Statistical Report 2012 by Victorian Cytology Service

STATISTICAL REPORT 2012

The Victorian Cervical Cytology Registry acknowledges the support of the Victorian Government

Editorial Committee: Associate Professor Dorota Gertig, VCCR Medical Director Associate Professor Marion Saville, VCS Executive Director Dr Julia Brotherton, Epidemiologist

Genevieve Chappell, VCCR Manager Bianca Barbaro, Senior Research Officer Lesley Rowlands, Follow-up Manager Produced by: Tanya Oâ&#x20AC;&#x2122;Farrell, Health Information Manager (Registry Operations)

Victorian Cervical Cytology Registry PO Box 161, Carlton South, Victoria 3053 Telephone: (03) 8417 6816 Email: tofarrel@vccr.org Website: www.vccr.org

CONTENTS EXECUTIVE SUMMARY

1. 1.1 1.2 1.3

INTRODUCTION Background Functions of the VCCR National Policy: the NHMRC Guidelines for the Management of Asymptomatic Women with Screen Detected Abnormalities and Renewal of the Cervical Screening Program The National HPV Vaccination Program Data included in this report

7 7 7

PARTICIPATION IN SCREENING Number of Pap tests and women screened Table 2.1: Number of Pap tests registered and number of women screened in Victoria, 1990–2012. Participation by Age Group Table 2.2: Estimated cervical screening rates by age group over one year, two year, three year and fi ve year periods. Figure 2.2.1: Estimated two year cervical screening rates by age group, 2000-01 to 2011-12. Table 2.2.1: Estimated two year cervical screening rates by age group, 2000-01 to 2011-12. Participation by Area 2.3.1 Participation by Medicare Locals Table 2.3.1: Estimated two year cervical screening rates by Medicare Local, 2010-2011 and 2011-2012. Figure 2.3.1: Estimated two year cervical screening rates by Medicare Local, 2011-2012. 2.3.2 Participation by Department of Health Region Table 2.3.2: Estimated two year cervical screening rates by Department of Health region, 2010–2011 and 2011–2012. Figure 2.3.2: Estimated two year cervical screening rates by Department of Health region, 2011–2012. 2.3.3 Participation by Local Government Area Table 2.3.3: Estimated two year cervical screening rates by Local Government Area, 2010–2011 and 2011–2012. Figure 2.3.3: Estimated two year cervical screening rates by Local Government Area, 2011–2012. Pap tests collected by Nurses Table 2.4: Proportion of Pap tests collected by nurses, 2003–2012. 2.4.1 Proportion of Pap Tests Collected by Nurses by Department of Health Region Table 2.4.1: Pap tests for women with a cervix collected by nurses, by Department of Health region, 2012. Figure 2.4.1: Proportion of Pap tests collected by nurses, by Department of Health region, 2012. Closing the Data Gaps:Identifying Aboriginal and Torres Strait Islander People, and collecting country of birth and language spoken at home Table 2.5 (a): Proportion of Women Screened by Aboriginal and Torres Strait Islander Origin. Table 2.5 (b): Proportion of Pap Tests by Practitioner Type with Aboriginal and Torres Strait Islander Origin Information recorded. 2.6 Frequency of Early Re-Screening Table 2.6: Subsequent Pap tests over a 21 month period for women with a negative report in February of 2011. Figure 2.6: Early re-screening after a negative Pap test report in February 2011 by age group.

9 9 9 9

1.4 1.5 2. 2.1 2.2

2.3

2.4

2.5

7 7 8

10 11 11 12 13 13 14 15 15 15 16 16 18 19 19 20 20 21 22 22 22 23 23 23

3. 3.1 3.2 3.3

CYTOLOGY REPORTS Unsatisfactory Pap tests Negative Pap tests Pap tests without an endocervical component Figure 3.3: Percentage of Pap tests without an endocervical component. Pap tests with a squamous abnormality Table 3.4: Number and percent of Pap tests collected in 2012 with a squamous abnormality. Pap tests with an endocervical abnormality Table 3.5: Number and percent of Pap tests collected in 2012 with an endocervical abnormality. Type of tests

24 24 24 24 24 25 25 25 25 25

HISTOLOGY REPORTS Table 4: Histology fi ndings reported to the VCCR in 2012.

26 26

HIGH-GRADE ABNORMALITY DETECTION RATES Figure 5.1: Detection rate of high-grade intraepithelial abnormalities (histologically - confi rmed) from 2009-2012 per 1,000 screened women. Figure 5.2: Trends in high-grade cervical abnormalities (histologically - confi rmed) by age, 2000–2012, VCCR.

3.4 3.5 3.6

27 27

CORRELATION BETWEEN CYTOLOGY AND HISTOLOGY REPORTS 28 Table 6.1: Correlation of squamous cytology to the most serious squamous histology within 6 months, women aged 20 to 69 years, cytology tests performed in 2011. 29 Table 6.2: Correlation of endocervical cytology to the most serious endocervical histology within 6 months, women aged 20 to 69 years, cytology tests performed in 2011. 30

FOLLOW-UP AND REMINDER PROGRAM Table 7: Number of fi rst and second reminder letters sent to women by the VCCR in 2012.

31 31

CERVICAL CANCER INCIDENCE AND MORTALITY IN VICTORIA Figure 8.1: Age-standardised incidence and mortality rates for all types of cervical cancer in Victoria, 1982–2012. Figure 8.2: Age-standardised incidence rates (ASR) for cervical cancer by histological subtype in Victoria, 1982–2012. Figure 8.3: Age-specifi c incidence rates of cervical cancer by histological subtype in Victoria, 2010–2012.

32 32 33 33

SCREENING HISTORY OF WOMEN DIAGNOSED WITH CERVICAL CANCER IN 2010 AND 2011 Table 9 (a): Screening history of Victorian women diagnosed with cervical cancer for the period 1 January 2010 to 31 December 2010. Table 9 (b): Screening history of Victorian women diagnosed with cervical cancer for the period 1 January 2011 to 31 December 2011.

34 35

ACKNOWLEDGEMENTS LIST OF ABBREVIATIONS GLOSSARY REFERENCES

36 36 37

APPENDIX 1. CYTOLOGY CODING SCHEDULE APPENDIX 2. REMINDER AND FOLLOW-UP PROTOCOL USED DURING 2012 APPENDIX 3. MAP OF MEDICARE LOCALS APPENDIX 3. MAP OF LOCAL GOVERNMENT AREAS - MELBOURNE APPENDIX 3. MAP OF LOCAL GOVERNMENT AREAS - VICTORIA

38 39 40 41 42

Victorian Cervical Cytology Registry Statistical Report 2012

EXECUTIVE SUMMARY

As part of the cervical screening program, the Victorian Cervical Cytology Registry (VCCR) plays an important role in improving the screening participation of Victorian women by sending reminder letters and conducting research into under-screening. In 2012 the VCCR introduced a second Pap test reminder letter for Victorian women, funded by the Victorian Government. Our evaluation showed that this letter increased participation among women overdue for a Pap test by 8.1% compared to the previous time period before the letter was introduced. Data in this report show that for the first time in over a decade there has been a small increase in screening participation across all age groups with an estimated 60% two year participation for 2011-2012 for women in the target age range of 20 to 69 years compared with 59.2% in the previous period of 2010-2011. The corresponding sustained increase in the number of women across all age groups having Pap tests, suggests that this is likely due to the second reminder letter initiative. However, substantial variation exists in screening rates between different areas of Victoria, as represented by Medicare Locals, with the lowest two year screening rate for 2011â&#x20AC;&#x201C;2012 at 53.2% and the highest at 67.6%. The screening rate for Victorian Department of Health regions ranged from 56.6% to 63.1%, while the estimated two year participation rate by Local Government Area ranged from 45.7% to 75.5%. As part of the follow-up and reminder program, the VCCR registered a total of 602,367 Pap tests in 2012, representing 574,123 women and sent over 410,000 follow-up and reminder letters to women and practitioners. More than 6,000 abnormal Pap tests were followed-up by the VCCR in 2012. Almost 120,000 second reminder letters were sent to women and of those sent after a negative Pap test, 24% had a subsequent Pap test within 3 months of the reminder. Of Pap tests recorded by the VCCR during the period of this report, a definite high-grade squamous cell abnormality was present in 0.8% of tests and an endocervical abnormality was identified in fewer than 0.1% of tests. For the 3,653 high-grade cytology tests reported, 2,911 were subsequently confirmed with high-grade histology on biopsy within a six month period. This represents a positive predictive value of 79.7% and reflects the high quality of laboratory reporting in Victoria. Over the last decade there has been a gradual increase in the proportion of Pap tests collected by nurses. In 2012 the number of Pap tests collected by nurses represented 5.6% of all Pap tests collected in Victoria and highlights the important role nurses have in the Cervical Screening Program.

VCCR continues to work closely with Program Partners to identify groups in our community that are less likely to screen. Collecting information from women attending screening about their identification as an Aboriginal and Torres Strait Islander, their Country of Birth and the Language Spoken at Home is critical for understanding who participates in cervical screening. The overall percentage of women screened in 2012 who had their Aboriginal and Torres Strait Islander status recorded by the VCCR was 19.4%, for country of birth 14.5% and language spoken at home 15.2%. According to the most recent data (2012) from the Victorian Cancer Registry, mortality from cervical cancer in Victoria is 1.1 per 100,000 women. This is a tremendous achievement and reflects the success of the organised cervical screening program, which is underpinned by the Pap test registries. Despite this success, further efforts are necessary to improve participation amongst under-screened women as 77% of Victorian women who were diagnosed with invasive cervical cancer in 2011 had never had a Pap test, or were lapsed screeners, prior to their cancer diagnosis. The VCCR is leading and collaborating on a number of research activities that will likely influence policy initiatives in cervical screening. Cervical abnormality rates in the cohort of young women who commenced screening following the introduction of the National HPV Vaccination Program in 2007 continue to be monitored in this report. Following the publication of VCCR data in the Lancet in 2011, which documented the first decline in high-grade abnormalities seen in a vaccinated population internationally1, histologicallyconfirmed high-grade abnormalities have continued to decline for women aged less than 20 years and in women aged 20 to 24 years. This year the Victorian Cytology Service (VCS) and the Australian Institute of Health and Welfare (AIHW) have published more world first findings, which have measured HPV vaccine effectiveness against cervical abnormalities using data obtained by linking the VCCR with the National HPV Vaccination Program Register2. The study found that women vaccinated in the school cohorts of the catch-up program (aged 12 to 17 years in 2007) attending screening have a 48% lower rate of high-grade abnormalities than unvaccinated women. As women vaccinated at earlier ages (the routine vaccination program is at 12 to 13 years of age) commence screening, the impact of the vaccine is expected to increase further.

1 Brotherton J, Fridman M, May C, Chappell G, Saville M, Gertig D. Early effect of the HPV vaccination programme on cervical abnormalities in Victoria, Australia: an ecological study. 2011. Lancet.377: 2085-2092 2 Gertig DM, Brotherton JML, Budd AC, Drennan K, Chappell G, Saville AM. Impact of a population-based HPV vaccination program on cervical abnormalities: a data linkage study. BMC Medicine 2013, 11:227. 6

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 or register of Victorian women’s Pap test results. Laboratories provide the VCCR with data on all Pap tests taken in Victoria, unless a woman chooses not to participate. The VCCR works closely with the Victorian Department of Health and other Program Partners including PapScreen Victoria which is responsible for the communications and recruitment program aimed at maintaining the high rates of participation of Victorian women in the National Cervical Screening Program.

1.2 FUNCTIONS OF THE VCCR The VCCR 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. The primary functions of the VCCR as specified in the Cancer Act 1958 are: a) to follow-up positive results from cancer tests, b) to send reminder notices when persons whose names appear in the register are due for cancer tests, c) subject to and in accordance with the regulations, to give access to the register to persons studying cancer; and d) 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 VCCR 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; and • the provision of aggregate data to the AIHW so that the National Cervical Screening Program can be judged against an agreed set of performance indicators.

