VCCR Statistical Report 2013 by Victorian Cytology Service

STATISTICAL REPORT 2013

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

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

Genevieve Chappell, VCCR Manager Bianca Barbaro, Geographical Consultant Lesley Rowlands, Follow-up Manager Produced by: Cathryn May, Data Manager Jennifer Nguyen, Health Information Manager

Victorian Cervical Cytology Registry PO Box 161, Carlton South Victoria 3053 (03) 9250 0399 registry@vccr.org www.vccr.org ISSN 2202-4417

CONTENTS EXECUTIVE SUMMARY

1. 1.1 1.2 1.3 1.4 1.5

7 7 7

INTRODUCTION Background Functions of the VCCR National Policy: The NHMRC guidelines for the management of asymptomatic women with screen detected abnormalities and Renewal of the Cervical Screening Program The National HPV Vaccination Program Data included in this report

2. PARTICIPATION IN SCREENING 2.1 Number of Pap tests and women screened Table 2.1: Number of Pap tests registered and number of women screened in Victoria, 1990â&#x20AC;&#x201C;2013. 2.2 Participation by age group Table 2.2: Estimated cervical screening rates by age group over one year, two year, three year and five year periods. Figure 2.2.1: Estimated two year cervical screening rates by age group, 2000-2001 to 2012-2013. 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 2012-2013. Table 2.2.1: Estimated two year cervical screening rates by age group, 2000-2001 to 2012-2013. 2.3 Participation by area 2.3.1 Participation by Medicare Locals Table 2.3.1: Estimated two year cervical screening rates by Medicare Local, 2011-2012 and 2012-2013. Figure 2.3.1: Estimated two year cervical screening rates by Medicare Local, 2012-2013. 2.3.2 Participation by Department of Health Region Table 2.3.2: Estimated two year cervical screening rates by Department of Health Region, 2011-2012 and 2012-2013. Figure 2.3.2: Estimated two year cervical screening rates by Department of Health Region, 2012-2013. 2.3.3 Participation by Local Government Area Table 2.3.3: Estimated two year cervical screening rates by Local Government Area, 2011-2012 and 2012-2013. Figure 2.3.3: Estimated two year cervical screening rates by Local Government Area, 2012-2013. 2.4 Pap tests collected by nurses Table 2.4: Proportion of Pap tests collected by nurses, 2004-2013. 2.4.1 Proportion of Pap tests collected by nurses by Department of Health Region Table 2.4.1: Pap tests for women with a cervix collected by nurses, by Department of Health Region, 2013. Figure 2.4.1: Proportion of Pap tests collected by nurses, by Department of Health Region, 2013. 2.5 Closing the data gaps: Identifying Aboriginal and Torres Strait Islander People, and collecting country of birth and language spoken at home Table 2.5.1: Reporting of Aboriginal and Torres Strait Islander status of women during 2013. Table 2.5.2: Proportion of Pap Tests by Practitioner Type with Aboriginal and Torres Strait Islander status information recorded, 2013. 2.6 Frequency of early re-screening Table 2.6: Subsequent Pap tests within a 21 month period for women with a negative test in February of 2012. Figure 2.6: Percentage of women by age group who re-screened early after a negative Pap test in February 2012.

7 7 8 9 9 9 9 10 11 11 11 12 13 13 14 15 15 15 16 16 18 19 19 20 20 21 22 22 22 23 23 23

3. 3.1 3.2 3.3 3.4 3.5 3.6

CYTOLOGY REPORTS Unsatisfactory Pap tests Negative Pap tests Pap tests without an endocervical component Figure 3.3: Percentage of Pap tests without an endocervical component, 2004-2013. Pap tests with a squamous abnormality Table 3.4: Number and percent of Pap tests collected in 2013 with a squamous abnormality. Pap tests with an endocervical abnormality Table 3.5: Number and percent of Pap tests collected in 2013 with an endocervical abnormality. Type of tests

24 24 24 24 24 25 25 25 25 25

HISTOLOGY REPORTS Table 4: Histology findings reported to the VCCR in 2013.

26 26

5. HIGH-GRADE ABNORMALITY DETECTION RATES Figure 5.1: Detection rate of high-grade intraepithelial abnormalities (histologically-confirmed) from 2009-2013 per 1,000 screened women. Figure 5.2: Trends in high-grade cervical abnormalities (histologically-confirmed) by age, 2000-2013, as recorded on the VCCR.

