Statistical Report 2006 by Victorian Cytology Service

Statistical Report 2006

VICTORIAN CERVICAL

CYTOLOGY REGISTRY

Victorian Cervical Cytology Registry STATISTICAL REPORT 2006 October 2007

Contact Details:

Cathryn Wharton Data Manager VCCR PO Box 161 Carlton South VIC 3053 Telephone: 03 9250 0390 Fax: 03 9349 1818 E-mail: cwharton@vccr.org Website www.vccr.org

CONTENTS EXECUTIVE SUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 1. INTRODUCTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 1.1

Background. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

1.2

Functions of the Pap test Registry . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

1.3

Data included in this report . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

2. PARTICIPATION IN SCREENING . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 2.1

National Policy: Implementation of the NHMRC Guidelines for the Management of Asymptomatic Women with Screen Detected Abnormalities . . . 7

2.2

Pap test numbers and women screened . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 Table 2.2:

2.3

2.4

Number of Pap tests registered and number of women screened in Victoria, for period 1990 to 2006. . . . . . . . . . . . . . . . . . 8

Participation by age group . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 Table 2.3:

Estimated proportion of women with a cervix who have had at least one Pap test for each time period, adjusted for hysterectomy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

Figure 2.3:

Estimated proportion of women with a cervix who have had at least one Pap test for two year periods from 2000, by age group. . 11

Participation by Areas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

2.4.1 Participation by Division of General Practice . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 Table 2.4.1: Biennial cervical screening rates by Division of General Practice, for the period 1 January 2005 to 31 December 2006. . . 13 2.4.2 Participation by Region of the Department of Human Services . . . . . . . . . . . . . 14 Table 2.4.2: Biennial cervical screening rates by Region of the Department of Human Services, for the period 1 January 2005 to 31 December 2006. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 Figure 2.4.2: Biennial cervical screening rates by Region of the Department of Human Services, for the period 1 January 2005 to 31 December 2006. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 2.4.3 Participation by Local Government Area . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 Table 2.4.3: Biennial cervical screening rates by Local Government Area, for the period 1 January 2005 to 31 December 2006. . . . . . . . . . . 16 2.5

Pap tests collected by nurses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 Table 2.5:

Proportion of Pap tests collected by nurses, for the period 1997 to 2006. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

2.5.1 Proportion of Pap tests collected by nurses by Region of the Department of Human Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 Table 2.5.1: Pap tests for women with a cervix collected by nurses in 2006 by Region of the Department of Human Services . . . . . . . . . . . . . 19 Figure 2.5.1: Proportion of Pap tests collected by nurses in 2006 by Region of the Department of Human Services . . . . . . . . . . . . . . . 20 1 Victorian Cervical Cytology Registry Statistical Report 2006

CONTENTS 2.6

Frequency of Early Re-Screening . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21 Table 2.6:

Subsequent Pap tests over a 21 month period for women with a negative report in February of each year . . . . . . . . . . . . . . . . . . 21

Figure 2.6:

Early re-screening after a negative Pap test report in February 2005 by age . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22 3. CYTOLOGY REPORTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 3.1

Reporting of squamous cells . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24 Table 3.1:

3.2

Squamous cell categories for Pap tests taken by general practitioners and nurses, 2006 . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

Reporting of endocervical component . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 Table 3.2:

Endocervical component for Pap tests taken by general practitioners and nurses, 2006 . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25

Figure 3.2:

Proportion of Pap tests collected by general practitioners and nurses with an endocervical component, for the period 2000 to 2006. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26

3.3

Reporting of other cells (non-cervical) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27

3.4

Use of recommendation codes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 Table 3.4:

Recommendation codes for Pap tests collected by general practitioners and nurses, for the period 1 July to 31 December 2006 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28

4. HISTOLOGY/ COLPOSCOPY REPORTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29 Table 4.1:

Histology and/or colposcopy findings reported to the VCCR in 2006. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29

5. CORRELATION BETWEEN CYTOLOGY AND HISTOLOGY REPORTS . . . . . . . . . 30 Table 5.1:

Histology findings following a cytology report, 2006 . . . . . . . . . . . 31

6. FOLLOW-UP AND REMINDER PROGRAM . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32 Table 6.1:

Number of reminder letters sent to women by the VCCR in 2006 . . 32

7. CERVICAL CANCER INCIDENCE AND MORTALITY IN VICTORIA . . . . . . . . . . . . 34 Figure 7.1: Age standardised incidence and mortality rates for cervical cancer in Victoria, for the period 1982 to 2004. . . . . . . . . 34 Table 7.1:

Number of cases and age-standardised incidence rates for cervical cancer by histological subtype in Victoria, for the period 1989 to 2004. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .35

Figure 7.2:

Age-specific incidence rates of cervical cancer in Victoria, by histology, for the period 2001 to 2004 . . . . . . . . . . . . . . . . . . . . . . 36

8. SCREENING HISTORY OF WOMEN DIAGNOSED WITH CERVICAL CANCER . . . 37 Table 8.1:

Screening history of Victorian women diagnosed with invasive cervical cancer, for the period 1 January 2002 to 31 December 2004. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37 ACKNOWLEDGEMENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39 LIST OF ABBREVIATIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40 APPENDIX 1. 2006 CYTOLOGY CODING SCHEDULE . . . . . . . . . . . . . . . . . . . . . . . . 41 APPENDIX 2. REMINDER AND FOLLOW-UP PROTOCOL USED IN 2006 . . . . . . . . . 42 2 Victorian Cervical Cytology Registry Statistical Report 2006

EXECUTIVE SUMMARY In 2006, more than 572,000 Pap tests were registered by the Victorian Cervical Cytology Registry (VCCR), representing almost 541,000 women. In its role as a safety net for the cervical screening program, VCCR sent almost 258,000 follow-up and reminder letters to women and practitioners. The estimated two year (2005-2006) participation of women in the target age range of 20 to 69 years was 63.4%. Although this represents a slight decline from the last report (65% in 2004-2005), there was a change in the method used to adjust for hysterectomy and this accounts for part of this difference. Women between 50 and 59 years of age had the highest biennial screening rate in 2005-2006 and the rate was lowest among women between 20 and 29 years of age. Substantial variation exists in screening rates between different areas of Victoria as represented by Divisions of General Practice, with the lowest two year screening rate being estimated at 56% and the highest at 77%. The screening rate for Victorian Regions of Department of Human Services (DHS) ranged from 58% to 67%. The estimated two year participation rates for Local Government Areas have been added to this report for the first time and range from 47% to 82%. Over the last decade there has been an increase in the proportion of Pap tests collected by nurses with 2.8% of all Victorian Pap tests being collected by nurses in 2006. The proportion of Pap tests collected by nurses in 2006 was higher in rural DHS regions than in the metropolitan regions. Of Pap tests reported in 2006 as being collected by general practitioners and nurses (approximating community based smears), 6.0% were reported as abnormal. A definite high-grade abnormality was present in 0.5% of smears. Endocervical component, a measure of Pap test quality, was present in 77% of smears taken from women with a cervix. The VCCR recorded almost 16,500 histology and colposcopy reports relevant to the cervix in 2006. For the 2,491 women with a high-grade cytology report, 1,904 were subsequently diagnosed with high-grade histology on biopsy within a 6 month period. This represents a positive predictive value of 76%. Due to the new coding system for cytology reports, in 2006 all high-grade abnormalities were included in this predictive value and not just CIN 3 as in previous statistical reports. Rates of cervical cancer incidence and mortality for Victoria through to 2004 have been provided by the Victorian Cancer Registry. Cervical cancer incidence has declined dramatically since the late 1980s when the organised screening program was introduced. Mortality from cervical cancer has continued to decline in Victoria and at 1.0 per 100,000 women is now among the lowest in the world. Of Victorian women diagnosed with invasive cervical cancer between 2002 and 2004, at least 86% had either no Pap test history or an inadequate screening history in the 10 years before diagnosis.

