Key policy priorities in summary
Cancer Council supports strategies to optimise uptake of prophylactic HPV vaccination by the target population, improve participation in the cervical screening program of eligible women, and further research to contribute to improvements in both programs.
Promote participation in the National HPV Vaccination Program among adolescents
The impact of the HPV vaccination on future cervical cancer incidence and mortality will be influenced by uptake of the vaccine by the population. National HPV vaccination data for girls turning 15 in 2016 shows 78.6% of girls had completed the full course of the HPV vaccine. Evidence shows higher coverage is possible through similar school-based vaccination programs in the UK, demonstrating room for improved coverage rates. For example, offering missed vaccine doses through schools the following year has been shown to improve course completion. Reminders via mail and SMS have also been shown to increase coverage.
The uptake of the HPV vaccines is influenced by the target population’s perceptions of benefits and risks and knowledge of the HPV vaccine as well as health professionals’ attitudes and advice. Therefore communication strategies targeting health professionals, parents, and adolescents – that are sensitive to culture, religion and age – are required to support uptake. Specific and targeted strategies are necessary to optimise uptake of HPV vaccination in population groups that are at higher risk of cervical cancer and/or have lower participation in cervical cancer screening, particularly Indigenous women and women of culturally and linguistically-diverse backgrounds.
Over the longer term, HPV vaccination has the greatest potential to reduce cervical cancer incidence and associated mortality in under-screened populations with a higher incidence of cervical cancer. There is a strong association between socioeconomic status, cervical screening, and cervical cancer incidence, with the lowest screening rates and highest incidence rates evident in the most disadvantaged areas. Conversely, national data has shown that HPV vaccination coverage has a much less pronounced socioeconomic gradient, with coverage rates only slightly lower in girls from the most disadvantaged areas, and early impact data suggests that the impact of HPV vaccination has been similar across different levels of disadvantage. In Australia, Indigenous women are twice as likely to be diagnosed with and over four times more likely to die of cervical cancer than non-Indigenous women. This higher risk is, in part, due to lower participation in the National Cervical Screening Program. National HPV vaccine uptake data are not available by Indigenous status, however, data from Queensland and the Northern Territory showed lower uptake in Indigenous girls aged 12-17 than in non-Indigenous girls in 2007. In Indigenous women, the prevalence of vaccine-targeted HPV types has decreased by 94% (from 24% to 1.4%). These results are consistent with surveillance data of non-Indigenous women, suggesting impact has been similar. Effective prevention will require a good understanding of barriers to participation in the National HPV Vaccination Program for this population and strategies to overcome these barriers.
Promote participation in cervical cancer screening
For women beyond the target age for vaccination, screening is still the most important strategy to prevent cervical cancer. The renewed NCSP provides an opportunity to increase participation among women in under-screened populations with the option for self-collection.
There is strong evidence that self-collection increases participation rates of women who do not attend regular screening. Addressing practical and perceived barriers of self-collection may increase usage among women who are never- or under-screened. Common barriers include fear of the procedure and results as well as access to healthcare services. Offering the option for self-collection to eligible women opportunistically may increase participation rates for this group.
Strategies to increase participation in under-screened populations should focus on making the renewed NCSP accessible and culturally appropriate to population groups including Indigenous and culturally and linguistically-diverse communities. Block blocking has been suggested as a strategy to improve participation rates among Indigenous women as it provides social support. Screening reminders and face-to-face consultations with healthcare professionals have been shown to increase the participation rates of under-screened women. The renewed NCSP will be supported by a new National Cancer Screening Register that will send invitations and reminder letters to women. Culturally appropriate support and information tailored to specific communities is needed. Engaging with the community and developing trust through Aboriginal Health Workers or bilingual health promotion officers is important for encouraging women to participate in cervical screening.
