VCCR Statistical Report 2014 by Victorian Cytology Service

StatiStical RepoRt 2014

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

Edi ToRial Commi T TEE

P rofessor Dorota Gertig, VCCR Medical Director

Associate Professor Marion Saville, VCS Executive Director

Associate Professor Julia Brotherton, VCCR Epidemiologist, NHVPR Medical Director

Genevieve Chappell, VCCR Manager

Bianca Barbaro, Geographical Consultant

Lesley Rowlands, Follow-up Manager

P R oduCEd by

Cathryn May, Data Manager

Louise Ang, Health Information Manager

Victorian c er vical c y tology Registry

03 9250 0399 registry@vccr.org www.vccr.org

ISSN 2202-4417

2.3.3

Tabl E 2.3.2 Estimated two year cervical screening rates by Health region, 2012-2013 and 2013-2014. 17

Tabl

F iGuRE 2.3.3 Estimated two year cervical screening rates by Local Government Area, 2013-2014. 2

2.4 c ervical Screening

2.5

e X ecUti V e SUMM a RY

tHe ceRVical ScReeNiNG pRoGRaM iS eNteRiNG aN eXcitiNG tiMe oF SiGNiFicaNt policY cHaNGe. iN 2014, tHe aUStRaliaN

GoVeRNMeNt aNNoUNceD tHat tHe pReSeNt ceRVical ScReeNiNG pRoGRaM Will cHaNGe to a pRiMaRY HpV DNa teSt at a FiVe YeaR

ScReeNiNG iNteRVal FoR WoMeN BetWeeN tHe aGeS oF 25 aND 74 YeaRS.

This strategy is known as Renewal and will commence on the 1 may 2017. The Renewal will ensure that a ustralian women have access to the best and safest screening program based on current evidence. until the changeover, the screening policy recommendation remains as two yearly Pap tests for women aged 18 to 69 years of age.

The Victorian Cervical Cytology Registry (VCCR) will continue to support the current program and is commencing preparations to support the Renewed program. VCCR is working closely with VCS Pathology to support the Compass trial, which is a randomised controlled trial that is comparing two and a half yearly cytology based cervical screening with five yearly primary HPV dN a testing. The Pilot trial commenced in oc tober 2013 and the main trial commenced in January 2015. The trial is a sentinel experience of the Renewed program and offers eligible Victorian women and their healthcare practitioners an opportunity to be part of the new screening program at an early stage. The trial is being led by researchers from the Victorian Cytology Service (VCS) and the Cancer Council New South Wales. The VCCR is providing follow-up and reminders to women in the Compass trial and this will ensure the Registry is prepared for the forthcoming changes.

o ne of the key activities of the VCCR is to improve participation of Victorian women in the cervical screening program by sending reminder letters and conducting research into under-screening. in 2 014, with ongoing assistance from the Victorian Government, the sending of second reminder letters to Victorian women regarding Pap tests continued to be an important initiative for the Cervical Screening Program.

during the screening period of 2011-2012, the estimated two year participation rate for women aged 20 to 69 years was 60.0%, which then increased to 60.4% for the period of 2012-2013. However, for the period of 2013-2014 two year participation declined to 59.2%, because of an increase in the eligible population for screening due to migration into Victoria and a small decline in Pap test numbers.

There has been an ongoing decline in two year participation among younger women (20 to 29 years of age) falling from 52.7% in 2006-2007 to 46.0% in 2013-2014. Whilst this is a continuation from an existing underlying trend, it may now reflect younger vaccinated women becoming complacent about the need for screening, as suggested by a recent publication of an analysis linking VCCR data with the National HPV Vaccination Program Register (NHVPR).1 Continued education of vaccinated women about screening is necessary to maximise protection from cervical cancer.

Substantial variation exists in screening rates between different areas of Victoria, as represented by me dicare l o cals,

with the two year screening rates for 2013-2014 ranging from 53.1% to 66.4%. The screening rate for Health regions ranged from 55.8% to 62.9%, while the estimated two year participation rate for l o cal Government a r eas ranged from 42.7% to 76.2%.

a s p art of the follow-up and reminder program, the VCCR registered a total of 595,142 Cervical Screening Tests (CSTs) 2 in 2014, representing 567,672 women, and sent 428,013 follow-up and reminder letters to women and practitioners. in 2 014 there were 3,706 HPV dN a tests (without l iquid b a sed Cytology) completed as part of the Compass trial, representing 3,577 women and inclusion of these data in the report is described further in Sections 1.6 and 2.1.

more than 6,600 abnormal Pap tests were followed-up by the VCCR in 2014 with a questionnaire to the practitioner. o f the 275,554 first reminders sent to women after a negative Pap test, 39% of women had a subsequent Pap test within three months. Just over 115,000 second reminder letters were sent to women and, of those sent after a negative Pap test (109,560), 23% had a subsequent Pap test within three months of the reminder.

o f P ap 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. o f the 3,621 high-grade cytology tests which had histology reported within six months, 2,893 were subsequently confirmed with high-grade histology on biopsy. This represents a positive predictive value of 79.9% and reflects the high quality of laboratory reporting in Victoria.

o ver the last decade there has been a gradual increase in the proportion of CSTs collected by nurses. in 2 014 CSTs collected by nurses represented 6.1% of all tests collected in Victoria, highlighting the significant 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 a b original or Torres Strait islander person, their Country of birth and the l anguage Spoken at Home is critical for understanding who participates in cervical screening. The overall percentage of women screened in 2014 who had their a b original or Torres Strait islander status recorded by the VCCR was 23.9%, for Country of birth 19.8% and l anguage Spoken at Home 20.6%.

a ccording to recent data (2014) from the Victorian Cancer Registry, mortality from cervical cancer in Victoria remains at very low levels, at 1.1 per 100,000 women. This is a tremendous achievement and reflects the success of the National Cervical Screening Program in Victoria, which is underpinned by the VCCR. d e spite this success, further efforts are necessary to improve participation amongst under-screened women as 74% of Victorian women who were diagnosed with invasive squamous cervical cancer in 2013 had never had a Pap test, or were lapsed screeners, prior to their cancer diagnosis.

1 bu dd a C br otherton J ml , G ertig dm , C hau T, d r ennan K, Saville m Cervical screening rates for women vaccinated against human papillomavirus m e d J a u st.2014;201:279-282.

2 C ervical Screening Tests (CSTs) refers to Pap tests collected as part of the National Cervical Screening Program, as well as both Pap tests and HPV d N a tests (without l i quid b a sed Cytology) collected as part of the Compass trial.

1. iNTRoduCTioN

1.1 BacKGRoUND

The Victorian Cervical Cytology Registry (VCCR) is one of eight such registries operating throughout Australia. 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 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 Human Services (DHHS) 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 FUNc tioNS oF tHe VccR

The VCCR facilitates regular participation of women in the National Cervical Screening Program by sending reminder letters to women for Cervical Screening Tests (CSTs) and by acting as a safety net for the follow-up of women with abnormal CSTs.

From October 2015, the new Victorian Improving Cancer Outcomes Act came into effect. However, prior to this (and relevant to the period of this report) the Cancer Act 1958 indicated the primary functions of the VCCR, which are to:

a) follow-up positive results from cancer tests

b) s end reminder notices to women who are due for cancer tests

c) w here appropriate, provide access to the Register to persons studying cancer

d) compile and publish statistics.

Secondary functions of the Registries around Australia 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 Cervical Screening Test (CST)

• the provision of quantitative data to laboratories to assist with their quality assurance programs

• the provision of aggregate data to the Australian Institute of Health and Welfare (AIHW) so that the National Cervical Screening Program can be judged against an agreed set of performance indicators.

1.3 N atioN a l policY: tHe NHMRc GUiDeliNe S FoR tHe M a N aGeMeNt oF a S YMp toM atic WoMeN W itH ScReeN De tecteD a BNoRM a litie S

On 1 July 2006, the National Health and Medical Research Council (NHMRC) Guidelines for the Management of Asymptomatic Women with Screen Detected Abnormalities 3 were implemented around Australia. The main changes to the previous guidelines were:

• the change of terminology for cytology reports to the Australian Modified Bethesda System 2004

• to r epeat Pap tests for most women with low-grade squamous abnormalities

• to not treat biopsy proven low-grade or HPV lesions

• to r efer all women with atypical glandular cells for colposcopy

• to r efer all women with a possible high-grade lesion for colposcopy

• 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. 4

3 N ational Health and Medical Research Council (NHMRC) 2005. Screening to prevent cervical cancer: guidelines for the management of asymptomatic women with screen-detected abnormalities, Canberra: NHMRC.