3 Victorian Cervical Cytology Registry Statistical Report 2006

1. INTRODUCTION 1.1 Background The Victorian Cervical Cytology Registry (VCCR) is one of eight such registries operating throughout Australia. Each State and Territory operates its own register. Victoria was the first State to establish such a register and commenced operation in late 1989 after amendments to the Cancer Act 1958. The Pap test Registries, as they are commonly known, were introduced progressively across Australia throughout the 1990s. The Registries are an essential component of the National Cervical Screening Program and provide the infrastructure for organised cervical screening in each State and Territory. The VCCR is a voluntary “opt-off” confidential database of Victorian women’s Pap test results. Laboratories provide the Registry with data on all Pap tests taken in Victoria, unless a woman chooses not to participate. The VCCR works closely with PapScreen Victoria which is responsible for the communications and recruitment program aimed at maintaining the high rate of participation of Victorian women in the National Cervical Screening Program. As described in more detail in Section 2, the NHMRC Guidelines for the Management of Asymptomatic Women with Screen Detected Abnormalities were implemented in July 2006. For the VCCR this meant implementing new coding for Pap test results and modifying the existing follow-up and reminder protocol to accommodate the new recommendations. 1.2 Functions of the Pap test Registry The Registry facilitates regular participation of women in the National Cervical Screening Program by sending reminder letters to women for Pap tests and by acting as a safety net for the follow-up of women with abnormal Pap tests. In this endeavour, 257,636 follow-up and reminder letters were mailed to women and practitioners by the VCCR in 2006. The primary functions of the VCCR as specified in the Cancer Act 1958 are: a)

to follow-up positive results from cancer tests; and

to send reminder notices when persons whose names appear in the register are due for cancer tests; and

subject to and in accordance with the regulations, to give access to the register to persons studying cancer; and

to compile statistics and, if the organisation considers it appropriate, to publish those statistics that do not identify the persons to whom they relate.

Secondary functions of the Registries have developed on a more regional basis. In Victoria, the role of the Registry includes: • the provision of the known screening history of a woman to the laboratory that is reporting the current Pap test; • the provision of quantitative data to laboratories to assist with their quality assurance programs; • the provision of aggregate data to the Commonwealth so that the National Cervical Screening Program can be judged against an agreed set of performance indicators.

4 Victorian Cervical Cytology Registry Statistical Report 2006

1. INTRODUCTION 1.3 Data included in this report This statistical report is one in a series of annual reports that have been published since the inception of the Victorian Registry. It provides timely information about screening in Victoria; in most areas, the data is additional to that published by the Australian Institute of Health and Welfare. Wherever possible, the same methodology has been adopted in this report as is used in the AIHW Report. Participation rates This report includes information on participation rates for women aged 20 to 69 years in ten year age groups. As described later in Section 2.3, for this particular statistical report two participation rates have been provided. The first has been adjusted with the 2001 hysterectomy fraction (which has been used in previous years) and the second adjusted with the 2004-05 hysterectomy fraction (which will be used in future reports). The variation between the two participation rates in this report illustrates the impact of the differences between the two hysterectomy fractions. Two year participation rates (using the 2004-05 hysterectomy fraction) are also provided for Divisions of General Practice, Regions of the Department of Human Services and Local Government Areas. Cytology coding Information is provided on the cytology report of Pap tests which are pre-coded by the pathology laboratory to the Registryâ&#x20AC;&#x2122;s Cytology Coding Schedule. Appendix 1 shows the Australia wide codes that were used from 1 July 2006 to correspond with the implementation of the new NHMRC guidelines. The Cytology Coding Schedule allows a Pap test report to be summarised to a six digit numeric code covering the type of test, site of test, the result for squamous cells, the endocervical component, other noncervical cells, and the recommendation made by the laboratory in regards to further testing. Prior to 1 July 2006, the Cytology Coding Schedule summarised results into a five digit numeric code for squamous cells, evidence of human papillomavirus infection, endocervical component, other non-cervical cells and the recommendation. During the change over to using the new coding schedule the old five digit code was mapped to the equivalent using the updated coding schedule. Data provided in this report uses the new coding. Histology/ colposcopy reports The 2006 histology and colposcopy registrations in this report are as notified by May 2007. The vast majority of histology reports are registered by this time, thus the data are reasonably complete. While reasonably comprehensive registration occurs for histology reports, a proportion of colposcopy results are also registered, most typically when a histology report is not available. For all the reports for 2006, 9.4% were obtained from colposcopy alone. These have not been included in the histology/ cytology correlation table.

5 Victorian Cervical Cytology Registry Statistical Report 2006

1. INTRODUCTION Follow-up protocol As of December 2005, the VCCR Reminder and Follow-up Protocol was revised and is based on the NHMRC Guidelines for the Management of Asymptomatic Women with Screen Detected Abnormalities. The Reminder and Follow-up Protocol used by the Registry in 2006 is shown in Appendix 2. Reminder letters are not sent to women whose Registry records indicate a past history of hysterectomy or of cervical or uterine malignancy, or to women who are over 70 years of age and whose last Pap test was normal. Cervical Cancer Incidence and Mortality Information on cervical cancer incidence and mortality is provided in this report. Also included is an additional section examining the screening history of Victorian women diagnosed with invasive cervical cancer between the start of 2002 and end of 2004.

6 Victorian Cervical Cytology Registry Statistical Report 2006

2. PARTICIPATION IN SCREENING 2.1 National Policy: Implementation of the NHMRC Guidelines for the Management of Asymptomatic Women with Screen Detected Abnormalities On 1 July 2006, the National Health and Medical Research Council Guidelines for the Management of Asymptomatic Women with Screen Detected Abnormalities (2005)1 were implemented around Australia. The main changes to the existing guidelines were: • the change of terminology for cytology reports to the Australian Modified Bethesda System 2004 • repeat Pap tests for most women with low-grade squamous abnormalities • not to treat biopsy proven low-grade or HPV lesions • referral of all women with atypical glandular cells for colposcopy • referral of all women with a possible high-grade lesion for colposcopy • use of HPV tests and cytology as a test for cure for women treated for CIN 2 and 3. 2.2 Pap test numbers and women screened During 2006, a total of 572,800 Pap tests were registered which originated from 540,700 women. From the previous year, this is a decrease of approximately 12,500 Pap tests and almost 9,000 women. It is possible that this reflects an early impact of the new NHMRC guidelines, due to the shift in recommended management of lowgrade abnormalities. Table 2.2 shows data on the number of Pap tests registered and the number of women from whom these tests originated, for each year of the Registry’s operation.

1 P. Blomfield, M. Davy, I. Hammond and G.Wain. The new NH&MRC guidelines for Management of abnormal Pap smears in asymptomatic Australian women. O&G, Vol 7, No 3, Spring 2005, page 25-27. 7 Victorian Cervical Cytology Registry Statistical Report 2006

2. PARTICIPATION IN SCREENING Table 2.2:

Number of Pap tests registered and number of women screened in Victoria, for period 1990 to 2006.

Year

Number of Pap tests registered

Number of women screened

2006

572,800

540,700

2005

585,300

549,700

2004

588,000

550,000

2003

571,000

532,000

2002

579,000

540,000

2001

577,000

542,000

2000

572,000

532,000

1999

603,000

558,000

1998

619,000

571,000

1997

587,000

535,000

1996

616,000

560,000

1995

590,000

530,000

1994

622,000

562,000

1993

571,000

523,000

1992

542,000

497,000

1991

545,000

498,000

1990

436,000

402,000

The number of women screened in each of these years is probably a slight overestimate because of incomplete record linkage due to there being no unique identifying number for each woman. Where possible, the Medicare number of women is used to assist with accurate record linkage. Since August 1999, the Registry has used SSA-Name in the matching of incoming tests to pre-existing data on the database. This has resulted in more complete record-linkage of different episodes of care for women, compared with the previous approach to record-linkage. In interpreting the information in the above table, it is important to realise that a proportion of women in Victoria are screened on an annual basis. Participation over a longer period of time than one year cannot be derived by adding the counts for individual years. The Registry is a voluntary â&#x20AC;&#x153;opt-offâ&#x20AC;? database; however, the non-participation rate in Victoria is estimated to be less than 1%. Where a woman objects to her Pap test being registered, the Registry holds no information about that test.

