Proposed new national cervical screening program. Dr Elizabeth Jackson Obstetrician Gynaecologist Cairns

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1 Proposed new national cervical screening program Dr Elizabeth Jackson Obstetrician Gynaecologist Cairns

2 Cervical cancer in Australia 12th most common cancer affecting Australian women cases of cervical cancer, 2.0 deaths per women ATSI 22.3 cases 10.6 per women Australia has the lowest cervical cancer mortality rate and second lowest incidence of cervical cancer rate in the world Pap smears have already halved the incidence and mortality of cervical cancer 85% of women in Australia with cervical cancer - not had a Pap smear or been inadequately screened in the past 10 years

3 Cervical cancer prevention Jan cervical cancer vaccine girls boys also Aims to prevent 70% of all HPV infections known to cause cervical cancer National cervical screening program (NCSP) since 1991

5 What is a Pap smear?

15 Proposed new NCSP May Government accepted proposal

16 Women yearly cervical screening primary HPV test with partial HPV genotyping reflex LBC triage for vaccinated and unvaccinated self collection for under-screened or never screened

19 HPV testing as a triage tool immediate HPV triage test is a more sensitive test than single repeat cytology test for detecting CIN 2 or greater lesions in with LSIL similiar specificity to cytology plsil restricting the HPV triage to older age groups was associated with higher specificity and a lower colposcopy referral rate > similiar gain in sensitivity compared with its use in all age groups for women older than 30 - more cost effective as well

20 Predicted models demonstrate in an unvaccinated population, partial HPV genotyping a reduction of cervical cancer incidence of 18% (95% CI 13-21%) a reduction of cervical cancer mortality by 18% (95% CI 14-21%) cost savings $33.8M - $52.8M (even greater in vaccinated population)

21 Case studies to demonstrate how the new guidelines apply

22 Case 1 20 year old woman presents to GP for her first Pap smear

23 Directed gynaecology history: LMP regular or irregular Dysmenorrhoea/menorrhagia PV discharge G P Prev Pap Specific symptoms for cervical dysplasia - Abnormal uterine bleeding - Intermenstrual bleeding - Postcoital bleeding - Dyspareunia Questions for RF for cervical dysplasia? Age of sexual debut Number of sexual partners, high parity Family history of reproductive cancers Smoker Completed 3 Guardasil vaccinations HIV coinfection HSV Chlamydia Immunosupression -dietary/nutritional

24 Examination Vulval and vagina (V&V) Cervical appearance ectropion/lesion Contact bleeding Perform Pap smear ensuring endocervical sampling Other: <25 chlamydia and gonorrhoea screening Safe sex counselling Contraceptive counselling

25 History: LMP 2/52 ago Nil abnormal bleeding Nil history of pelvic pain On COCP for contraception Examination NAD Contact bleeding with Pap smear HSIL on Pap smear X1 sexual partner with sexual debut at 18 Has completed 3 vaccines with Guardasil at high school Non-smoker No family history of reproductive cancers

26 Patient is referred for colposcopy Colposcopy consistent with CIN 3 -Cervical biopsy inflammation and reactive changes -Pap smear LGSIL -Moved interstate, followup Pap in 12 months

27 Presents for followup Pap 12 months later -onset of intermenstrual bleeding -Pap smear NAD (inadequate) -HPV negative

28 Presents to GP with worsening abnormal bleeding 12 months later again GP assessment: - Non-compliant with COCP (misses occasional COCP) - Menorrhagia - Intermenstrual bleeding - Pap repeated?hgsil - Referred to gynaecologist

29 Colposcopy performed - 3cm Cervical cancer - Biopsy confirmed adenocarcinoma of the cervix - CT/PET + MRI + EUA cystoscopy - Stage 1B1 Adenocarcinoma Treatment For trachelectomy + fertility preservation

30 How would the new cervical cancer guidelines change this patient s outcome?

31 It wouldn t Between 1991 and 2010, the number of new cases of cervical cancer in women aged years was approximately 10 per year (range 4 to 18). There have been 0 to 2 deaths per year in women aged years over this same period.

32 How would the new cervical cancer guidelines change? - Cervical screening has not altered incidence and mortality of cervical cancer in women under 25 - History of abnormal bleeding would warrant referral to gynaecologist - Cervical cancer vaccine is not protective against all forms of cervical cancer 70% HPV 16 and HPV % cervical cancers HPV detected

33 - cervical cancer under 25 is rare - the incidence of cervical cancer under 25 is falling since HPV vaccinations, and will continue to fall - HPV usual transient in young sexually active women, over treatment leads to possible problems in later pregnancy

34 Case 2 56 year old woman with 6 month history of post-coital bleeding Menopause at 51 Nil previous gynaecology concerns History reveals x2 new partners in preceeding 24 months GP review: STI screen negative, LSIL on Pap (February 2015)

35 Referred to gynaecologist for colposcopy (March 2015) Repeat Pap HSIL and with normal colposcopy but type 3 transformation zone Fischer Cone Biopsy performed CIN 2 (April 2015)

36 - Risk factors for dysplasia assessed (unchanged) - Abnormal bleeding, especially PCB requires gynaecologist referral (unchanged) - LSIL in women over 30 current guidelines for colposcopy assessment - In new guidelines > HPV detected - reflex liquid base cytology >colposcopy - Current exit test for Pap smear is for women aged 70 with 2 normal Pap smears within the last 5 years. Women can request a Pap smear over 70 - Exit HPV in new guidelines years

37 - Women greater than 50 are identified as under screened - Most people will clear HPV in under 2 years - Persistent HPV leads to cervical cancer (up to 10 years)

38 An HPV test every five years is more effective than, and just as safe as, screening with a Pap test every two years An HPV test every five years can save more lives and women would need fewer tests than in the current two-yearly Pap test program

39 Until changes to the NCSP occur, continue on current program consumer resources and health professional training; new clinical guidelines for women with a positive test result; new pathology laboratory performance measures and standards; workforce changes; and register changes.

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