers did not systematically collect information on the Aboriginal and Torres Strait Islander status of women screened because pathology request forms, the main data source for the registers, do not routinely have a field to collect Aboriginal and Torres Strait Islander status.21,22 The commencement of the National Cancer Screening Register in 2017 was anticipated to change this, but Aboriginal and Torres Strait Islander status was still only complete for 72.5% of those screened over the period 2018–21.11

Aboriginal and Torres Strait Islander women have lower participation rates in cervical screening, with Australian studies finding participation rates that are 30–50% lower than for non-Indigenous Australian women.23,24 Studies have also shown a higher rate of screen-detected low- and high-grade lesions and histologically confirmed high-grade lesions.25,26 Because data on HPV infections collected prior to the introduction of HPV vaccination suggested that prevalence is similar in Aboriginal and Torres Strait Islander and non-Indigenous Australian women, especially for the two HPV types responsible for most cervical abnormalities and cancers (types 16 and 18), these differences are most likely due to differences in cervical screening and smoking rather than exposure to HPV.27 Because of this higher risk, there is a difference in the recommended follow-up between non-Indigenous Australian and Aboriginal and Torres Strait Islander women who have a repeated detection of a non-16/18 HPV at one year without concomitant high-grade cellular changes on LBC (intermediate-risk pathway). Those who are aged 50 years or older, previously underscreened (two or more years overdue for a primary screening test) or Aboriginal or Torres Strait Islander are recommended to go to colposcopy to assess the cervix, whereas other people are recommended to repeat the test in another 12 months. (For flow charts for the management of oncogenic HPV results, see Useful resources.)

In one jurisdiction, it was found that Aboriginal and Torres Strait Islander women who participated in cervical screening appeared to re-attend for screening just as regularly as non-Indigenous Australian women,24 indicating that increasing the participation among Aboriginal and Torres Strait Islander women who never screen is critical to improving participation rates and cancer outcomes. Factors that may increase the participation of Aboriginal and Torres Strait Islander women in cervical screening are:

  • the inclusion of cervical screening programs within primary healthcare services
  • culturally appropriate care
  • appropriate staff, including female staff, and the involvement of Aboriginal health workers
  • community participation
  • linkages between services
  • continuous quality improvement activities
  • patient educational events
  • the ability to self-collect the cervical screen.4,14,28–30

Aboriginal and Torres Strait Islander women who have participated in cervical screening report that they perceived it as a way of staying strong and healthy (for themselves, their families and communities) and exerting control over their health.4

Cervical screening on a self-collected sample is now available as a choice for anyone who is eligible and due for cervical screening (previously only available to those who were aged 30 years and over, and either never screened or two years or more overdue for screening). Any woman due for cervical screening should be offered the choice of HPV testing on a self-collected vaginal sample or on a clinician-collected sample. The self-collected test is as sensitive for detecting precancer as a clinician-collected sample (when polymerase chain reaction-based assays are used, as mandated by laboratory standards in Australia).31 Several studies have found self-collection to be highly acceptable, feasible and effective for Aboriginal and Torres Strait Islander women.14,30 It is recommended that women with an oncogenic HPV-positive (type 16 or 18) result on a self-collected test are referred directly for colposcopy, with an LBC sample to be collected at colposcopy. In the case of women with HPV detected (non-16/18) on a self-collected sample, it is generally recommended they return for a clinician-collected sample so that an LBC test can be done; refer to NCSP guidelines for further management.3

Women vaccinated against HPV are currently recommended to follow the same cervical screening recommendations as unvaccinated women because the vaccine does not cover all types of HPV that cause cervical cancer, and some women may have been exposed to HPV prior to being vaccinated.

Symptomatic women

Cervical screening recommendations apply to asymptomatic women. Women with symptoms (persistent unexplained intermenstrual bleeding, postcoital bleeding or postmenopausal bleeding) or abnormalities of the cervix on examination suggestive of cervical cancer should be investigated appropriately, and may need to be referred for specialist review and treatment as required.3,32 Intermenstrual and other irregular bleeding patterns are common, particularly in women using hormonal contraception or hormonal treatment. The Royal Australian and New Zealand College of Obstetricians and Gynaecologists advises that women at risk of sexually transmissible infections should have appropriate tests performed.

Assess smoking status

Smoking is a risk factor for the development of cervical cancer. Refer to the Recommendations table for more detail.