8 Victorian Cervical Cytology Registry Statistical Report 2006

2. PARTICIPATION IN SCREENING 2.3 Participation by age group Method of calculating participation The participation of women in cervical screening by age group is expressed as a percentage. â&#x20AC;˘ The denominator is the Estimated Resident Female Population based on Australian Bureau of Statistics data for Victoria (ERP)2, after adjustment for the estimated proportion of women who have had a complete hysterectomy. While recent VCCR statistical reports have used hysterectomy data from the 2001 National Health Survey3, the 2004-05 survey provides more recent national hysterectomy estimates in the general population4. â&#x20AC;˘ The numerator is estimated from the VCCR database. It is the number of women resident in Victoria who had at least one Pap test in the time period of interest and who appear to have a cervix (that is, they have not had a hysterectomy according to information held by the Registry). Table 2.3 shows the estimated percentage of eligible women with a cervix that had at least one Pap test in 2006 and during the periods of 2005-2006, 2004-2006 and 20022006. Limitations Participation rates are necessarily imprecise and measurement error may affect both the denominator and the numerator. As discussed earlier, the biggest impact on denominator error comes from uncertainty about hysterectomy rates. Only women with a cervix are considered eligible for cervical screening and adjustment must be made for the proportion of women in the population who have had a hysterectomy. Measurement error in Registry data comes from imperfect record-linkage between multiple Pap tests from the same woman (resulting in an overestimate of the number of women screened) and from inaccuracies in the Registry database in recording whether the Pap test was taken from a woman with or without a cervix.

2 Australian Bureau of Statistics. Population by Age and Sex, Australian States and Territories, June 2005. 3 Australian Bureau of Statistics. National Health Survey, 2001. 4 Australian Bureau of Statistics. National Health Survey, 2004-05. 9 Victorian Cervical Cytology Registry Statistical Report 2006

2. PARTICIPATION IN SCREENING Table 2.3:

Estimated proportion of women with a cervix who have had at least one Pap test for each time period, adjusted for hysterectomy. % screened 2006 (1 year)

% screened 2004-2006 (3 years)

2004-05 hysterectomy fraction

2001 hysterectomy fraction

2004-05 hysterectomy fraction

2001 hysterectomy fraction

20-29 yrs 29.3%

29.3%

53.2%

68.2%

30-39 yrs 36.4%

36.6%

66.0%

66.3%

40-49 yrs 38.4%

36.8%

69.6%

50-59 yrs 39.7%

38.0%

60-69 yrs 33.7% 20-69 yrs 35.4%

Age Group

2001 hysterectomy fraction

% screened 2005-2006 (2 years)

2004-05 hysterectomy fraction

% screened 2002-2006 (5 years) 2001 hysterectomy fraction

2004-05 hysterectomy fraction

68.3%

89.3%

89.4%

80.6%

81.0%

94.0%

94.4%

66.7%

82.3%

78.9%

91.0%

87.3%

71.8%

68.8%

82.4%

79.0%

88.3%

84.6%

34.8%

61.5%

63.6%

68.7%

71.0%

71.7%

74.2%

34.9%

64.2%

63.4%

77.0%

76.1%

89.0%

88.0%

Table 2.3 illustrates the variation in the participation rates within an age group due to adjustment of the denominator by the different hysterectomy fractions. The differences between the two fractions in the younger age groups (20-29 years and 30-39 years) are smaller and therefore reflect only small variation. However, in the age groups of 40-49 years and 50-59 years the 2004-05 hysterectomy fraction is lower than the 2001 fraction, which makes the eligible population (the denominator) larger and is reflected in a lower participation rate. For the age group of 60-69 years, the 2004-05 hysterectomy fraction is higher which is reflected in a higher participation rate. Overall across all age groups, the 2004-05 hysterectomy fraction is lower and is therefore reflected in a lower participation rate. Because of such variation, the participation rates presented in this report should be interpreted and used with caution. For all data presented in the remainder of this report, the 2004-05 hysterectomy fraction has been used. During 2006 the participation rate declined slightly to 34.9% from 36.4% in 2005 (2005 data not shown). The two year participation rate also dropped slightly to 63.4% from 65.0% in 2004-2005 (2004-2005 data not shown). Adjustment using the newer hysterectomy fraction accounts for 0.8% of the change in the two year participation rate compared to the older fraction. The biennial participation rate in Victoria is higher than the national average. The most recently available national data shows that in 2004-2005 the two yearly national participation rate for women aged 20-69 years was 61.0%5. Over the three year period from 2004 to 2006, the estimated participation rate of Victorian women aged between 20 and 69 years in the Pap test screening program was 76.1%. Table 2.3 also shows the five year estimated participation rate from 2002 to 2006 being 88.0%.

5 AIHW & DoHA. Cervical screening in Australia 2004-2005, August 2006. Canberra. 10 Victorian Cervical Cytology Registry Statistical Report 2006

2. PARTICIPATION IN SCREENING Figure 2.3:

Estimated proportion of women with a cervix who have had at least one Pap test for two year periods from 2000, by age group.

80% 70%

% Participation

60% 50% 40% 30% 20% 10% 0%

2000-2001 2001-2002 2002-2003 2003-2004 2004-2005 2005-2006* Time Period 20-29 yrs

30-39 yrs

40-49 yrs

50-59 yrs

60-69 yrs

* Note that the 2005-2006 data has been adjusted with the 2004-05 hysterectomy fraction which has slightly reduced participation rates compared with using the 2001 hysterectomy fraction.

Figure 2.3 shows that participation in cervical screening has remained relatively stable over time for each age group since 2001. Women over 40 years of age have the highest two year screening rates with a steady increase until age 59 when the participation drops off slightly for 60 to 69 year old women.

11 Victorian Cervical Cytology Registry Statistical Report 2006

2. PARTICIPATION IN SCREENING 2.4 Participation by Areas Method of calculating participation The participation for Divisions of General Practice, Regions of the Department of Human Services and Local Government Areas are expressed as a percentage. • The denominator is the estimated number of eligible women, resident in the postcodes of each area, adjusted for the proportion of women estimated to have had a hysterectomy (using the 2004-05 hysterectomy fraction). • The numerator is the number of women who had at least one Pap test in the two year time period and who have not had a hysterectomy according to the information held by the VCCR. Changes to the participation rates for Divisions of General Practice and Regions of Department of Human Services from previous years may reflect the impact of the 200405 hysterectomy fraction which is lower than the 2001 hysterectomy fraction that has been used in the past (refer to Section 2.3). Limitations This type of information, being small-area data, is subject to greater measurement error than the data in Sections 2.2 and 2.3. The main source of inaccuracy in the following tables derives from applying the national hysterectomy fraction to the relatively small female population resident in the postcodes. Other additional (but probably lesser) sources of measurement error derive from: • the use of the service provider’s postcode of practice if the woman’s residential postcode is not known to the Registry, • the proportion of Victorian Pap tests reported by laboratories outside of Victoria who do not report to the Registry (this will mainly affect areas located on the Victoria/New South Wales and Victoria/South Australia borders); and • the differences between the postcode assigned by the Australian Bureau of Statistics to the Estimated Resident Population data and the postcode nominated by the woman.

12 Victorian Cervical Cytology Registry Statistical Report 2006

2. PARTICIPATION IN SCREENING 2.4.1 Participation by Division of General Practice The Commonwealth Department of Health and Ageing assigns almost all Victorian postcodes to a Division of General Practice. There are twenty nine Divisions of General Practice located solely within Victoria. Using methods discussed in the beginning of Section 2.4 with the allocation of postcodes to each Division, the estimated two year participation rates have been calculated. Table 2.4.1:

Division Number 301 302 303 304 305 306 307 308 310 311 312 313 314 315 316 317 318 319 320 322 323 324 325 326 327 328 330 331 332

