Hello everyone, thank you so much for joining us on what is the ultimate Alt Wednesday in the series for 2021. So, thank you very much for joining us on what is a really, really hot topic, I am really quite excited about this topic, so I am going to start the webinar by acknowledging the traditional owners of the lands from where all of us are joining today, I’m on Wurundjeri Country in Melbourne CBD, and I wish to pay my respects to elders, past, present and emerging and any Aboriginal or Torres Strait Islander person who is joining us on the webinar. Before we get stuck into what is actually going to be a really informative evening, I just want to stop and thank Sally Cockburn from RACGP Victoria and from all of the Victorian GPs, who have been seen over this year for this series because of several reasons, first of all, we have had such amazing speakers invited and I know that is because Sally Cockburn has the most amazing little rapport and connections, and we have benefited from that. Also, because I have actually found that really a relief in many ways to be able to talk about something that is not necessarily all COVID related, and keep our medical education on topics that are still occurring in the world that are necessarily all about pandemic, so I found that really refreshing, and finally just to thank Sally because it is a huge amount of work that she puts in every month in setting these webinars up, so Sally thank you very much, please do not leave us next year, I am sure that we can do more of this, so many topics to explore, so I am going to handover to Sally now, who is going to introduce our guest speaker who is a person known to all of us, and so we have got some really exciting uptakes in the world of women’s health to hear about this evening. Thank you Sally.
3:35
Thank you, Anita, and can I just sort of back out here. Thank you so much for everything that you have done this year for all of us as members of the RACGP and you and your council are just wonderful, so thank you very much, and also a big thank you to the behind-the-scenes people that no one ever sees tonight, Renny and Lorraine, who really do the work and get the stuff happening. First of all, can I say welcome to our regular RACGP Alt Wednesday webinar, now this is the final event for this year as Anita said and first may I also acknowledge the traditional custodians of the land from wherever we are right now. I am on the land of the Bunurong people of the Koolin nation and I respectfully acknowledge the elders, past, present, and emerging. Now this is your first Alt Wednesday, welcome, and we cover things that you maybe did not learn in medical school and first of all let us start with some housekeeping and can I say a big thank you to those of who have come to every event, it has just been wonderful to have so many of you here, and I just want to do a big shout out to Dr Murali because every week Dr Murali with a big smile on her face obviously says hello and hello from Dr Murali so hello back at you Dr Murali and to everybody else who contributes and we do want you to contribute and what we are going to do is ask for you to put your questions in the Q&A. Please keep them on the topic and if you see a question that you think is something that you really want to put up the scale, please just check the little thumbs up icon to upscale the particular question. Now the chat function does not work, so please do not bother putting anything in there, except if we need to put general messages from admin. Now, I just thought you might find it interesting that tonight I have got here and I want to say if there is anyone who is as anxious as me, My Harrison’s Textbook of Medicine from 1980, and this topic is not in here, so you know, it is pretty pathetic, really that is just how much time changes. I wonder if there is anyone also may be as anxious as me put your thing in your question if you want to, were you at Princess Henry’s Hospital in the 1980s where Gabriel Medley worked and spawned the Victorian Cytology Service through an active parliament in 1989 and the whole screening program for cervical cancer began and now it has been enormously successful, it is a mainstay of general practice, perhaps these have been around since 1920s, but it was not until relatively recently that some big changes happened and indeed keep changing and keep happening, which is why I really felt it was important that we do this topic tonight and the ground-breaking work of Australia's own Prof Ian Fraser and the latest _____, we have been able to access a vaccine against the non-carcinogenic strains of HPV and more recently the two-yearly Pap smear, which was very successful, has been replaced by the five-yearly cervical screening program looking for HPV genetic material. In fact, I will tell you right now, think about this one, what do COVID and cervical cancer screening have in common, think about it and I will answer that question later. Anyway, so just last month, the federal government made two announcements and in a relatively fast succession that hopefully by 2035, we may allow elimination of cervical cancer, something we will define shortly, and I just sort of thought I want to let you know that I hate it when my patients come and tell me something they have read on the Herald Sun or seen on the current affair or did I say Sunrise because I was on that the other day and I do not know anything about it and so I thought tonight we will bring on the icon of cervical screening. She is a globally respected cytologist. She is the executive director and public officer of the Australian Centre for Prevention of Cervical Cancer. It is Prof Marion Saville AM. Now, Marion has kindly joined us, she is in her car at the moment because Melbourne’s traffic is back to what it was. Marion, welcome.
7:41
Welcome and thanks for having me on Sally.
7:42
Oh, it is wonderful of you to be here, and can I just tell you that when I was speaking to one of my colleagues that you were coming on, their response was “Oh, I know that name, it is at the bottom of the all the cervical screening reports I receive”. She was all so starstruck and did a bit of a fan girl thing. So, thank you for being such an icon and people may not be aware that the VCS has changed its name to be ACPCC. Can you just tell us what that means.
8:11
So it is really important as we expand our work out of Victoria and diversify some cytology, we still do quite a lot cytology as you would know, but we are doing a lot more that our name reflects a little bit more about our major purpose, which is to see the elimination of cervical cancer and we are working beyond Victoria in Australia and into the region, but one of the things that we are very keen to let you know is that VCS Pathology is retaining that name because we know that all of you know what is VCS Pathology. So, it is really the entity or overarching name that is changing, but not VCS Pathology.