1.3 NATIONAL POLICY: THE NHMRC GUIDELINES FOR THE MANAGEMENT OF ASYMPTOMATIC WOMEN WITH SCREEN DETECTED ABNORMALITIES AND RENEWAL OF THE CERVICAL SCREENING PROGRAM On 1 July 2006, the National Health and Medical Research Council (NHMRC) Guidelines for the Management of Asymptomatic Women with Screen Detected Abnormalities (2005)3 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, • to refer all women with atypical glandular cells for colposcopy, • to refer all women with a possible high-grade lesion for colposcopy; and • to use HPV tests and cytology as a test of cure for women treated for CINII and CINIII. The VCCR participates in the National Safety Monitoring of the NHMRC guidelines. The cervical screening program is presently undergoing a renewal, which aims to identify the best screening program for Australian women given recent changes to available technology and the implementation of the National HPV Vaccination Program. Further information can be found at http://www.cancerscreening.gov.au/internet/screening/ publishing.nsf/Content/ncsp-renewal

1.4 THE NATIONAL HPV VACCINATION PROGRAM The National HPV Vaccination Program commenced in April 2007 and is already having a substantial impact on the prevalence of HPV infection and cervical lesions in vaccinated cohorts 4. Between 2007 and 2009, 12 to 26 year old females were offered the quadrivalent HPV vaccination (Gardasil) in a national catch-up program provided through schools, general practice and other community providers. Since 2009 the program has offered routine vaccination through schools for 12 to 13 year old girls and, from 2013, vaccination to boys at 12 to 13 years, with a two year catch-up program for 14 to 15 year old boys. The Pap test Registries around Australia play an important role in monitoring the impact of the vaccination program on participation rates in cervical screening and on cervical abnormalities and cancer in the long term. The importance of continuing regular Pap tests for vaccinated women is emphasised as part of the National HPV Vaccination Program.

3 NHMRC Screening to prevent cervical cancer: guidelines for the management of asymptomatic women with screen-detected abnormalities,2005. http://www.nhmrc.gov.au/publications/synopses/wh39syn.htm 4 Tabrizi SN, Brotherton JML, Kaldor JM, Skinner SR, Cummins E, Liu B, Bateson D, McNamee K, Garefalakis M, Garland SM. Fall in Human Papillomavirus Prevalence Following a National Vaccination Program. J Infect Dis. 2012; 206 (11): 164551. Available at http://jid.oxfordjournals.org/content/early/2012/10/17/infdis.jis590.full.pdf+html Victorian Cervical Cytology Registry Statistical Report 2012

A National HPV Vaccination Program Register (the HPV Register)5 was established to support, monitor and evaluate the National HPV Vaccination Program. VCS Inc, which has operated the Victorian Cervical Cytology Registry for over 20 years, was engaged by the Department of Health and Ageing in February of 2008 to establish and manage the National HPV Vaccination Program Register. The HPV Register receives data from all states and territories and from all types of vaccination providers including Local Councils (who in some States deliver the school vaccination program), General Practitioners, nurses and other immunisation providers around Australia. The Register records basic demographic information and information about doses administered in Australia. The HPV Register supports the program by sending statements on vaccination status to eligible vaccine recipients and their providers, and by providing reports and de-identified data to approved providers and researchers. Linkage of data held by the HPV Register with information held by the Pap test and cancer registries will be a critical component of monitoring and evaluating the impact of vaccination. The first study demonstrating populationbased effectiveness of the HPV vaccination program was recently published by the VCCR. A de-identified data linkage was undertaken between the NHVPR and the VCCR, and demonstrated a 48% reduction on the rates of the most serious cervical pre-cancers for women who had been completely vaccinated in the school-program, compared with unvaccinated women6.

1.5 DATA INCLUDED IN THIS REPORT This statistical report provides timely information about cervical screening in Victoria during 2012. In most cases the methodology and terminology used in VCCR reports is consistent with that published by the AIHW as part of reporting indicators for the National Cervical Screening Program7. Participation rates This report includes information on participation rates for women aged 20 to 69 years in ten year age groups and five year age groups for the 20 to 29 group. Population data has been adjusted to exclude women who have had a hysterectomy using modeling carried out by the AIHW based on the National Hospital Morbidity Database. The two year participation rates are also presented by Medicare Locals, Department of Health region and Local Government Area. The number and proportion of Pap tests collected by nurses is presented in this report, by year and Department of Health region. Further information regarding Pap tests collected by nurses is available in the report ‘Evaluation of Pap tests collected by Nurses in Victoria during 2012’, available on our website at http://www.vccr.org/stats.html The Participation in Screening section also includes some limited information on the identification of Aboriginal and Torres Strait Islander women and the collection of indicators

5 6 7 8

of cultural diversity, such as country of birth and language spoken at home. Information on the proportion of women who re-screen early is also featured. Cytology coding Information provided on the cytology report of Pap tests is pre-coded by the pathology laboratory to the Cytology Coding Schedule. Appendix 1 outlines the Australia-wide cytology codes that have been used since 1 July 2006 to correspond with the implementation of the 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 non-cervical cells, and the recommendation made by the laboratory in regard to further testing. Data are presented on the proportion of Pap tests classified according to their results as unsatisfactory, negative, squamous abnormality present and endocervical abnormality present. The percentage of Pap tests collected during 2012 without an endocervical component is also presented. Histology/colposcopy reports The 2012 histology results in this report are as notified by 30 June 2013. The vast majority of histology reports are notified by this time. While reasonably comprehensive notification occurs for histology reports, a proportion of colposcopy only results are also notified, most typically when a histology report is not available. Data included in this report excludes results reported from a colposcopy report alone (i.e. no laboratory report). In 2013, the VCCR implemented routine collection of data on colposcopies performed in Victoria. This will assist with the follow-up of abnormalities and the monitoring of colposcopy quality. Follow-up protocol The VCCR Reminder and Follow-up Protocol 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 VCCR in 2012 is shown in Appendix 2. Reminder letters are not sent to women whose VCCR 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 courtesy of the Victorian Cancer Registry at the Victorian Cancer Council. Also included is a section examining the screening history of Victorian women diagnosed with invasive and micro-invasive cervical cancer during 2010 and 2011.

The National HPV Vaccination Program Register website. http://www.hpvregister.org.au Gertig DM, Brotherton JML, Budd AC, Drennan K, Chappell G, Saville AM. Impact of a population-based HPV vaccination program on cervical abnormalities: a data linkage study. BMC Medicine 2013, 11:227. Australian Institute of Health and Welfare 2013. Cervical screening in Australia 2010-2011. Cancer Series 76. Cat. no. CAN 72. Canberra:AIHW

2. PARTICIPATION IN SCREENING

2.1 NUMBER OF PAP TESTS AND WOMEN SCREENED Table 2.1 shows data on the number of Pap tests registered and the number of women screened for each year of the VCCR’s operation. During 2012 a total of 602,367 Pap tests were registered from 574,123 women. From the previous year, this is an increase of 30,225 Pap tests and 28,328 women. Since 2003, 95% of women with a Pap test record on the VCCR have a Medicare number available, and from 1999 the VCCR has used SSA-Name (matching software) in the linking 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. In interpreting the information in Table 2.1, it is important to realise that a proportion of women in Victoria are screened on an annual basis. The VCCR is a voluntary “opt-off” registry; however, the proportion of women who are part of the screening program but decide to opt-off the VCCR is estimated to be fewer than 1%. Correlating VCS laboratory records with those held by the VCCR shows a ten year (2003-2012) opt-off rate of 0.34%. Where a woman objects to her Pap test being registered, the VCCR holds no information about that test.

2.2 PARTICIPATION BY AGE GROUP Method of calculating participation The participation of women estimated to be part of the Victorian Cervical Screening Program by age group is expressed as a percentage. This is determined by dividing the number of women screened by the number of women in the general population who are eligible for screening. • The number of women screened (numerator) is determined 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 have not had a hysterectomy according to information held by the VCCR. • The eligible population (denominator) is the number of women in the general population averaged for the time period of interest, and adjusted to include only women with an intact cervix. To determine this, the Victorian Estimated Resident Population (ERP)8 collected by the Australian Bureau of Statistics (ABS) is averaged and then adjusted to exclude the proportion of women estimated to have had a hysterectomy using hysterectomy fractions. Whilst VCCR participation statistics produced prior to the 2011 Statistical Report used hysterectomy fraction estimates from the National Health Survey 9, these data are no longer collected by the ABS.

Table 2.1: Number of Pap tests registered and number of women screened in Victoria, 1990–2012.1

Year

Number of Pap Tests registered

Number of women screened

2012 2011

602,367 572,142

574,123 545,795

2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990

573,837 584,274 565,655 585,556 572,734 585,324 587,959 571,601 579,178 577,176 572,045 602,400 618,490 584,830 617,182 588,788 622,992 570,605 540,474 544,415 435,706

547,440 556,498 538,229 557,371 540,681 549,642 550,148 532,418 540,653 542,402 531,787 557,257 569,858 533,525 559,625 529,270 562,243 522,322 494,875 496,301 400,147

1 The number of Pap tests registered and women screened on the Registry as at 30 September 2013.

In this and the previous report, and consistent with the national approach, the population data for the latest screening periods have been adjusted with hysterectomy estimates from analysis conducted by the AIHW using data from the National Hospital Morbidity Database (NHMD)10. For more details about the changes to methods refer to the 2011 Statistical Report at http://www.vccr.org/stats.html It is important to appreciate that changes in the methods used to calculate participation impact upon the actual participation estimates. Hence comparisons in participation over time should be made with caution. Limitations of participation statistics One limitation to these participation statistics is the imperfect record-linkage between multiple Pap tests from the same woman that could result in an overestimate of the number of women screened. In addition, where site of specimen information is not reported to the Registry when a Pap test is taken from a woman without a cervix, the woman will be incorrectly included in the numerator.

8 Australian Bureau of Statistics. 3101.0 – Australian Demographic Statistics, Dec 2012 (release date 20/6/13) 9 Australian Bureau of Statistics. 4364.0 – National Health Survey: Summary of Results, 2004-2005 (release date 27/2/2006) 10 Australian Institute of Health and Welfare 2013. Cervical screening in Australia 2010-2011. Cancer Series 76. Cat. no. CAN 72. Canberra:AIHW Victorian Cervical Cytology Registry Statistical Report 2012

Participation in cervical screening by age group Table 2.2 shows the estimated cervical screening rates by age group for one, two, three and fi ve year periods, with the population data adjusted with estimated hysterectomy rates from the NHMD11. There was a slight increase in the one year screening rate from the previous year for women aged 20 to 69 years, at 33.1% in 2012, compared with 31.8% for 201112. Although there was an increase in the eligible screening population in 2012, the increase in participation was a result of a larger increase in the number of women who were being screened. The two year screening rate (for the calendar years of 2011 â&#x20AC;&#x201C; 2012) for women aged 20 to 69 years is estimated to be 60.0%, which is a slight increase from 59.2%13 for the previous reporting period (2010 â&#x20AC;&#x201C; 2011). As observed with the one year participation data, the slight increase is due to a greater increase in the number of women screened than in the eligible population. This trend was observed among all age groups. The 20 to 29 year old cohort reported the lowest participation at 26.3%, compared to the 40 to 49 and 50 to 59 year old cohorts, each with 36.9%. The increase in one year participation and to a lesser extent two year participation, across all age groups coincides with the implementation of the second reminder letter by the VCCR in June 2011. The evaluation of the second reminder letter showed an increase of 8.1% (2,308 women) when comparing the same period before (Jun-Dec 2009) and after the implementation (Jun-Dec 2011)14. A greater impact on two year participation is expected next year as a full two years of the second reminder project will be included.

Over the three year period from 2010-2012, the participation rate of Victorian women aged 20 to 69 years was estimated at 72.4%, a slight increase from the previous period of 2009-2011 (72.0%). Table 2.2 also highlights the fi ve year estimated participation rate of 83.9% for 2008-2012, which is a slight decrease from the previous period (84.1%)15. Three and fi ve year participation rates for women aged 20 to 39 years decreased from the previous period, where as participation for women aged over 40 years increased16. Estimated two year participation over time As seen in fi gure 2.2.1, there was a small decline over time for each age group between 2000-2001 and 2010-2011; however an increase in the number of women being screened in each age group in the most recent 2011-2012 period has resulted in a slight increase in participation across all age groups. The decline in participation evident in previous years is a refl ection of the growing Victorian population, refi ning of the method to determine the participation statistics including more precise hysterectomy fractions; and in some instances actual declines in the number of women screened. Typically women aged 40 to 49 years and 50 to 59 years have the highest two year screening rates and women aged 20 to 29 years have the lowest screening rate. This trend towards decreasing participation in young women has also been seen nationally and internationally17.