Estimated biennial cervical screening rates by Division of General Practice, for the period 1 January 2005 to 31 December 2006. % screened 95% confidence interval 2005-2006 Melbourne Division of GP 66.6% (66.2%-66.9%) North East Valley Division of GP 70.2% (69.8%-70.5%) Inner Eastern Melbourne Division of GP 72.4% (72.0%-72.8%) Inner South East Melbourne Division of GP 71.4% (71.1%-71.8%) Westgate Division of GP 56.2% (55.8%-56.6%) Western Melbourne Division of GP 61.9% (61.6%-62.3%) North West Melbourne Division of GP 61.9% (61.6%-62.2%) The Northern Division of GP, Melbourne 58.6% (58.2%-59.0%) Whitehorse Division of GP 66.6% (66.2%-66.9%) Greater South Eastern Division of GP 67.5% (67.1%-67.9%) Monash Division of GP 63.9% (63.4%-64.4%) Central Bayside Division of GP 77.0% (76.6%-77.4%) Knox Division of GP 64.1% (63.7%-64.4%) Dandenong & District Division of GP 61.7% (61.4%-62.0%) Mornington Peninsula Division of GP 61.8% (61.5%-62.2%) GP Association of Geelong 61.9% (61.5%-62.3%) Central Highlands Division of GP* 57.7% (57.3%-58.1%) North-East Victorian Division of GP 65.9% (65.4%-66.5%) Eastern Ranges Division of GP 62.8% (62.4%-63.2%) South Gippsland Division of GP 59.4% (58.7%-60.1%) Central-West Gippsland Division of GP 60.2% (59.6%-60.7%) Otway Division of GP* 63.8% (63.3%-64.3%) Ballarat & District Division of GP* 62.3% (61.8%-62.8%) Bendigo & District Division of GP* 58.4% (57.8%-59.0%) Goulbourn Valley Division of GP 62.1% (61.5%-62.7%) East Gippsland Division of GP 63.5% (62.8%-64.2%) Western Victorian Division of GP 58.9% (58.2%-59.6%) Murray Plains Division of GP 61.3% (60.4%-62.1%) Mallee Division of GP 60.1% (59.4%-60.8%) Division Name

* For this report the Central Highlands Division of GP, Otway Division of GP, Ballarat & District Division of GP and Bendigo & District Division of GP have had a correction in the assignment of postcodes which may have had an affect on the participation rate from previous years.

Victorian Cervical Cytology Registry Statistical Report 2006

2. PARTICIPATION IN SCREENING 2.4.2 Participation by Region of the Department of Human Services Most Victorian postcodes are assigned to a Region of the Department of Human Services (DHS). Victoria is divided into eight Regions, five in rural Victoria and three covering metropolitan Melbourne. Using methods discussed in the beginning of Section 2.4 with the allocation of postcodes to each region, the two year participation rates have been calculated. Figure 2.4.2 also illustrates the two year participation rate by DHS region.

Table 2.4.2:

Biennial cervical screening rates by Region of the Department of Human Services, for the period 1 January 2005 to 31 December 2006. % screened 2005-2006

95% confidence interval

Barwon South Western

62.5%

(62.2%-62.9%)

Eastern Metropolitan

66.8%

(66.6%-67.0%)

Gippsland

60.8%

(60.5%-61.2%)

Grampians

58.4%

(58.0%-58.8%)

Hume

64.4%

(64.0%-64.8%)

Loddon Mallee

61.5%

(61.1%-61.8%)

North West Metropolitan

61.6%

(61.4%-61.7%)

Southern Metropolitan

66.3%

(66.1%-66.4%)

Region Name

14 Victorian Cervical Cytology Registry Statistical Report 2006

2. PARTICIPATION IN SCREENING Figure 2.4.2: Biennial cervical screening rates by Region of the Department of Human Services, for the period 1 January 2005 to 31 December 2006.

LODDON MALLEE 61.5% GRAMPIANS 58.4%

HUME 64.4%

GIPPSLAND 60.8%

BARWON SOUTH WESTERN 62.5%

NORTH WEST METRO 61.6%

SOUTHERN METRO 66.3%

EASTERN METRO 66.8%

15 Victorian Cervical Cytology Registry Statistical Report 2006

2. PARTICIPATION IN SCREENING 2.4.3 Participation by Local Government Area Within Victoria there are 79 Local Government Areas (LGAs). Using methods discussed at the beginning of Section 2.4, and an algorithm to determine the allocation of postcodes to LGA6, the estimated two year participation rate by LGA has been calculated. Table 2.4.3:

Biennial cervical screening rates by Local Government Area, for the period 1 January 2005 to 31 December 2006.

DHS region

Barwon S/W

Eastern Metro

Gippsland

Grampians

Local Government Area Colac-Otway Corangamite Glenelg Greater Geelong Moyne Queenscliffe Southern Grampians Surf Coast Warrnambool Boroondara Knox Manningham Maroondah Monash Whitehorse Yarra Ranges Bass Coast Baw Baw East Gippsland Latrobe South Gippsland Wellington Ararat Ballarat Golden Plains Hepburn Hindmarsh Horsham Moorabool Northern Grampians Pyrenees West Wimmera Yarriambiack

% screened 2005-2006 67.1% 61.0% 54.9% 61.3% 66.8% 70.5% 67.1% 63.0% 67.1% 73.1% 64.5% 69.9% 65.7% 62.1% 64.8% 64.4% 53.1% 63.7% 63.3% 58.0% 63.7% 63.5% 56.1% 57.4% 55.3% 63.0% 56.8% 61.4% 61.4% 58.5% 50.8% 51.8% 55.9%

95% confidence interval (65.9%-68.4%) (59.5%-62.4%) (53.6%-56.3%) (60.9%-61.7%) (65.3%-68.2%) (67.3%-73.7%) (65.7%-68.6%) (61.8%-64.2%) (66.1%-68.1%) (72.7%-73.5%) (64.1%-65.0%) (69.4%-70.4%) (65.1%-66.2%) (61.7%-62.6%) (64.3%-65.2%) (63.9%-64.9%) (52.0%-54.2%) (62.8%-64.6%) (62.4%-64.2%) (57.3%-58.7%) (62.6%-64.9%) (62.6%-64.4%) (54.3%-58.0%) (56.8%-58.0%) (53.9%-56.8%) (61.5%-64.5%) (54.3%-59.3%) (60.1%-62.8%) (60.3%-62.5%) (56.7%-60.2%) (48.5%-53.2%) (48.9%-54.6%) (53.6%-58.2%)

6 Postcode to LGA converter algorithm supplied by the Victorian Department of Human Services. 16 Victorian Cervical Cytology Registry Statistical Report 2006

2. PARTICIPATION IN SCREENING DHS region

Local Government Area

Alpine Benalla Greater Shepparton Indigo Mansfield Hume Mitchell Moira Murrindindi Strathbogie Towong Wangaratta Wodonga Buloke Campaspe Central Goldfields Gannawarra Greater Bendigo Loddon-Mallee Loddon Macedon Ranges Mildura Mount Alexander Swan Hill Banyule Brimbank Darebin Hobsons Bay Hume Maribyrnong North-West Metro Melbourne Melton Moonee Valley Moreland Nillumbik Whittlesea Wyndham Yarra Bayside Cardinia Casey Frankston Glen Eira Southern Metro Greater Dandenong Kingston Mornington Peninsula Port Phillip Stonnington

% screened 2005-2006 65.3% 66.4% 61.2% 65.2% 70.0% 60.0% 63.8% 63.9% 64.9% 53.9% 71.0% 64.6% 62.2% 62.5% 51.0% 59.4% 59.6% 58.3% 66.0% 56.5% 72.9% 58.8% 68.2% 61.8% 62.3% 56.4% 58.5% 62.6% 58.5% 46.9% 66.1% 63.1% 75.2% 59.2% 56.2% 70.6% 82.1% 63.9% 61.8% 58.3% 73.3% 60.5% 63.9% 64.7% 70.6% 75.8%

95% confidence interval (63.8%-66.9%) (64.9%-67.9%) (60.5%-62.0%) (63.7%-66.6%) (67.9%-72.1%) (59.0%-61.1%) (62.6%-64.9%) (62.3%-65.4%) (63.0%-66.8%) (51.4%-56.4%) (69.9%-72.1%) (63.7%-65.6%) (59.9%-64.6%) (61.6%-63.5%) (49.3%-52.8%) (57.6%-61.2%) (59.0%-60.2%) (56.1%-60.4%) (65.1%-66.9%) (55.7%-57.4%) (71.6%-74.2%) (57.5%-60.1%) (67.7%-68.7%) (61.4%-62.2%) (61.8%-62.8%) (55.8%-57.1%) (58.0%-58.9%) (61.9%-63.3%) (57.8%-59.1%) (46.2%-47.5%) (65.6%-66.7%) (62.7%-63.6%) (74.6%-75.9%) (58.7%-59.7%) (55.7%-56.7%) (70.1%-71.2%) (81.7%-82.6%) (63.2%-64.7%) (61.4%-62.2%) (57.8%-58.8%) (72.8%-73.7%) (60.0%-61.0%) (63.4%-64.4%) (64.2%-65.2%) (70.1%-71.1%) (75.3%-76.3%) 17

Victorian Cervical Cytology Registry Statistical Report 2006

2. PARTICIPATION IN SCREENING 2.5 Pap tests collected by nurses During 2006, a total of 16,035 Pap tests were collected by 236 nurses. This number represents 2.8% of all Pap tests collected in Victoria during 2006. As shown in Table 2.5, the number of Pap tests collected by nurses has more than doubled over the last ten years.