8:49
And so we still send our things to VCS Pathology and so can we start by putting it in context about what is the burden of cervical cancer in Australia at the moment in our community.
9:06
Well, we have got actually quite low rates of cancer around 900 or so cases per annum in Australia and about 250 deaths per annum, so we got good control and we brought our incidents down to about 6 per 100,000, which is getting close to the 4 per 100,000 target for considered eliminated as a public health problem.
9:30
Now that is what I wanted to just define, because the word elimination and eradication are two different things. Can you just explain what they mean because patients are “Oh, we are going to get completely wrong”, that is not the case.
9:42
Yeah, so elimination as a public health problem means that it will be effectively controlled and a rare disease and the cancers that will be left behind are those that we have not been preventing with Pap smears either, the rare types of cervix cancer, not associated with HPV, so both squamous cell carcinoma and almost all adenocarcinomas are caused by HPV, and it is my great hope that by changing to the screening program that will actually have an impact on adenocarcinomas because actually the absolute incidence has been unchanged for decades despite our screening program.
10:16
So can we just go back to talk about the difference between the Pap smear program and, then the five, oh I showed what I was going to show later, I gave you a little hint everyone, the Pap smear that has been around since 1920 that we have had a two-yearly program, how does that differ from the five-yearly cervical cancer or cervical screening program that has been that has been in existence for a few years now.
10:42
Well, because we know the natural history is HPV infection comes first, most of us will have an HPV infection, particularly when we are so sexually active, most of us will clearly develop some form of immunity and that will be fine, so some, and we do not know what the determinant is of this, so there is a persistent infection with one of the types that is more oncogenic and over a decade or more that infection can cause in situ disease and eventually cancer, so we are going to be also giving natural history that we know to pick up the precancerous or in situ disease with Pap smears, but because we are using a very sensitive PCR test looking for the HPV infection that happens earlier, we have got the opportunity to lengthen out the interval with this very sensitive test, so it is the introduction of HPV test, together with our long-standing HPV vaccination program that has the model of showing Australia first in the world and hopefully Victoria first in Australia to reach the elimination target, but of course with the eradication that is when infectious disease is completely gone, and not only gone, but you do not have to continue with your preventative efforts, that is the fundamental difference between elimination and eradication under the WHO. Elimination, the disease is controlled, but you have to continue preventative efforts.
12:10
I remember when _____ and _____ first were announced the vaccine, the cervical cancer vaccine, they said, in a few generations, we hope that we will get rid of it completely, but that has been softened to elimination, but I mean what do we tell our daughters, we have all been vaccinated, about screening.
12:38
The oldest of the women that were offered publicly funded vaccination are now 41, 42, and _____ vaccine including the 16 18 protection, the program is sort of tailored to work for them, as well as, unvaccinated people, and you know the partial genotyping we do in the screening program. I think what will happen though when those who are younger than my daughters, who have been vaccinated with the 9-vaccine that you have referred to before, the oldest of them are not quite in our program, I think there is another little while to go with them, 5 to 10 years of that order, when they have the screening program, we will have to go back to the modellers and look at the evidence because I suspect that they might need one or two tests in their lifetime.
13:28
So, we need to tell our young women in our practices, who say what do I need to do that for, I have been vaccinated.
13:35
Essential that they are continued to be screened because the new test is working really well with vaccination and you know if you find HPV and particularly HPV 16 18, it does not really matter at that point what the vaccination history was and that is the risk factor and whether you missed a dose or whether you have a breakthrough infection, very rare, it is really irrelevant, but we have reason of stratifying the risk, but that is so scarce.
14:05
And so, the screening program at the moment is to do the liquid-based rake, if you would call it a rake, and I send that off to do an HPV test, correct.
14:26
Yeah, that is right.
14:27
And now the announcement of the elimination program, we will come back to what changed there because it is quite controversial to many of our colleagues here, the elimination program, what is the announcement that the government made the other day.
14:45
Oh, so, the government has funded us at the Australian Centre to develop an elimination strategy for Australia, so we have got a year to do that, and we also received some funding for operational aspects of the compass trial as well
15:00
And it is your group and you are collaborating with people around the world on this sort of thing.
15:05
We have got a lot of international collaborations, but for this project, it is going to be a lot of consultation with everyone who is interested in cervical screening from participants, representatives of under screen groups and really importantly, you know the general practice community, it has been I think one of the strengths of the cervical screening program as compared to the bowel screening program that it is embedded in primary care and in that relationship and actually when you get onto the other stuff, Sally, I will tell you that overseas self-collection is also a request from the government right in high income countries and that is a model we fought against I think quite successfully on the government committees because I think you know the cervical screening program has got its challenges with participation, but it is a lot better than the bowel screening program, and we know from the evidence that any cancer screening participation, one of the strongest predictors is a recommendation from a trusted primary care.
16:03
So, let us just move into that area because I think that this is what a lot of people want to understand and if anyone would like to put up in Q&A, the answer to my question which is what do COVID prevention and cervical cancer prevention have in common and do not get confused and do not tell this to your patients, this is just for us and it involves this, that I will come back to that. Can we talk about the people who are at risk, the populations, the special populations, who we are missing in our cancer screening program.
