Feature

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What GPs need to know about the renewed National Cervical Screening Program

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Cervical screening in Australia will change from 1 December, with Pap smears to be replaced with a new five-yearly cervical screening test.
 
The renewed National Cervical Screening Program is for asymptomatic women who are vaccinated and unvaccinated for human papillomavirus (HPV) and who have commenced sexual activity. The program also provides advice about the management of symptomatic women.
 
A five-yearly HPV test is more effective, just as safe, and is expected to result in a significant reduction (24–36%) in the incidence and mortality from cervical cancer in Australian women when compared with the program it replaces (which is based on two-yearly Pap smears).

The renewed program is expected to improve the rate of detection of precursors of both adenocarcinoma and squamous cell cervical cancers, which are caused by persistent infection with oncogenic HPV types.
 
Key changes to screening
Five-yearly primary HPV testing with partial genotyping and liquid-based cytology (LBC) triage. Screening starts at age 25 (sexually active only), and finishes with an exit test from ages 70–74. 
 
Under-screened women aged at least 30 years can take a vaginal HPV self-sample (refer to ‘Self-collection’ section, below, for latest information on self-collected specimen testing). To be considered ‘under-screened’, women must be more than two years overdue for screening (which currently means four years since their last negative Pap test) and have declined (for whatever reason) a speculum examination.
 
Women at any age with possible symptoms of cervical cancer (bleeding, discharge, pain) should have a co-test (HPV and cytology) and appropriate referral, regardless of when their last cervical screening test was performed. GPs can request a co-test on the pathology form.
 
Test procedures
GPs should continue to take a sample from the cervix in the same manner, ie insert a speculum, visualise the cervix and sample from the transformation zone. Transfer the cellular material into a liquid-based medium. Do not prepare a glass slide. GPs make a request for a cervical screening test or ‘CST’ on the request form.
 
The primary (first) test will be for 14 oncogenic HPV types known to be associated with the development of invasive cervical cancer. This test will separately identify oncogenic HPV types 16 and 18, which cause 70–80% of cervical cancer, and 12 other oncogenic HPV types known as oncogenic HPV (not 16/18).
 
All samples in which oncogenic HPV is detected will have cytology performed on the same cervical sample. This is known as reflex liquid-based cytology (reflex LBC) and the laboratory will carry out cytology without the need for a specific request from you.
 
Cervical screening test is an HPV test and any reflex liquid-based cytology (LBC) test done on cervical cells in a liquid-based sample.
 
Recommendations:

• Women with a negative cervical screening test result (no oncogenic HPV detected) should re-screen in five years.
• Women with oncogenic HPV types 16/18 detected should be referred directly for colposcopy.
• Women with other oncogenic HPV types (not 16/18) detected should be triaged according to the reflex LBC result and screening history.
• Women who do not have oncogenic HPV detected on a self-collected sample should re-screen in five years.
• Women with an unsatisfactory cervical screening test result (HPV or LBC) should return in 6–12 weeks for a repeat HPV or cytology.

Transition to the new program
Women older than age 25:

• Recall at the time recommended according to their result under the current program. Request a cervical screening test.
• Women eligible for a test of cure after treatment of a histologically confirmed high-grade squamous lesion (HSIL) should start or continue co-testing, request a co-test (HPV and cytology).

Women younger than age 25:

• Those  have had a negative Pap test will not be eligible for a cervical screening test until they are 25.
• Those who have had a high-grade result should start or continue follow-up test of cure (HPV and LBC). Request a co-test.
• Those who are in follow-up for a possible/low-grade squamous intraepithelial lesion (pLSIL/LSIL) Pap test result in the previous program should have a cervical screening test at their next scheduled follow-up appointment, even if this means they are not yet 25.
• If oncogenic HPV is not detected, the woman can return to five-yearly screening. If oncogenic HPV is detected, the woman should be referred for colposcopy informed by reflex LBC.

Women at any age who have been treated for adenocarcinoma in situ (AIS) should have annual co-testing (HPV and LBC) indefinitely.

Self-collection
GPs should note the status of self-collected specimen testing: Self-collection for the renewed cervical screening program will not be available from 1 December, with a validation process of the laboratory and platform testing processes still underway. The test will not be claimable under the Medicare Benefits Schedule (MBS). GPs should not offer self-collection to eligible women until further notice.

Self-collection is a vaginal swab taken by a woman for HPV testing. The sample contains vaginal, not cervical, cells.

 
The vaginal HPV test is sufficiently accurate and includes partial genotyping for HPV 16/18. LBC cannot be performed on the vaginal sample. Self-sampling must be performed in a healthcare setting – it is not available as a home-based test or mail out kit.
 
Self-collection will be an alternative pathway that can help to overcome barriers to having a clinician-collected cervical screening test. Women who are eligible for self-collection will benefit by participation in screening, and will also benefit by being reassured they are at low risk of cervical cancer if oncogenic HPV is not detected.
 
Chlamydia testing in the context of the renewed National Cervical Screening Program
When undertaking cervical screening in women who are also eligible for a chlamydia test, take the cervical sample as usual and transfer it to the liquid-based medium and request a cervical screening test and chlamydia test. Ensure the woman has signed the Medicare assignment on the request form.
 
Sexually active asymptomatic women aged under 25 with a negative Pap test result are not eligible for a cervical screening test until they turn 25. They should instead see their GP for an annual chlamydia test, contraceptive counselling and safe-sex advice.
 
Visit RACGP.TV to view Changes to Cervical Screening, a video resource presented by Dr Lara Roeske and Dr Stella Heley designed to support GPs and their practice teams in the transition to the new guidelines. In addition, resources supporting the renewed National Cervical Screening Program are available at VCS Pathology.

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