Table 2.5

Proportion of Pap tests collected by nurses, for the period 1997 to 2006. Year

Number of Pap tests collected by nurses

% of all Victorian Pap tests

2006

16,035

2.8%

2005

14,375

2.5%

2004

13,100

2.2%

2003

11,494

2.0%

2002

10,635

1.8%

2001

11,017

1.9%

2000

9,628

1.7%

1999

9,922

1.6%

1998

9,858

1.6%

1997

7,155

1.2%

In comparison with all Pap tests collected in Victoria during 2006, Pap tests collected by nurses were more likely to have an endocervical component7. Of Pap tests collected by nurses, the majority were conducted in General Practice or a Community Health setting. During 2006, 37.1% of the Pap tests collected by nurses were from women over 50 years of age compared with 28.8% for all Pap tests collected in Victoria during this period8.

7 An indicator of smear quality, see Section 3.2 (Cytology reports) . 8 VCCR Evaluation of Pap tests collected by Nurses in Victoria during 2006 Report. 18 Victorian Cervical Cytology Registry Statistical Report 2006

2. PARTICIPATION IN SCREENING 2.5.1 Proportion of Pap tests collected by nurses by Region of the Department of Human Services Most Victorian postcodes are assigned to a Region of the Victorian Department of Human Services (DHS). Victoria is divided into eight regions, five in rural Victoria and three covering metropolitan Melbourne. Table 2.5.1 and Figure 2.5.1 show that the rural DHS regions had a higher proportion of tests collected by nurses, for women with a cervix, than those within metropolitan Melbourne.

Table 2.5.1

Pap tests for women with a cervix collected by nurses in 2006 by Region of the Department of Human Services.

Region name

Number of Pap tests collected by nurses

Number of nurses in each region

% of all Victorian Pap tests collected by nurses

Barwon South Western

1,485

4.4%

924

0.9%

Gippsland

1,546

6.9%

Grampians

1,440

7.7%

Hume

1,202

4.8%

Loddon Mallee

3,930

13.6%

North West Metropolitan

3,863

2.5%

Southern Metropolitan

1,341

1.0%

Eastern Metropolitan

19 Victorian Cervical Cytology Registry Statistical Report 2006

2. PARTICIPATION IN SCREENING Figure 2.5.1: Proportion of Pap tests collected by nurses in 2006 by Region of the Department of Human Services.

LODDON MALLEE 13.6% GRAMPIANS 7.7%

HUME 4.8%

GIPPSLAND 6.9%

BARWON SOUTH WESTERN 4.4%

NORTH WEST METRO 2.5%

20 Victorian Cervical Cytology Registry Statistical Report 2006

SOUTHERN METRO 1.0%

EASTERN METRO 0.9%

2. PARTICIPATION IN SCREENING 2.6 Frequency of Early Re-Screeninig While the Australian screening policy is for repeated testing every two years after a negative Pap test report, many women are screened more frequently than this. A small level of early re-screening can be justified on the basis of a past history of abnormality. In late 2000, the National Cervical Screening Program adopted the following definition of early re-screening: Early re-screening is the repeating of a Pap test within 21 months of a negative Pap test report, except for women who are being followed up in accordance with the NHMRC guidelines for the management of cervical abnormalities. This definition recognises that some re-screening may occur opportunistically between 21 and 24 months after a negative Pap test report and this may be cost-effective. The following table shows the number of further tests over a 21 month period for women who received a negative Pap test report in the February of each year. The data shows that 75% of women aged 20-69 years who were screened in February 2005 had no further tests within the next 21 months. Of women aged 20-69 years who were screened in February of 2005, 25% underwent early re-screening. The data in Table 2.6 shows a substantial improvement in early re-screening between 1996 and 2005. Among women screened in 1996, 43% had one or more Pap tests within 21 months. By 2005, this figure had fallen to just over 25%.

Table 2.6

Subsequent Pap tests over a 21 month period for women with a negative report in February of each year.

Number of subsequent Pap tests

Feb Feb Feb Feb 2005 2004 2003 2002

Feb Feb Feb Feb Feb Feb 2001 2000 1999 1998 1997 1996

No further tests 75%

74% 73%

69%

68%

65% 66%

63%

59%

57%

22%

22% 23%

26%

27%

29% 28%

31%

34%

<1%

<1% <1% <1% <1%

<1% <1%

5 or more

<1% <1% <1% <1%

<1% <1%

21 Victorian Cervical Cytology Registry Statistical Report 2006

2. PARTICIPATION IN SCREENING Some variation in early re-screening occurs by age group. The following graph shows the proportion of women, by age group, who had early re-screening after a negative Pap test report in February 2005. As seen in previous years, early re-screening peaks in the age group 30-39 years and is least evident in the age group 60-69 years.

Figure 2.6:

Early re-screening after a negative Pap test report in February 2005 by age.

30%

% Early re-screening

25% 20% 15% 10% 5% 0% 20-29 years

30-39-years

40-49 years Age groups

22 Victorian Cervical Cytology Registry Statistical Report 2006

50-59 years

60-69 years

3. CYTOLOGY REPORT Cytology reports received by the VCCR are coded numerically according to the following categories of information which comprise the main aspects of a Pap test report: * Squamous cell code * Endocervical component code * Other (non-cervical) cell code * Recommendation code The following analyses relate only to the 471,681 Pap tests collected by general practitioners and nurses in 2006 and use the Cytology Coding Schedule which was implemented in July of 2006. Pap tests collected by obstetricians, gynaecologists or at hospital outpatient clinics have been excluded from the analyses in Section 3 as these are more likely to be reported as abnormal. These selection criteria thus approximate ‘community based Pap tests’ from the general female population. In the following tables, ‘Average’ refers to the frequency of use of the report codes across all Pap tests collected by general practitioners and nurses in 2006. ‘Range’ is the highest and lowest proportion for individual laboratories registering a minimum of 500 Pap tests during 2006; ten laboratories fulfilled these criteria. Five laboratories were excluded from this measurement because they reported less than 500 Pap tests to the Victorian Cervical Cytology Registry in 2006; three of these laboratories were either located on the border of Victoria and New South Wales or were located interstate. The following information on the distribution of cytology reports for squamous cells, endocervical component, other cells and the recommendation code is based on women with a cervix.

23 Victorian Cervical Cytology Registry Statistical Report 2006

3. CYTOLOGY REPORT 3.1 Reporting of squamous cells The following table shows the distribution of cytology reports for the eight squamous cell codes used during 2006. Table 3.1:

Squamous cell categories for Pap tests taken by general practitioners and nurses, 2006.

Squamous Cell Code

Average*

Range#

Unsatisfactory

2.0%

0.7% - 4.9%

Satisfactory (no abnormal cells or only reactive changes)

91.9%

82.2% - 94.9%

Possible low-grade squamous intraepithelial lesion

2.2%

0.5% - 4.2%

Low-grade squamous intraepithelial lesion

2.9%

2.5% - 8.1%

Possible high-grade squamous intraepithelial lesion

0.4%

0.1% - 0.8%

High-grade squamous intraepithelial lesion

0.5%

0.3% - 1.1%

High-grade squamous intraepithelial lesion with possible micro-invasion/ invasion

<0.1%

0.01% - 0.04%

Squamous carcinoma

<0.1%

0.00% - 0.04%

* All data use the Cytology Coding Schedule implemented in July 2006. # All laboratories, excluding those reporting fewer than 500 Pap tests.

The proportion of abnormal Pap tests in 2006 was less than 6.1% and this has been stable since 2003. A definite high-grade abnormality (i.e. high-grade lesion with or without possible microinvasion or invasion, or invasive squamous cell carcinoma) was reported in just over 0.5% of Pap tests, compared with 0.7% in 2005.

