Policy context

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Policy context

This section outlines the history and current context of Australian government policy relating to cervical cancer screening and human papillomavirus (HPV) immunisation. It is anticipated that the population-based delivery of the prophylactic HPV vaccine will influence changes to the national screening policy. A Renewal of the National Cervical Screening Program (NCSP) commenced in 2011, including assessment of the evidence for screening tests and pathways, the screening interval and age range. The Renewal is expected to be implemented by December 2017.

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HPV vaccination

Two prophylactic HPV vaccines have been approved by the Therapeutic Goods Administration (TGA) for use in Australia.

In 2006 the TGA approved the quadrivalent HPV vaccine Gardasil for use in women aged 9–26 years and males aged 9–15 years. The TGA subsequently approved extension of the age ranges, up to 45 years for females and up to 26 years for males. The bivalent vaccine Cervarix was approved by the TGA in 2007 and is registered for use in women aged 10–45 years.

In 2007 Australia commenced the National HPV Vaccination Program to deliver a HPV vaccine (Gardasil) to girls via schools. For the first two years of the program there was also a ‘catch-up’ program, providing free vaccine to all girls and women up to 26 years of age, through schools as well as general practice and community health centres. Between 2007 and 2009, 72% of girls aged 14 and 15, and nearly 66% of girls aged 16 and 17 received the full three doses need to protect them from HPV. Data from the National HPV Vaccination Catch-up Program shows the coverage rate for women aged 18–19 years who completed the full course was 38% and about 30% of the cohort of women aged 20–26 years completed the full course[1].

There is an ongoing school-based vaccination program, offering the vaccine to all girls aged 12–13 years, in the first year of high school or last year of primary school (depending on the state/territory). The Australian Immunisation Handbook provides clinical guidelines for administration of the vaccine. National HPV vaccination data for girls aged 15 in 2009 shows 70.8% of girls had completed the full course of the HPV vaccine[1].

The National HPV Vaccination Program Register monitors and reports HPV vaccine coverage. Existing infrastructure such as Pap test registers and cancer registers enables some monitoring of the impact of the HPV vaccination program. However a more comprehensive HPV surveillance program is needed to monitor type-specific HPV infection in the Australian population – to measure reduction in the types targeted by vaccination and any change in other HPV types – as well as incidence of genital warts and recurrent respiratory papillomatosis[2].

See the HPV School vaccination program website for more information about the current vaccination program.

Vaccination of boys

In November 2011 the Pharmaceutical Benefits Advisory Committee (PBAC) recommended Gardasil be approved for vaccination of boys aged 12–13, plus a two-year catch-up program covering boys in year nine at school.

In July 2012, the Australian Government announced a plan to include boys on the National HPV Vaccination Program from 2013[3]. According to the announcement, the Government will fund the vaccine for 12- and 13-year-old boys through school-based programs under the National Immunisation Program. Year 9 boys and boys aged 14–15 years (who may not be in Year 9) will also be able to get the vaccine through a catch-up program in 2013 and 2014, as per the PBAC recommendations[3].

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National Cervical Screening Program

Screening for cervical cancer was introduced in Australia on an ad hoc basis in the 1960s. Guidelines on cervical screening programs published in 1986 by the World Health Organization and the International Agency for Research on Cancer were used as a basis for a review of cervical screening in Australia, conducted on behalf of Australian Health Ministers Advisory Council[4]. Following this review, cervical screening was organised into a structured program, known today as the National Cervical Screening Program. The program was implemented in 1991 as a joint initiative of the Australian, State and Territory Governments.

Women in the target age group of 20–69 years are recruited by a variety of initiatives determined mainly at the state/territory level. Recruitment strategies are implemented for particular population sub-groups, such as older women, Australian Aboriginal and Torres Strait Islander women, and women from culturally diverse backgrounds. State and territory cancer organisations have been involved in coordinating the establishment of state Pap test registries and recruitment of women to the screening program. In some states and territories, Cancer Councils maintain an important role in cervical screening programs.

The national policy for Australia’s NCSP guidelines for screening state:

  • Routine screening with Pap smears should be carried out every two years for women who have no symptoms or history suggestive of cervical pathology.
  • All women who have ever been sexually active should start having Pap smears between the ages of 18 and 20 years, or one or two years after first having sexual intercourse, whichever is later.
  • Pap smears may cease at the age of 70 years for women who have had two normal Pap smears within the last five years. Women over 70 years who have never had a Pap smear, or who request a Pap smear, should be screened.