Table 2.2: Estimated cervical screening rates by age group over one year, two year, three year and fi ve year periods.

% screened 2012 (1 year) 26.3%

Age Group 20 to 29 yrs - 20 to 24 yrs - 25 to 29 yrs

% screened 2011-2012 (2 years) 47.1% 23.2% 29.3%

% screened 2010-2012 (3 years) 60.6% 41.7% 52.2%

% screened 2008-2012 (5 years) 80.1% 54.7% 66.2%

75.7% 84.4%

30 to 39 yrs 40 to 49 yrs

33.8% 36.9%

61.3% 66.9%

75.8% 80.0%

90.9% 89.0%

50 to 59 yrs 60 to 69 yrs 20 to 69 yrs

36.9% 33.3% 33.1%

67.2% 61.6% 60.0%

77.8% 68.8% 72.4%

82.8% 69.8% 83.9%

Notes 1. 2. 3.

The eligible female population is adjusted for the estimated proportion of women who have had a hysterectomy using hysterectomy fractions derived from the National Hospital Morbidity Database. The table provides the percentage of women screened as a proportion of the eligible female population (crude rate). Women screened only includes women who have not had a hysterectomy according to information held by the VCCR. Periods covered apply to calendar years.

11 Ibid. 12 Victorian Cervical Cytology Registry, Statistical Report 2011. Available at: http://www.vccr.org/stats.html 13 Ibid. 14 Ibid. 15 Ibid. 16 Ibid. 17 Lancucki L, Fender M, Koukari A, Lynge E, Mai V et al. A fall-off in cervical screening coverage of younger women in developed countries. 2010: J Med Screen.17:91-6 10

Figure 2.2.1: Estimated two year cervical screening rates by age group, 2000-01 to 2011-12. 80

Participation rate (%)

70 60 50 40 30 20 10 0 ‡

‡

Time Period 20 - 29 yrs

30 - 39 yrs

40 - 49 yrs

50 - 59 yrs

60 - 69 yrs

20 - 69 yrs

Notes 1. 2.

The graph provides the percentage of women screened as a proportion of the eligible female population (crude rate). Women screened only includes women who have not had a hysterectomy according to information held by the VCCR. The eligible female population is adjusted for the estimated proportion of women who have had a hysterectomy using hysterectomy fractions as indicated by the symbols *, † and ‡; which are outlined in further detail below. Periods covered apply to calendar years.

Table 2.2.1: Estimated two year cervical screening rates by age group, 2000-01 to 2011-12.

Participation % 20-69yrs

20-29yrs

30-39yrs

40-49yrs

50-59yrs

60-69yrs

2000-2001*

66.6%

56.0%

70.0%

74.0%

76.0%

58.0%

2001-2002*

64.4%

57.0%

67.0%

69.0%

70.0%

58.0%

2002-2003*

63.9%

55.0%

66.0%

69.0%

70.0%

58.0%

2003-2004*

64.4%

54.0%

67.0%

70.0%

72.0%

60.0%

2004-2005*

65.0%

54.4%

67.4%

70.5%

71.9%

60.9%

2005-2006 †

63.4%

53.2%

66.3%

66.7%

68.8%

63.6%

2006-2007

†

63.1%

52.7%

65.4%

66.5%

69.6%

64.4%

2007-2008 †

62.3%

51.2%

64.5%

65.9%

69.3%

64.1%

2008-2009

†

61.3%

48.5%

63.7%

65.5%

69.4%

64.6%

2009-2010 †

60.7%

47.1%

62.6%

65.5%

69.9%

65.3%

2010-2011 ‡

59.2%

46.6%

61.1%

66.1%

59.7%

2011-2012

60.0%

47.1%

61.3%

66.9%

67.2%

61.6%

‡

* 2000-2001 to 2004-2005 data has been adjusted using the 2001 National Health Survey hysterectomy fractions estimates. † 2005-2006 to 2009-2010 data has been adjusted using the 2004-05 National Health Survey hysterectomy fractions estimates. ‡ 2010-2011 and 2011-2012 data has been adjusted using the National Hospital Morbidity Database (NHMD) hysterectomy fraction estimates (courtesy of the Australian Institute of Health and Welfare).

Victorian Cervical Cytology Registry Statistical Report 2012

2.3 PARTICIPATION BY AREA Method of calculating participation The participation rate for age eligible women in cervical screening for Medicare Locals (ML), Department of Health (DH) regions and Local Government Areas (LGAs) is expressed as a percentage. • The numerator is the number of women by postcode 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. • The denominator is the estimated number of women in each Postal Area18 adjusted to exclude the proportion of women estimated to have had a hysterectomy. The 2011–2012 data are adjusted by the hysterectomy fractions from the National Hospital Morbidity Database19. The average female population over each two year period is used as the denominator. To calculate the estimated participation rates for areas, mapping of data by Australia Post postcodes and Postal Areas to LGAs and Medicare Locals was done using conversion files provided by the Victorian Department of Health and the Commonwealth Department of Health and Ageing respectively. The mapping of the 2011–2012 participation data for LGAs is based on concordances20 consistent with the new ABS Australian Statistical Geography Standard (ASGS)21. Participation data by DH region are calculated as an aggregate of LGAs, while Medicare Locals were created based on the Commonwealth Department of Health Postcode to Medicare Local concordance file22.

Other additional (but probably lesser) sources of measurement error derive from: • the proportion of Victorian Pap tests reported by laboratories outside of Victoria which are not reported to the VCCR (this will mainly affect areas located on the Victoria/New South Wales and Victoria/South Australia borders); and, • the differences between the Australia Post postcodes used to report screening numbers according to address data given by the woman (used as the numerator in calculating participation) and the ABS Postal Areas for which population statistics are available (used as the denominator). It is important to note that although there are commonalities between postcodes and Postal Areas, they are not exact matches and their boundaries can differ. The underlying reason for the differences in these boundaries is that the ABS Postal Areas were created specifically for Census purposes and disseminating statistics, while postcodes are designed to distribute mail. When comparing participation rate estimates by geographical area, it should also be noted that these are crude rates i.e. they have not been age-adjusted. Therefore areas with older populations will have apparently higher screening rates than areas with a high population of young women because of the strong correlation between age and screening rates.

Limitations Small-area data (eg. DH regions, LGAs and Medicare Locals) are subject to greater measurement error than the data in sections 2.1 and 2.2. The main source of inaccuracy in the following tables is derived from applying the national hysterectomy fractions to the relatively small female population resident in the Postal Areas.

18 ABS 2012, customized report. Data using 2011 postal boundaries: Victorian Female Estimated Resident Population by Postal Area at 30 June 2010 and 30 June 2011. 19 Australian Institute of Health and Welfare 2013. Cervical screening in Australia 2010-2011. Cancer series 76. Cat. No. CAN 72. Canberra:AIHW 20 2012 Postcode to LGA converter algorithm (based on 2011 Mesh Block boundaries) supplied by Victorian Department of Health and based on ABS Australian Statistical Geography Standard (ASGS) correspondence. 21 Australian Bureau of Statistics,2011. Australian Statistical Geography Standard (ASGS): Volume 1 – Main Structure and Greater Capital City Statistical Areas, July 2011. Cat. No: 1270.0.55.001. 22 Australian Government Medicare Local Boundary and Concordance Files website. http://www.medicarelocals.gov.au/internet/ medicarelocals/ publishing.nsf /Content/digital-boundaries, cited 4 October 2013. 12

2.3.1 Participation by Medicare Locals In 2011 the Australian Government established the new Medicare Local 23 area network to replace the previous Divisions of General Practice, to plan and fund community- based primary care across Australia. Participation rates for 2010-2011 and 2011-2012 were calculated for the 17 Medicare Locals in Victoria which are partially or entirely located within Victoria. Using methods discussed at the beginning of Section 2.3, the estimated two year participation rates have been calculated for these areas. Table 2.3.1: Estimated two year cervical screening rates by Medicare Local, 2010-2011 and 2011-2012. Medicare Local Number

Medicare Local Name

ML201 ML202 ML203 ML204 ML205 ML206 ML207 ML208 ML209 ML210 ML211 ML212 ML213 ML214 ML215 ML216 ML217

Inner North West Melbourne Bayside South Western Melbourne Macedon Ranges and North Western Melbourne Northern Melbourne Inner East Melbourne Eastern Melbourne South Eastern Melbourne Frankston - Mornington Peninsula Barwon Grampians Great South Coast Lower Murray Loddon - Mallee - Murray Goulburn Valley Hume Gippsland

2010-20111 % screened (95% CI)

2011-20121 % screened (95% CI)

56.7% (56.4%-57.0%) 64.5% (64.3%-64.7%) 52.4% (52.0%-52.8%) 55.4% (55.1%-55.7%) 58.1% (57.9%-58.3%) 62.1% (61.9%-62.3%) 61.8% (61.5%-62.0%) 56.0% (55.7%-56.2%) 58.9% (58.5%-59.2%) 62.2% (61.9%-62.5%) 55.5% (55.1%-55.9%) 60.7% (60.2%-61.3%) 58.7% (57.9%-59.5%) 60.7% (60.3%-61.1%) 56.3% (55.8%-56.7%) 65.5% (65.0%-66.0%) 59.7% (59.4%-60.1%)

57.2% (57.0%-57.5%) 65.0% (64.8%-65.2%) 53.2% (52.8%-53.5%) 55.9% (55.6%-56.1%) 59.0% (58.8%-59.2%) 62.8% (62.6%-63.0%) 62.4% (62.1%-62.6%) 56.5% (56.2%-56.7%) 59.2% (58.9%-59.6%) 63.3% (62.9%-63.6%) 56.8% (56.4%-57.2%) 61.2% (60.6%-61.7%) 61.4% (60.6%-62.1%) 62.8% (62.4%-63.3%) 58.3% (57.8%-58.8%) 67.6% (67.1%-68.1%) 60.1% (59.8%-60.5%)

Notes 1.

2010 -2011 and 2011-2012 data: Postcodes mapped to Medicare Locals based on the Commonwealth Department of Health Postal Area to Medicare Local concordance file. Population data adjusted using estimated hysterectomy fractions from the AIHW National Hospital Morbidity Database.

The table provides the percentage of women screened as a proportion of the eligible female population (crude rate). Women screened only includes women who have not had a hysterectomy according to information held by the VCCR.

Periods covered apply to calendar years.

23â&#x20AC;&#x192; www.medicarelocals.gov.au Victorian Cervical Cytology Registry Statistical Report 2012

Figure 2.3.1: Estimated two year cervical screening rates by Medicare Local, 2011-2012.

Medicare Local boundaries have been truncated where they overlap the Victorian border. This includes the Lower Murray (ML 213), Loddonâ&#x20AC;&#x201C;Mallee-Murray (ML 214), and Hume (ML 216) Medicare Locals. Refer to Appendix 3 for a map of Medicare Locals which have not been truncated at the border.

2.3.2 Participation by Department of Health Region Victoria is divided into eight Department of Health (DH) regions, with fi ve in rural Victoria and three covering metropolitan Melbourne. Using methods discussed at the beginning of Section 2.3, the two year participation rates have been calculated.

Table 2.3.2: Estimated two year cervical screening rates by Department of Health region, 2010–2011 and 2011–2012.