24 Victorian Cervical Cytology Registry Statistical Report 2006

3. CYTOLOGY REPORT 3.2 Reporting of endocervical component The following table shows the distribution of cytology reports for technically satisfactory Pap tests, for the codes relating to the endocervical component. Pap tests which are known to have been collected post-hysterectomy are excluded.

Table 3.2:

Endocervical component for Pap tests taken by general practitioners and nurses, 2006.

Endocervical Component Code

Average*

Range#

No endocervical component present

23.1%

19.4% - 33.2%

No abnormality or only reactive changes

76.6%

66.1% - 78.3%

Atypical endocervical cells of uncertain significance

<0.1%

<0.1% - <0.1%

Possible high-grade endocervical glandular lesion

<0.1%

<0.1% - <0.1%

Adenocarcinoma-in-situ

<0.1%

<0.1% - <0.1%

Adenocarcinoma-in-situ with possible micro-invasion/ invasion

0.0%

0.0% - <0.1%

Adenocarcinoma

0.0%

0.0% - <0.1%

* All data use the Cytology Coding Schedule implemented in July 2006. # All laboratories, excluding those reporting fewer than 500 Pap tests.

25 Victorian Cervical Cytology Registry Statistical Report 2006

3. CYTOLOGY REPORT As illustrated in Figure 3.2, the proportion of Pap tests with an endocervical component has gradually decreased from 82.7% in 2000 to 76.9 % during 2006. This decrease has also been seen at a national level. The reason for the decreasing proportion of Pap tests with an endocervical component is unclear. Figure 3.2:

Proportion of Pap tests collected by general practitioners and nurses with an endocervical component, for the period 2000 to 2006.

90% 80%

Percentage

70% 60% 50% 40% 30% 20%

2000

2001

2002

2003

2004

2005

2006

Year

Type of Pap test In July 2006, the VCCR began recording the type of Pap test taken i.e. conventional cytology or liquid-based specimen. Between 1 July and 31 December 2006 (when the new NHMRC guidelines were effective) the proportion of liquid-based Pap tests was 4.4% (10,454 of 238,835) of all Pap tests collected by general practitioners and nurses in this time. Most of these tests are â&#x20AC;&#x153;split samplesâ&#x20AC;? where a conventional smear is accompanied by the liquid-based specimen. Very small numbers were liquid-based specimens only (<0.1%).

26 Victorian Cervical Cytology Registry Statistical Report 2006

3. CYTOLOGY REPORT 3.3 Reporting of other cells (non-cervical) Of Pap tests collected by general practitioners and nurses, 99.9% of the cytology reports indicated no other (non-cervical) abnormal cells were present. Among the Pap tests collected by general practitioners and nurses during 2006 with abnormal non-cervical cells, there were: • 86 reports of atypical endometrial cells of uncertain significance • 28 reports of atypical glandular cells of uncertain significance • 37 reports of possible endometrial adenocarcinoma •

2 reports of possible high-grade lesions which were non-cervical

• 19 reports of malignant cells of the uterus •

2 reports of malignant cells from the ovary; and

•

3 reports of other malignant cells (such as metastatic malignancy).

3.4 Use of recommendation codes Table 3.4 shows statistics for the recommendation codes where a recommendation was given. However, due to the changes in coding related to the implementation of the NHMRC guidelines in July 2006 only data for the second half of 2006 is shown. ‘Average’ uses data relating to Pap tests with a recommendation from all laboratories. The statistics listed under ‘Range’ are confined to the ten laboratories that attached recommendations to more than 80% of their general practitioner/nurse Pap tests and where a minimum of 500 such reports were made. In calculating these percentages, the number of tests with recommendations in the six month period was used as the denominator. Not all cytology reports include a recommendation by the laboratory about the next stage of care for the woman. During 2006, 4,822 cytology reports (1.0%) issued to general practitioners and nurses did not include a recommendation. This decline from 20,470 (4.2%) for 2005 is possibly due to the increased discussion around the new NHMRC guidelines.

27 Victorian Cervical Cytology Registry Statistical Report 2006

3. CYTOLOGY REPORT Table 3.4:

Recommendation codes for Pap tests collected by general practitioners and nurses, for the period 1 July to 31 December 2006.

Recommendation Code

Average*

Range#

Repeat smear in 2 years

81.7%

72.7% - 86.0%

Repeat smear in 1 year

10.6%

5.4% - 14.5%

Repeat smear in 6 months

0.6%

0.3% - 3.1%

Repeat smear in 6 to 12 weeks

2.1%

0.8% - 5.0%

Colposcopy/ biopsy recommended

1.9 %

1.0% - 4.8%

Already under gynaecological management

0.2%

<0.1% -2.3%

Referral for specialist opinion

0.1%

<0.1% - 0.5%

Other

0.2%

<0.1% - 1.1%

Symptomatic- clinical management required

2.6%

1.1% - 3.6%

* All data use the Cytology Coding Schedule implemented in July 2006. # All laboratories, excluding those reporting fewer than 500 Pap tests.

Among Pap tests receiving a recommendation in this six month period, the proportion recommending a repeat Pap test in two years was 81.7%. The proportion of Pap tests with a referral of a repeat in one year was 10.6%. The above six month data also reflects the use of the symptomatic code by all laboratories, which became a requirement after the new Cytology Coding Schedule was implemented. The table shows that laboratories used the symptomatic code for 2.6% of the Pap tests collected by general practitioners and nurses.

28 Victorian Cervical Cytology Registry Statistical Report 2006

4. HISTOLOGY/ COLOSCOPY REPORTS This section describes the histology/ colposcopy reports that were notified to the VCCR during 2006. The proportion of colposcopy reports recorded increased to 9.4% due to an increase in the number of questionnaires for low-grade abnormalities sent out by the Registry. The majority of all relevant cervical biopsies are reported to the Registry; however, as reporting is voluntary there are fluctuations in numbers from year to year and reporting is therefore not complete. All cancers are notified by laboratories, hospitals and the VCCR to the Cancer Registry at the Cancer Council Victoria. In 2006, there were 16,466 reports relating to the cervix, with each woman being counted only once on the basis of her most serious report for the year. In ascertaining the most serious report for each woman, histology results took precedence over colposcopy results. The following table shows the distribution of the further investigations for 2006. Table 4.1:

Histology and/ or colposcopy findings reported to the VCCR in 2006.

Histology/ colposcopy findings

Number

Invasive cancer

0.5%

Micro-invasive cancer

0.2%

CIN 3 with questionable micro-invasion

0.1%

1,487

9.0%

267

1.6%

1,417

8.6%

High-grade - not otherwise defined

0.6%

CIN - not otherwise defined

0.1%

1,748

10.6%

HPV effect

968

5.9%

Low-grade - not otherwise defined

840

5.1%

Benign changes

6,095

37.0%

Normal

3,262

19.9%

135

0.8%

16,466*

100%

CIN 3 CIN 2/3 CIN 2

CIN 1

Unsatisfactory Total * Includes findings from 1,547 colposcopy reports.

Among the 85 women whose further investigations resulted in a diagnosis of invasive cervical cancer, 49 (58%) were of squamous type, 26 (30%) were adenocarcinomas, 6 (7%) were adenosquamous carcinomas and 4 (5%) were other types. Of the 31 women with micro-invasive carcinoma, 25 (81%) were squamous and 6 (19%) adeno type. Among the 1,487 cases of CIN 3, 1,403 (94%) were of squamous type, 47 (3%) adeno type and 37 (3%) adenosquamous type. 29 Victorian Cervical Cytology Registry Statistical Report 2006

5. CORRELATION BETWEEN CYTOLOGY AND HISTOLOGY REPORTS Table 5.1 shows the correlation between the histology findings and the prediction made on cytology immediately prior to the histology report. Colposcopy reports have been excluded from this analysis as laboratory performance measures are based solely on histology. This correlation is important to laboratories in assisting with quality control and performance measures required by the National Pathology Accreditation Advisory Council (NPAAC)9. The correlation is restricted to cases where the cytology was reported as abnormal in a six month period preceding the histology report. In cases where the histology report followed a negative cytology report, up to 30 months has been allowed between the cytology and the histology. In interpreting this information, it is important to remember that only a minority of lowgrade cytology (atypia and CIN 1) is further investigated by colposcopy or biopsy, and an even smaller percentage of negative cytology reports are followed by a colposcopy or biopsy. Women who have a biopsy are likely to be an atypical subset of the whole group of women with negative or low-grade cytology reports. The presentation of Table 5.1 differs from statistical reports of previous years, due to the new Cytology Coding Schedule implemented in July 2006. The cytology prediction reflects the Australian Modified Bethesda System 2004, while the histology outcome remains unchanged.