Women with abnormal Pap test results are managed in accordance with the National Health and Medical Research Council guidelines[5].

Expenditure on the National Cervical Screening Program was $125 million in 2008–09[6]. This increased from $88 million in 2001–02 and $103.6 million in 2004–05[6]. For further information on the cost of cervical cancer in Australia see Economic impact.

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Participation

Cervical cytology registers in Australia provide information on the majority of women who undergo screening, although an estimated 1–3% of women choose not to be included on the register[4]. Recent NSW data showed only 0.8% of women ‘opted off’ the NSW register[7].

For all 2-year periods from 2004–2005 to 2008–2009, NCSP participation rates remained steady at 59% in the target age group of 20-69 years[8]. This decreased slightly to around 57–58% between 2009–2010 and 2011–2012[8].

In 2011–2012, a total of 3.9 million women participated in the NCSP, of whom 3.7 million (96.1%) were in the target age group of 20–69. This represents 57.3% of women in the target age group, which, when age-standardised to allow analysis of trends and differentials, equates to a participation rate of 57.7%[8]. Participation was highest for women aged 45–49 at (63.9%), followed by women aged 50–54 (63.3%), and is lower on either side of these age groups (See Table 1)[8].


Table 1. Participation in NCSP by age, 2011–2012

Age group 20–24 25–29 30–34 35–39 40–44 45–49 50–54 55–59 60–64 65–69
Women 339,106 430,035 447,873 458,225 460,431 425,213 390,561 322,080 269,357 180,857
Crude rate (%) 42.8 52.2 58.2 60.6 61.9 63.9 63.3 61.2 59.5 51.5

Source: AIHW 2014[8]
Note: Crude rate is the number of women screened in 2011–2012 as a percentage of the ABS estimated resident population for women aged 20–69, adjusted to include only women with an intact cervix using age-specific hysterectomy fractions derived from the AIHW National Hospitals Morbidity Database


The proportion of women re-screening early (within 21 months) decreased from 13.3% for the 2010 cohort to 13.0% for the 2011 cohort, this is relatively stable after a steady decline since the 2000 cohort, for which the proportion of women rescreening early was above 30%[8]. Early re-screening increases the cost of the program and reduces cost-effectiveness.

Measuring participation in the NCSP over longer periods reveals higher levels of women having cervical cytology tests. An AIHW analysis of state and territory cervical cytology register data shows that while 57.3% of the estimated eligible women aged 20–69 years had at least one test in the two years 2011–2012, 70.2% had at least one test in the three years 2010–2012, and 83.3% participated in the NCSP in the five years 2008–2012[8].

Improving screening rates

A recent review of studies focused on cancer screening found scant evidence of the effectiveness of particular strategies for targeting ‘hard-to-reach’ groups of women[9]. For women of culturally and linguistically diverse backgrounds, the most effective strategies appeared to be coaching, community interventions, multi-component interventions and counselling. However, the small number of studies focused on engaging Indigenous (Native American, Hawaiian, Canadian and Alaskan) women, women with low income and non-urban women made it difficult to discern trends in effectiveness[9]. Only about half the studies reported a statistically significant increase in uptake. More effort is needed to identify and evaluate strategies, and sustain short-term interventions that appear successful, to increase participation of women in groups at higher risk in Australia.

Targeted efforts and better data collection (e.g. routine recording of Aboriginal and Torres Strait Islander status) are needed to further understand barriers to participation in prevention programs and improve outcomes for at-risk populations.

Self-sampling technologies have proven to be highly acceptable to women and have the potential to improve screening participation rates among underscreened women (see Self-sampling, below).

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National Cervical Screening Program Renewal

New evidence about the optimal screening age range and interval; the introduction of HPV vaccination and developments in new technologies for the early detection of cervical cancer have led to the need to review the policy and operation of the NCSP. See sections on New screening technologies and Impact of HPV vaccination on screening for more information.

The aim of the NCSP Renewal is to ensure that all Australian women, HPV vaccinated and unvaccinated, have access to a cervical screening program that is acceptable, effective, efficient and based on current evidence and best practice. The Renewal assessed the evidence for screening tests and pathways, the screening interval, age range and commencement for both vaccinated and non-vaccinated women, to determine a cost-effective screening pathway and program model through an expert review of Australia’s cervical screening program, commencing in late 2011.