16:42
We have got very good evidence that Aboriginal and Torres Strait Islander people have poor outcomes and participate less in the screening and that is probably because of our programs. Aboriginal women are more than twice as likely to get cervical cancer and almost four times as likely to die of it. So, that is the one we have evidence for.
17:02
I am laughing because I think the person who has answered the question has insider knowledge and yes, Kate, you are right, and what they have in common is this little number, so self-collection, and I am going to open this one because it is not a dummy, it is the flock-based figure, now this is different to the water-based, so this is why this is different. The self-collection is managed differently from your end, the lab end, than our water-based ones, correct.
17:37
Yeah, I think that is important, so if you do a usual cervical screening test at the moment, you send us a vial, we do the HPV test, and in the event that we find HPV, we can do reflex cytology, so we just do the cytology test. The difference is going to be with self-collection, if 16 or 18 are detected we recommend referral to colposcopy and the colposcopist can actually do the cytology at the time of colpo as part of the workup. So, cytology, so is a bit like we are talking about the pelvic exam, _____ being part of screening to being part of diagnosis.
18:15
So, let us talk about the difference between the screening in an asymptomatic population versus someone in a symptomatic population or someone who has already got an abnormality because there are very different things.
18:31
Yeah, so screening as you said is for well people who are age eligible woman and of course transgender men need to be screened, unless any of those people had a hysterectomy. They are asymptomatic and we take a screening test, that is quite different from anyone that might have postcoital bleeding, intermenstrual bleeding or postmenopausal bleeding, all of which are abnormal, the rarer presentations of cervix cancer you think about it are persistent, abnormal really foul discharge, so not a bit of discharge, but you know something persistent and so obviously when someone has symptoms, it is critical to investigate symptoms, you are on a diagnostic pathway, you are not a screening pathway, and they are very distinct, and I can just tell you that going back a decade or so, England increased its age of starting screening to 25, they stayed with cytology, it was quite a long time ago, and in fact they had a huge problem where there were a handful of really unfortunate cases where young woman with symptoms have been turned away and not offered a workup because they were 25 and one of them was a very, you might remember this was a very popular contestant on one of the original reality TV shows, and so it was public, and she had a delayed diagnosis with advanced stage cancer, and that was confusion between screening and diagnosis, so screening starts at 25, symptoms at any age need to be investigated. Examinations, co-test cytology, and HPV tests.
20:23
So, let us just expand on that because what are the current recommendations, you have just talked about the diagnosis, let us talk what are the current recommendations for cervical screening.
20:33
So, anyone with a cervix should be screened from the age of 25 to the age of 74.
20:41
What if they say, but I have never had sex?
20:47
So, we have to have a discussion about what that means because certainly you do not need penetrative sex to have it.
20:51
Ask Bill Clinton, just been watching that on the tele.
20:56
Yeah, you have to have a conversation with your patient about any sexual activity transmission with fingers, with toys and of course women who have sex with women can transmit HPV and can get cervix cancer, and I was just talking to you previously about one of our patients who is helping us with the campaign and she is a gay woman who thought she did not need screening, eventually had a test, she had a self-collected test, and that led to the diagnosis of an early cancer unfortunately, but she was successfully treated because it was a screen detected and early cancer that led to her wife getting screened and then talking in their community about the need to be screened and the availability of self-collection if you ever did.
21:47
I just want to look at a few questions, and can I encourage people, please do not wait till the last 5 minutes of the webinar to ask questions, if you got questions, please put him in there now, and Dr Murali is putting a lot of questions, thanks Dr Murali, and I think a couple of these you have already answered. She has asked if below 25 years of age and someone has symptoms, how do we get the CST for them with Medicare rebate because we do not use a screening test on someone who has got symptoms.
22:12
What I would like you to do is you collect a sample in the usual way and you write on the form, symptomatic, maybe tell us what those symptoms are and co-test.
22:25
Okay.
22:26
And that means that we would do the cytology, even if the HPV is negative.
22:31
Okay and they will get a Medicare rebate for that or they will not be charged, okay, thank you so much for that one, Dr Murali, and another one from Dr Murali. I do not know whether we know the answer to this yet. HPV vaccine given at school, do we know how long it lasts and whether boosters are required, it is a bit like COVID time. Do we have something about the requirements?
22:54
Yeah, so, we expect lifelong immunity, and having said that, the group in Scandinavia that were in the initial clinical trials are continuing to be followed, looking for breakthrough disease, by which we mean biopsy confirmed CIN2 and 3, and we are seeing no indication from that, but it is being monitored, and if we are going to need to revaccinate or do anything about that, we would get an early signal from the followup of those trial people before anyone in our program would be affected.
23:32
Now, Celeste has asked a question here, that I think you have also answered this one, she has asked what if a woman is bisexual with no heterosexual penile penetration or sexual intercourse, just instrument penetration with toys, scrupulously cleaned after excision, no genital skin to skin contact, no oral sex, would that be considered sexual contact and hence start CST from 25.
24:00
I am a little bit sceptical.
24:05
Self-collection is one thing that has scrupulously scrupulous grading.
24:09
Yes, I mean certainly HPV can be transmitted on sex toys without question, that has been demonstrated, so certainly that would be necessary.