CORRELATION BETWEEN CYTOLOGY AND HISTOLOGY REPORTS Table 6.1: Correlation of squamous cytology to the most serious squamous histology within six months, women aged 20 to 69 years, for cytology tests performed in 2012. Table 6.2: Correlation of endocervical cytology to the most serious endocervical histology within six months, women aged 20 to 69 years, for cytology tests performed in 2012.

FOLLOW-UP AND REMINDER PROGRAM Table 7: Number of first and second reminder letters sent to women by the VCCR in 2013.

31 31

CERVICAL CANCER INCIDENCE AND MORTALITY IN VICTORIA Figure 8.1: Age-standardised incidence and mortality rates for all types of cervical cancer in Victoria, 1982-2013. Figure 8.2: Age-standardised incidence rates for cervical cancer by histological subtype in Victoria, 1982-2013. Figure 8.3: Age-specific incidence rates of cervical cancer by histological subtype in Victoria, 2011-2013.

SCREENING HISTORY OF WOMEN DIAGNOSED WITH CERVICAL CANCER IN 2012 Table 9: Screening history of Victorian women diagnosed with cervical cancer for the period 1 January 2012 to 31 December 2012.

27 27

32 33 33 34 34

ACKNOWLEDGEMENTS LIST OF ABBREVIATIONS GLOSSARY REFERENCES

36 36 37

APPENDIX 1. CYTOLOGY CODING SCHEDULE APPENDIX 2. REMINDER AND FOLLOW-UP PROTOCOL USED DURING 2013 APPENDIX 3. MAP OF MEDICARE LOCALS APPENDIX 3. MAP OF LOCAL GOVERNMENT AREAS – MELBOURNE APPENDIX 3. MAP OF LOCAL GOVERNMENT AREAS – VICTORIA

38 39 40 41 42

Victorian Cervical Cytology Registry Statistical Report 2013

EXECUTIVE SUMMARY

One of the key activities of the Victorian Cervical Cytology Registry (VCCR) is to improve participation of Victorian women in the cervical screening program by sending reminder letters and conducting research into underscreening. In 2013, 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 2010-2011, the estimated two year participation rate for women aged 20 to 69 years was 59.2%, which then increased to 60.0% for the period of 2011-2012. In the 2012-2013 period the two year participation increased still further to 60.4%. This sustained increase in the number of women across all age groups having Pap tests suggests this is due to the second reminder letter initiative. However, substantial variation exists in screening rates between different areas of Victoria, as represented by Medicare Locals, with the two year screening rates for 2012-2013 ranging from 53.8% to 68.2%. The screening rate for Victorian Department of Health regions ranged from 56.9% to 63.7%, while the estimated two year participation rate by Local Government Area ranged from 44.4% to 76.3%. As part of the follow-up and reminder program, the VCCR registered a total of 600,769 Pap tests in 2013, representing 571,558 women, and sent 410,544 follow-up and reminder letters to women and practitioners. More than 6,000 abnormal Pap tests were followed-up by the VCCR in 2013. Of the 261,640 first reminders sent to women after a negative Pap test, 41% of women had a subsequent Pap test within three months. Almost 112,000 second reminder letters were sent to women and, of those sent after a negative Pap test, 24% had a subsequent Pap test within three months of the reminder. Of Pap tests recorded by the VCCR during the period of this report, a definite high-grade squamous cell abnormality was present in 0.7% of tests and an endocervical abnormality was identified in fewer than 0.1% of tests. For the 3,811 high-grade cytology tests reported, 2,999 were subsequently confirmed with high-grade histology on biopsy within a six month period. This represents a positive predictive value of 78.7% and reflects the high quality of laboratory reporting in Victoria.