The recommendations of the review were made to the Australian Government by the Medical Services Advisory Committee (MSAC) in April 2014. The primary recommendation of the review was that an HPV test replace the Pap smear as the primary screening tool for the NCSP. MSAC has recommended, for both HPV vaccinated and unvaccinated, women that[10]:

  • an HPV test be undertaken every five years, with partial HPV genotyping and liquid-based cytology triage for HPV-positive women;
  • cervical screening commence at 25 years of age;
  • women have an exit test between 70 and 74 years of age; and
  • women with symptoms (including pain or bleeding) should have a cervical test at any age.

The review of international evidence indicated that an HPV test every five years is more effective than, and just as safe as, screening with a Pap test every two years. A modelled evaluation of the effectiveness in the Australian context found that HPV testing is projected to decrease cervical cancer incidence by 15–18% and cervical cancer mortality by 16–18%, compared with current practice[10].

The Renewal of the National Cervical Screening Program will be implemented on 1 December 2017. In the meantime, women are encouraged to continue to participate in the screening program.

See HPV DNA testing for more information on the HPV test.

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References

  1. 1.0 1.1 Department of Health. Human Papillomavirus (HPV). [homepage on the internet] Canberra: Department of Health; 2017 Nov 18 [cited 2013 Oct 8; updated 2013 Feb 14]. Available from: http://health.gov.au/internet/immunise/publishing.nsf/Content/immunise-hpv.
  2. Brotherton JM, Kaldor JM, Garland SM. Monitoring the control of human papillomavirus (HPV) infection and related diseases in Australia: towards a national HPV surveillance strategy. Sex Health 2010 Sep;7(3):310-9 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/20719220.
  3. 3.0 3.1 Department of Health and Ageing. Department of Health and Ageing announcement. [homepage on the internet] Canberra: Commonwealth of Australia; 2012 Jul Available from: http://www.health.gov.au/internet/ministers/publishing.nsf/Content/mr-yr12-tp-tp059.htm.
  4. 4.0 4.1 Australian Institute of Health and Welfare. Breast and cervical cancer screening in Australia 1996-1997. Canberra: AIHW; 1998. Report No.: Cancer Series. Cat. no. CAN 3.. Available from: http://www.aihw.gov.au/WorkArea/DownloadAsset.aspx?id=6442454247.
  5. National Health and Medical Research Council. Screening to prevent cervical cancer: guidelines for the management of asymptomatic women with screen-detected abnormalities. Canberra: Commonwealth of Australia; 2005 Available from: http://www.nhmrc.gov.au/_files_nhmrc/publications/attachments/wh39.pdf.
  6. 6.0 6.1 Australian Institute of Health and Welfare. Health system expenditure on cancer and other neoplasms in Australia 2008-09. Canberra: AIHW; 2013 Dec 16. Report No.: Cancer series 81. Cat. no. CAN 78. Available from: http://aihw.gov.au/publication-detail/?id=60129545611.
  7. Cancer Institute NSW. Cervical cancer screening in New South Wales: annual statistical report 2007–08. Sydney: Cancer Institute NSW,; 2011 Jun Available from: http://www.cancerinstitute.org.au/media/125242/cervical-cancer-screening-in-nsw-2007-08.pdf.
  8. 8.0 8.1 8.2 8.3 8.4 8.5 8.6 Australian Institute of Health and Welfare. Cervical screening in Australia 2011–2012. Canberra: AIHW; 2014. Report No.: Cancer series no.82. Cat. no. CAN 79. Available from: http://aihw.gov.au/publication-detail/?id=60129546865.
  9. 9.0 9.1 Day S, van Dort P, Tay-Teo K. Improving participation in cancer screening programs. Volume 3, knowledge translation: a review of strategies to increase participation in cancer screening. Victoria: Victorian Cytology Service; 2010 May Available from: http://www.vccr.org/downloads/Vol%203%20Knowledge%20Translation.pdf.
  10. 10.0 10.1 Medical Service Advisory Committee. National Cervical Screening Program Renewal: Executive summary. Commonwealth of Australia; 2013 Nov. Report No.: MSAC application no. 1276. Available from: http://www.cancerscreening.gov.au/internet/screening/publishing.nsf/Content/754127911763F571CA257B8A001ADDC5/$File/WebAccessiblility_Combined_Executive_summary__Final_27Nov2013_SentToDoHA.pdf.

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