9 National Pathology Accreditation Advisory Council. Performance Measures for Australian Laboratories reporting Cervical Cytology, 2006. 30 Victorian Cervical Cytology Registry Statistical Report 2006

5. CORRELATION BETWEEN CYTOLOGY AND HISTOLOGY REPORTS Table 5.1:

Histology findings following a cytology report, 2006*. Cytology Prediction

Histology findings

Negative %

Lowgrade %

Glandular %

Possible high-grade %

Highgrade %

0.0%

0.5%

0.4%

Cancer – invasive other

<0.1%

0.0%

0.2%

0.5%

Cancer – micro-invasive

0.0%

<0.1%

3.2%

0.4%

0.6%

CIN 3 with questionable micro-invasion

<0.1%

0.0%

0.4%

0.3%

CIN 3

0.7%

4.5%

9.7%

22.9%

39.1%

CIN 2/3

0.2%

1.0%

0.0%

4.7%

6.4%

CIN 2

1.2%

10.4%

3.2%

18.8%

27.9%

High-grade- not otherwise defined

0.2%

0.5%

0.0%

1.4%

1.2%

CIN 1

3.2%

27.9%

9.7%

11.2%

9.2%

HPV effect

2.9%

12.7%

3.2%

4.6%

2.5%

Low-grade- not otherwise defined

3.0%

6.8%

3.2%

3.8%

1.8%

Normal, benign

88.6%

36.2%

67.8%

31.1%

10.1%

Total

100%

Cancer – invasive squamous

* The above correlation table excludes colposcopy findings.

Of women with a high-grade cytology report, 76.4% (1,904/2,491) were subsequently diagnosed with high-grade histology (CIN 2, CIN 2/3, CIN 3, cancer, high-grade - not otherwise defined) at biopsy. This figure represents the positive predictive value of a high-grade cytology report for high-grade histology. The NPAAC performance standards require that not less than 65% of cytology specimens with a definite highgrade epithelial abnormality are confirmed on histology within 6 months as having a high-grade abnormality or cancer. Because of the NHMRC coding changes, the positive predictive value cannot be compared with the data for 2005 as the cytology was separated into CIN 2 and CIN 3. 31 Victorian Cervical Cytology Registry Statistical Report 2006

6. FOLLOW-UP AND REMINDER PROGRAM Throughout 2006 there continued to be minor adjustments to the VCCR Reminder and Follow-up Protocol (refer to Appendix 2) following the introduction of the new NHMRC Guidelines. The following is a summary of the VCCR follow-up activities during 2006. Reminders Between 1 January 2006 and 31 December 2006, 248,116 reminder letters were sent to women in the categories shown in Table 6.1. Table 6.1:

Number of reminder letters sent to women by the VCCR in 2006.

Pap test report category

Number

High-grade with subsequent biopsy

681

High-grade no subsequent Pap test by 12/12

133

Low-grade with subsequent biopsy

855

Low-grade – previous test abnormal or fluctuating abnormality Low-grade – over 30 with no negative cytology in previous 3 years Low-grade – all other women Negative with previous abnormal Negative Unsatisfactory with previous abnormal Unsatisfactory

2,258 738 3,504 23,725 213,756 42 2,424

Of the 213,756 reminders sent after a negative Pap test, 72,587 (34%) women had a subsequent Pap test within three months of the date of the reminder. By mid year 2007, 124,409 (58%) women had a repeat Pap test. Follow-up During 2006, the VCCR sent out 1,760 questionnaires to practitioners seeking further information after a high-grade abnormality on Pap test and 7,760 after a low-grade abnormality. These questionnaires are part of the follow-up of abnormal smears and seek information on colposcopy or biopsy to alter the follow-up interval accordingly. During the year, 887 women with a high-grade abnormality required further follow-up by the Registry. For these women, at least one phone call to the practitioner was made to ascertain follow-up, with many requiring additional calls. As the Registry was unable to ascertain whether the woman was aware of her abnormal result in 317 cases, letters were sent, mostly by registered mail, to these women.

32 Victorian Cervical Cytology Registry Statistical Report 2006

6. FOLLOW-UP AND REMINDER PROGRAM Practitioner Lists During 2006, Practice Based Reminder (PBR) lists were sent every four months to approximately 1,000 practitioners who had requested to receive them. Practice Based Reminder lists detail women who are between 21 and 27 months since their last negative Pap test and are about to receive reminders from the Registry. The lists enable practices to send the Registry address updates and other information relevant to follow-up and can help establish for them if a woman has had a test elsewhere. Around 1,300 clinics/practices were sent Practice Incentive Program (PIP) lists in each quarter of 2006. The lists contain women who have not had a Pap test for at least 4 years and are therefore considered to be ‘high risk’. The lists are sent to the clinic where the woman’s last Pap test was taken and practitioners receive an incentive payment if these women have a subsequent Pap test.

33 Victorian Cervical Cytology Registry Statistical Report 2006

7. CERVICAL CANCER INCIDENCE AND MORTALITY IN VICTORIA The aim of the cervical cancer screening program is to reduce the incidence and mortality from cervical cancer. Data on cancer incidence and mortality are collected by the Victorian Cancer Registry and notifications are required from laboratories, hospitals and the VCCR. Figure 7.1 shows the incidence and mortality rates for cervical cancer in Victoria from 1982 to 2004. The incidence of cervical cancer has declined dramatically since the 1980s when the organised screening program was introduced. There was a plateau in incidence in 2000 and slight increase noted since 2002 with a subsequent drop. The mortality from cervical cancer in Victoria has declined gradually over time and since 2000 has been around 1.0 per 100,000 women, which is among the lowest in the world .

Figure 7.1:

Age standardised incidence and mortality rates for cervical cancer in Victoria, for the period 1982 to 2004.

Rate per 100,000 Victorian Women

0 1982 1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004 Year Incidence

mortality

Source: Unpublished data, Victorian Cancer Registry, Cancer Council Victoria.

34 Victorian Cervical Cytology Registry Statistical Report 2006

7. CERVICAL CANCER INCIDENCE AND MORTALITY IN VICTORIA Table 7.1 shows the number of cases and incidence rates for cervical cancer by histological type over time. The greatest impact of the cervical screening program is on squamous cell carcinoma of the cervix, with incidence rates declining from 6.5 per 100,000 women in 1989 to 1.7 per 100,000 in 2004. Incidence rates for microinvasive cancer have declined slightly over time. Rates for other cancers, comprising predominantly cervical adenocarcinomas, are slightly lower than in the early 1990s although it is recognised that cervical screening is less effective for the detection of adenocarcinomas.

Table 7.1:

Number of cases and age-standardised incidence rates for cervical cancer by histological subtype in Victoria, for the period 1989 to 2004.

Invasive squamous cell carcinoma

Invasive other morphology

Year Number ASR

Number ASR

Micro-invasive squamous cell carcinoma Number ASR

1989

172

6.5

2.2

1.5

1990

135

4.8

3.0

2.1

1991

138

4.9

2.8

2.1

1992

123

4.1

2.0

2.3

1993

126

4.4

2.8

1.7

1994

133

4.4

114

4.1

2.5

1995

107

3.5

2.2

2.6

1996

2.7

2.4

2.3

1997

2.9

1.8

1.6

1998

109

3.3

2.6

0.8

1999

2.9

1.8

0.8

2000

2.3

1.6

0.5

2001

2.1

1.6

0.7

2002

2.7

1.0

0.8

2003

2.6

1.7

0.9

2004

1.7

1.4

1.0

Note:

Other cancers are comprised of cervical adenocarcinomas, mixed adenosquamous carcinomas and small cell carcinomas. ASR is the age-standardised incidence rate. Source: Unpublished data, Victorian Cancer Registry, Cancer Council Victoria.