24:21
So, the discussion to have again is risk-benefit ratio, you know there is what is your risk of having the test versus ____ explain it that way, which probably brings us into this group of people, the vulnerable group of people, who I have got several in my practice, who every time I open my medical directory, it comes up recall, recall, recall, open it up, Pap smear due, Pap smear due, I bring it up, and then they go, I will get around to it or they have been sexually abused as a young person and so look, I really cannot do this, all these women who just say you know whatever, let us talk about this whole issue of self-collection and where we are at with it and what the new announcement was.
25:04
So, currently, self-collection is available to anyone who is at least 30 and at least two years overdue for screening and they need to have said no to a practitioner collected sample.
25:20
So, when we do that, and they have to do it through us, they have to come in and get the swab from us, it is not sent to them directly at the moment, this is something we do in general practice.
25:31
The main way it is done is through face-to-face contact and general practice, we did develop a sort of home-based self-collection to meet the needs of some people in the pandemic and that is still there at VCS Pathology, so if you were doing a telehealth consultation and you are getting all those messages, so you could have the conversation with your patient, you could show them hopefully, maybe it is a video consultation and not a telephone one, I know a lot of them are telephone and then you could just send a request form to VCS home-based self-collection. We would then do all the checking on the register for eligibility and assuming they are at least two years overdue and they are at the right age, we will send a kit, and everything is in the kit that the patient needs, including the return envelope, it is all postage paid and then the results come back to you.
26:30
If they do not send it back, do you notify us that you have not received, and I know that it is probably an awful question to ask, but… you know, I do not…
26:37
No, that is a very sensible question to ask. We notify you if we think they are not eligible and we will help you drop that screening history from the register and we will also notify you at about a month if we have not had it back and we in our pilots when self-sampling was offered by practitioners over the consultation table, we are getting about 85% uptake amongst people who had absolutely said no to a Pap smear back then. In our home-based self-collection, it is a very small number, but we are getting about two thirds of them back, so I prefer to be done in the practice, I think it is more likely to be done.
27:17
Can we just use our flock ones, or do you have to use if we have got base flock, ones in our practice, if we are going to do it or do you send them out to us, what we….
27:24
We send you those with top ones out and it is really important that you use those and that is because we do not have any manufacturers that have got a claim for self-collection in Australia yet, and so we have done an in-house validation and that is the flock for the TGA, that is the crossroad that the TGA has approved, and we get in a lot of trouble if we process things that are not according to the TGA approval.
27:50
And so the reason why it has to be managed carefully is because it is dry and we have to make sure that women understand how to use them, so are there are any special instructions that we need to like move …., I mean like…
28:06
Yeah, actually the reason why I have to be a bit fractious about the swab is regulatory more than scientific. If it is a flock swab, it is probably going to work, but for regulatory reasons, I have to insist on that swab, which is a pack … but that is life. I think the main thing when you tell patients is to give them the confidence, so it is pretty likely they can do this themselves.
28:29
It is got a red line on it about there, is that sort of and that is where you put it in, but do not worry, you cannot get lost in there.
28:40
Yeah, so we tell patients in our Malaysian project to hold it at the red line and when the fingers meet the regular, you are about right.
28:52
So, then they are doing this, some of them are doing it obviously without practice, and as you say, if we are doing telehealth, and it is COVID or they are in a rural and remote area, at least they are getting screened, I mean a lot of us are saying, although we actually examine them, are you examining them, what if they say no, what if they have got a cultural objection to being examined, what do you say to people who say that you know, I want to do a PV. I always do a PV, I have always done a PV.
29:19
Yeah, and I used to always do a lot of cytology too, but the evidence is moving along, and I think the pelvic exam for screening was for the purpose of collecting the sample, and so, I think the pelvic exam will remain an important tool for the investigation of symptoms and signs, whether of cervical disease or other gynaecologic disease, but there is no evidence that in itself looking at the cervix adds anything in an asymptomatic screening situation that makes sense.
29:57
That makes perfect sense, _____ asks and I think we have also answered this too, you are ahead of all the questions, any changes in the self-collection criteria, but maybe this is leading us into what is coming on 1 July 2022, and this was also announced by the minister and your organisation.
30:19
Around about a week or two ago on Elite National Cervical Screening Day or something.
30:23
So, 17 November was the first anniversary of the WHO strategy, and we are trying to move you know the cervical cancer day to so, 17 November, and yes, that was the day the minister announced that, or maybe he did it the week before, I think ….
30:42
Within a week of each other which was… that was the ...
30:44
Yeah, they were, even I am muddled now, anyway. What the minister has announced is the Australian Government is taking the decision to act on the recommendation from MSAC that self-collection should be made available as a mechanism of screening at the participants’ choice and that will take effect from 1 July 2022, so the medical services advisor committee as you would know have done a thorough evaluation and shown that compared to clinician-collected samples, self-collected samples are safe and effective.
31:18
And that was another question, now where did I see it, it keeps moving around here, oh, it is actually, it is from Dr Murali again, how accurate is the self-collection and what percentage is that now?
31:38
So, there is an interesting story here, when we went into renewal, getting ready for 2017, a big meta-analysis was suggesting we are going to lose a bit of sensitivity about 8% compared with clinician-collected cervical samples and then after we started the renewal that was updated, focussing only on PCR-based tests, so in 2018, we learnt that self-collected samples were indistinguishable from clinician-collected samples for the detection of precancer. So, equally as effective as if you take a sample from the cervix and this is because what is happening is virus is being shed into the vagina and we are using PCR, which as you all know is incredibly sensitive to find the virus if it is there.