Support a national HPV surveillance program
A national surveillance program should be supported to monitor HPV genotypes causing cervical cancers and genital warts. While the IMPACT study has been funded, there are areas that require development in order to comprehensively monitor the impact of vaccination on cervical cancer. Reporting of HPV status to the cancer registry will further assist with the understanding of the contribution of vaccine- and non-vaccine targeted HPV types to cancer burden over time. The recording of Indigenous status and country of birth on vaccine consent forms and pathology collection forms for cervical screening tests should be strongly encouraged and will enable evaluation of effectiveness of programs and other targeted efforts.
- National HPV Vaccination Program Register. Coverage Data. [homepage on the internet] Melbourne: Victorian Cytology Service; [cited 2017]. Available from: http://www.hpvregister.org.au/research/coverage-data.
- Sinka K, Kavanagh K, Gordon R, Love J, Potts A, Donaghy M, et al. Achieving high and equitable coverage of adolescent HPV vaccine in Scotland. J Epidemiol Community Health 2014 Jan;68(1):57-63 Available from: http://www.ncbi.nlm.nih.gov/pubmed/23986492.
- Brotherton JM, Winch KL, Bicknell L, Chappell G, Saville M. HPV vaccine coverage is increasing in Australia. Med J Aust 2017 Apr 3;206(6):262 Available from: http://www.ncbi.nlm.nih.gov/pubmed/28359009.
- Das JK, Salam RA, Arshad A, Lassi ZS, Bhutta ZA. Systematic Review and Meta-Analysis of Interventions to Improve Access and Coverage of Adolescent Immunizations. J Adolesc Health 2016 Oct;59(4S):S40-S48 Available from: http://www.ncbi.nlm.nih.gov/pubmed/27664595.
- Barbaro B, Brotherton JM. Assessing HPV vaccine coverage in Australia by geography and socioeconomic status: are we protecting those most at risk? Aust N Z J Public Health 2014 Oct;38(5):419-23 Available from: http://www.ncbi.nlm.nih.gov/pubmed/24962721.
- Smith MA, Liu B, McIntyre P, Menzies R, Dey A, Canfell K. Trends in genital warts by socioeconomic status after the introduction of the national HPV vaccination program in Australia: analysis of national hospital data. BMC Infect Dis 2016 Feb 1;16:52 Available from: http://www.ncbi.nlm.nih.gov/pubmed/26829924.
- Australian Institute of Health and Welfare, Australasian Association of Cancer Registries. Cancer in Australia: an overview, 2012. Canberra: AIHW; 2012. Report No.: Cancer series no. 74. Cat. no. CAN 70.
- Australian Institute of Health and Welfare & Cancer Australia. Cancer in Aboriginal and Torres Strait Islander peoples of Australia: an overview. Canberra: AIHW; 2013. Report No.: Cancer series no.78. Cat. no. CAN 75. Available from: http://www.aihw.gov.au/publication-detail/?id=60129544700.
- Australian Institute of Health and Welfare. Cervical screening in Australia 2014–2015. Canberra: AIHW; 2017. Report No.: Cancer Series No. 105, Cat. no. CAN 104. Available from: https://www.aihw.gov.au/getmedia/adc621ce-a54a-4680-8b37-2a70d897964a/20434.pdf.aspx?inline=true.
- Whop LJ, Garvey G, Baade P, Cunningham J, Lokuge K, Brotherton JM, 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 May 15;122(10):1560-9 Available from: http://www.ncbi.nlm.nih.gov/pubmed/27149550.
- Brotherton JM, Murray SL, Hall MA, Andrewartha LK, Banks CA, Meijer D, et al. Human papillomavirus vaccine coverage among female Australian adolescents: success of the school-based approach. Med J Aust 2013 Nov 4;199(9):614-7 Available from: http://www.ncbi.nlm.nih.gov/pubmed/24182228.
- McGregor S, Saulo D, Brotherton JML, Liu B, Phillips S, Skinner SR, et al. Decline in prevalence of human papillomavirus infection following vaccination among Australian Indigenous women, a population at higher risk of cervical cancer: The VIP-I study. Vaccine 2018 Jul 5;36(29):4311-4316 Available from: http://www.ncbi.nlm.nih.gov/pubmed/29880245.