4 A ustralian Institute of Health and Welfare (AIHW) 2013. Report on monitoring activities of the National Cervical Screening Program Safety Monitoring Committee. Cancer series 80. Cat. no. CAN 77. Canberra: AIHW.

1.4

While the National Cervical Screening Program has been successful since its introduction in 1991, the science relating to cancer continues to change. New technology to assist with the detection of cervical cancer has been developed, new evidence has emerged about the optimal screening age range and interval, and the HPV vaccine has become available.

During 2011, the Standing Committee on Screening of the Australian Health Ministers’ Advisory Council commenced the review of the policy and operation of the National Cervical Screening Program. Input and feedback was sought from expert committees including the Medical Services Advisory Committee (MSAC) and reference groups for the best evidence on screening tests and pathways, the screening interval, age range and commencement into the program for both HPV vaccinated and non-vaccinated women.5 A cost-effective screening pathway and program model was then proposed and endorsed to ensure women have access to a cervical screening program that is safe, effective and efficient, and based on current evidence. The planned commencement date of the renewed program is 1 May 2017.

In summary the recommendations for Renewal include:

• a new Cervical Screening Test – a HPV DNA test – to become the primary screening test, followed by a triage Pap test if necessary

• HPV testing to be done every five years for HPV vaccinated and unvaccinated women aged 25 to 74 years

• w omen with symptoms can have a cervical test at any age

• invitations for screening, recall, and follow-up to be done for women

• the option of a self-collect HPV sample for under-screened and never screened women. 6

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.7 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. From 2013, vaccination of boys at 12 to 13 years has also been offered, with a two year catch-up program for 14 to 15 year old boys finishing in 2014.

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.

A National HPV Vaccination Program Register (the HPV Register) 8 was established to support, monitor and evaluate the National HPV Vaccination Program. The Victorian Cytology Service (VCS) Ltd., which has operated the VCCR for over 25 years, was engaged by the Department of Health and Ageing in February of 2008 to establish and manage the National HPV 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 HPV vaccine 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 cervical screening and cancer registries will be a critical component of monitoring and evaluating the impact of vaccination. Through de-identified data linkage undertaken between the HPV Register and the VCCR through to the end of 2011, we demonstrated a 48% reduction in the rates of the most serious cervical pre-cancers for women who had been completely vaccinated in the school-program, compared with unvaccinated women.9 These data indicate that the downward trend observed among young women within VCCR and national screening data can be ascribed to HPV vaccination.

5 A ustralian Government, Department of Health, National Cervical Screening Program Renewal website. http://cancerscreening.gov.au/ internet/screening/publishing.nsf/Content/cervical-screening-1, viewed 5 October 2015.

6 Ibid.

7 Tabrizi SN,

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.

8 T he National HPV Vaccination Program Register website. http://www.hpvregister.org.au , viewed 5 October 2015.

9 G ertig 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.

ReNe Wa l oF tHe N atioN a l ceRV ical ScReeNiNG pRoGR a M

1.5 tHe N atioN a l Hp V VacciN atioN pRoGR a M

Brotherton JML, Kaldor JM, Skinner SR, Cummins E, Liu

1.6 Data iNclUDeD iN tHiS RepoR t

This statistical report provides timely information about cervical screening in Victoria during 2014. In most cases the methodology and terminology used in VCCR reports are consistent with that published by the Australian Institute of Health and Welfare (AIHW) as part of reporting indicators for the National Cervical Screening Program.10

c ervical Screening te sts

While the VCCR records Pap test data for Victorian women, it also logs the data from the Compass trial. The Compass trial is a clinical trial comparing two and a half-yearly Pap test screening with five yearly HPV DNA screening.11 The Compass Pilot study commenced recruitment in October of 2013 and the Main trial commenced recruitment in January of 2015.

In line with Cervical Screening Renewal, HPV DNA tests are now considered Cervical Screening Tests (CSTs) along with Pap test cytology. Where relevant, both the Pap tests and HPV DNA tests completed as part of the Compass trial have been incorporated into the statistics in this report and noted where applicable. Generally, Compass HPV DNA tests (without Liquid Based Cytology) are included in the participation statistics in Section 2 of this report but not in the other sections which relate to cytology or histology.

p ar ticipation rates

This report includes information on participation rates of CSTs (i.e. conventional Pap tests and Pap tests/HPV DNA tests (without Liquid Based Cytology) as part of the Compass trial) for women aged 20 to 69 years in 10 year age groups and additionally by five year age groups for the 20 to 29 year old group. Population data have been adjusted to exclude women who have had a hysterectomy, using modeling carried out by the AIHW based on the National Hospital Morbidity Database (NHMD). The two year participation rates are also presented by Medicare Local (ML), Health region and Local Government Area (LGA).

The number and proportion of CSTs collected by nurses are presented in this report, by year and Health region. Further information regarding CSTs collected by nurses is available in the report Evaluation of Cervical Screening Tests collected by Nurses in Victoria during 2014, available on the VCCR website at http://www.vccr.org/data-research/statistical-reports/annualnurse-reports

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 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.

c y tology coding

Information provided on the cytology report of Pap tests is pre-coded by the pathology laboratory according 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.12 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, squamous cell result, endocervical cell result, other non-cervical cell result, and the recommendation made by the laboratory in regard to further testing.

Data are presented in this report on the proportion of Pap tests classified according to results, including unsatisfactory, negative, squamous abnormality and endocervical abnormality. The percentage of Pap tests collected during 2014 without an endocervical component is also presented.

Histology reports

The 2014 histology results in this report are as notified to the VCCR by 6 July 2015. The vast majority of histology reports were notified by this time. The VCCR also receives a proportion of colposcopy only results, 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). This report also provides information on the correlation of cytology reports received by the VCCR during 2013 and subsequent histology reports received up to six months later.

In 2013, the VCCR implemented a program for colposcopists to submit additional information relating to colposcopies performed in Victoria. This will assist with the follow-up of abnormalities and the monitoring of colposcopy quality. Summary reports are being provided to colposcopists to assist them in monitoring and improving their practice.

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 13 The Reminder and Followup protocol used by the VCCR in 2014 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.

c ervical 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 2013.

10 A ustralian Institute of Health and Welfare (AIHW) 2015. Cervical screening in Australia 2012-2013. Cancer series no.93. Cat. no. CAN 91. Canberra: AIHW. 11 C ompass trial website. http://www.compasstrial.org.au , viewed 5 October 2015.

12 N ational Health and Medical Research Council (NHMRC) 2005. Screening to prevent cervical cancer: guidelines for the management of asymptomatic women with screen-detected abnormalities, Canberra: NHMRC. 13 Ibid.

2. Pa R TiCiPaTioN iN SCREENiNG

2.1 NUMBeR oF ceRV ical ScReeNiNG te S t S

a ND WoMeN ScReeNeD

Table 2.1 shows data on the number of Cervical Screening Tests (CSTs) registered and the number of women screened for each year of the Victorian Cervical Cytology Registry’s (VCCR) operation. During 2014, a total of 595,142 tests were registered from 567,672 women. From the previous year, this is a decrease of 5,789 tests and 4,029 women screened.

As described in Section 1.6, CSTs include HPV DNA tests (without Liquid Based Cytology) and Pap tests as part of the Compass trial, as well as Pap tests as part of the National Cervical Screening Program. Table 2.1 includes 147 Compass HPV DNA tests (without Liquid Based Cytology) from 138 women for 2013, and 3,706 Compass HPV DNA tests (without Liquid Based Cytology) from 3,577 women for 2014.

In interpreting the information in Table 2.1, it is important to consider that while it is recommended that women screen every two years, a small proportion of women in Victoria are screened on an annual basis. Additionally, correct attribution of CSTs to the same woman over time is not always possible, sometimes resulting in a possible over-estimation of women recorded on the VCCR. However, over the last 10 years, 95% of women with a Pap test record on the VCCR have had a Medicare number recorded. This has resulted in more complete recordlinkage of different episodes of care for women.