Region Name

2010-20111 % screened (95% CI)

2011-20121 % screened (95% CI)

Barwon South Western

61.8% (61.5%-62.1%)

62.6% (62.3%-62.9%)

Eastern Metropolitan

62.0% (61.8%-62.1%)

62.6% (62.5%-62.8%)

Gippsland

59.7% (59.4%-60.1%)

60.1% (59.7%-60.5%)

Grampians

56.3% (55.9%-56.7%)

57.6% (57.2%-58.0%)

Hume

60.6% (60.2%-61.0%)

62.6% (62.2%-62.9%)

Loddon Mallee

61.0% (60.7%-61.3%)

63.1% (62.8%-63.4%)

Northern West Metropolitan

56.0% (55.8%-56.1%)

56.6% (56.5%-56.8%)

Southern Metropolitan

60.5% (60.3%-60.6%)

60.9% (60.8%-61.1%)

Notes 1. 2010–2011 and 2011-2012 data: Participation data by DH region is calculated as an aggregate of LGAs. Postcode/ Postal Areas mapped to LGA using a converter algorithm supplied by the Victorian Department of Health and based on ABS Australian Statistical Geography Standard (ASGS) 2011 correspondence data. Population data adjusted using estimated hysterectomy fractions from the AIHW National Hospital Morbidity Database. 2.

Periods covered apply to calendar years.

Figure 2.3.2: Estimated two year cervical screening rates by Department of Health region, 2011-2012.

Unincorporated Victoria refers to the areas within Victoria which are not administered by incorporated local government bodies.

Victorian Cervical Cytology Registry Statistical Report 2012

2.3.3 Participation by Local Government Area Within Victoria there are 79 Local Government Areas (LGAs). Using methods discussed at the beginning of Section 2.3, the estimated two year participation rates have been calculated. Table 2.3.3: Estimated two year cervical screening rates by Local Government Area, 2010–2011 and 2011–2012.

DH region Barwon South West

21750 21830 22410 22750 25490 26080 26260 26490 26730

Eastern Metropolitan

21110 23670 24210 24410 24970 26980 27450 20740 20830 22110 23810 26170 26810 20260 20570 22490 22910 22980 23190 25150 25810 25990 26890 27630 20110 21010 22830 23350 24250 24850 24900 25620 26430 26670 26700 27170

Gippsland

Grampians

Hume

LGA Code1

LGA 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 Alpine Benalla Greater Shepparton Indigo Mansfield Mitchell Moira Murrindindi Strathbogie Towong Wangaratta Wodonga

2010–20112 % screened (95% CI) 66.4% (65.1%-67.6%) 57.8% (56.3%-59.3%) 57.1% (55.7%-58.4%) 61.1% (60.7%-61.5%) 61.1% (59.6%-62.6%) 69.5% (66.2%-72.8%) 61.9% (60.4%-63.3%) 67.4% (66.4%-68.5%) 63.6% (62.6%-64.6%) 67.0% (66.6%-67.4%) 62.4% (61.9%-62.8%) 65.1% (64.6%-65.7%) 60.9% (60.4%-61.5%) 57.2% (56.8%-57.7%) 60.1% (59.6%-60.5%) 61.8% (61.4%-62.3%) 60.0% (58.9%-61.1%) 61.4% (60.5%-62.3%) 61.9% (61.1%-62.8%) 56.4% (55.8%-57.1%) 62.8% (61.6%-63.9%) 59.6% (58.7%-60.5%) 50.4% (48.6%-52.2%) 56.1% (55.5%-56.7%) 61.5% (60.1%-62.8%) 65.3% (63.8%-66.8%) 52.4% (49.8%-54.9%) 58.0% (56.6%-59.3%) 54.9% (53.9%-56.1%) 53.4% (51.6%-55.2%) 52.6% (50.3%-55.0%) 44.9% (41.8%-48.0%) 54.5% (52.1%-56.9%) 68.8% (67.2%-70.4%) 67.6% (66.1%-69.1%) 57.0% (56.2%-57.7%) 66.0% (64.6%-67.5%) 65.8% (63.8%-67.8%) 54.0% (53.0%-55.0%) 54.2% (53.1%-55.4%) 57.2% (55.6%-58.8%) 63.9% (62.0%-65.8%) 63.9% (61.5%-66.4%) 67.3% (66.2%-68.4%) 64.3% (63.3%-65.2%)

2011–20122 % screened (95% CI) 62.9% (61.6%-64.2%) 61.6% (60.1%-63.1%) 56.7% (55.3%-58.0%) 62.5% (62.1%-62.9%) 62.2% (60.8%-63.7%) 73.6% (70.4%-76.7%) 61.9% (60.4%-63.3%) 67.7% (66.6%-68.7%) 63.0% (62.0%-64.0%) 67.4% (67.0%-67.8%) 62.7% (62.3%-63.2%) 66.0% (65.5%-66.5%) 60.6% (60.0%-61.1%) 57.9% (57.5%-58.3%) 61.0% (60.6%-61.5%) 63.4% (62.9%-63.8%) 59.0% (57.9%-60.0%) 63.4% (62.5%-64.2%) 62.2% (61.3%-63.0%) 57.5% (56.8%-58.1%) 63.6% (62.5%-64.7%) 58.0% (57.1%-58.9%) 57.2% (55.3%-59.0%) 56.7% (56.2%-57.3%) 62.1% (60.7%-63.4%) 62.7% (61.2%-64.2%) 57.3% (54.7%-59.9%) 60.4% (59.1%-61.7%) 58.1% (57.0%-59.1%) 51.6% (49.8%-53.3%) 55.8% (53.5%-58.1%) 47.7% (44.5%-50.9%) 53.4% (51.0%-55.8%) 67.2% (65.6%-68.9%) 70.3% (68.8%-71.8%) 59.6% (58.8%-60.3%) 67.8% (66.3%-69.2%) 67.0% (65.0%-69.0%) 55.3% (54.3%-56.3%) 56.7% (55.5%-57.8%) 59.6% (58.0%-61.2%) 64.3% (62.4%-66.2%) 67.2% (64.8%-69.6%) 70.3% (69.2%-71.3%) 66.0% (65.0%-66.9%)

DH region Loddon Mallee

Northern & Western Metropolitan

Southern Metropolitan

LGA Code1

21270 21370 21670 22250 22620 23940 24130 24780 25430 26610 20660 21180 21890 23110 23270 24330 24600 24650 25060 25250 25710 27070 27260 27350 20910 21450 21610 22170 22310 22670 23430 25340 25900 26350

LGA Buloke Campaspe Central Goldfields Gannawarra Greater Bendigo Loddon Macedon Ranges Mildura Mount Alexander Swan Hill Banyule Brimbank Darebin Hobsons Bay Hume Maribyrnong Melbourne Melton Moonee Valley Moreland Nillumbik Whittlesea Wyndham Yarra Bayside Cardinia Casey Frankston Glen Eira Greater Dandenong Kingston Mornington Peninsula Port Phillip Stonnington

2010–20112 % screened (95% CI) 62.7% (60.3%-65.2%) 58.7% (57.7%-59.6%) 49.2% (47.5%-51.0%) 57.0% (55.1%-58.9%) 61.0% (60.4%-61.6%) 53.5% (51.2%-55.7%) 68.4% (67.6%-69.2%) 58.8% (57.9%-59.6%) 72.9% (71.6%-74.2%) 55.6% (54.3%-56.9%) 64.2% (63.7%-64.7%) 54.5% (54.1%-54.9%) 57.7% (57.2%-58.1%) 58.0% (57.4%-58.6%) 52.3% (51.9%-52.8%) 54.9% (54.4%-55.6%) 45.6% (45.1%-46.1%) 51.6% (51.0%-52.1%) 60.8% (60.3%-61.3%) 57.2% (56.8%-57.7%) 71.3% (70.6%-71.9%) 54.8% (54.3%-55.2%) 49.3% (48.8%-49.7%) 65.4% (64.9%-66.0%) 72.6% (72.1%-73.1%) 56.4% (55.8%-57.1%) 56.8% (56.4%-57.1%) 55.4% (54.9%-55.9%) 63.1% (62.6%-63.6%) 54.3% (53.8%-54.8%) 61.5% (61.0%-61.9%) 62.1% (61.6%-62.6%) 63.4% (62.9%-63.9%)

65.5% (65.0%-66.0%)

2011–20122 % screened (95% CI) 62.9% (60.5%-65.4%) 63.2% (62.2%-64.2%) 53.1% (51.4%-54.9%) 59.4% (57.5%-61.3%) 62.2% (61.6%-62.8%) 52.9% (50.7%-55.1%) 69.0% (68.2%-69.9%) 61.2% (60.4%-62.0%) 75.5% (74.2%-76.7%) 59.9% (58.5%-61.2%) 65.1% (64.6%-65.6%) 54.6% (54.2%-55.0%) 59.0% (58.5%-59.4%) 60.4% (59.8%-61.0%) 53.6% (53.2%-54.0%) 56.7% (56.0%-57.3%) 45.7% (45.2%-46.2%) 51.7% (51.1%-52.2%) 61.1% (60.6%-61.7%) 58.5% (58.1%-59.0%) 71.5% (70.8%-72.1%) 55.3% (54.8%-55.7%) 49.6% (49.2%-50.1%) 66.2% (65.6%-66.7%) 73.9% (73.4%-74.4%) 57.2% (56.6%-57.9%) 57.3% (56.9%-57.6%) 55.2% (54.7%-55.7%) 64.2% (63.7%-64.6%) 54.6% (54.2%-55.1%) 61.3% (60.9%-61.8%) 63.0% (62.6%-63.5%) 62.9% (62.4%-63.4%) 66.6% (66.1%-67.1%)

Notes 1.

Refer to Appendix 3 for maps showing Local Government Area codes.

2010–2011 and 2011-2012 data: Postcode/ Postal Areas mapped to LGA using a converter algorithm supplied by the Victorian Department of Health and based on ABS Australian Statistical Geography Standard (ASGS) 2011 correspondence data. Population data adjusted using estimated hysterectomy fractions from the AIHW National Hospital Morbidity Database.

Periods covered apply to calendar years.

Victorian Cervical Cytology Registry Statistical Report 2012

Figure 2.3.3: Estimated two year cervical screening rates by Local Government Area*, 2011â&#x20AC;&#x201C;2012.

% PARTICIPATION Less than 50% 50% - 55% 55% - 60% 60% - 65% 65% - 70% Greater than 70% Unincorporated Victoria

INSET: Melbourne and surrounds

Unincorporated Victoria refers to the areas within Victoria which are not administered by incorporated local government bodies. * Note that maps showing Victorian LGA codes are provided in Appendix 3.

2.4 PAP TESTS COLLECTED BY NURSES The credentialling of nurses every three years to perform Pap tests recognises nurses’ expertise and dedication to the Victorian Cervical Screening Program. This process has been set in place to allow nurses to be accountable to the public and responsible for their individual practice while at the same time maintaining a standard of excellence. The credentialling program is coordinated by PapScreen Victoria. During 2012, a total of 33,875 Pap tests were collected and reported to the Registry by 416 credentialled nurses. This number represents 5.6% of all Pap tests collected in Victoria during 2012. This figure reflects the significant growth in the role of nurses in cervical screening, with the proportion of Pap tests performed by nurses having steadily increased over the years from an initial reported figure of 0.8% (5,170 tests) in 1996. Table 2.4 shows the number and proportion of Pap tests collected by nurses since 2003. Nurse Pap test data highlight the increasingly important role that nurses have in the delivery of the Victorian Cervical Screening Program, particularly in relation to the increasing number of Pap tests collected by them in recent years and the high quality of their tests. As observed in recent years, Pap tests collected by nurses are more likely to have an endocervical component, which is considered to be a reflection of test quality. General Practice and Community Health settings remain the main types of practices where nurses collect Pap tests (85.5% of practice types in 2012). During 2012, 39.2% of the Pap tests collected by nurses were from women over 50 years of age compared with 30.1% collected by other provider types in Victoria during this period 24.

Table 2.4: Proportion of Pap tests collected by nurses, 2003–2012.

Year

Number of Pap tests collected by nurses

% of all Victorian Pap tests

2012

33,875

5.6%

2011

31,613

5.5%

2010

28,546

5.0%

2009

25,594

4.4%

2008

21,668

3.8%

2007

18,651

3.2%

2006

16,035

2.8%

2005

14,375

2.5%

2004

13,100

2.2%

2003

11,494

2.0%

24 VCCR Evaluation of Pap tests collected by Nurses in Victoria during 2012 report. Refer to www.vccr.org/stats.html Victorian Cervical Cytology Registry Statistical Report 2012

2.4.1 Proportion of Pap tests collected by nurses by Department of Health Region Data on Pap tests collected by nurses were analysed by Department of Health (DH) region. The following table and figure show that the rural DH regions had a higher proportion of tests collected by nurses, for women with a cervix, than those within metropolitan Melbourne. The proportion of Pap tests collected by nurses increased across Barwon South West, Eastern Metropolitan, Loddon Mallee and the Northern and Western Metropolitan regions. The largest increases in the proportion of Pap tests collected by nurses were seen in the Loddon Mallee (3.4%) and Barwon South West regions (0.9%)25.