35 Victorian Cervical Cytology Registry Statistical Report 2006

7. CERVICAL CANCER INCIDENCE AND MORTALITY IN VICTORIA Figure 7.2 shows the age-specific incidence rates of cervical cancer by histology and age, grouped over the period 2001-2004. The age-specific incidence of cervical cancer increases steadily after the age of 30 years with a peak in the mid-40s and another in the mid-60s for squamous cell carcinoma. Micro-invasive cervical cancer peaks at around 30 years of age and declines steadily thereafter. The incidence of other types of cervical cancer, predominantly adenocarcinomas, peaks in the mid-30s and again in the mid-40s.

Figure 7.2:

Age-specific incidence rates of cervical cancer in Victoria, by histology, for the period 2001 to 2004.

8.0 Invasive squamous cell carcinoma 7.0 Rate per 100, 000 women

Micro-invasive squamous cell carcinoma 6.0 Other morphology 5.0 4.0 3.0 2.0 1.0 0.0 0-4

5-9

10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69

Age (years) Source: Unpublished data, Victorian Cancer Registry, Cancer Council Victoria.

36 Victorian Cervical Cytology Registry Statistical Report 2006

8. SCREENING HISTORY OF WOMEN DIAGNOSED WITH CERVICAL CANCER The total number of Victorian women diagnosed with invasive cervical cancer between 1 January 2002 and 31 December 2004 was 392. This includes 250 women with a diagnosis of squamous cell carcinoma and 142 women with other types of invasive cervical cancer (including small cell carcinoma, mixed adenosquamous and adenocarcinoma). Of these 392 women, 134 were only recorded on the Victorian Cancer Registry and not on the VCCR, suggesting that these women have no history of Pap test screening. For the remaining 258 women with invasive cervical cancer who are recorded on the VCCR, their screening history for ten years prior to diagnosis was reviewed to determine if their screening history was adequate.

Table 8.1:

Screening history of Victorian women diagnosed with invasive cervical cancer, for the period 1 January 2002 to 31 December 2004.

Screening History A. Women with no screening history B. Women with inadequate screening C. Women with some screening history**

Squamous cell carcinoma Number (%)

Total Number (%)

80 (32%)

(38%)

134 (34%)

155 (62%)

(35%)

204 (52%)

(27%)

54 (14%)

142 (100%)

392 (100%)

15 Total

Other invasive cervical cancer* Number (%)

(6%)

250 (100%)

* Other cervical cancers include small cell carcinoma, mixed adenosquamous and adenocarcinoma. ** Requires further review

37 Victorian Cervical Cytology Registry Statistical Report 2006

8. SCREENING HISTORY OF WOMEN DIAGNOSED WITH CERVICAL CANCER As shown in Table 8.1, the screening history of the 392 women diagnosed with invasive cervical cancer in the three year time period can be classified into the following three groups. A. Women with no previous screening 134 women (34%) with invasive cervical cancer recorded on the Victorian Cancer Registry were not known to the VCCR and most likely had no Pap test screening history. A small proportion of these women may have been screened interstate or overseas, or have opted-off the VCCR. B. Women with inadequate screening history According to the VCCR records 204 of the women (52%) had an inadequate screening history. This is defined as women with no record of a Pap test in the previous ten years, or those with only 1 or 2 Pap tests or less than 3 negative tests in the ten years prior to their cancer diagnosis. C. Women with some screening history (this is to be further evaluated) Of the women diagnosed with an invasive cervical cancer, 54 (14%) had additional Pap test screening in the 10 years prior to their diagnosis with between 3 and 21 Pap tests per woman. While the smear quality of these 54 women has already been addressed by the NPAAC laboratory performance measures, the records of these 54 women will be further reviewed and categorised to determine if they appear to have had adequate screening and follow-up which complied with the guidelines during that time. The majority of these women were diagnosed with glandular cervical cancers, which are harder to prevent through cervical screening. In summary, at least 86% of the women diagnosed with invasive cervical cancer had no Pap test history or inadequate Pap test screening in the ten years before their diagnosis (groups A and B). For squamous invasive cancers, 94% of the women were never or inadequately screened, whereas for glandular cancers this proportion was 73%. This does not necessarily reflect a failure of cervical screening but rather a recognition that Pap test screening is aimed primarily at preventing squamous cervical cancers.

38 Victorian Cervical Cytology Registry Statistical Report 2006

ACKNOWLEDGEMENTS The production of this report would not be possible without the cooperation of the staff of the pathology laboratories of Victoria, the staff of the Registry, and the support of the Management Committee. Very sincere thanks are extended to the members of all these groups. Associate Professor Marion Saville, Director of VCS Inc, provided valuable clinical input into aspects of this report. The figures on incidence and mortality from cervical cancer were kindly provided by the Victorian Cancer Registry at the Cancer Council Victoria. We would like to thank Vicky Thursfield and Professor Graham Giles for their assistance in providing these data.

Staff of the Victorian Cervical Cytology Registry:

Medical Director

Associate Professor Dorota Gertig

Follow-up and Quality Manager

Cathy Burrows

Data Manager

Cathryn Wharton

Supervisor

Grace Zampogna

Assistant Supervisor

Angela Rhine

Data Processing Officers

Mary Berias Mandy Blair Angela Carini Tania Vigilante Vittoria Verrocchi Veronica Vocal

VCCR IT team:

Matthew Cunningham Matthew Boler Leigh Trevaskis Danny Mohar Andrew Trinh

39 Victorian Cervical Cytology Registry Statistical Report 2006

LIST OF ABBREVIATIONS ABS:

Australian Bureau of Statistics

ASR:

Age-Standardised Rate (per 100,000 Victorian women standardised to World Standard Population)

CIN:

Cervical Intraepithelial Neoplasia

ERP:

Estimated Resident Population

HPV:

Human Papillomavirus

NHMRC:

National Health and Medical Research Council

NPAAC:

National Pathology Accreditation Advisory Council

VCCR:

Victorian Cervical Cytology Registry

40 Victorian Cervical Cytology Registry Statistical Report 2006

Cell numbers and preservation satisfactory. No abnormality or only reactive changes

Possible low-grade squamous intraepithelial lesion (LSIL)

Low-grade LSIL (HPV and/ or CIN I)

Possible high-grade squamous intraepithelial lesion (HSIL)

High-grade squamous intraepithelial lesion (HSIL) (CIN II/ CIN III)

High-grade squamous intraepithelial lesion (HSIL) with possible micro-invasion/ invasion

Squamous carcinoma

No recommendation

Repeat smear 3 years

Repeat smear 2 years Repeat smear 12 months

RØ

R2 R3

Cervical

Unsatisfactory for evaluation e.g. poor cellularity, poor preservation, cell detail obscured by inflammation/blood/ degenerate cells

Vaginal

Liquid based specimen

Endocervical component present. No abnormality or only reactive changes

Adenocarcinoma-in-situ with possible micro-invasion/ invasion

R6 R7

Colposcopy/ biopsy recommended Already under gynaecological management

Repeat smear 6 - 12 weeks

Repeat smear 6 months

Malignant cells - ovary Malignant cells - other Referral to specialist Other management recommended

O8 O9 R8 R9

Symptomatic-clinical management required

Malignant cells - vagina

Malignant cells - uterine body

Possible high-grade lesion non-cervical

Possible endometrial adenocarcinoma

Atypical glandular cells of uncertain significance - site unknown

CYTOLOGY

Adenocarcinoma

Adenocarcinoma-in-situ

Possible high-grade endocervical glandular lesion

Atypical endometrial cells of uncertain significance

No other abnormal cells

Due to the unsatisfactory nature of the smear, no assessment has been made

Other/Non-cervical

Other gynaecological site

Conventional and liquid based specimen

SPECIMEN

Atypical endocervical cells of uncertain significance

No endocervical component

EØ

Not applicable: vault smear/ previous hysterectomy

Due to the unsatisfactory nature of the smear, no assessment has been made

Endocervical

E-

Conventional smear

Not stated

Squamous Cell

BØ

Site

Not stated

AØ

Type

APPENDIX 1. 2006 CYTOLOGY CODING SCHEDULE RECOMMEND

Victorian Cervical Cytology Registry Statistical Report 2006

APPENDIX 2. REMINDER AND FOLLOW-UP PROTOCOL USED IN 2006

42 Victorian Cervical Cytology Registry Statistical Report 2006

Victorian Cervical Cytology Registry Statistical Report 2006