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 10 year (2005-2014) opt-off rate of 0.35%. Where a woman objects to her Pap test being registered, the VCCR holds no information about that test.

taBle 2.1 Number of Cervical Screening Tests (CSTs) registered and number of women screened in Victoria, 1990-2014.

Notes

• T he number of CSTs registered and women screened on the Registry as of 17 Nov 2015. CSTs include Pap tests and both Pap tests and HPV DNA tests (without Liquid Based Cytology) completed as part of the Compass trial (refer to section 1.6).

2.2 pa R ticipatioN 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.

T he 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 CST in the time period of interest and have not had a hysterectomy according to information held by the VCCR. It includes women who have participated in the Compass trial.

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 female Estimated Resident Population (ERP)14 calculated by the Australian Bureau of Statistics (ABS) is averaged over two years and then adjusted to exclude the proportion of women estimated to have had a hysterectomy using the known percentage of women who have not had a hysterectomy. Whilst VCCR participation statistics produced prior to 2011 used hysterectomy fraction estimates from the National Health Survey,15 these data are no longer collected by the ABS. In VCCR Statistical reports from 2011 onwards, population data for the latest screening periods have been adjusted with hysterectomy estimates from analysis conducted by the Australian Institute of Health and Welfare (AIHW) using data from the National Hospital Morbidity Database (NHMD).16

This is consistent with the national approach.

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.

l imitations of participation statistics

As previously discussed, one limitation to these participation statistics is the imperfect record-linkage between multiple CSTs from the same woman that could result in an overestimate of the number of women screened. This needs to be considered carefully when looking at participation over a longer time period (such as for three or five years) as this overestimate of women screened will be relatively amplified thereby producing an overestimate in participation.

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.

p articipation in cervical screening by age group

Table 2.2 shows the estimated cervical screening rates for Victorian women by age group for one, two, three and five year periods, with data adjusted to exclude women who have had a hysterectomy.

taBle 2.2 Estimated cervical screening rates by age group over one year, two year, three year and five year periods.

14 A ustralian Bureau of Statistics (ABS). 3101.0 – Australian Demographic Statistics, Dec 2014 (release date 25/6/2015).

15 A ustralian Bureau of Statistics (ABS). 4364.0 – National Health Survey: Summary of Results, 2004-2005 (release date 27/2/2006).

16 A ustralian Institute of Health and Welfare (AIHW) 2015. Cervical screening in Australia 2012-2013. Cancer series no.93. Cat. no. CAN 91. Canberra: AIHW.

Notes

• T he eligible female population is adjusted to exclude the estimated proportion of women who have had a hysterectomy using hysterectomy fractions derived from the NHMD.

• T he 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.

• Women screened by the Compass trial are included.

• P eriods covered apply to calendar years.

There was a decrease in the one year screening rate for women aged 20 to 69 years during 2014, from 32.3%in 201317 to 31.6% for 2014. Whilst there was only a small decrease in the number of women who were screened, the decrease in participation was also influenced by the increase in the eligible screening population across all age groups in 2014.

The two year screening rate (for the calendar years of 2013-2014) for women aged 20 to 69 years is estimated at 59.2%, which is a slight decrease from 60.4% for the previous reporting period (2012-2013).18 The small decline in the number of women screened during this two year period along with an increase in the eligible population has led to this decline in participation. The 20 to 29 year old cohort reported the lowest two year participation rate at 46.0% (a decrease from 47.1% reported for the previous period) while the 50 to 59 year old cohort had the highest participation at 67.3% (for 2013-2014).

Over the three year period from 2012-2014, the participation rate of Victorian women aged 20 to 69 years is estimated at 72.6%, almost on par with the previous period of 2011-2013 (72.7%). Table 2.2 also highlights the five year estimated participation rate of 83.9% for 2010-2014, which is a slight decrease from the previous period (84.0%).19 Three and five year participation rates for women aged between 20 and 39 years decreased slightly from the previous period, whereas participation for women aged over 50 years increased.

17 V ictorian Cervical Cytology Registry (VCCR), Statistical Report 2013 Available from: http://www.vccr.org/data-research/statistical-reports 18 Ibid. 19 Ibid.

e s timated two year participation over time

As seen in Table 2.2.1 and Figure 2.2.1, there was a small decline in participation over time for each age group between 2000-2001 and 2010-2011. An increase in the number of women being screened occurred in most age groups in the 2011-2012 and 2012-2013 periods. It is likely that the introduction of a second reminder letter 20 in 2013 was responsible for the improved participation in women aged 40 and over during that period. In contrast, the 2013-2014 period has seen a decline in participation across all age groups, particularly in the younger cohorts of women aged less than 50 years (refer to Figure 2.2.1).

taBle 2.2.1 Estimated two year cervical screening rates by age group, 2000-2001 to 2013-2014.

20 to 24 years25 to 29 years20 to 29 years30 to 39 years40 to 49 years50 to 59 years60 to 69 years20 to 69 years

Notes

• * 2 000-2001 to 2004-2005 population data has been adjusted using the 2001 National Health Survey hysterectomy fractions estimates.

† 2005-2006 to 2009-2010 population data has been adjusted using the 2004-05 National Health Survey hysterectomy fractions estimates. ‡ 2010-2011 to 2013-2014 population data has been adjusted using the NHMD hysterectomy fractions estimates (courtesy of the AIHW).

• Women screened by the Compass trial are included.

• P eriods covered apply to calendar years.

FiGURe 2.2.1 Estimated two year cervical screening rates by age group, 2000-2001 to 2013-2014.

Notes

• T he 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 to exclude the estimated proportion of women who have had a hysterectomy using hysterectomy fractions as indicated by the symbols *, † and ‡; which are outlined in the notes under Table 2.2.1.

• Women screened by the Compass trial are included.

• P eriods covered apply to calendar years.

T he second reminder letter provides

for a woman to attend for a Pap test if the first reminder following a negative result does not result in a Pap test being received by the Register within 36 months.

Figure 2.2.2 illustrates the consistent decline in participation over time in the 20 to 24 and 25 to 29 year age groups. This selective decline in participation among younger women may be related to the HPV vaccination campaign which commenced in 2007. This is a cause for concern as younger vaccinated women may be becoming complacent about the need for screening, as suggested by a recent publication of an analysis linking VCCR data with the National HPV Vaccination Program Register (NHVPR). 21 Continued education of vaccinated women about screening is necessary to maximise protection from cervical cancer. FiGURe 2.2.2 Estimated two year cervical screening rates for women aged 20 to 24 years and 25 to 29 years, 2003-2004 to 2013-2014.

National HPV Vaccination Program

Screening period

Budd AC, Brotherton JML, Gertig DM, Chau T, Drennan K, Saville M. Cervical screening rates for women vaccinated against human papillomavirus Med J Aust.2014;201:279-282.

2.3 Pa R TiCiPaTioN by a RE a

Method of calculating participation

The participation rate for age eligible women (i.e. aged 20 to 69 years) in cervical screening for Medicare Locals (MLs), Health 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 Cervical Screening Test (CST) in the time period and who have not had a hysterectomy according to the information held by the Victorian Cervical Cytology Registry (VCCR).

The denominator is the estimated number of women in each Postal Area22 adjusted to exclude the proportion of women estimated to have had a hysterectomy using the hysterectomy fractions from the National Hospital Morbidity Database (NHMD). 23

To calculate the estimated participation rates for areas, data by Australia Post postcodes and Postal Areas were mapped to LGAs and ML using conversion files sourced from the Australian Bureau of Statistics (ABS) and the Commonwealth Department of Health respectively.

The mapping of the 2013-2014 participation data for LGAs is based on concordances 24 consistent with the ABS Australian Statistical Geography Standard (ASGS). 25 Participation data by Health regions are calculated as an aggregate of LGAs, while MLs were created based on the Commonwealth Department of Health Postcode to ML concordance file. 26

l imitations of participation statistics by area Small-area data (e.g. Health regions, LGAs and MLs) 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 are likely from:

• an overestimate of women screened due to conservative file matching by the VCCR

• applying the national hysterectomy fractions to the relatively small female population resident in the Postal Areas

• the proportion of Victorian Pap tests reported by laboratories outside of Victoria which are not reported to the VCCR (this mainly affects areas located on the Victoria/ New South Wales and Victoria/South Australia borders)

• 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.