Table 2.4.1: Pap tests for women with a cervix collected by nurses, by Department of Health region, 2012.

Region name

Number of Pap tests collected by nurses1

Number of nurses in each region2

% Pap tests in region collected by nurses

Barwon South West

3,915

10.7%

Eastern Metropolitan

2,324

2.1%

Gippsland

2,365

9.9%

Grampians

4,046

19.7%

Hume

3,878

14.8%

Loddon Mallee

7,046

23.2%

Northern & Western Metropolitan

7,168

101

4.1%

Southern Metropolitan

2,738

2.0%

1 Excludes 345 post-hysterectomy Pap tests and 50 women whose postcode was missing or not able to be matched. 2 Excludes seven nurses whose postcode could not be matched.

25â&#x20AC;&#x192; Ibid. 20

Figure 2.4.1: Proportion of Pap tests collected by nurses, by Department of Health region, 2012.

Unincorporated Victoria refers to the areas within Victoria which are not administered by incorporated local government bodies.

Victorian Cervical Cytology Registry Statistical Report 2012

2.5 CLOSING THE DATA GAPS: IDENTIFYING ABORIGINAL AND TORRES STRAIT ISLANDER PEOPLE, AND COLLECTING COUNTRY OF BIRTH AND LANGUAGE SPOKEN AT HOME Data from the AIHW26 has shown that Aboriginal and Torres Strait Islander women are five times more likely to die of cervical cancer than non-Aboriginal and Torres Strait Islander women. The national “Closing the Gap” strategy is a commitment by all Australian Governments to overcome disadvantage and improve the lives and health outcomes of Aboriginal and Torres Strait Islander people27. Women from Culturally and Linguistically Diverse (CALD) backgrounds have also been identified as an under-screened group28. Strategies for engaging with Aboriginal and Torres Strait Islander and CALD women, and increasing participation, are a priority for the Victorian Department of Health as outlined in the Victorian Public Health and Well Being Plan 2011-2015 and the previous governments’ Victorian Cancer Action Plan (2008-2011). Where provided by practitioners, laboratories, and directly by women through updates of personal information, the VCCR will record if a woman has identified as an Aboriginal and Torres Strait Islander person as well as her country of birth and language spoken at home as indicators of cultural diversity.

VCCR is working closely with Program Partners including the Department of Health, PapScreen Victoria and VCS Pathology to improve the identification of Aboriginal and Torres Strait Islander women and the ongoing collection of CALD data to the Registry. VCS Pathology continues to work with nurses who collect Pap tests, to support and encourage the identification of Aboriginal and Torres Strait Islander women and the recording of this information on the VCS Pathology Request Forms. Nurse Practitioners have the highest proportion of any practitioner type, 94.1%, of Pap tests where this information was reported. Table 2.5 (b) shows the proportion of Pap tests by practitioner type where Aboriginal and Torres Strait Islander information was recorded in the woman’s record. Table 2.5 (b): Proportion of Pap Tests by Practitioner Type with Aboriginal and Torres Strait Islander Origin Information recorded.

Practitioner Type

No.

General Practitioner

67259

14.0%

1122

15.1%

Hospital

Nurse Practitioner

31865

94.1%

Obstetrician & Gynaecologist

14473

18.4%

359

15.4%

Other

Aboriginal and Torres Strait Islander Women

Culturally and Linguistically Diverse Women

In 2012 the overall percentage of women screened who had their Aboriginal and Torres Strait Islander origin recorded by the VCCR was 19.4%. Table 2.5 (a) shows the number and proportion of women by their identification as an Aboriginal and Torres Strait Islander person.

In 2012 the overall percentage of women screened who had a Country of Birth recorded by the VCCR was 14.5%. The most common countries of birth outside of Australia were Vietnam, England, New Zealand, United Kingdom (includes Channel Islands and Isle of Man)29, China (excludes SARS and Taiwan), India, Italy, Philippines, Greece and Malaysia.

Table 2.5 (a): Proportion of Women screened by Aboriginal and Torres Strait Islander Origin.

The overall percentage of women screened who had Language Spoken at Home recorded was 15.2%. The most common languages reported, other than English, were Vietnamese, Italian, Greek, Mandarin, Chinese (not elsewhere classified), Arabic, Spanish, Cantonese, Turkish and Maltese.

Status

No.

Aboriginal

1052

0.2%

Torres Strait Islander

0.0%

Aboriginal & Torres Strait Islander

172

0.0%

Not Aboriginal & Torres Strait Islander

110,336

19.2%

Not Collected

462,508

80.6%

0.0%

Declined to Answer Total

574123

100.0%

26 Australian Institute of Health and Welfare October 31st 2011 http://www.aihw.gov.au/media-release-detail/?id=10737420434 27 Australian Government, Department of Social Services, http://www.dss.gov.au/our-responsibilities/indigenous-australians/programs-services/closing-the-gap 28 Mullins R Anti Cancer Council Victoria, 2006 Evaluation of the impact of PapScreen’s Campaign on Culturally and Linguistically Diverse (CALD) Women http://www.cancervic.org.au/downloads/cbrc_research_papers/Cervical_cancer_research/06rep_rm_eval_PapScreen_campaign_CALD_women.pdf 29 United Kingdom (includes Channel Islands and Isle of Man) is assigned when the Country of Birth is not further specified. 22

2.6 FREqUENCY OF EARLY RE-SCREENING

Table 2.6: Subsequent Pap tests over a 21 month period for women with a negative report in February of 2011.

While the Australian screening policy recommends screening every two years after a negative Pap test report, a proportion of women are screened more frequently. A small level of early re-screening can be justifi ed on the basis of a past history of abnormality. In late 2000, the National Cervical Screening Program adopted the following defi nition 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 defi nition 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.

Table 2.6 shows the number of further Pap tests over a 21 month period for women who received a negative Pap test report in the February of 2011. The data show that 86.4% of women aged 20 to 69 years who had a negative Pap test in February 2011 had no further tests within the next 21 months. This data is comparable with that provided in the 2009, 2010 and 2011 Statistical Reports, however not with prior reports, as the method of determining the percentage now excludes women who have an abnormality within 36 months of their negative index Pap test.

Percent

No further tests

86.4 %

13.0 %

0.5%

< 0.1%

< 0.01 %

5 or more

< 0.01 %

Figure 2.6 : Early re-screening after a negative Pap test report in February 2011 by age group. 16 Percentage of early re-screening

To determine how many women are truly screened early, women with a prior cytological or histological abnormality recorded by the VCCR within 36 months of the index Pap test were excluded. This is in line with the national reporting of indicators by the AIHW for the same period and is also consistent with the NHMRC Guidelines.

Number of subsequent Pap tests since February 2011

14 12 10 8 6 4 2 0 20-29 yrs

30-39 yrs

40-49 yrs

50-59 yrs

60-69 yrs

As seen in Figure 2.6, some variation in early re-screening occurs by age group. The graph shows the proportion of women, by age group, who had early re-screening after a negative Pap test report in February 2011.

Victorian Cervical Cytology Registry Statistical Report 2012

3. CYTOLOGY REPORTS

Cytology reports received by the VCCR are coded according to the 2006 Cytology Coding Schedule (refer to Appendix 1). From this coding, Pap test results are categorised into the broader groups of unsatisfactory, negative, having no endocervical component, and having a squamous abnormality or endocervical abnormality. These groupings are consistent with the cytology result types requested by the AIHW for the reporting of national indicators for the same period. For this analysis, the results of 593,119 Pap tests from any provider type were considered. These include Pap tests which were collected during 2012, from women of any age, but not post-hysterectomy smears (also referred to as vault smears).

3.1 unsatisfactory pap tests An unsatisfactory Pap test result is defined as having: • unsatisfactory squamous cells (SU) and unsatisfactory endocervical cells (EU); or • unsatisfactory squamous cells (SU) and no endocervical cells (E0) or no endocervical abnormality (E1). Of Pap test results received during 2012 by the VCCR, 14,700 were recorded as having an unsatisfactory result. This equates to 2.5% of Pap tests. The National Pathology Accreditation Advisory Council (NPAAC) Performance measures for Australian laboratories reporting cervical cytology (NPAAC 2006) includes a recommended standard for the proportion of specimens reported as unsatisfactory as between 0.5% and 5.0% of all specimens reported 30.

3.2 negative pap tests A negative Pap test result is defined as having squamous cells with no abnormality (S1) and no endocervical cells (E0) or no endocervical abnormality (E1). Of the Pap test results received during 2012 by the VCCR, 538,455 were recorded as having a negative result. This equates to 90.8% of Pap tests.

3.3 Pap tests without an endocervical component The presence of endocervical cells within a Pap test specimen is considered to be a reflection of test quality. Pap tests identified as not containing an endocervical component are coded as having a result of E0 for the endocervical cell result. Of the Pap test results received during 2012 by the VCCR, 153,123 were recorded as not having an endocervical component present in the specimen. This equates to 25.8% of Pap tests. As illustrated in Figure 3.3, the proportion of Pap tests without an endocervical component has gradually increased from 19.7% in 2004 to 25.8% in 2012 (p < 0.001). This increase has also been seen at a national level. The reason for the decline in Pap tests with an endocervical component is unclear. It is likely to be multi-factorial, and a more detailed analysis of these trends is being completed by the VCCR.

Figure 3.3: Percentage of Pap tests without an endocervical component.

Percentage

30 25 20 15 10 5 0 2004

2005

2006

2007

2008

2009

2010

2011

2012

Year

30 Australian Institute of Health and Welfare 2013. Cervical screening in Australia 2010-2011. Cancer series 76. Cat.no. CAN 72. Canberra:AIHW. 24

3.4 Pap tests with a squamous abnormality

Table 3.5: Number and percent of Pap tests collected in 2012 with an endocervical abnormality.

Table 3.4 shows that the proportion of Pap tests with a squamous cell abnormality (with an abnormality of possible low-grade lesion or worse) in 2012 was 39,621 which equates to 6.7% of all Pap tests for the year. A definite high-grade abnormality (i.e. high-grade lesion with or without possible micro-invasion or invasion, invasive squamous cell carcinoma) was reported in 0.8% of all Pap tests for 2012. Table 3.4: Number and percent of Pap tests collected in 2012 with a squamous abnormality.

Squamous Cell Code

Number of Pap tests

% of Pap tests

Possible low-grade squamous intraepithelial lesion (LSIL) (S2)

19,091

3.2%

Low-grade squamous intraepithelial lesion (LSIL) (S3)

11,371

1.9%

Possible high-grade squamous intraepithelial lesion (HSIL) (S4)

4,496

0.8%

High-grade squamous intraepithelial lesion (HSIL) (S5)

4,521

0.8%

High-grade squamous intraepithelial lesion (HSIL) with possible micro-invasion/ invasion (S6)

0.1%

Squamous carcinoma (S7)

0.01%

Endocervical Component Code

Number of Pap tests

% of Pap tests

Atypical endocervical cells of uncertain significance (E2)

239

0.1%

Possible high-grade endocervical glandular lesion (E3)

166

0.1%

Adenocarcinoma in situ (E4)

0.1%

Adenocarcinoma in situ with possible micro-invasion/invasion (E5)

0.01%

Adenocarcinoma (E6)

0.01%

3.6 TYPE OF TESTS In July 2006, the VCCR began recording the type of Pap test taken; that is, conventional cytology, liquid-based specimen or combination. During 2012 the proportion of liquidbased tests was 4.0% of all tests reported to the Registry. Nearly all of these tests were â&#x20AC;&#x153;split samplesâ&#x20AC;? where the conventional Pap smear is accompanied by the liquidbased specimen. Very small numbers were liquid-based specimens only (0.2%).