32:27
Can I just get a clarification on that? The self-collection will not, only if you do cytology on it, but when you do not do cytology on it, we look for a screening test, you are only looking for the PCR result, the genetic material, so obviously, they did do some cytology on that lot that you are talking about.
32:55
So, there are comparison studies where people have had both.
33:03
Oh, I reckon. Now can we just go back to the July 2022, that is when any woman can use the self-collection.
33:13
Anyone with screening can choose self-collection or practitioner collections.
33:19
Okay, and if they choose, so, does that mean they get it from us or where do they get it from.
33:22
Yeah, they will get it from you.
33:25
Okay, so, we have to be ready that if they requested, we do not have to say get up on there, I want to do the collection, it is better. This is just as good, just as accurate, and for screening for asymptomatic. If they have got symptoms, that is a different story.
33:40
That is exactly right and you should tell them there is about overall a 9/10 chance it will be negative and it will be done.
33:49
But from our perspective from July 2022, will you still be the only lab doing it or are there other labs that will be accredited by that point.
34:00
I would imagine other labs will get accredited. I would love to catch all that work, it would be very good for us, and I think one of the things that has been really important is that the government has announced this date, so that labs have got time to get ready, and there is an asset that has accreditation in Europe to self-collection, and I would imagine they would be talking to the TGA as we speak, it would not make sense if they were, so look, I want to say that I think the other labs will probably be a bit annoyed and then they will realise that they just need to get moving on this and I think we have all seen how we in the laboratory sector and including VCS as is turns out have been able to scale up for COVID testing. So, you know these are business decisions for labs to make, and I am sure they will make the decision.
34:55
And just to clarify, a self-collected PCR test is as accurate as a practitioner-collected PCR test?
35:05
That is exactly right.
35:08
And I cannot image any lab doing this, if they do not do the flock-based ones, they would not dare tell us that, no you need to do the practitioner-based collection.
35:22
Well, actually not. Can I go back to one thing, Sally, I think it is important that you say to patients if you are one of the sort of 7% to 8% who have HPV non-16, 18, or a type of HPV we are not quite so worried about urgently sending on, I am going to need to call you back to take your sample myself, so 90% of people will be HPV negative, job done, 2% will have 16 or 18 and they will need to go to colposcopy and the sample could be taken there. The remaining 8% will need to come back to you to have a sample collected for cytology, so that we can decide whether they need ongoing followup or immediate referral to colpo.
36:08
So, we need to warn them of that, that you know, you may get a call back if you have this and we may need to eventually do the internal, which is going to be a wonderful conversation with those women who do not even want to have the internal, but…
36:18
Yes, but Sally in our pilots of what the practitioner said is once we detected HPV, it sort of changed the conversation from a screening conversation to a diagnosis conversation in that the patients hear that differently, you know, I am not saying it is easy and certainly in under-screened people, the other thing that our pilots found is that when under-screened people access screening through self-collection, they do need more support through the screening pathway. They are going to need more consultation and talking and hopefully referral to a sort of reasonably sensitive colposcopy practice.
36:55
We will have some people coming and going, so someone has just asked a question, and I do not know if we have covered that, but I think we should cover it again, oh, it just disappeared, I had it when it disappeared, what is it? Can self-collection be done now or do the patients need to wait until July 2022, can you just reiterate what is the current eligibility for doing a self-collected screening.
37:27
Like 30 and at least two years overdue for screening or never screened.
37:32
And then in July 2022, anyone who requests it.
37:35
Anyone who is eligible for screening.
37:42
I have to say good on you, Kate, and thank you. Kate, says 8 November was the date the minister announced self-collection, thank you, Kate, thank you very much for being there, we appreciate it, now Felicity asks, are there any circumstances where you would give Gardasil 9 in someone previously vaccinated with either the original Gardasil or the cervix.
38:11
Look, there is no recommendation to do that, there is no particular contraindication that will cost money. I have 21 and 18-year-old daughters and they have got quadrivalent Gardasil and I am not suggesting they get Gardasil 9. There is a lot of evidence to suggest that the HPV that causes the cancer has been acquired probably by your mid-20s, so preventing the infection is probably not very effective after that time, and the most important message for women is to continue to participate in screening. That is going to be the most effective protection against cervix cancer.
38:57
I have got, Penelope says I have seen a dermatologist vaccinate a woman in her 50s with intractable genital warts with Gardasil. Is there any evidence that this is helpful in this particular patient wants to go into remission? I am probably getting outside your area of expertise.
39:14
Yeah, look, I am not aware of any evidence about it and I do not feel qualified to make any comments unfortunately.
39:22
We will give an infectious diseases specialist some time to talk about that.
39:26
I have friends that could help. I am happy to email you something, Sally, afterwards.
39:30
Yeah, that would be great, there is also, I mean, I think we get a lot of this, and please say if you rather if you do not want to answer this, but we are not getting out of vaccine questions, can I please remind you that Marion is a cytologist, not a virologist, so she may feel uncomfortable. This one is, is there any benefit to have the vaccine in adult age, if they did not have a vaccine in the teenage age, and I think you have said they have probably already acquired whatever they can acquire by the age or whatever.