22 A ustralian Bureau of Statistics (ABS) 2015, customised report. Victorian Female Estimated Resident Population by Postal Area at 30 June 2013 and 30 June 2014.

23 A ustralian Institute of Health and Welfare (AIHW) 2015. Cervical screening in Australia 2012-2013. Cancer series no.93. Cat. no. CAN 91. Canberra: AIHW.

24 2 014 Postcode to LGA converter algorithm (based on 2011 Mesh Block boundaries) supplied by the ABS and based on the Australian Statistical Geography Standard (ASGS) correspondence.

25 A ustralian Bureau of Statistics (ABS) 2011. Australian Statistical Geography Standard (ASGS): Volume 1 – Main Structure and Greater Capital City Statistical Areas, July 2011. Cat. No: 1270.0.55.001.

26 A ustralian Government Medicare Local Statistics, Boundary and Concordance files website. http://www.medicarelocals.gov.au/ internet/medicarelocals/publishing.nsf/Content/digital-boundaries , viewed 25 September 2015.

2.3.1 pa R ticipatioN BY MeDica Re local

In 2011, the Australian Government established the Medicare Local 27 area network to replace the previous Divisions of General Practice. Table 2.3.1 shows the participation rates for the 17 MLs in Victoria, which are partially or entirely located within Victoria, using methods discussed at the beginning of Section 2.3.

taBle 2.3.1 Estimated two year cervical screening rates by medicare local, 2012-2013 and 2013-2014.

1. 2 012-2013 and 2013-2014 data: postcodes mapped to ML based on the Commonwealth Department of Health Postal Area to ML concordance file. Population data adjusted using estimated hysterectomy fractions from the AIHW NHMD.

Notes

• Women screened by the Compass trial are included.

• P eriods covered apply to calendar years.

FiGURe 2.3.1 Estimated two year cervical screening rates by medicare local, 2013-2014.

% PARTICIPATION

% paRticipatioN less than 50%

% PART ICIPAT ION Less th an 50% Greater th an 70% 50% - 55%

% PART ICIPAT ION

50% - 55%

Less than 50% Greater than 70%

55% - 60%

55% - 60% 60% - 65% 65% - 70% Greater than 70%

- 55%

- 60%

60% - 65%

50% - 55% 55% - 60% 60% - 65% 65% - 70%

- 65%

65% - 70%

- 70%

Less th an 50% Greater th an 70%

Medicare Local boundaries have been truncated where they overlap the Victorian border. This includes the Lower Murray (ML 213), Loddon-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.

INSET:

2.3.2 pa R ticipatioN BY HealtH ReGioN

Victoria is divided into eight Health regions, with five 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 Health region, 2012-2013 and 2013-2014.

1. 2 012-2013 and 2013-2014 data: participation data by Health region is calculated as an aggregate of LGAs. Postcode/Postal Areas mapped to LGA using a 2014 converter algorithm supplied by the ABS and based on the ASGS correspondence data. Population data adjusted using estimated hysterectomy fractions from the AIHW NHMD.

Notes

• Women screened by the Compass trial are included.

• P eriods covered apply to calendar years.

% PARTICIPATION

FiGURe 2.3.2 Estimated two year cervical screening rates by Health region, 2013-2014.

Gippsland

Barwon-South Wester n Southern Metro

Loddon Mallee Hume

Grampian s Easter n Metro

2.3.3 pa R ticipatioN BY local GoV eRNMeNt aRe a

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, 2012-2013 and 2013-2014.

1. Refer to Appendix 3 for maps showing LGA codes.

2. 2 012-2013 and 2013-2014 data: Participation data by Health region is calculated as an aggregate of LGAs. Postcode/Postal Areas mapped to LGA using a 2014 converter algorithm supplied by the ABS and based on the ASGS correspondence data. Population data adjusted using estimated hysterectomy fractions from the AIHW NHMD. 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.

Notes

• Women screened by the Compass trial are included.

• P eriods covered apply to calendar years.

FiGURe 2.3.3 Estimated two year cervical screening rates by local Government area, 2013-2014.

% PARTICIPATION

% paRticipatioN

% PART ICIPAT ION

Less than 50%

less than 50%

Less th an 50%

% PART ICIPAT ION

50% - 55%

55% - 60%

Less th an 50%

55% - 60%

60% - 65%

55% - 60%

50% - 55%

65% - 70%

60% - 65%

55% - 60%

60% - 65%

Greater than 70%

65% - 70%

unincorporated Victoria

60% - 65%

65% - 70%

Greater than 70%

65% - 70%

Greater th an 70%

See Inset

INSET: Melbourne and surrounds

Unincorporated Victoria refers to the areas within Victoria which are not administered by incorporated local government bodies. Refer to Appendix 3 for maps showing Victorian LGA codes.

ML211

ML217

ML214

ML213

2.4

ceRV ical ScReeNiNG

te S t S collecteD BY

NURSe S

The credentialling of nurses every three years to perform Cervical Screening Tests (CSTs) 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.

The Registry has included data on CSTs where nurses are credentialled and funded by the Victorian Department of Health and Human Services (DHHS) to be eligible for their own ‘practice number’ at VCS Pathology. Also included in the data are CSTs from nurses using private pathology services. These nurses provide cervical screening data to PapScreen Victoria, which is then provided to the Victorian Cervical Cytology Registry (VCCR) for analysis.

During 2014, a total of 36,410 CSTs were collected and reported to the Registry by 443 credentialled nurses. This number represents 6.1% of all CSTs collected in Victoria during 2014. This figure reflects the significant growth in the role of nurses in cervical screening, with the proportion of CSTs 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 CSTs collected by nurses over the last 10 years.

taBle 2.4 Proportion of Cervical Screening Tests collected by nurses, 2005-2014.

2.4.1 pRopoR tioN oF ceRV ical

ScReeNiNG te S t S collecteD BY

NURSe S BY HealtH ReGioN

Data on CSTs collected by nurses were analysed by Health region. 31 The following table and figure show that the rural Health regions had a higher proportion of tests collected by nurses, for women with a cervix, than those within metropolitan Melbourne. Between 2013 and 2014 the proportion of CSTs collected by nurses decreased across all Health regions except Gippsland. The largest change between 2013 and 2014 was seen in the Grampians region, which saw a three percent reduction in the number of tests.

taBle 2.4.1 Cervical Screening Tests collected by nurses, by Health region, 2014.

Nurse cervical screening 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 CSTs collected by nurses in recent years and the high quality of their tests. As observed in recent years, CSTs collected by nurses are more likely to have an endocervical component, which is considered to be a reflection of test quality. 28 General Practice and Community Health settings remain the main types of practices where nurses collect CSTs (85% of practice types in 2014). 29 During 2014, 40.7% of the CSTs collected by nurses were from women over 50 years of age compared with 32.7% collected by other provider types in Victoria during this period. 30

1. E xcludes 274 post-hysterectomy tests, two interstate postcodes and 69 tests where postcode was missing or not able to be matched.

2. E xcludes 40 nurses who do not collect postcode data when submitted to PapScreen Victoria and eight nurses with interstate postcodes.

Notes

• D epartment of Health, Modelling GIS and Planning Products Unit (2013). Concordance file created using Australia Post postcode file, ABS digital geographic boundaries (Cat. no. 1270.0.55.006) and Health regions. The 5,258 tests from nurses using private pathology services are not included in these statistics as postcode was not collected.

28 V CCR, Evaluation of Cervical Screening Tests collected by Nurses in Victoria during 2014, p. 8. Available from: http://www.vccr.org/data-research/ statistical-reports/annual-nurse-reports

Ib id p. 4.

Ib id p. 6.

Ib id p. 7.

FiGURe 2.4.1 Proportion of Cervical Screening Tests collected by nurses, by Health region, 2014.