3.5 Pap tests with an endocervical abnormality The presence of endocervical cells within a Pap test specimen is necessary for the detection and reporting of glandular abnormalities including atypical cells, possible high-grade lesions, endocervical adenocarcinoma in situ and adenocarcinoma. The following table shows the proportion of Pap tests for 2012 where an endocervical abnormality was detected. Pap tests which are known to have been collected posthysterectomy are excluded. For 2012, the total number of Pap tests with an endocervical abnormality (atypical endocervical cells of uncertain significance or worse) was 505, which equates to fewer than 0.1% of all Pap tests for the year.

Victorian Cervical Cytology Registry Statistical Report 2012

4. HISTOLOGY REPORTS

This section describes the histology reports that were notified to the VCCR during 20121. Although the reporting of histology results is not mandatory, the majority of all relevant cervical biopsies are reported to the VCCR. All cancers are notified to the Victorian Cancer Registry by laboratories, hospitals and the VCCR. In 2012, there were 20,630 histology reports relating to the cervix received by the VCCR.The following table shows the distribution of histology findings for 2012. Note that the data presented in Table 4 includes all histology reports received by the VCCR, and is not restricted to the most severe report for a woman.

Table 4: Histology findings reported to the VCCR in 2012.

Histology findings

Endocervical abnormality

( 0.1%)

Adenosquamous carcinoma

( 0.1%)

Endocervical adenocarcinoma, invasive

(0.2%)

Endocervical adenocarcinoma, micro-invasive

( 0.1%)

High-grade carcinoma in situ/ adenocarcinoma in situ

( 0.3%)

High-grade endocervical abnormality, adenocarcinoma in situ

114

(0.6%)

High-grade endocervical abnormality, endocervical dysplasia

( 0.1%)

(0.0%)

Squamous cell carcinoma, invasive

106

(0.5%)

Squamous cell carcinoma, micro-invasive

(0.1%)

High-grade squamous abnormality, CIN III

2,922

(14.2%)

High-grade squamous abnormality, CIN II

2,136

(10.4%)

241

(1.2%)

High-grade squamous abnormality, CIN not otherwise specified Low-grade squamous abnormality Benign changes/normal Unsatisfactory TOTAL 1 The number of Histology Reports notified to the VCCR as at 30 June 2013. 2 Carcinoma of the cervix â&#x20AC;&#x201C; other: includes small cell carcinoma and other malignant lesions (may include tumours of non-epithelial origin).

(%)

Endocervical atypia

Squamous abnormality

Number

Carcinoma of the cervix â&#x20AC;&#x201C; other2

3,373

(16.3%)

11,302

(54.8%)

258

(1.3%)

20,630

(100%)

5. HIGH-GRADE ABNORMALITY DETECTION RATES

In 2012 the overall rate of histologically-confirmed high-grade abnormalities detected in Victoria for women aged 20 to 69 years was 7.65 per 1,000 women screened.31 Figure 5.1 illustrates the detection rate of histologicallyconfirmed high-grade intraepithelial abnormalities per 1,000 screened women for the years 2009-2012 by five year age group. The graph clearly illustrates that younger women have a much higher rate of high-grade abnormalities, resulting from high rates of incident HPV infection following the onset of sexual activity, than older women. Notable however are the year on year declines in the rate in the youngest women (aged 20 to 24 years), corresponding to the implementation of the HPV vaccination program between 2007-2009. Historically this age group has had the highest rates of abnormalities but from 2009 the rate has been higher amongst 25 to 29 year olds. Since 2008 the rate in 20 to 24 year olds has fallen from 21.1 (not shown in figure) to 15.3 per 1,000 in 2012 (p< 0.001) (2009 = 18.7; 2010 = 17.9; 2011=15.8). The youngest vaccinated women, who are less likely to have been previously exposed to high-risk HPV types through sexual activity, are now commencing cervical screening. According to the National HPV Vaccination Program Register, Victorian women aged 15 to 19 years in 2012 have a notified three-dose vaccine coverage of 72.6% and those aged 20 to 24 years have a notified coverage of 52.9% (NHVPR, unpublished data).

Figure 5.2 shows the rate of histologically-confirmed high-grade cervical abnormalities by year since 2000, for young women (< 20, 20-24,25-29) and those 30+ years of age.32 The previously noted decline, following the National HPV Vaccination Program, in women under 20 years of age is continuing, with a near halving of the rate of 11 cases per 1,000 women screened in 2006 down to 6 cases per 1,000 in 2012 (p< 0.001). Rates in women 20 to 24 years have been declining since 2010; however there has been a steady rise in detection rates for 25 to 29 year old women over the last 10 years. The VCS and the AIHW have undertaken an analysis of de-identified linked data from the VCCR and the NHVPR to determine whether the declines observed in high-grade abnormality rates amongst young women (aged 12 to 17 years in 2007) since the vaccination program are due to vaccination. The analysis confirmed that vaccinated women attending screening have a 48% lower rate of high-grade abnormalities than unvaccinated women, after adjusting for age, socioeconomic status and area of residence (Hazard Ratio 0.72 (95%CI 0.58-0.91) for receipt of any number of doses of HPV vaccine). This is the first international evidence of the effectiveness of HPV vaccination in preventing high-grade cervical abnormalities in a population.33

Figure 5.1: Detection rate of high-grade intraepithelial abnormalities (histologically-confirmed) from 2009-2012 per 1,000 screened women. 2012 2011 2010 2009

Rate per 1,000 screened women

18 16 14 12 10 8 6 4

Rate per 1,000 screened women

Figure 5.2: Trends in high-grade cervical abnormalities (histologically-confirmed) by age, 2000 - 2012, VCCR.

2 0

0 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 yrs yrs yrs yrs yrs yrs yrs yrs yrs yrs

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012

Year

Age group <20 yrs

20-24 yrs

25-29 yrs

30+ yrs

31 Note that the method used to calculate the rate of high grade abnormalities has been updated to be consistent with the AIHW indicator 4.2 (Australian Institute of Health and Welfare 2013. Cervical screening in Australia 2010-2011. Cancer series 76. Cat. no. CAN 72. Canberra: AIHW). Therefore rates are slightly different to those presented in previous reports. 32 Ibid. 33 Gertig DM, Brotherton JML, Budd AC, Drennan K, Chappell G, Saville AM. Impact of a population-based HPV vaccination program on cervical abnormalities: a data linkage study. BMC Medicine 2013, 11:227. Victorian Cervical Cytology Registry Statistical Report 2012

6. CORRELATION BETWEEN CYTOLOGY & HISTOLOGY REPORTS Tables 6.1 and 6.2 show the correlation between cytology results and histology findings. The correlation is restricted to cytology performed in 2011 where a subsequent histology test was reported within six months. If multiple histology results were reported the most severe result is used. Colposcopy reports, without histological confirmation, have been excluded from this analysis. In interpreting this information, it is important to remember that only a minority of low-grade cytology (atypia and CINI) is further investigated by colposcopy or biopsy, and an even smaller percentage of negative cytology reports are followed by 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 correlation data presented uses the Cytology Coding Schedule implemented in July 2006 which is based on the Australian Modified Bethesda System of 2004 (refer to Appendix 1). Each Pap test is assigned a summary code (negative, low-grade, glandular, possible high-grade and high-grade) based on specific criteria of the squamous, endocervical and other/non-cervical codes. The correlation uses this classification for cytology. The histology classification and method of correlation presented is consistent with the AIHW national reporting indicators. It is based on the test, not the woman, and the data includes women aged 20 to 69 years. It also includes the records of women who reside outside of Victoria but have data recorded on the VCCR.

Where a definite high-grade squamous cytology result was reported, 79.7% (2911/3653) of women were subsequently diagnosed with high-grade histology at biopsy (including high-grade CIN not otherwise specified, CINII, CINIII and micro-invasive and invasive squamous carcinoma). This figure represents the positive predictive value of a high-grade cytology report for high-grade histology. The National Pathology Accreditation Advisory Council (NPAAC) performance standards require that not less than 65% of cytology specimens with a definite high-grade epithelial abnormality is confirmed on histology within six months as having a high-grade abnormality or cancer 34 . Women with a Pap test report of ‘atypical endocervical or glandular cells of uncertain significance’ have glandular (or endocervical) cells on their smear which, in the opinion of the reporting pathologist, appear unusual but are not sufficiently abnormal to justify a more significant diagnosis. Unfortunately there is overlap in the cellular features caused by benign, inflammatory changes (by far the most common cause) and more significant processes such as pre-cancer (occasionally) and cancer (rarely). The NHMRC Guidelines 35 recommend colposcopy as an initial evaluation because of the risk of invasive cancer 36. Of the 26 cytology reports of ‘atypical endocervical or glandular cells of undetermined significance’, 2 were subsequently diagnosed with invasive or micro-invasive cancer (where histology was available within six months after the cytology result). There were no cases of cervical cancer reported on histology within 6 months of a low-grade squamous cytology in 2011 (Table 6.1).

34 National Pathology Accreditation Advisory Council (NPAAC) 2006. Performance Measures for Australian Laboratories Reporting Cervical Cytology, Canberra: Department of Health and Ageing. 35 NHMRC Screening to prevent cervical cancer: guidelines for the management of asymptomatic women with screen-detected abnormalities, 2005 http://www.nhmrc.gov.au/publications/synopses/wh39syn.htm 36 Appendix 8. Outcome after a cytological prediction of glandular abnormality in 1999. Author Dr Heather Mitchell. Screening to prevent Cervical Cancer Guidelines for the management of asymptomatic women with screen detected abnormalities. Available from the NHMRC website www.nhmrc.gov.au/_files_nhmrc/publications/attachments/wh39.pdf 28

Table 6.1: Correlation1 of squamous cytology to the most serious squamous histology within 6 months, women aged 20 to 69 years, cytology tests performed in 2011.

Cytology Prediction Histology finding

Negative2

Possible Low-Grade

Low-Grade

Possible High-Grade3

High-Grade4

High-Grade Plus5

SCC

HG: High-Grade LG: Low-Grade SQ: Squamous

Negative HS01

LG SQ abnormality

3,236 76.3%

1406

51.6%

670

31.4%

996

31.6%

354

9.7%

5.4%

3.0%

776

18.3%

936

34.3%

1042

48.9%

672

21.3%

388

10.6%

3.6%

0.0%

0.4%

0.9%

1.2%

2.1%

1.5%

0.0%

9.1%

126

3.0%

224

8.2%

270

12.7%

629

19.9%

865

23.7%

16.1%

0.0%

2.0%

134

4.9%

124

5.8%

780

24.7%

1944

53.2%

46.4%

30.3%

<0.1%

0.0%

0.2%

0.7%

7.1%

3.0%

<0.1%

0.0%

0.2%

0.6%

21.4%

54.5%

4242

100%

2725

100%

2132

100%

3153

100%

3653

100%

Squamous Abnormality

HS02

HG SQ abnormality CIN NOS

HS03.1

HG SQ abnormality CIN II HS03.2

HG SQ abnormality CIN III HS03.3

SQ Cell Carcinomaâ&#x20AC;&#x201C; micro-invasive HS04.1

SQ Cell Carcinoma â&#x20AC;&#x201C; invasive HS04.2

Totals

1 The correlation excludes diagnosis based on colposcopic impression alone 2 Negative cytology: no abnormal squamous cells or only reactive changes 3 Possible high-grade cytology: includes possible high-grade squamous intraepithelial lesion 4 High-grade cytology: includes high-grade squamous intraepithelial lesion 5 HG Plus: includes high-grade squamous intraepithelial lesion with possible micro-invasion/invasion

Victorian Cervical Cytology Registry Statistical Report 2012

Table 6.2: Correlation1 of endocervical cytology to the most serious endocervical histology within 6 months, women aged 20–69 years, cytology tests performed in 2011.

