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

Chapter 15: Prevention and early detection of cancer
Prevention and early detection of cervical cancer
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☰ Table of contents

Recommendations: Prevention and early detection of cervical cancer

Preventive intervention type

Who is at risk?

What should be done?

How often?

Level/ strength of evidence

References

Immunisation

 Adolescents (girls and boys) aged 9–18 years Promote human papillomavirus (HPV) vaccination for the prevention of cervical cancer – ideally age 11–13 years, prior to onset of sexual activity (Can be accessed through National Immunisation Program [NIP] – school vaccination programs or through clinic/ community services for those aged 10–15 years, timing depending on state or territory)

Vaccination up to age 18 years is recommended but should include discussion of potential benefit based on risk of previous exposure		 As per National Immunisation Program Schedule (NIPS) (varies between states and territories)22 IIB 6,23
Women and men aged ≥19 years (not subsidised through the NIPS – check state/ territory rules regarding catch-up programs) Vaccination of all women and men against HPV not recommended – conduct individual risk and benefit assessment As per The Australian immunisation handbook IIB 6
Men who have sex with men (not subsidised through the NIPS – check state/ territory rules regarding catch-up programs) 4vHPV vaccine recommended for men who have not been vaccinated, but should take into account likelihood of past exposure to HPV and risk of future exposure As per The Australian immunisation handbook IIB 6

Screening

 Asymptomatic women aged 25–69 years who have ever been sexually active

Offer cervical screening test (HPV) from age 25 years (or two years after commencing sexual activity, whichever is later) regardless of whether HPV vaccination has been given

Note: As of 1 December 2017, Pap smears are no longer recommended as a screening test for cervical cancer

 Every five years II, III–IIA 24-27
Asymptomatic women aged 70–74 years who have ever been sexually active Exit cervical screening test (HPV) for those who have been regularly screened Exit test between ages 70 and 74 years III–IIA 24, 25
Asymptomatic underscreened women – women who are 30 years of age and have never been screened or women aged ≥30 years who are at least two years late for cervical screening Offer clinician-collected cervical screening test (HPV). If declined, recommend self-collected sample (should become available in 2018) and explain slightly lower accuracy of testing. Inform clients on the recommendation for clinician-collected liquid-based cytology (LBC) sample or colposcopy if self-collected sample is oncogenic HPV positive Promote cervical screening if overdue, and then routine fiveyearly screening if negative II, III–IIA 28
Women with recent abnormal Pap smears, previously treated for high-grade squamous intraepithelial lesion (HSIL), or at high risk of cervical abnormalities (eg immune suppression, in-utero exposure to diethylstilbestrol [DES]) Screening recommendations are more complex and recommend consultation of guidelines for higher risk groups – refer to ‘Resources’ Follow-up intervals vary by condition II, III–IIC 24, 28

Behavioural

 All women Assess smoking status and advise that smoking increases risks of cervical dysplasia and cervical cancer (refer to Chapter 1: Lifestyle, ‘Smoking’) As part of annual health assessment III–IIB 29,30
Offer a sexual health review (refer to Chapter 14: Sexual health and bloodborne viruses) As part of annual health assessment GPP  

Overview

Cancer is estimated to cause 9% of the burden of disease for Aboriginal and Torres Strait Islander peoples, and accounts for 9% of the health gap between Aboriginal and Torres Strait Islander peoples and the non-Indigenous population. Aboriginal and Torres Strait Islander peoples have a 1.7 times higher burden of disease due to cancer when compared to the non-Indigenous population.1
Inadequate recording of Aboriginal and Torres Strait Islander status on cancer registries and in death registers in many jurisdictions means that reported statistics on cancer incidence and mortality are likely to underestimate true rates of cancer. Aboriginal and Torres Strait Islander peoples have a higher incidence of preventable cancers, such as lung, cervical and liver cancer. In addition, due to later diagnosis and poorer access to adequate treatment, Aboriginal and Torres Strait Islander peoples have higher case fatality rates for many cancers compared to the rest of the population.2–4

Cancer incidence and mortality

Overall, the most recent analysis reports an age-standardised incidence rate for cancer that is 10% higher for Aboriginal and Torres Strait Islander peoples compared to non-Indigenous people. The most commonly diagnosed cancer in Aboriginal and Torres Strait Islander peoples for 2008–12 was lung cancer (average of 173 cases per year), followed by breast cancer in females (143), colorectal cancer (116) and prostate cancer (101). Age-standardised incidence rates are higher in Aboriginal and Torres Strait Islander peoples for liver cancer (2.8 times as high), cervical cancer (2.2), lung cancer (2.0), cancer of unknown primary site (1.9), uterine cancer (1.7) and pancreatic cancer (1.4) when compared to non-Indigenous people.3 Conversely, age-standardised incidence rates for Aboriginal and Torres Strait Islander peoples are lower for colorectal cancer and breast cancer in females (rate ratio of 0.9), non-Hodgkin lymphoma (0.8) and prostate cancer (0.7) when compared to non-Indigenous people. Some of this may be attributable to lower uptake of screening by Aboriginal and Torres Strait Islander peoples.3