Unincorporated Victoria

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

Gippsland

Barwon-South Western Southern Metro North & West Metro

Loddon Mallee Hume Grampians Eastern Metro

2.5 cloSiNG tHe Data Gap S: iDeNtiF Y iNG a BoRiGiN a l a ND toRRe S S tR a it iSl a NDeR people , a ND collectiNG coUNtRY oF BiR tH a ND la NGUaGe Sp oK eN at HoMe

Data from the Australian Institute of Health and Welfare (AIHW) has shown that Aboriginal and Torres Strait Islander women are four times more likely to die of cervical cancer than non-Aboriginal and Torres Strait Islander women. 32 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 people. 33

Women from Culturally and Linguistically Diverse (CALD) backgrounds have also been identified as an under-screened group. 34 Strategies for engaging with Aboriginal and Torres Strait Islander and CALD women, and increasing participation, are a priority for the Victorian Department of Health and Human Services (DHHS) 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 Victorian Cervical Cytology Registry (VCCR) will record if a woman has identified as an Aboriginal and/or Torres Strait Islander person, as well as her Country of Birth and Language Spoken at Home, as indicators of cultural diversity.

a b original and torres Strait islander women

In 2014, the overall percentage of women screened who had their Aboriginal and/or Torres Strait Islander status recorded by the VCCR was 23.9% (n= 135,436). Table 2.5.1 shows the number of women by their identification as an Aboriginal and/ or Torres Strait Islander person, the proportion for those on the VCCR whom data was collected, and a comparison to data from the 2011 Census.

taBle 2.5.1 Reporting of aboriginal and Torres Strait islander status of women screened during 2014.

VCCR is working closely with Program Partners including the DHHS, PapScreen Victoria and VCS Pathology to improve the identification of Aboriginal and Torres Strait Islander women and the ongoing collection and reporting of CALD data to the Registry. VCS Pathology continues to work with nurses who collect Cervical Screening Tests (CSTs), 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. Of all practitioner types, nurses have the highest rate of reporting these data, with 97.0% of CSTs collected by nurses during 2014 including this information. Table 2.5.2 shows the number and proportion of Pap tests by practitioner type, where Aboriginal and Torres Strait Islander information was recorded on the woman’s record.

taBle 2.5.2 Number and proportion of Pap tests collected during 2014 with aboriginal and Torres Strait islander status recorded by Practitioner type.

Notes

• Women screened by the

are included.

Notes

• E xcludes women who had a HPV DNA test (without Liquid Based Cytology) as part of the Compass Trial.

culturally and l inguistically Diverse (c al D) women

During 2014, the overall percentage of women screened who had a Country of Birth recorded by the VCCR was 19.8%.

The most common countries of birth outside of Australia were Vietnam, England, New Zealand, United Kingdom (includes Channel Islands and Isle of Man), 36 China, India, Philippines, Italy, Greece and Malaysia.

The overall percentage of women screened during 2014 who had Language Spoken at Home recorded was 20.6%.

37 The most common languages reported other than English were Vietnamese, Italian, Greek, Mandarin, Chinese (not elsewhere classified), Arabic, Spanish, Cantonese, Turkish and French.

32 A ustralian Institute of Health and Welfare (AIHW) 2015. Cervical screening in Australia 2012-2013. Cancer series no.93. Cat. no. CAN 91. Canberra: AIHW.

33 C ouncil of Australian Governments, Closing the Gap in Indigenous Disadvantage website. https://www.coag.gov.au/closing_the_gap_in_ indigenous_disadvantage, viewed 9 November 2015.

34 Mullins R 2006. Evaluation of the impact of PapScreen’s Campaign on Culturally and Linguistically Diverse (CALD) Women. Melbourne: Cancer Council Victoria. Available here: http://www.cancervic.org.au/ downloads/cbrc_research_papers/Cervical_cancer_research/06rep_ rm_eval_PapScreen_campaign_CALD_women.pdf

35 Women screened by the Compass trial are included.

36 United Kingdom (includes Channel Islands and Isle of Man) is assigned when the Country of Birth is not further specified.

37 Women screened by the Compass trial are included.

1. A ustralian Bureau of Statistics. 2075.0 – Census of Population and Housing – Counts of Aboriginal and Torres Strait Islander Australians, 2011. First issue released 21/06/2012. Table 3B, Census Counts, Indigenous Status –2001-2011, Victorian data.

Compass trial

2.6 FReQUeNcY oF ea RlY Re-ScReeNiNG

While the current 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 justified on the basis of a past history of abnormality.

In late 2000, the National Cervical Screening Program adopted the following definition of early re-screening:

Early re-screening is the repeating of a Pap test within 21 months of a negative Pap test report, except for women who are being followed up in accordance with the NHMRC guidelines for the management of cervical abnormalities.

This definition recognises that some re-screening may occur opportunistically between 21 and 24 months after a negative Pap test report and this may be cost-effective.

To determine how many women are truly screened early, women with a prior cytological or histological abnormality recorded by the Victorian Cervical Cytology Registry (VCCR) within 36 months of the index Pap test were excluded. This is in line with the national reporting of indicators by the Australian Institute of Health and Welfare (AIHW) for the same period and is also consistent with the National Health and Medical Research Council (NHMRC) Guidelines.

Table 2.6 shows the number of subsequent Cervical Screening Tests (CSTs) over a 21 month period for women who received a negative Pap test report in February of 2013. These data show that 88.5% of women aged 20 to 69 years who had a negative Pap test in February 2013 had no further tests within the next 21 months. Over the last decade there has been an increase in the proportion of women with no repeat CSTs, indicating a decreasing rate of early re-screening.

Of the women who had an index Pap test during February of 2013, 11.5% were subsequently re-screened early (with at least one CST) over the next 21 months. As seen in Figure 2.6, some variation in early re-screening occurs by age group.

taBle 2.6 Subsequent Cervical Screening Tests within a 21 month period for women with a negative Pap test in February of 2013.

Notes

• T his data includes the 17 women who had an index Pap test during February of 2013, and then a HPV DNA test as part of the Compass trial within the next 21 months. As the Compass Pilot trial did not commence until October of 2013 only Pap tests are considered for index tests.

FiGURe 2.6 Percentage of women by age group who had an index Pap test in February of 2013 and then re-screened early.

Notes

3. Cy ToloGy REP oRTS

Cytology reports received by the Victorian Cervical Cytology Registry (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 reported to the Australian Institute of Health and Welfare (AIHW) for the national indicators for the same period.

For this analysis, the results of 582,744 Pap tests from any provider type were considered. These include Pap tests which were collected during 2014, from women of any age, but exclude post-hysterectomy smears (also referred to as vault smears).

3.1 UNS atiSFac toRY pap te S t S

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 2014 by the VCCR, 15,463 were recorded as having an unsatisfactory result. This equates to 2.7% 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. 38

3.2 NeGati V e pap te S t S

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 2014 by the VCCR, 529,463 were recorded as having a negative result. This equates to 90.9% of Pap tests.

3.3 pap te S t S W itHoU t a N eNDoceRV ical coMp

oNeNt

The presence of endocervical cells within a Pap test specimen is considered to be an indicator that the transformation zone (TZ) of the cervix has been sampled. Most pre-cancerous abnormalities of the cervix arise in the TZ. Pap tests identified as not containing an endocervical component (ECC) are coded as having a result of E0 for the endocervical cell result.

Of the Pap test results received during 2014 by the VCCR, 158,010 were recorded as not having an ECC present in the specimen. This equates to 27.1% of Pap tests.

As illustrated in Figure 3.3, the proportion of Pap tests without an ECC has gradually increased from 21.4% in 2005 to 27.1% in 2014 (p < 0.0001).

FiGURe 3.3 Percentage of Pap tests without an endocervical component, 2005-2014.

The proportion of Pap tests containing an ECC has also been declining at a national level. VCCR therefore conducted a retrospective cohort study to evaluate the hypothesis that ECC negative (ECC-) Pap tests may be associated with reduced sensitivity. This study confirmed that women without ECC had a lower rate of confirmed HGA and no significant increase in the rate of invasive cervical cancer following ECCtests and the results do not support differential (accelerated) follow-up in women with a negative test without an ECC. 39

39 S ultana F, English DR, Simpson JA, Canfell K, Gertig DM,

High-grade cervical abnormalities and cervical cancer in women following a negative Pap smear with and without an endocervical component: A cohort study with 10 years of follow-up. Int J Cancer 2014 Sept 1;135(5):12139.

Saville M.