40:03
The important message is that you think of a vaccine as preventing infection. They are not curative at all and a HPV type to which a person has already been exposed is, you are not going to be protected by the vaccine, and there is no way of knowing which ones they are, so for a whole range of reasons, it is probably not recommended to be vaccinated at that age.
40:25
Yes, please. And it will cost them a lot of money, if they have obviously got _____. So, let us just go back to our original question of what do COVID and cervical cancer have in common, which is a really, I do not want that to get out of the public domain, but we said we are using the same flocky flocky PCR test and preventative vaccines. Well, am I right, is that a good one, and thank you Dr Murali because you talked about directed towards the genome of the virus, and I think we are saying the same thing, but I mean, look, there was only a fun throwaway thing, please do not take that seriously, but it is the same swab that is stuck up you know, it is not the exact same swab that _____
41:11
We were sending those swabs out to you because no one had any swabs and we did a GP recall, some might remember, and we got a lot of swabs back from general practitioners we had sent out for screening, and they were used in COVID testing, until the supply issues were managed.
41:34
I am not quite sure saying, however, you are getting it here, but I will ask the question if it makes sense to you Marion. Age under 25, multiple pregnancies, vaginal birth, asymptomatic, do they need CST. So, this is the question of someone who is obviously I presume you are meaning thy are obviously sexually active, they are asymptomatic, and I think this is an important thing, why starting at 25.
41:58
Because the evidence shows that we do not prevent cancer through screening in the under 25's, the rates are very low, extremely low and in fact if you go back to the guidelines, the guidelines actually say there is no evidence for early screening even to those who have been exposed to HPV very young through unwanted sexual activity. There is still no evidence for earlier screening and the guidelines have a sort of permissive recommendation in there saying that if there has been sexual activity prior to 14 and prior to vaccination, you could consider a test between 20 and 24, and I think a lot of practitioners, particularly if they take the recommendations all out and have them in a list and they do not have all the backup information, some people have taken that to be you must do a screen in that age group with that history and are asking questions and that was never the intent. We have been screening for decades as you said, Sally, and were shown really major changes in the cancer rates over those decades through screening in Australia, but when you look at the graph for the under 25's, the rate is practically at zero and it is flat. We have had no impact through screening.
43:16
And I seem to recall, please correct me if I am wrong, but I seem to recall probably in the early 2000s, there was a point made that I could have stopped with playing with the swab, there was a point made that people under I think it was under the 20, I do not know which age, they seem to get the HPV and then they shed it and then it went away again and we were giving a lot of extra testing in these young people who would have got rid of it anyway.
43:42
That is right and I go back to what I said right at the beginning. We are almost all going to get an HPV infection when we start having sexual activity and contact, and when I say almost all, lifetime prevalence above 80% and then clearer, so we do not actually want to find the acute HPV infections, we want to find the persistent HPV infections because they are the ones at risk of causing precancer and cancer.
44:06
Now, Anita has just asked something here and I am going to see what it is before it disappears, it went, Anita, do you want to ask it yourself.
44:19
Marion, just to clarify during last year and actually this year, a lot of women that we thought needed to go to colposcopy because they were over the age of 30 with new findings or they had a persistent or low-grade HPV effect without demonstrable CIN2 or 3, we thought those patients would go for colposcopy and we started getting fairly rude _____ messages back from certain hospitals saying we are not seeing these women for colposcopy, we will deal with it in a year’s time, if the problem still exists. So, the question is, was that a lot based on science and emerging evidence from studies or was that really done to manage what was a public health squeeze and having limited resources.
45:05
There is probably both, so what happened was that when we get into our second year of the screening program, the colposcopist started saying when I see these women with non-16, 18, and no high-grade disease and persistence for a year, I find nothing, and by the end of the second year of the program, there are two thirds of colposcopy referrals, so they are getting overwhelmed with colposcopy referrals, so at that point, we got some data from the women's hospitals from David Wrede’s group supported by Jeff Chan. The program then asked the National Cancer Screening Register for data, which essentially confirmed at a national level that picture that these women are actually at very low risk of high-grade disease, and so then the guidelines group was reconvened, I chaired that guidelines group and what we have done is we have added a year onto the followup in that non-16, 18 in the absence of any high-grade disease on cytology, with some caveats around it, but I think what you are experiencing was that because the colposcopy clinics were so overwhelmed, this was pre-pandemic even, with all the referrals, they kind of jumped the gun and they were a little bit abrupt in their communications, I am pretty aware of that.
46:26
We will have to be a bit careful with situations like the reality TV person.
46:30
Yeah.
46:31
You just need one of those to end up on a frontpage of the Herald Sun.
46:36
Yes, and look it is really important and while I have the audience, I will just make this point, there are some caveats, so people who are over 50 in that situation go after a year, Aboriginal Torres Strait Islander people, I am just blanking, people are being exposed to DES and one other. Kate will message it to you, Sally. So, previously under-screened people, Sally, that is really important, so someone who was under-screened at the point of the initial test, and so if you are patient, if you have got to bounce back and your patient is over 50, Aboriginal or you actually self-collected, so they must be under-screened, then you should go back the colp clinic and point out that this is not the policy, and we have been in a process of just writing to the colp clinics, just to point that out as well, but I think…
47:32
And it may be GP liaison officers, often we have many who attend in our audience that they can help us out here.
