Preventing cervical cancer: don't ditch the Pap test yet!

[Please note that this media release was published in 2015. The National Cervical Screening Program has changed and pap smears are no longer used.]

Cervical screening in Australia

The Pap test, developed by Dr George Papanikolaou over 80 years ago, has been the keystone of the Australian National Cervical Screening Program( NCSP) since its introduction in 1991. Australia now has the second lowest cervical cancer rate in the world, yet despite the huge public health success of the program 229 women still died of cervical cancer in 2012 (1) with an average age 50 years. Importantly, almost 80% of women who do develop cervical cancer have not been screened or had regular screening tests.

Pap testing

The Pap test involves visualising the cervix using a speculum and good light source, taking a sample of cells from the squamocolumnar junction using a designated brush, broom or spatula and placing the cells onto a glass slide for fixing prior to transfer to the cytology lab for staining and reading. No woman wakes up in the morning looking forward to a Pap test so making the experience as friendly, dignified and comfortable as possible through skilled communication and examination techniques is essential.

Current screening guidelines

Current guidelines advise women to start screening from the age of 18 years or 2 years after first becoming sexually active, whichever is later, and then continue with 2-yearly screening until the age of 70. It is essential to recognise that the definition of cervical screening refers to a Pap test taken from an asymptomatic woman. Women with symptoms of possible cervical pathology, including those with post-coital bleeding, inter-menstrual bleeding or pain, require an appropriate diagnostic work-up. Furthermore, women with an unusual looking cervix which could be suggestive of cervical disease also require gynaecological referral.

The Pap test detects pre-malignant cytological changes which are graded using the modified Bethesda system into low grade and high grade squamous intraepithelial lesions (LSIL, HSIL) and glandular lesions. The laboratory report of the Pap test result also includes a management recommendation based on the woman's previous Pap test results. The Pap test registry plays an essential role in tracking an individual woman's cervical screening history as well as providing population-based data for monitoring trends at a local as well as state level.

Changes to the screening program

As everyone will be aware, the current cervical screening program based on the Pap test will be changing in 2017. This change, known as 'the renewal', is based on new knowledge and understandings about the role of HPV (Human Papilloma Virus) in the development of cervical cancer, the success of the HPV vaccine program as well as new testing technologies.

HPV infection is the first step in developing 99% of cervical cancer and while most women clear virus within 2 to 3 years, those in whom the virus persists are at risk of cancer. Approximately 70% of cervical squamous and adenocarcinomas are associated with HPV types 16 or 18 while the remainder are associated with other high risk HPV types, and a significant reduction in vaccine-targeted HPV types as well as herd immunity has been reported in 2014 (2).

From 2017 the cervical screening program will replace the Pap test with a primary HPV test every 5 years for vaccinated as well as unvaccinated women, starting at the age of 25 years and continuing until 70-74 years of age with an exit HPV test. This change follows extensive expert review of the current international evidence and modelling which find that HPV testing every 5 years is more effective than, and just as safe as, screening with a Pap test every 2 years. For further information and a review of the evidence behind the changes you can go to

• www.msac.gov.au
• www.cancerscreening.gov.au/internet/screening/publishing.nsf/Content/cervical-screening-1

Business as usual: don't ditch the Pap test yet!

Until the changes are implemented it is essential that it is 'business as usual' with asymptomatic women being encouraged to have a screening Pap test every 2 years. Opportunistically asking women when their last test was during a consultation for other issues is a useful way of ensuring that women are not missing out on this important preventative health intervention.

Women of any age who have symptoms suggestive of cervical cancer should have appropriate diagnostic testing which may include a test for chlamydia, a pelvic ultrasound as well as a Pap test, depending on the clinical scenario. Currently the only indication for doing an HPV test is as a 'test of cure' following treatment of a biopsy proven high grade lesion.

The following sources have useful information on cervical screening:

Family Planning NSW

• Pap test factsheet : https://www.fpnsw.org.au/health-information/pap-test-and-cervical-screening/pap-tests
• "Untold stories" - Experiences of cervical cancer screening told by women from diverse cultures: https://www.fpnsw.org.au/untoldstories
• "The Being a Healthy Woman factsheets" - designed to assist women with an intellectual disability to understand life changes, the importance of a healthy lifestyle, or the need to see a doctors includes a factsheet on Pap tests: https://www.fpnsw.org.au/health-information/disability/being-healthy-woman-factsheets
• Talkline : 1300 658 886
• Family Planning NSW courses for doctors and registered nurses on cervical screening : https://www.fpnsw.org.au/education-training/courses

Cervical screening NSW

• Resources for health professionals and patients including multicultural factsheets on cervical screening: www.csp.nsw.gov.au

National Cervical Screening Programme

• Patient factsheets on cervical screening: www.cancerscreening.gov.au/internet/screening/publishing.nsf/Content/resources-menu?OpenDocument&CATEGORY=2Consumer+Resources-3&SUBMIT=Search

References:

1. Cervical screening in Australia 2012-2013 .Cancer series Number 93 AIHW Canberra http://www.aihw.gov.au/WorkArea/DownloadAsset.aspx?id=60129550872. Accessed online 22/8/2015.

2. Tabrizi Sepehr et al Assessment of herd immunity and cross protection after a human papillomavirus vaccination programme in Australia: a repeat cross- sectional study. Lancet Infect Dis, 2014, published online August 6, 2014.