3.4 pap te S t S W itH a SQUa MoUS a BNoRM a lit Y

As seen in Table 3.4, the number of Pap tests collected during 2014 with a squamous cell abnormality (an abnormality of possible low-grade lesion or worse) was 37,492, which equates to 6.4% of all Pap tests for the year. The proportion of Pap tests with definite high-grade abnormality (i.e. high-grade lesion with or without possible micro-invasion or invasion, invasive squamous cell carcinoma) was reported as 0.8% in 2014.

taBle 3.4 Number and percent of Pap tests collected in 2014 with a squamous abnormality.

3.5 pap te S t S W itH a N eNDoceRV ical a BNoRM a lit Y

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 2014 where an endocervical abnormality was detected. Pap tests which are known to have been collected post-hysterectomy are excluded. For 2014, the total number of Pap tests with an endocervical abnormality (atypical endocervical cells of uncertain significance or worse) was 535, which equates to fewer than 0.1% of all Pap tests for the year.

taBle 3.5 Number and percent of Pap tests collected in 2014 with an endocervical abnormality.

Atypical endocervical cells of uncertain significance (E2)

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

Possible high-grade endocervical glandular lesion (E3)

in situ (E4)

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

Adenocarcinoma (E6)

3.6 t Y pe oF te S t S

As per the Cytology Coding Schedule (Appendix 1), the VCCR records the type of Pap test taken as:

• conventional cytology (A1)

• l iquid-based specimen (A2), or

• split sample, i.e. conventional and liquid based specimen (A3).

During 2014, the proportion of liquid-based tests (A2 and A3) was 5.0% of all tests reported to the Registry. Nearly all of these tests were ‘split samples’ (A3), where the conventional Pap smear is accompanied by the liquid-based specimen. Only 0.5% of all Pap tests were liquid-based specimens only (i.e. A2).

4. HiS ToloGy REP oRTS

This section describes the histology reports that were notified to the Victorian Cervical Cytology Registry (VCCR) during 2014. Although the reporting of histology results was not mandatory during 2014, the majority of all relevant cervical biopsies were reported to the VCCR for this period. From October 2015, the new Victorian Improving Cancer Outcomes Act requires mandatory reporting of all cervical screening tests and relevant histology to the Registry. All cancers must also be notified to the Victorian Cancer Registry by laboratories, hospitals and the VCCR.

In 2014, there were 21,627 histology reports relating to the cervix received by the VCCR. The following table shows the distribution of histology findings for 2014. Note that data presented in Table 4 includes all histology reports received by the VCCR, and are not restricted to the most severe report for a woman.

taBle 4 Histology findings reported to the VCCR in 2014.

1. T he number of histology reports notified to the VCCR as at 6 July 2015. 2. C arcinoma of the cervix – other: includes small cell carcinoma and other malignant lesions (may include tumours of non-epithelial origin).

5. HiGH-GR a dE abNoRm aliT y dE TECTioN R aTES

In 2014, the overall rate of histologically-confirmed high-grade abnormalities detected in Victoria for women aged 20 to 69 years was 6.88 per 1,000 women screened. 40

Figure 5.1 illustrates the detection rate of histologically-confirmed high-grade intraepithelial abnormalities per 1,000 screened women for each year from 2010 to 2014 by five year age group. The graph clearly illustrates that younger women have a much higher rate of high-grade abnormalities than older women. The higher rates of abnormality in younger women are a result of incident HPV infection following the onset of sexual activity. The youngest HPV vaccinated women (aged 12 years during the first year of the HPV vaccination program), who are less likely to have been infected with high-risk HPV types through sexual activity, are now commencing cervical screening. Notable in the data are the year-on-year declines in the rate for the youngest women (aged 20 to 24 years), subsequent to the implementation of the HPV vaccination program between 2007 and 2009. Historically this age group had the highest rates of abnormalities but from 2010 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 11.0 per 1,000 in 2014 (p < 0.0001) (2009=18.7; 2010=17.9; 2011=15.8; 2012=15.3; 2013=13.5).

FiGURe 5.1 detection rate of high-grade intraepithelial abnormalities (histologically-confirmed) from 2010-2014 per 1,000 screened women.

According to the National HPV Vaccination Program Register (NHVPR), Victorian women aged 15 to 19 years in 2014 have a notified three-dose vaccine coverage of 72.5%, those aged 20 to 24 years have a notified coverage of 61.3% and those aged 25 to 29 years have a notified coverage of 33.2% (NHVPR, unpublished data). Rate per 1,000 screened women

Interestingly, following an underlying increasing trend in incidence, the high-grade detection rate for 25 to 29 year old women for 2014 is slightly lower than in previous years (2008=18.4, 2009=18.9, 2010=18.1, 2011=18.8, 2012=18.8, 2013=17.7, 2014= 15.5). This suggests that the vaccination coverage rate in this age group may now be sufficient to be preventing new infections and high-grade disease, despite many women in this age group having been sexually active prior to vaccination.

40 N ote that the method used to calculate the rate of high-grade abnormalities is consistent with the Australian Institute of Health and Welfare (AIHW) Indicator 4.2 (Refer to: AIHW 2015. Cervical screening in Australia 2012-2013. Cancer series no.93. Cat. no. CAN 91. Canberra: AIHW). The denominator also includes a small number of women who were screened by a HPV DNA test (without Liquid Based Cytology) as part of the Compass trial. Refer to information about the Compass trial in Section 1.6.

Figure 5.2 shows the rate of histologically-confirmed high-grade cervical abnormalities by year since 2000, for young women (< 20 years, 20 to 24 years, 25 to 29 years, 30 to 34 years) and those 35+ years of age. The previously noted decline in women under 20 years of age (following the implementation of the National HPV Vaccination Program between 2007-2009) is continuing, with the rate more than halving from 11 cases per 1,000 women screened in 2006 down to less than four cases per 1,000 in 2014 (p < 0.0001). Also notable is the declining high-grade detection rate for women aged 20 to 24 years, with the rate progressively and continuously declining since 2008.

FiGURe 5.2 Trends in high-grade cervical abnormalities (histologically-confirmed) by age, 2000-2014, as recorded on the VCCR.

Notes

• 3 5+yrs includes all women aged 35 years or older and is not restricted to 69 years.

6. CoRREl aTioN bE TWEEN Cy ToloGy a Nd HiS ToloGy REP oRTS

Tables 6.1 and 6.2 show the correlation between cytology results and histology findings. The correlation is restricted to cytology performed in 2013 where a subsequent histology test was reported within six months. Colposcopy reports, without histological confirmation, have been excluded from this analysis.

In interpreting this information, it is important to consider 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). The following correlation tables compare the cytology result with the most severe histology finding within a six month period (including same day), for squamous and endocervical abnormalities. The histology classification and method of correlation presented is consistent with the Australian Institute of Health and Welfare (AIHW) national

reporting indicators. It is based on the test, not the woman, and these data include women aged 20 to 69 years at the time of the cytology test. They also include the records of women who reside outside of Victoria but have data recorded on the Victorian Cervical Cytology Registry (VCCR).

Where a definite high-grade squamous cytology result was reported, 79.9% (2,893/3,621) of cytology tests were subsequently followed by a 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 squamous 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 must be confirmed on histology within six months as having a high-grade abnormality or cancer. 41

As seen in Table 6.1 there was one case of invasive cervical cancer and two cases of micro-invasive cervical cancer reported on histology within six months of a low-grade squamous cytology in 2013. 1.

taBle 6.1 Correlation of squamous cytology to the most serious squamous histology within six months, for women aged 20 to 69 years, for cytology tests performed in 2013.

4. S CC: Squamous cell carcinoma.

Women with a Pap test report of ‘atypical endocervical or glandular cells of uncertain significance’ (E2) 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 National Health and Medical Research Council (NHMRC) Guidelines 42 recommend colposcopy as an initial evaluation because of the risk of invasive cancer. 43 As seen in Table 6.2, of the 31 cytology reports of ‘atypical endocervical or glandular cells of undetermined significance’ (E2), two of those who underwent histological evaluation within six months were subsequently diagnosed with micro-invasive or invasive cancer.

taBle 6.2 Correlation of endocervical cytology to the most serious endocervical histology within six months, for women aged 20 to 69 years, for cytology tests performed in 2013.

1. A IS: Adenocarcinoma in situ.

2. E ndocervical adenocarcinoma – invasive: includes adenocarcinoma and embryonal/clear cell carcinoma.

3. C arcinoma of the cervix – other: includes small cell carcinoma and other malignant lesions (may include tumours of non-epithelial origin).