Age-standardised mortality rates are higher for Aboriginal and Torres Strait Islander peoples compared to non-Indigenous people for cervical cancer (3.8 times as high), liver cancer (2.5), lung cancer (1.8), uterine cancer and cancer of unknown primary site (both 1.6) and pancreatic cancer (1.3).3 The age-standardised mortality rate was lower for Aboriginal and Torres Strait Islander peoples Australians than for non-Indigenous Australians for colorectal cancer (rate ratio 0.7).5


Prevention and early detection of cervical cancer

Background

The incidence of cervical cancer in Aboriginal and Torres Strait Islander women is 2.2 times higher than in non-Indigenous women. Cervical cancer mortality is 3.8 times higher in Aboriginal and Torres Strait Islander versus non-Indigenous women.3

Interventions

Vaccination against human papillomavirus (HPV) is recommended due to the link between cervical HPV infection and the development of cervical dysplasia. As the vaccine works by preventing HPV infection and cervical dysplasia, and cannot treat existing HPV infection or disease, vaccination is ideally given prior to onset of sexual activity, or otherwise as early as possible. The HPV vaccine is provided free in schools to all males and females aged 12–13 years under the National HPV Vaccination Program. Some older women and men at higher risk of HPV-related cancers may also benefit from HPV vaccination, which may be funded in some states through catch-up programs if adolescent vaccination was missed. Refer to The Australian immunisation handbook for more details.6

Pap smears have been shown to reduce the risk of developing cervical cancer due to detecting and treating 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. In 2014–15 in Australia, 57% of the target population participated in screening.3 National participation rates have remained stable over the last 10 years, with participation rates tending to be lower in lower socioeconomic groups and remote areas.7

Cervical screening state registers have not systematically collected information on the Aboriginal and Torres Strait Islander status of women screened3 because pathology report forms, the main data source for the registers, do not collect Aboriginal and Torres Strait Islander status. This is expected to change with the commencement of the national cancer screening register.8

Aboriginal and Torres Strait Islander women tend to have lower participation rates in cervical screening programs, with studies finding participation rates that are 30–50% lower than for non-Indigenous women.9–11 One study recently showed a higher rate of screen-detected low-grade and high-grade lesions and histologically confirmed high-grade lesions.12

In one jurisdiction, it was found that Aboriginal and Torres Strait Islander women who participated in cervical screening appeared to participate just as regularly as non-Indigenous women, 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 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 health workers; community participation; linkages between services; continuous quality improvement activities; reminder letters and patient educational events.9,13–17 The Practice Incentives Program (PIP) currently provides financial incentives for accredited health services to provide cervical screening, including additional incentives for screening in under-screened women. This will change with the implementation of a quality improvement PIP in mid-2018.18

The National Cervical Screening Program changed on 1 December 2017. The Pap smear test has been replaced by a new HPV cervical screening test with reflex liquid-based cytology (LBC) for oncogenic HPV positive samples. Evidence shows that HPV-based cervical screening is more sensitive than Pap smear screening, will detect high-grade cervical lesions earlier, and will prevent more cervical cancers. Other program changes include five-yearly HPV screening from age 25 years (or two years after commencing sexual activity, whichever is later) with an exit test for women between the ages of 70 and 74 years. For women with previously normal Pap smears, the new test will be performed two years after the last Pap test. For women with positive HPV and LBC results or with recent abnormalities under the previous Pap smearbased cervical screening program, new guidelines are available online with details of further screening and follow-up recommendations – refer to ‘Resources’.19,20

There is no evidence to suggest that receiving an HPV positive test result would be any different to receiving an abnormal Pap test result for Aboriginal and Torres Strait Islander women. Cervical screening providers and other relevant health service staff should discuss HPV in terms of being the most common sexually transmitted infection (STI) that affects most sexually active people at some point in their life, explain the renewed cervical screening program using the HPV test, and answer questions that patients may have about the test. Specific educational information for Aboriginal and Torres Strait Islander women may be useful once developed.20

Cervical screening self-collection – for women who are under-screened (aged >30 years and never screened, or >30 years and two years or more overdue for screening), the cervical screening provider is able to offer the option of a self-collected HPV test in the clinic once testing arrangements are finalised in 2018. The self-collected test has slightly reduced sensitivity – that is, it may be slightly more likely to miss picking up cervical HPV than a clinician-collected sample, but is preferable to remaining unscreened. Under-screened women who elect to perform self-sampling should be encouraged to have a clinician-collected sample when next due. For women with an oncogenic HPV-positive (type 16 or 18) result on a self-collected test, it is recommended that they are referred directly for colposcopy with LBC to be collected at colposcopy; women with HPV-positive (not type 16 or 18) result on a self-collected sample are recommended to return for a clinician-collected LBC test – refer to National Cervical Screening Program guidelines for further management.20

Women vaccinated against HPV should follow the same cervical screening recommendations as unvaccinated women because the vaccine does not cover all strains of HPV that cause cervical cancer, and some women may have been exposed to HPV prior to being vaccinated.20,21

Symptomatic women – cervical screening recommendations apply to asymptomatic women. Women with symptoms or abnormalities of the cervix on examination should be investigated appropriately and referred for specialist review and treatment as required.

Assess smoking status – smoking is a risk factor for development of cervical cancer. Refer to ‘Recommendations’ for more detail.

 

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

 





 
 
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