  1. National Health and Medical Research Council (NHMRC) Centre of Research Excellence in Cervical Cancer Control. Cervical cancer elimination progress report: Australia’s progress towards the elimination of cervical cancer as a public health problem. NHMRC, 2023 [Accessed 15 May 2024].
  2. World Health Organization (WHO). Global strategy to accelerate the elimination of cervical cancer as a public health problem. WHO, 2020 [Accessed 15 May 2024].
  3. Cancer Council Australia. National Cervical Screening Program. Guidelines for the management of screen-detected abnormalities, screening in specific populations and investigation of abnormal vaginal bleeding. Cancer Council Australia, 2022 [Accessed 15 May 2024].
  4. Butler TL, Anderson K, Condon JR, et al. Indigenous Australian women’s experiences of participation in cervical screening. PLoS One 2020;15(6):e0234536. doi: 10.1371/journal.pone.0234536.
  5. Australian Technical Advisory Group on Immunisation (ATAGI). Human papillomavirus (HPV). In: Australian immunisation handbook. Australian Government, 2023 [Accessed 15 May 2024].
  6. Department of Health and Aged Care. National Immunisation Program schedule. Australian Government, 2023 [Accessed 15 May 2024].
  7. Collins S, Rollason TP, Young LS, Woodman CB. 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. doi: 10.1016/j.ejca.2009.09.015.
  8. International Collaboration of Epidemiological Studies of Cervical Cancer; Appleby P, Beral V, 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. doi: 10.1002/ijc.21493.
  9. Australasian Society for HIV, Viral Hepatitis and Sexual Health Medicine (ASHM). Standard asymptomatic check-up. ASHM, 2021 [Available at
  10. Australasian Society for HIV, Viral Hepatitis and Sexual Health Medicine (ASHM). Aboriginal and Torres Strait Islander people. ASHM, 2021 [Accessed 15 May 2024].
  11. Australian Institute of Health and Welfare (AIHW). National Cervical Screening Program monitoring report 2022. AIHW, 2022 [Accessed 15 May 2024].
  12. Hall MT, Simms KT, Lew JB, et al. The projected timeframe until cervical cancer elimination in Australia: A modelling study. Lancet Public Health 2019;4(1):e19–27. doi: 10.1016/S2468-2667(18)30183-X.
  13. Whop LJ, Cunningham J, Garvey G, Condon JR. Towards global elimination of cervical cancer in all groups of women. Lancet Oncol 2019;20(5):e238. doi: 10.1016/S1470-2045(19)30237-2.
  14. Whop LJ, Smith MA, Butler TL, et al. Achieving cervical cancer elimination among Indigenous women. Prev Med 2021;144:106314. doi: 10.1016/j.ypmed.2020.106314.
  15. National Health and Medical Research Council Centre of Research Excellence in Cervical Cancer Control (C4). Cervical cancer elimination progress report. C4, 2021 [Accessed 15 May 2024].
  16. National Centre for Immunisation Research and Surveillance (NCIRS). Human papillomavirus (HPV) vaccines for Australians. [Fact sheet] NCIRS, 2023 [Accessed 15 May 2024].
  17. Ronco G, Dillner J, Elfström KM, et al. Efficacy of HPV-based screening for prevention of invasive cervical cancer: Follow-up of four European randomised controlled trials. Lancet 2014;383(9916):524–32. doi: 10.1016/S0140-6736(13)62218-7.
  18. Lew JB, Simms KT, Smith MA, et al. Primary HPV testing versus cytology-based cervical screening in women in Australia vaccinated for HPV and unvaccinated: Effectiveness and economic assessment for the National Cervical Screening Program. Lancet Public Health 2017;2(2):e96–107. doi: 10.1016/S2468-2667(17)30007-5.
  19. Department of Health and Aged Care. Resources for Aboriginal and Torres Strait Islander women – National Cervical Screening Program. Australian Government, 2022 [Accessed 15 May 2024].
  20. Australian Institute of Health and Welfare (AIHW). Cervical screening in Australia 2018. AIHW, 2018 [Accessed 15 May 2024].
  21. Australian Institute of Health and Welfare (AIHW). The inclusion of Indigenous status on pathology request forms. AIHW, 2013 [Accessed 15 May 2024].
  22. Whop LJ, Cunningham J, Condon JR. How well is the National Cervical Screening Program performing for Indigenous Australian women? Why we don’t really know, and what we can and should do about it. Eur J Cancer Care (Engl) 2014;23(6):716–20. doi: 10.1111/ecc.12244.
  23. Dasgupta P, Cramb S, Baade P, et al. Regional variation in cervical cancer screening participation & outcomes among Aboriginal and non-Aboriginal Australian women: New South Wales (2006–2013). Cancer Council Queensland, 2018.
  24. Whop LJ, Garvey G, Baade P, et al. The first comprehensive report on Indigenous Australian women’s inequalities in cervical screening: A retrospective registry cohort study in Queensland, Australia (2000–2011). Cancer 2016;122(10):1560–69. doi: 10.1002/cncr.29954.
  25. Whop LJ, Baade P, Garvey G, et al. Cervical abnormalities are more common among Indigenous than other Australian women: A retrospective record-linkage study, 2000–2011. PLoS One 2016;11(4):e0150473. doi: 10.1371/journal.pone.0150473.
  26. Li M, Roder D, Whop LJ, et al. Aboriginal women have a higher risk of cervical abnormalities at screening; South Australia, 1993–2016. J Med Screen 2019;26(2):104–12. doi: 10.1177/0969141318810719.
  27. Garland SM, Brotherton JM, Condon JR, et al. Human papillomavirus prevalence among Indigenous and non-Indigenous Australian women prior to a national HPV vaccination program. BMC Med 2011;9(1):104. doi: 10.1186/1741-7015-9-104.
  28. Diaz A, Vo B, Baade PD, et al. Service level factors associated with cervical screening in Aboriginal and Torres Strait Islander primary health care centres in Australia. Int J Environ Res Public Health 2019;16(19):3630. doi: 10.3390/ijerph16193630.
  29. Jaenke R, Butler TL, Condon J, et al. Health care provider perspectives on cervical screening for Aboriginal and Torres Strait Islander women: A qualitative study. Aust N Z J Public Health 2021;45(2):150–57. doi: 10.1111/1753-6405.13084.
  30. Whop LJ, Butler TL, Lee N, et al. Aboriginal and Torres Strait Islander women’s views of cervical screening by self-collection: A qualitative study. Aust N Z J Public Health 2022;46(2):161–69. doi: 10.1111/1753-6405.13201.
  31. Arbyn M, Smith SB, Temin S, Sultana F, Castle P; Collaboration on Self-Sampling and HPV Testing. Detecting cervical precancer and reaching underscreened women by using HPV testing on self samples: Updated meta-analyses. BMJ 2018;363:k4823. doi: 10.1136/bmj.k4823.
  32. Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG). Investigation of intermenstrual and postcoital bleeding. RANZCOG, 2021 [Accessed 15 May 2024].




 

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