4. G landular cytology: includes atypical glandular cells of uncertain significance (E2).

5. P ossible high-grade cytology: includes possible high-grade endocervical glandular lesion.

Notes

• T he correlation excludes diagnosis based on colposcopic impression alone. This analysis allows for cytology to be the same day as cancer diagnosis.

41 N ational Pathology Accreditation Advisory Council (NPAAC) 2006. Performance Measures for Australian Laboratories Reporting Cervical Cytology, Canberra: Department of Health and Ageing.

42 N ational Health and Medical Research Council (NHMRC) 2005. Screening to prevent cervical cancer: guidelines for the management of asymptomatic women with screen-detected abnormalities, Canberra: NHMRC.

43 Mitchell HS. Outcome after a cytological prediction of glandular abnormality. Aust NZJ Obstet Gynaecol. 2004; 44(5):436-40.

7. FolloW-uP a Nd REmiNdER PRoGR a m

The Victorian Cervical Cytology Registry (VCCR) Reminder and Follow-up Protocol (refer to Appendix 2) adheres to the 2005 National Health and Medical Research Council (NHMRC) Guidelines.

As part of the follow-up service provided by VCCR, a total of 428,013 follow-up and reminder letters were mailed to women and practitioners in 2014.

Second reminder letters were implemented as part of the routine correspondence of the VCCR in 2012 following a successful pilot in 2011. All letters are printed in-house on a weekly basis for mail-out. Ongoing funding for the second reminder letter is subject to evaluating and monitoring the success of the initiative with regards to the response by women and economic viability. Based upon the positive outcomes of the evaluation report for the period 1 July 2013 to 30 June 2014, the Department of Health and Human Services (DHHS) has extended the funding for the second reminder initiative until June 2016.

The following is a summary of the VCCR follow-up activities during 2014.

First reminders to women

Between 1 January 2014 and 31 December 2014, 289,433 first reminder letters were sent to women in the categories shown in Table 7.

Of the 275,554 reminders sent after a negative Pap test, 107,793 (39%) women had a subsequent Pap test within three months of the date of the reminder.

Second reminders to women

Between 1 January 2014 and 31 December 2014, 115,156 second reminder letters were sent to women, in the categories shown in Table 7.

Of the 109,560 reminders sent after a negative Pap test, 25,197 (23%) women had a subsequent Pap test within three months of the date of the reminder.

Follow-up

During 2014, the VCCR sent out 1,737 questionnaires to practitioners seeking further information after a high-grade abnormality on Pap test and 4,895 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 13,729 reminder letters to practitioners, following low-grade or unsatisfactory Pap tests.

During the year, 697 women with a high-grade abnormality required further follow-up by phone call as no further information had been received by five and a half 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 434 cases, the Registry sent letters to these women, mostly by registered mail to ensure that they were aware of their abnormality. In 2014, 8,011 Victorian women had a high-grade abnormality reported on one or more of their Pap tests, 7,251 (91%) of whom were followed up with colposcopy and/or biopsy within the following six to nine months. A further 482 (6%) women with high-grade abnormalities predicted on their Pap tests in 2014 were followed up with a Pap test only. For women who had low-grade abnormalities requiring further investigation, on whom the VCCR had not received follow-up information, 2,459 letters were sent to these women in 2014. The VCCR followed up 170 non-cervical abnormalities with letters to the practitioners seeking information about further investigations.

taBle 7 Number of first and second reminder letters sent to women by the VCCR in 2014.

8. CERV iCa l Ca NCER iNCidENCE

The aim of the Cervical 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 (VCR) and notifications are compulsory from laboratories, hospitals and the Victorian Cervical Cytology Registry (VCCR).

During 2014, 177 new cases of cervical cancer (all types) were reported to the VCR, and 53 Victorian women died due to cervical cancer. 44

Figure 8.1 shows the incidence and mortality rates from cervical cancer in Victoria from 1982 to 2014. 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 four and five per 100,000 women. A slight increase in incidence was noted in 2012 (5.7 per 100,000 women), however this has been followed by a subsequent decline to 4.7 per 100,000 women during 2014.

The mortality from cervical cancer in Victoria has declined gradually over time and since 2002 has been around one per 100,000 women, which is among the lowest in the world. 45 The mortality rate for all types of cervical cancer in 2014 was 1.1 per 100,000 Victorian women (2012: 1.0 and 2013: 1.0).

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 invasive squamous cell carcinoma of the cervix, with age-standardised incidence rates declining from 6.3 per 100,000 women in 1989 to 1.8 per 100,000 in 2014. Incidence rates for micro-invasive cancer have increased slightly since 2000; and in 2014 were 1.0 per 100,000 women screened (2011: 1.1, 2012: 1.0 and 2013: 1.4). Cervical screening is less effective for the detection of adenocarcinomas, 46 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-specific incidence rates of cervical cancer by histology and age, grouped over the three year period of 2012 to 2014. The age-specific incidence of invasive squamous cervical cancer increases in the 30 to 34 year old age group to peak at age 35 to 39 years, followed by subsequent peaks in women aged 50 to 54 years, 70 to 74 years and 85+ years. Micro-invasive cervical cancer peaks in women aged 35 to 39 years of age and declines steadily thereafter. Other cervical cancers peak at 40 to 44 years of age, decline until 70 to 74 years of age and then peak again for women aged 85+ years.

FiGURe 8.1 age-standardised incidence and mortality rates for all types of cervical cancer in Victoria, 1982-2014.

Notes

• S ource: Victorian Cancer Registry, Cancer Council Victoria 2015.

44 T hursfield V, Farrugia H 2015. Cancer in Victoria: Statistics & Trends 2014, Melbourne: Cancer Council Victoria. 45 International Agency for Research on Cancer (IARC). GLOBOCAN 2012: Estimated Cancer Incidence, Mortality and Prevalence Worldwide in 2012, online analysis. http://globocan.iarc.fr/Pages/online.aspx , viewed 8 October 2015.

46 N ational Health and Medical Research Council (NHMRC) 2005. Screening to prevent cervical cancer: guidelines for the management of asymptomatic women with screen-detected abnormalities, Canberra: NHMRC.

FiGURe 8.2 age-standardised incidence rates for cervical cancer by histological subtype in Victoria, 1982-2014.

Notes

• O ther cervical cancers are comprised of all other types, including adenocarcinomas.

• S ource: Victorian Cancer Registry, Cancer Council Victoria 2015.

FiGURe 8.3 age-specific incidence rates of cervical cancer by histological subtype in Victoria, 2012-2014.

Notes

• O ther cervical cancers are comprised of all other types, including adenocarcinomas.

• S ource: Victorian Cancer Registry, Cancer Council Victoria 2015.

9. SCREENiNG HiS ToRy oF WomEN diaGNoSEd

CERV iCa l Ca NCER iN 2 013

According to the Victorian Cancer Registry (VCR), 170 Victorian women were diagnosed with cervical cancer in 2013 (1 January-31 December). Of these women, 65 were diagnosed with invasive squamous cell carcinoma, 46 with micro-invasive squamous cell cancer and 59 with other types of invasive cervical cancer (including adenocarcinoma, small cell carcinoma, mixed adenosquamous adenocarcinoma and carcinosarcoma/sarcoma). 47

During 2013, 139 women were recorded on the Victorian Cervical Cytology Registry (VCCR) as having a histologicallyconfirmed invasive or micro-invasive cervical cancer, with 112 having an invasive cancer diagnosis (squamous or other type) and 27 having a micro-invasive diagnosis. An audit was conducted on the screening histories of these women recorded on the VCCR based on criteria used in other international studies. 48 All screening tests within six months of diagnosis were excluded (as it is assumed these led to the diagnosis) and the following categories were used:

a Never screened (coverage failure)

B. L apsed screening: with more than two and a half years between the cancer diagnosis and the ultimate Pap test, or more than 18 months if there is a history of abnormality and a 12 month screening interval is recommended under the Guidelines

c A dequately screened (screening failure): with less than two and a half years between the cancer diagnosis and the ultimate Pap test

D. D elayed diagnosis (biopsy, management or treatment failure): e.g. no colposcopy and/or biopsy recorded

e Not eligible: women over the age of 70 years and no longer eligible for the screening program

F. Other: see Note 5 under Table 9.

47 V ictorian Cancer Registry 2015. Unpublished data. Melbourne: Cancer Council Victoria.

48 S asieni P, Adams J, Cuzick J. Benefits of cervical screening at different ages: evidence from the UK audit of screening histories. Br J Cancer 2003; 89(1):88-93.