47:42
I also need to just as the clinicians sending referrals, the more information the better they can respond, so we have got to be explicit if it is screening versus symptoms. They can only know if they are Aboriginal or Torres Strait Islander if we let them know, we can only expect a clinic to respond to an under-screened person, if we say they are under-screened, so it is really important and plus also I learned during all of these, if you smell a rat and you think that the patient needs to be seen, you have got to push back and say I really think this needs to be seen, so just some important ways we can make this system work because it is strained at the moment.
48:24
It is strained and it has become very clear to me that often these decisions are being made by somebody, who is quite clerical, who does the first pass, and so you know if something does not seem right and you push back, I think it gets escalated.
48:29
And also just a plug from my beautiful VCS is you can pick up the phone and ask someone what I am going to do with this lady, plain, I am going now, Sally.
48:50
No, no, do not go, I love it, I love it, and I agree with you the more you ring pathology labs and speak to a clinician the better. I often ring labs to say can I speak to a clinician please and that will be wonderful, now Selma is asking, because I think we are getting a bit confused about what we are talking about here, screening and vaccination, we are taking about elimination being a combination of screening and vaccination is an additional component for the difficult people to get, and I just want to ask this question from Selma, and I do not think this is the place to answer it, but as Selma says that she sees international patients, she sees a lot of refugees, can they have the vaccine in their 30s, 40s, and 50s, and I think again you answered that.
49:38
Yeah, they will not benefit much from the vaccine, it is hard to access, and I am sure they do not have much money, but they do need to be screened, and if they have come from cultures where it is difficult to do a pelvic exam, please, please, please offer them self-collection. I sometimes have to turn down processing self-collection swabs, if the patient is not eligible, if it is not the right swab, but we certainly will not turn it down, we are now a bulk-billing lab, you may know, we are no longer block funded as of 1 July 2021, but if you have got a refugee, if there are any problems with not having a Medicare card yet, do not worry about that. We will process that. We will absorb that.
50:26
So again, should we put on, and I am just thinking about Selma’s cohort, should she put on it, you know that this is a refugee who has never had a Pap smear, they are over 30, that they are eligible for self-collection, put the clinical info.
50:40
Yeah, definitely put the clinical info on and particularly let us know if it is a refugee in the instance of there is not a Medicare number for us to charge against. That will avoid getting a bill and then needing to deal with the bill, we would waive it of course, but it stresses everyone out at your end when that happens. So, if we cannot charge Medicare, we send the bill, unless we have got something like refugee, asylum seeker, some reason why there was not a Medicare number. International students all have the insurance.
51:16
And the insurance pays for it.
51:17
Yeah.
51:18
Now Kate has put a whole lot of very useful information up here, and Kate, I should get you to put your thing up and do it yourself because you have written wonderful things. Additionally, the NCSP guidelines outline separate guidance for other groups of participants, which fall outside the new recommendations, now when you say new recommendations, are these the new recommendations as of July.
51:40
That is right. That is the extra year of followup for a _____.
51:45
Oh, sorry, so this is, okay, and that is immune deficient patients, participants exposed to a DES in utero. Participants currently undergoing test of cure following treatment for histological HSIL and participants over 70 attending for an exit test.
52:07
That is right.
52:09
So, can you just put that in context again for us.
52:14
So, any of those participants with any abnormality pretty much are going to colposcopy in any case, so immunosuppressed, you go to colposcopy immediately with any abnormality, over 70, on your exit test, we do not wait around, you may have repeated annual test, you get to go to colposcopy and get it resolved etc.
52:33
So, at 70, someone who has been undergoing the annual colposcopies or has had abnormalities can go for an exit colposcopy.
52:44
Yes, unless they have got adenocarcinoma in situ.
52:51
What if there is someone who has had a high-grade abnormality and they have just been observed and I think I have got a few of those, where they have just been observed and they have now gone onto their five yearly and then hit 70, can I say see you later and again to come back if you get symptoms.
53:06
We recommend a test between the age of 70 and 74, and if that is negative, see you later, bye.
53:15
When you say test, you mean either one of these or one that I do.
53:21
Either. Yeah.
53:23
Now, I think that is a group for whom self-collection is very attractive as postmenopausal women, right.
53:32
It is little.
53:34
Yes, it is very small.
53:36
That’s it. And look, a lot of people have vaginismus, have pain, and to be able to do this is is I think is a wonderful thing. I think that many many patients are going to be very happy. Now, I would just say, Kate has actually put up here there are communications about intermediate-risk pathways on your vcs.org.au website and I wonder whether there may be one you can give us some resources that we can send people to in particular, maybe, and we can email them out to Marion, but if people want to look on the Q&A capes put up, I think that and Anita said the key message the lab needs the extra info on our patients in the clinical notes i.e. immunocompromised indeed.
54:11
You know, if they are immune compromised and you say that, we will give you the three-year recommendation for screening that those patients need.
54:31
And now, I was just going to say Selma, who is the doctor who looks after the refugees has said, so what lab do I send it to. At the moment, the self-collection, it is only VCS, is that correct.
54:40
That is right, there are couple of other interstate labs in Australia, but in Melbourne, well, yeah.
54:48
We are only in Victoria here and so it is the VCS, which is where a lot of people send their swabs anyway, and keep an eye out if you want to know who the others are, I am sure that they will be telling you the other labs once they are accredited, but there is no other lab that is accredited in Victoria at the moment to do the self-collection, and I think that is really important.