Cytology Prediction Histology finding

Negative

Atypical Endocervical cells of uncertain significance4

Possible High-Grade5

Adenocarcinoma in situ (AIS)

HG: High-Grade

Negative HE01

Endocervical Atypia HE02

Endocervical Abnormality

HG Endocervical Abnormality, Endocervical Dysplasia

AIS with Adenocarcinoma possible micro-invasion /invasion E5

1736

95.5%

30.8%

6.5%

0.0%

0.2%

3.8%

2.2%

0.0%

1.3%

50.0%

56.5%

50.9%

42.9%

12.5%

2.0%

7.7%

19.6%

25.5%

0.0%

2.2%

1.8%

0.0%

0.6%

3.8%

13.0%

21.8%

57.1%

87.5%

0.3%

3.8%

0.0%

0.1%

0.0%

1818

100%

HE03.1

HG Endocervical Abnormality, Adenocarcinoma in situ HE03.2

HG Carcinoma in situ / Adenocarcinoma in situ HE03.3

Endocervical Adenocarcinoma – micro-invasive HE04.1

Endocervical Adenocarcinoma – invasive2 HE04.2

Adenosquamous Carcinoma HE04.3

Carcinoma of the cervix – Other3 HE04.4

Totals

1 The correlation excludes diagnosis based on colposcopic impression alone 2 Endocervical adenocarcinoma – invasive: includes adenocarcinoma and embryonal/clear cell carcinoma 3 Carcinoma of the cervix – other: includes small cell carcinoma and other malignant lesions (may include tumours of non-epithelial origin) 4 Glandular cytology: includes atypical glandular cells of uncertain signifi cance (E2) 5 Possible high-grade cytology: includes possible high-grade endocervical glandular lesion

7. FOLLOW UP & REMINDER PROGRAM

The VCCR Reminder and Follow-up Protocol (refer to Appendix 2) adheres to the 2006 NHMRC Guidelines. As part of the follow-up service provided by VCCR, a total of 410,680 follow-up and reminder letters were mailed to women and practitioners in 2012. Second reminder letters were implemented as part of the routine correspondence of the VCCR in June 2011 and are printed in-house on a weekly basis for mail-out. The implementation costs and outcomes of the first seven months of the second reminder initiative were evaluated and published in an interim report37. Based upon the positive outcomes of the interim evaluation, the Department of Health has extended the funding for the second reminder initiative until June 2014. The following is a summary of the VCCR follow-up activities during 2012. First Reminders to Women Between 1 January 2012 and 31 December 2012, 270,989 first reminder letters were sent to women in the categories shown in Table 7. Of the 258,047 reminders sent after a negative Pap test, 103,634 (40%) women had a subsequent Pap test within three months of the date of the reminder.

Follow-up During 2012, the VCCR sent out 1,854 questionnaires to practitioners seeking further information after a high grade abnormality on Pap test and 4,493 after a low-grade abnormality. These questionnaires are part of the follow-up of abnormal tests and seek information on colposcopy or biopsy to alter the follow-up interval accordingly. The VCCR also sent out 12,406 reminder letters to practitioners, following low-grade or unsatisfactory Pap tests. During the year, 802 women with a high-grade abnormality required further follow-up by the VCCR as no further information had been received by 5.5 months after their Pap test. For these women, at least one phone call to the practitioner was made to ascertain follow-up, with many requiring additional calls. In 345 cases, the Registry sent letters to these women, mostly by registered mail to ensure that they were aware of their abnormality. For women who had low-grade abnormalities requiring further investigation, on whom the VCCR had not received follow-up information; 2,178 letters were sent to these women in 2012. The VCCR followed up 151 non-cervical abnormalities with letters to the practitioners seeking information about further investigations.

Second Reminders to Women Between 1 January 2012 and 31 December 2012; 117,460 second reminder letters were sent to women, in the categories shown in Table 7. Of the 112,469 reminders sent after a negative Pap test; 26,974 (24%) women had a subsequent Pap test within three months of the date of the reminder.

Table 7: Number of first and second reminder letters sent to women by the VCCR in 2012.

Pap test report category

First Reminders

Second Reminders

1,180

402

High-grade no subsequent Pap test by 12 months

158

Low-grade - with subsequent biopsy or colposcopy

1,674

612

800

329

High-grade with subsequent biopsy

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

504

227

5,534

2,005

Negative with previous abnormal

25,033

10,823

Negative

233,014

101,646

120

2,972

1,308

Unsatisfactory with previous abnormal Unsatisfactory

37 Interim evaluation report of Second Reminder, VCCR. Prepared by Lesley Rowlands, Genevieve Chappell and Dorota Gertig, April 2012 Victorian Cervical Cytology Registry Statistical Report 2012

8. CERVICAL CANCER INCIDENCE & MORTALITY IN VICTORIA The aim of the cervical cancer screening program is to reduce the incidence of and mortality from cervical cancer. Data on cancer incidence and mortality are collected by the Victorian Cancer Registry and notifi cations are compulsory from laboratories, hospitals and the VCCR. Figure 8.1 shows the incidence and mortality rates from cervical cancer in Victoria from 1982 to 2012. The incidence of cervical cancer has declined dramatically since the 1980s, with a considerable decline from the mid 1990s. There was a plateau in incidence in 2000 and the rate has remained relatively stable since that time at between 4 and 5 per 100,000 women. A slight increase has been noted in 2012, as the incidence rate for cervical cancer was 5.7 per 100,000 women (2010: 5.0 and 2011: 4.9). The mortality from cervical cancer in Victoria has declined gradually over time and since 2002 has been around 1.0 per 100,000 women, which is among the lowest in the world 38 . The mortality rate for all types of cervical cancer in 2012 was 1.1 per 100,000 Victorian women (2010: 1.3 and 2011: 1.1). Figure 8.2 shows the age-standardised incidence rates for cervical cancer by histological subtype over time.

The greatest impact of the cervical screening program has been on squamous cell carcinoma of the cervix, with age-standardised incidence rates declining from 6.3 per 100,000 women in 1989 to 2.7 per 100,000 in 2012. This is a marginal increase from an incidence rate of 2.0 in 2010 and 2.2 in 2011 per 100,000 women. Incidence rates for micro-invasive cancer have increased slightly since 2000; and in 2012 were 1.1 per 100,000 women screened (2010: 1.2 and 2011: 1.1). Cervical screening is less effective for the detection of adenocarcinomas 39, which now represent a larger proportion of all cancers due to the success of the program in reducing the incidence of squamous cancers. It is anticipated that HPV vaccination programs will reduce the future incidence of adenocarcinomas. Figure 8.3 shows the age-specifi c incidence rates of cervical cancer by histology and age, grouped over the three year period of 2010 to 2012. The age-specifi c incidence of invasive squamous cervical cancer increases in the 30 to 34 year old age group to peak at age 45 to 49 years, followed by a subsequent peak in women aged in their early 70s. Micro-invasive cervical cancer peaks at around 30 years of age and declines steadily thereafter.

Figure 8.1: Age-standardised incidence and mortality rates for all types of cervical cancer in Victoria, 1982â&#x20AC;&#x201C;2012.

Rate per 100,000 women

(age-standardised to the World Standard Population)

Incidence Mortality

10 8 6 4 2

1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012

Year Source: Thursfi eld V, Farrugia H. Cancer in Victoria: Statistics and Trends 2011. Cancer Council Victoria, Melbourne 2012.

38 Ferlay J, Shin HR, Bray F, Forman D, Mathers C and Parkin DM. GLOBOCAN 2008 v2.0, Cancer Incidence and Mortality Worldwide: IARC CancerBase No.10 [Internet]. Lyon, France: International Agency for Research on Cancer; 2010. Available from: http://globocan.iarc.fr 39 NHMRC Screening to prevent Cervical Cancer: guidelines for the management of asymptomatic women with screen-detected abnormalities,2005 http://nhmrc.gov.au/publications/synopses/whj39syn.htm 32

Figure 8.2: Age-standardised incidence rates (ASR) for cervical cancer by histological subtype in Victoria, 1982â&#x20AC;&#x201C;2012.

Rate per 100,000 women

(age-standardised to the World Standard Population)

Invasive squamous cell carcinoma Micro-invasive squamous cell carcinoma Other invasive morphology

7 6 5 4 3 2 1

1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012

Year Other cervical cancers are comprised of all other types, including adenocarcinomas. Source: Unpublished data, Victorian Cancer Registry, Cancer Council Victoria.

Figure 8.3: Age-specifi c incidence rates of cervical cancer by histological subtype in Victoria, 2010â&#x20AC;&#x201C;2012.

Invasive squamous cell carcinoma Micro-invasive squamous cell carcinoma Other invasive morphology

10 8 6 4 2

85+

80-84

75-79

70-74

65-69

60-64

55-59

50-54

45-49

40-44

35-39

30-34

25-29

20-24

15-19

10-14

5-9

0 0-4

Rate per 100,000 women

(age-standardised to the World Standard Population)

Age (Years) Other cervical cancers are comprised of all other types, including adenocarcinomas. Source: Unpublished data, Victorian Cancer Registry, Cancer Council Victoria.

Victorian Cervical Cytology Registry Statistical Report 2012

9. SCREENING HISTORY OF WOMEN DIAGNOSED WITH CERVICAL CANCER IN 2010 AND 2011 According to the Victorian Cancer Registry (VCR), 183 Victorian women were diagnosed with cervical cancer in 2010 and 185 women in 2011 (January 1 â&#x20AC;&#x201C; December 31). The screening histories of women with histologicallyconfi rmed invasive and non-invasive cervical cancer recorded on the Victorian Cervical Cytology Registry (VCCR) is outlined below.

Of these women diagnosed with cervical cancer, 113 with an invasive cancer diagnosis and 26 with a micro-invasive diagnosis were also recorded on the VCCR and thus a screening history was available for review.

Cervical Cancer Diagnoses in 2010 Of the 183 women diagnosed with cervical cancer in 2010, 77 were diagnosed with invasive squamous cell carcinoma, 38 with micro-invasive squamous cell cancer and 68 with other types of invasive cervical cancer (including adenocarcinoma, small cell carcinoma, mixed adenosquamous adenocarcinoma and carcinosarcomas/ sarcomas) 40 . Of these women diagnosed with cervical cancer, 137 were also recorded on the VCCR, and thus a screening history was available for review. Cervical Cancer Diagnoses in 2011 Of the 185 women diagnosed in 2011, 83 were diagnosed with invasive squamous cell carcinoma, 36 with microinvasive squamous cell cancer and 66 with other types of invasive cervical cancer 41.

An audit was conducted on the screening histories of women recorded on the VCCR with cervical cancer based on criteria used in other international studies 42. The following categories were used, and all screening tests within 6 months of diagnosis were excluded (as it is assumed these led to the diagnosis): A. Never screened (coverage failure), B. Lapsed screening: with more than two and a half years between the cancer diagnosis and the ultimate Pap test, C. Adequately screened (screening failure): with less than two and a half years between the cancer diagnosis and the ultimate Pap test, D. Delayed diagnosis: eg. no colposcopy and/or biopsy recorded [biopsy, management or treatment failure], E. Not eligible: Women over the age of 70 years and no longer eligible for the screening program1.

Table 9 (a): Screening history of Victorian women diagnosed with cervical cancer for the period 1 January 2010 to 31 December 2010.

Screening History

Invasive Squamous cell carcinoma Number (%)

Other invasive cervical cancer Number (%)

Invasive Sub-Total

Micro-invasive Sub-Total

Invasive & Micro-invasive Total

A. Never screened

49%

51%

50%

47%

50%

B. Lapsed screeners (last screen greater than 2.5 years)

30%

26%

28%

29%

28%

C. Adequately screened (last screen within 2.5 years)

13%

18%

15%

18%

16%

D. Delayed diagnosis

E. Not eligible

100%

145

100%

183

100%

Total

40 Unpublished data, Victorian Cancer Registry, Cancer Council Victoria 41 Ibid. 42 Sasieni P, Adams J, Cuzick J. BeneďŹ ts of cervical screening at different ages: evidence from the UK audit of screening histories. 2003. Br J Cancer. 89 (1): p. 88-93. 34

Table 9 (b): Screening history of Victorian women diagnosed with cervical cancer for the period 1 January 2011 to 31 December 2011.