Table 9 classifies the screening history of women diagnosed with invasive and micro-invasive cervical cancer into one of the following four general groups, with numbers for invasive cancers (green column) discussed more below.

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 (and thus it is assumed they were never screened) or were recorded on the VCCR but their first Pap test was within six months of diagnosis and was therefore considered to be part of the diagnostic pathway. Table 9 shows that, of women diagnosed with an invasive cervical cancer during 2013, 44 (35%) had no screening history.

A proportion of those unknown to the VCCR may have been screened interstate or overseas, or have opted-off the Registry.

B. Women with a lapsed screening history

According to the VCCR records, there were 49 women (40%) diagnosed with invasive cervical cancer that were categorised 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. It is interesting to note that of the 49 women who are lapsed screeners, 30 (61%) did not have a screening test within five and a half years or more of their diagnosis.

Taken together, the data above for ‘never screened’ women and ‘lapsed screeners’ indicate that, for invasive cervical cancers diagnosed during 2013:

• 74% of women with invasive squamous cell cancer had no screening history or had a lapsed screening history.

• 76% of women with invasive glandular cancer had no screening history or had a lapsed screening history.

c. Women with an adequate screening history

Of the women diagnosed with invasive cervical cancer, nine women (7%) 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. Of these women, 78% (i.e. 7/9) were diagnosed with glandular cervical cancers, which are harder to detect through cervical screening.

D. Women with a delayed diagnosis

Of the women diagnosed with frankly invasive cervical cancer (squamous or other), 14 (11%) appear to have had a delayed diagnosis or management failure on the limited information available to the VCCR.

taBle 9 Screening history of Victorian women diagnosed with cervical cancer for the period 1 January 2013 to 31 december 2013.

1. Woman recorded on the VCCR but has no screening history prior to diagnosis.

2. E stimated remaining number of women, not accounted for on the VCCR (i.e. VCR-VCCR).

3. L apsed screener, >18 months: women with a history of abnormality where a 12 month interval is recommended under the Guidelines.

4. 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 http://www.cancerscreening.gov.au

5. O ne woman had an unsatisfactory Pap test result, not followed up; and another woman had a failed ‘test of cure’.

6. O ther types of invasive cervical cancer may include adenocarcinoma, small cell carcinoma, mixed adenosquamous adenocarcinoma and carcinosarcoma/sarcoma.

Notes

• D ata only includes women with a Victorian postcode.

• D ue to rounding percentages, there may be some discrepancy in totals not adding up.

aCKNoW lEdGEmENTS

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 Victorian Cervical Cytology Registry (VCCR) and the Victorian Cytology Service information & Communication Technology team. Very sincere thanks are extended to the members of all these groups. in p articular, 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 figures on incidence and mortality from cervical cancer were kindly provided by the Victorian Cancer Registry (VCR) at the Cancer Council Victoria. We would like to thank Vicky Thursfield and Helen Farrugia for their assistance in providing these data.

liS T oF abbREV i aTioNS

aBS australian bureau of Statistics

aiHW australian institute of Health and Welfare

ciN Cervical intraepithelial Neoplasia

cSt Cervical Screening Test

ecc Endocervical component

eRp Estimated Resident Population, as provided by the abS

HpV Human Papillomavirus

HSil High-grade squamous intraepithelial lesion

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 ltd.

GloS S a Ry REFERENCES

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.

Cervical Screening Test(s) (CST[s]) This term refers to Pap tests collected as part of the National Cervical Screening Program, as well as both Pap tests and HPV DNA (without Liquid Based Cytology) tests collected as part of the Compass trial. 50

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.

Compass trial This is a clinical trial comparing two and a half yearly Pap test screening with five-yearly HPV DNA screening.51

Cytology The microscope evaluation of a sample of cells obtained from a tissue (or body fluid) 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.

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

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.

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

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 sometimes 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.

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.

Immunisation Inducing immunity against infection by the use of an antigen to stimulate the body to produce its own antibodies. 52

Incidence The number of new cases (for example, of an illness or event) occurring during a given period.

Intraepithelial lesion Lesion confined 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 (NCSP) Australia-wide systematic approach to cervical screening based on sound international scientific 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.

Pap test (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. Named after the test’s inventor, Dr Papanicolaou.

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

Renewal This is a strategy for reviewing the National Cervical Screening Program (NCSP). A new endorsed screening pathway and program model will ensure women have access to a cervical screening program that is safe, effective and efficient, and based on current evidence. The planned commencement date of the renewed program is 1 May 2017. 53

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.

Squamous cells Thin and flat cells, shaped like soft fish 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.

49 Unless otherwise indicated, all definitions have been sourced from the following publications:

– Australian Institute of Health and Welfare 2014. Cervical screening in Australia 2011-2012 . Cancer series no.82. Cat. no. CAN 79. Canberra: AIHW.

– N ational Health and Medical Research Council (NHMRC) 2005. Screening to prevent cervical cancer: guidelines for the management of asymptomatic women with screen-detected abnormalities, Canberra: NHMRC.

50 C ompass trial website: http://www.compasstrial.org.au/, viewed 10 November 2015.

51 Ibid.

52 A ustralian Institute of Health and Welfare, 2008. Australia’s health 2008 . Cat. no. AUS 99. Canberra: AIHW, p 557.

53 A ustralian Government, Department of Health, National Cervical Screening Program Renewal website. http://cancerscreening.gov.au/internet/screening/publishing.nsf/Content/renewal-3 , viewed 5 October 2015.

a PPENdi X 1.

Cy ToloGy CodiNG SCHEdulE

SSquamous cell

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

endocervical

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

S1 Cell numbers and preservation satisfactory. No abnormality or only reactive changes e- Not applicable: vault smear / previous hysterectomy

S2 Possible low-grade squamous intraepithelial lesion (LSIL)

other / Non-cervical

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

No other abnormal cells

eØ No endocervical component 02 Atypical endometrial cells of uncertain significance

S3 Low-grade LSIL (HPV and / or CIN I) e1

Endocervical component present. No abnormality or only reactive changes 03 Atypical glandular cells of uncertain significance –site unknown

S4 Possible high-grade squamous intraepithelial lesion (HSIL) e2 Atypical endocervical cells of uncertain significance

S5 High-grade squamous intraepithelial lesion (HSIL) (CIN II / CIN III)

Possible endometrial adenocarcinoma

e3 Possible high-grade endocervical glandular lesion 05 Possible high-grade lesion –non-cervical

S6 High-grade squamous intraepithelial lesion (HSIL) with possible microinvasion / invasion e4 Adenocarcinoma in situ

Malignant cells – uterine body

S7 Squamous carcinoma e5 Adenocarcinoma in situ with possible microinvasion / invasion 07 Malignant cells – vagina e6 Adenocarcinoma

Malignant cells – ovary

Malignant cells – other

RØ No recommendation

Repeat smear six months

R1 Repeat smear three years R5 Repeat smear 6-12 weeks

R2 Repeat smear two years R6 Colposcopy / biopsy recommended

R3 Repeat smear 12 months R7 Already under gynaecological management

Referral to specialist

Other management recommended

Symptomatic-clinical management required

a PPENdi X 2. REmiNdER a Nd FolloW-uP

PRoToCol uSEd duRiNG 2014

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

monthsSecond reminder to woman Negative – Previous smear abnormal or past history of biopsy proven CIN 2 or CIN 3 without HPV ‘test of cure’

monthsFirst reminder to woman

monthsSecond reminder to woman

Unsatisfactory

Reminder to practitioner

monthsFirst reminder to woman

monthsSecond reminder to woman

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).

a PPENdi X 3.

a P oF mEdiCa RE loCa l S

50% - 55%

55% - 60%

60% - 65%

65% - 70%

l GoV ERNmENT a RE a S – mElbouRNE

50% - 55%

55% - 60%

60% - 65%

65% - 70%

Refer to Table 2.3.3 for key to LGA codes by LGA names.

ML211

ML217 ML214

Less than 50%

50% - 55%

55% - 60%

60% - 65%

65% - 70%

Greater than 70%

ML211