- Machalek DA, Garland SM, Brotherton JML, Bateson D, McNamee K, Stewart M, et al. Very Low Prevalence of Vaccine Human Papillomavirus Types Among 18- to 35-Year Old Australian Women 9 Years Following Implementation of Vaccination. J Infect Dis 2018 Apr 23;217(10):1590-1600 Available from: http://www.ncbi.nlm.nih.gov/pubmed/29425358.
- Nelson EJ, Maynard BR, Loux T, Fatla J, Gordon R, Arnold LD. The acceptability of self-sampled screening for HPV DNA: a systematic review and meta-analysis. Sex Transm Infect 2017 Feb;93(1):56-61 Available from: http://www.ncbi.nlm.nih.gov/pubmed/28100761.
- Verdoodt F, Jentschke M, Hillemanns P, Racey CS, Snijders PJ, Arbyn M. Reaching women who do not participate in the regular cervical cancer screening programme by offering self-sampling kits: a systematic review and meta-analysis of randomised trials. Eur J Cancer 2015 Nov;51(16):2375-85 Available from: http://www.ncbi.nlm.nih.gov/pubmed/26296294.
- Sultana F, English DR, Simpson JA, Drennan KT, Mullins R, Brotherton JM, et al. Home-based HPV self-sampling improves participation by never-screened and under-screened women: Results from a large randomized trial (iPap) in Australia. Int J Cancer 2016 Jul 15;139(2):281-90 Available from: http://www.ncbi.nlm.nih.gov/pubmed/26850941.
- McLachlan E, Anderson S, Hawkes D, Saville M, Arabena K. Completing the cervical screening pathway: Factors that facilitate the increase of self-collection uptake among under-screened and never-screened women, an Australian pilot study. Curr Oncol 2018 Feb;25(1):e17-e26 Available from: http://www.ncbi.nlm.nih.gov/pubmed/29507491.
- University of Melbourne and Victorian Cytology Service. Self-collection Pilot Project - improving access to cervical screening for under-screened women: Evaluation report. Melbourne: Victorian Department of Health and Human Services; 2017 Feb [cited 2018] Available from: https://mspgh.unimelb.edu.au/__data/assets/pdf_file/0011/2791163/Self-collection-pilot-project-final-report.pdf.
- Pilkington L, Haigh MM, Durey A, Katzenellenbogen JM, Thompson SC. Perspectives of Aboriginal women on participation in mammographic screening: a step towards improving services. BMC Public Health 2017 Sep 11;17(1):697 Available from: http://www.ncbi.nlm.nih.gov/pubmed/28893225.
- Duffy SW, Myles JP, Maroni R, Mohammad A. Rapid review of evaluation of interventions to improve participation in cancer screening services. J Med Screen 2017 Sep;24(3):127-145 Available from: http://www.ncbi.nlm.nih.gov/pubmed/27754937.
- DiGiacomo M, Davidson P, McGrath S, Dharmendra T and Thompson S. Cancer in Aboriginal and Torres Strait Islander peoples: a rapid review of the literature. Sydney: Cancer Institute NSW; 2012 [cited 2018] Available from: https://www.saxinstitute.org.au/wp-content/uploads/REPORT_Cancer-in-Aboriginal-populations-1.pdf.
- Barbaro B, Brotherton J and Gertig D. Improving cancer screening participation in under-screened, never-screened and hard-to-reach population: Environmental survey results for participants. Melbourne: Victorian Cytology Service; 2010 Jun Available from: http://www.vccr.org/site/VCCR/filesystem/documents/dataandresearch/EvalandMonReports/Enviro%20Survey.pdf.
- HPV Surveillance Working Group of the Communicable Diseases Network Australia. Human Papillomavirus (HPV) Surveillance Plan – an integrated approach to monitoring the impact of HPV vaccine in Australia. Canberra: Communicable Diseases Network Australia of Australian Health Protection Principal Committee, Australian Government Department of Health; 2013 Dec Available from: http://www.health.gov.au/internet/main/publishing.nsf/content/e5b543ce209e55c3ca257f48001d65ef/$file/hpv-surveillance-plan.pdf.