55:06
Can I interrupt, I am sorry to, for Selma, we have got I think about 10 to 12 languages covered in terms of information sheets for how to collect your self-collected samples, so we can email those to her if that is helpful.
55:27
Oh, Selma, you are not Victoria, you are in NSW. She has confirmed at Armidale, not Armadale, Selma you are in NSW, is there a lab in NSW that they can use, Marion. I did not realise, you have snuck in from over the border, Selma. Good on you.
55:49
So, Douglass Hanly Moir does process self-collected samples.
55:53
Yes, you send it to DHM.
55:56
Yeah, it is DHM. We get swabs from all over Australia and particularly Central Australia, we are very happy if there are any issues, we will take them from anywhere to process them. Make sure that your get the right swab for them. I think it is the same swab, but contact them and ask them about self-collection.
56:21
I am just going to ask Lorraine, thanks for putting so many links up here. I am just wondering if everyone can see the Q&A, have a read of Kate Wilkinson’s things and copy the links that she has put up there, or Lorraine, whether you put them in the chat, if you cannot copy links from the chat, then maybe Kate, you can send out stuff that we cannot send to all our delegates, which would be great.
56:49
I think trying to get on it is a bit organised for you to send out, Sally.
56:52
That would be fabulous and Kate said what you are doing after the seminar.
56:56
No, she said that.
56:58
Yes.
57:00
I can also send out to the seminar. Thank you, Kate. That would be picked up. Kate is wonderful.
57:06
I am finding it difficult to follow that Kate has put so much stuff in there, I am just finding it difficult to follow. Okay, so _____ has said, are we supposed to get these from VCS, and Kate has said, yes you can register to get them sent out to your practice, is that correct, Marion _____.
57:26
Yes, we really will send them out. If you are not already using VCS Pathology, we just need to set you up as a referring clinician. Yeah.
57:32
Okay, so Penelope Martin has asked, why do we need speculum examination. Now she may have missed the original, what is the recommendation from the College of O&G.
57:42
Well, the recommendation from the college of O&G is that speculum examination or internal pelvic examination is not recommended as a routine.
57:52
Even in asymptomatic patients.
57:54
Even asymptomatic patients.
57:56
So, it is not a screening test.
57:59
No.
58:00
We do no need to do it as a screening test, oh, and hang on, what Penelope has then said, I am sorry I was meaning from mid next year and all of my practice speculum has been the most disliked, well there you go Penelope, that these people can ask for this. You do not have to do it. Can we offer them self-collection?
58:21
Yes.
58:23
So, what if they say, but I might have ovarian cancer, can you do internal. You can still do an internal if they wanted, but it is not going to be to be on an angle.
58:35
A lot of people who have participated regularly or want to continue having their sample collected in the usual way, that…
58:47
And also, just in closing because we are coming up against the end of the session, Dr Murali has asked, sometimes after hysterectomy, vault screening is advised, that is when you have still a cervix, is not it. If they have not got a cervix?
59:00
After a complete hysterectomy, there are some circumstances, for example, if nobody knows what it was for, if there was CIN2 or 3 found in the hysterectomy specimen, there is a range of indications in the post-hysterectomy screening chapter, any place in those where it is only an HPV test that is required and not a co-test, you could use self-collection. Anytime you seek co-test, it is not going to work.
59:30
So, someone who has had a hysterectomy and basically says, I do not whether I have got a cervix or not or whatever, a self-collection will at least tell you whether they have got HPV and we do not to do it. Okay.
59:43
That is right.
59:45
Can I just say Marion, it has been an absolute pleasure having you here. Thank you for sitting in your car and doing this and I really appreciate it and can I just say to all our participants it has just been such a privilege being here with you all and I believe Anita continuing next year.
60:00
We will see you all next year, kind of bit some water is coming of my eye, it has been such a big year, and I know Sally, Alt Wednesday has been a real favorite, so we really finished on a high. So, Marion, thank you, you are rather alone and much respected in the field of women’s health, so thank you very much for putting up with all the disaster out there in Melbourne and the traffic and talking to us nevertheless, so thank you to everyone. Please pay attention to all of the events that are going to start to happen with Vic Vac as of January/February 2022, but for now from Alt Wednesday, we are going to say, thank you. Thank you, Sally, so much for this series.
60:51
And can I just put a plug-in that if you have ideas for topics, please email the college and tell us, and I will give you a little hint what we are looking at for upcoming next year. Do you know what the office of the public advocate does? Well, you will find out. Yes, the office of the public advocate looks after the rights of people with disability and they have put out a video on talking to people with disabilities in general practice, they are going to talk to us. Also, do you know how to help a patient through writing their advanced care directives. We will do that as well. So, that is just a couple of things we will be doing.
61:30
Big year next year. _____ pandemic _____.
61:31
Absolutely, Marion, thank you very much. I have got the red mark right here. It is the happiest red mark I have ever had. I have just had my third jab and I am feeling really like my immune system is gunning it. So, I wish everyone a very, very happy and safe summer, and thank you everyone.
61:48
Thank you so much, everyone.
61:52
And Lorraine is just saying, Marion, do not worry, you are not the only one. When Lorraine closes off, we will all just go.
62:02
Thank you. Thanks Sally, thanks Anita, and thanks Lorraine.
62:03
Happy New Year to everyone. Bye, everyone.