Screening History

Invasive Squamous cell carcinoma Number (%)

Other invasive cervical cancer Number (%)

Invasive Sub-Total

Micro-invasive Sub-Total

Invasive & Micro-invasive Total

A. Never screened

52%

45%

49%

53%

50%

B. Lapsed screeners (last screen greater than 2.5 years)

29%

26%

28%

31%

28%

C. Adequately screened (last screen within 2.5 years)

13%

18%

15%

11%

15%

D. Delayed diagnosis

11%

E. Not eligible1

100%

149

100%

185

100%

Total

1 Women over 70 years and with a negative screening history are outside the eligible range for the screening program. Refer to the National Cervical Screening Program at www.cancerscreening.gov.au

Invasive Cervical Cancers. Tables 9(a) and 9(b) classify the screening history of women diagnosed with invasive cervical cancer into one of the following four groups: A. Women with no previous screening history The never screened category includes women who were on the VCR and either not recorded on the VCCR (37 women in 2010 and 36 women in 2011); and thus it is assumed they were never screened, or were recorded on the VCCR but their first Pap test was within 6 months of diagnosis (36 women in 2010 and 37 women in 2011). A proportion of those unknown to the VCCR may have been screened interstate or overseas, or have opted-off the Registry.

C. Women with an adequate screening history Of the women diagnosed with cervical cancer, 22 (15%) women in 2010 and 23 (15%) women in 2011 have been assessed as having an adequate screening history with at least one Pap test between six months and two and a half years prior to their cancer diagnosis. Over half of these women in both 2010 and 2011 were diagnosed with glandular cervical cancers, which are harder to detect through cervical screening.

B. Women with a lapsed screening history According to the VCCR records, there were 41 women (28%) in each of 2010 and 2011 that were categorized as lapsed screeners. This is defined as women with no record of a Pap test within two and a half years of their cancer diagnosis (but more than six months prior to diagnosis) in accordance with the current National screening policy recommendation of two yearly screening. The proportion of squamous invasive cancers for which there was either no screening history or a lapsed screening history was 79% in 2010 and 81% in 2011. For glandular invasive cancers, it was 77% in 2010 and 71% in 2011.

D. Women with a delayed diagnosis Of the women diagnosed with frankly invasive squamous cervical cancer, 9 (6%) women in 2010 and 11 (7%) women in 2011 appear to have had a delayed diagnosis or management failure on the limited information available to the VCCR. Pap tests are not very effective at detection of adenocarcinoma, due to the difficulty of sampling the endocervical canal, hence delayed diagnosis may play a role in detection of these cancers.

Victorian Cervical Cytology Registry Statistical Report 2012

ACKNOWLEDGEMENTS

The production of this report would not be possible without the co-operation of the staff of the pathology laboratories of Victoria, the staff of the VCCR and the ICT team. Very sincere thanks are extended to the members of all these groups. In particular, special thanks go to the dedicated VCCR staff for their collection of high-quality information and the provision of an excellent service for women and health practitioners. The fi gures 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 Thursfi eld and Helen Farrugia for their assistance in providing these data.

LIST OF ABBREVIATIONS ABS:

Australian Bureau of Statistics

AIHW:

Australian Institute of Health and Welfare

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

HSIL:

High-grade squamous intraepithelial lesion

ICT:

Information and Communication Technology

LSIL:

Low-grade squamous intraepithelial lesion

NHMRC: National Health and Medical Research Council

NHVPR:

National HPV Vaccination Program Register

NPAAC:

National Pathology Accreditation Advisory Council

PPV:

Positive Predictive Value

SCC:

Squamous Cell Carcinoma

VCCR:

Victorian Cervical Cytology Registry

VCR:

Victorian Cancer Registry

VCS:

Victorian Cytology Service Inc.

GLOSSARY REFERENCES 43

Adenocarcinoma – A rare cancer affecting the cervix, but involving the columnar cells rather than the squamous cells. The columnar cells are involved in glandular activity. Adenocarcinoma has a different type and rate of progression and is not so often picked up in a Pap test Atypia – Abnormality in a cell (to a lower degree than dysplasia) Biopsy of the Cervix – Removal of a small piece of the cervix for examination under a microscope Carcinoma in Situ – Cancer cells that are restricted to the surface epithelium. The abnormal cells are evident throughout each of the layers of the epithelium but they have not extended into other, deeper tissue or surrounding areas Cervix – The neck of the uterus (womb), located at the top of the vagina Colposcopy – A detailed examination of the lower genital tract with a magnifying instrument called a colposcope. This method of non-invasive evaluation allows the clinician to more accurately assess a cytologic abnormality by focusing on the areas of greatest abnormality and by sampling them with a biopsy to obtain a tissue diagnosis Cytology – The microscope evaluation of a sample of cells obtained from a tissue (or body fl uid) during procedures such as Pap tests. The sample does not permit evaluation of the underlying structure of the tissue of origin (cf. histology) Dysplasia - Abnormal appearance, development or growth patterns of cells

Immunisation – Inducing immunity against infection by the use of an antigen to stimulate the body to produce its own antibodies (AIHW (2008) Australia’s Health 2008, Cat. No. AUS 99. AIHW, Canberra) Incidence – The number of new cases (for example, of an illness or event) occurring during a given period Intraepithelial lesion – Lesion confi ned to the surface layer of the cervix Invasive Cancer – A tumour whose cells have the potential to spread to nearby healthy or normal tissue or to more distant parts of the body Lesion – Alteration of surface tissue, caused by injury or disease Malignant – Abnormalities in cells or tissues consistent with cancer Micro–invasive squamous cell carcinoma (micro–invasive cancer) – A lesion in which the cancer cells have invaded just below the surface of the cervix, but have not developed any potential to spread to other tissues National Cervical Screening Program – Australia-wide systematic approach to cervical screening based on sound international scientifi c evidence, the aim of which is to reduce the incidence and mortality rates for cervical cancer Opportunistic screening – Taking Pap smears when a woman visits her GP for another reason

Glandular Lesion – Lesion involving the columnar cells of the cervix, which produce mucus and have both a different appearance and a different function from the squamous cells

Pap Tests (or Smear) – Simple procedure in which a number of cells are collected from the cervix, smeared onto a microscope slide and sent to a laboratory for cytological examination to look for changes that might lead to cervical cancer. Up to 90% accurate and the best way to prevent squamous cervical cancer. Named after the test’s inventor, Dr Papanicolaou

Histology – The microscope study of the minute and detailed structure and composition of tissues

Pathology – Laboratory-based study of disease, as opposed to clinical examination of systems

Human Papillomavirus – Group of viruses that can cause infection in the skin surface of different areas of the body, including the genital area. The virus can cause visible genital warts. Some types can cause the abnormal cell changes which are detected on a Pap test and which can sometimes cause cancer.

Screening – Testing of all people at risk of developing a certain disease, even if they have no symptoms. Screening tests can predict the likelihood of someone having or developing a particular disease

Endocervix – Internal canal of the uterine cervix and its epithelium, not usually visible on inspection of the cervix

Hysterectomy – Refers to the surgical procedure whereby all or part of the uterus is removed Hysterectomy Fraction – The proportion of women who have had their uterus removed by hysterectomy

Squamous cells – Thin and fl at cells, shaped like soft fi sh scales. They line the outer surface of the cervix (ectocervix). They meet with columnar cells in the squamo-columnar junction. Abnormalities associated with squamous cells are the most likely abnormalities to be picked up by Pap tests Squamous cell carcinoma – A carcinoma arising from the squamous cells of the cervix

43 Unless otherwise indicated, all defi nitions have been sourced from the following publications: Australian Institute of Health and Welfare 2013. Cervical screening in Australia 2010-2011. Cancer series 76. Cat. no. CAN 72. Canberra: AIHW NHMRC Screening to prevent cervical cancer: guidelines for the management of asymptomatic women with screen-detected abnormalities, 2005. http://www.nhmrc.gov.au/publications/synopses/wh39syn.htm Victorian Cervical Cytology Registry Statistical Report 2012

RECOMMENDATION

CYTOLOGY

SPECIMEN

APPENDIX 1. CYTOLOGY CODING SCHEDULE

Type

AØ Not stated

A1 Conventional smear

A2 Liquid based specimen

A3 Conventional and liquid based specimen

Site

BØ Not stated

B1 Cervical

B2 Vaginal

B3 Other gynaecological site

Squamous Cell

Endocervical

Other/Non-cervical

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

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

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

E-

Not applicable: vault smear/ previous hysterectomy

No other abnormal cells

Possible low-grade squamous intraepithelial lesion (LSIL)

EØ

No endocervical component

Atypical endometrial cells of uncertain significance

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

Endocervical component present. No abnormality or only reactive changes

Atypical glandular cells of uncertain significance - site unknown

Possible high-grade squamous intraepithelial lesion (HSIL)

Atypical endocervical cells of uncertain significance

Possible endometrial adenocarcinoma

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

Possible high-grade endocervical glandular lesion

Possible high-grade lesion non-cervical

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

Adenocarcinoma in situ

Malignant cells - uterine body

Squamous carcinoma

Adenocarcinoma in situ with possible microinvasion/ invasion

Malignant cells - vagina

Adenocarcinoma

Malignant cells - ovary

Malignant cells – other

RØ

No recommendation

Repeat smear 6 months

Referral to specialist

Repeat smear 3 years

Repeat smear 6 - 12 weeks

Other management recommended

Repeat smear 2 years

Colposcopy/ biopsy recommended

Symptomatic-clinical management required

Repeat smear 12 months

Already under gynaecological management

– –

All other women

Previous smear abnormal or past history of biopsy proven CIN 2 or CIN 3 without HPV ‘test of cure’

All other women

Yes

–

Previous smear also abnormal or fluctuating low-grade abnormality

Woman aged 30+ years and no negative cytology in preceding 36 mths

–

Yes

subsequent Biopsy or colposcopy other circumstances Yes –

time 12 mths 21 mths 4 mths 5.5 mths 6 mths 12 mths 21 mths 15 mths 24 mths 4 mths 6 mths 12 mths 21 mths 7 mths 8.5 mths 15 mths 24 mths 13.5 mths 15 mths 24 mths 15 mths 24 mths 27 mths 36 mths 12 mths 21 mths 6 mths 9 mths 18 mths

action by registry 1st Reminder to woman 2nd Reminder to woman Questionnaire to practitioner Telephone call to practitioner Letter to woman 1st Reminder to woman 2nd Reminder to woman 1st Reminder to woman 2nd Reminder to woman Questionnaire to practitioner Letter to woman 1st Reminder to woman 2nd Reminder to woman Questionnaire to practitioner Letter to woman 1st Reminder to woman 2nd Reminder to woman Reminder to practitioner 1st Reminder to woman 2nd Reminder to woman 1st Reminder to woman 2nd Reminder to woman 1st Reminder to woman 2nd Reminder to woman 1st Reminder to woman 2nd Reminder to woman Reminder to practitioner 1st Reminder to woman 2nd Reminder to woman

Victorian cerVical cytology registry po Box 161, carlton south, victoria 3053 phone (03) 9250 0399 fax: (03) 9349 1818 email: registry@vccr.org website: www.vccr.org

victorian cervical cytology registry acknowledges the support of the victorian government

this protocol is adjusted in some unusual clinical circumstances (e.g. post-hysterectomy, after a diagnosis of cervical or endometrial malignancy, women aged 70+ years).

Unsatisfactory

Negative

Low-grade squamous abnormality

cytology report High-grade squamous abnormality or any glandular abnormality

victorian cervical cytology registry summary of follow-up and reminder protocol

APPENDIX 2. REMINDER AND FOLLOW-UP PROTOCOL USED DURING 2012

Victorian Cervical Cytology Registry Statistical Report 2012

May 2013 VCCR-Pub-19 V10

APPENDIX 3. MAP OF MEDICARE LOCALS

ML215 ML211

ML216

ML204 ML205

ML203 ML213

ML201 ML206

ML207

ML202 ML208

ML210

ML217 ML209

INSET: Melbourne and surrounds

ML214

Medicare Locals Victoria

ML216 ML215

ML211

See Inset

ML212

ML210

ML217

APPENDIX 3. MAP OF LOCAL GOVERNMENT AREAS MELBOURNE

Victorian Cervical Cytology Registry Statistical Report 2012

APPENDIX 3. MAP OF LOCAL GOVERNMENT AREAS – VICTORIA