Over the last decade there has been a gradual increase in the proportion of Pap tests collected by nurses. In 2013 Pap tests collected by nurses (including for the first time those known to have reported under a GPs provider number and to any pathology provider) represented 6.3% of all Pap 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 Aboriginal or Torres Strait Islander person, their country of birth and the language spoken at home is critical for understanding who participates in cervical screening. The overall percentage of women screened in 2013 who had their Aboriginal or Torres Strait Islander status recorded by the VCCR was 21.8%, for country of birth 17.3% and language spoken at home 18.3%. According to recent data (2013) from the Victorian Cancer Registry, mortality from cervical cancer in Victoria remains at very low levels, 1.1 per 100,000 women. This is a tremendous achievement and reflects the success of the organised cervical screening program, which is underpinned by the Pap test Registry. Despite this success, further efforts are necessary to improve participation amongst underscreened women as 83% of Victorian women who were diagnosed with invasive squamous cervical cancer in 2012 had never had a Pap test, or were lapsed screeners, prior to their cancer diagnosis.

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 other Program Partners including PapScreen Victoria which is responsible for the communications and recruitment program aimed at maintaining the high rates of participation of Victorian women in the National Cervical Screening Program.

1.2 FUNCTIONS OF THE VCCR The VCCR facilitates regular participation of women in the National Cervical Screening Program by sending reminder letters to women for Pap tests and by acting as a safety net for the follow-up of women with abnormal Pap tests. The primary functions of the VCCR as indicated in the Cancer Act 1958 are to: a) follow-up positive results from cancer tests, b) send reminder notices to women who are due for cancer tests, c) where appropriate, provide access to the register to persons studying cancer; and d) compile and publish statistics. Secondary functions of the Registries have developed on a more regional basis. In Victoria, the role of the VCCR includes: • the provision of the known screening history of a woman to the laboratory that is reporting the current Pap test, • the provision of quantitative data to laboratories to assist with their quality assurance programs; and • the provision of aggregate data to the 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 2 3 4

1.3 NATIONAL POLICY: THE NHMRC GUIDELINES FOR THE MANAGEMENT OF ASYMPTOMATIC WOMEN WITH SCREEN DETECTED ABNORMALITIES AND RENEWAL OF THE CERVICAL SCREENING PROGRAM On 1 July 2006, the National Health and Medical Research Council (NHMRC) Guidelines for the Management of Asymptomatic Women with Screen Detected Abnormalities (2005)1 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 repeat Pap tests for most women with low-grade squamous abnormalities, • to not treat biopsy proven low-grade or HPV lesions, • to refer all women with atypical glandular cells for colposcopy, • to refer all women with a possible high-grade lesion for colposcopy; and • to use HPV tests and cytology as a test of cure for women treated for CINII and CINIII. The VCCR participates in the National Safety Monitoring of the NHMRC guidelines.2 A review of the National Cervical Screening program, known as “Renewal” commenced in November 2011. The Renewal program is aimed at ensuring human papillomavirus (HPV) vaccinated and non-vaccinated women have access to an acceptable, effective and efficient cervical screening program based on evidence and best practice. Throughout 2013, extensive consultations and a review of evidence were undertaken which are informing the development of a new screening pathway and program model.3

1.4 THE NATIONAL HPV VACCINATION PROGRAM The National HPV Vaccination Program commenced in April 2007 and is already having a substantial impact on the prevalence of HPV infection and cervical lesions in vaccinated cohorts.4 Between 2007 and 2009, 12 to 26 year old females were offered the quadrivalent HPV vaccination (Gardasil) in a national catch-up program provided through schools, general practice and other community providers. Since 2009 the program has offered routine vaccination through schools for 12 to 13 year old girls. From 2013, vaccination to 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. CONTINUED OVERLEAF >>

NHMRC Screening to prevent cervical cancer: guidelines for the management of asymptomatic women with screen-detected abnormalities, 2005. http://www.nhmrc.gov.au/guidelines/publications/wh39, viewed 28 October 2014. Australian Department of Health, National Cervical Screening Program Safety Monitoring Committee website. http://www.cancerscreening.gov.au/internet/screening/publishing.nsf/Content/safety-monitoring-committee, viewed 28 October 2014. Australian Government Department of Health, National Cervical Screening Program Renewal website. http://www.cancerscreening.gov.au/internet/screening/publishing.nsf/Content/ncsp-renewal, viewed 21 November 2014. Tabrizi SN, Brotherton JML, Kaldor JM, Skinner SR, Cummins E, Liu B, Bateson D, McNamee K, Garefalakis M, Garland SM. Fall in Human Papillomavirus Prevalence Following a National Vaccination Program. J Infect Dis. 2012; 206 (11): 164551. http://jid.oxfordjournals.org/content/early/2012/10/17/infdis.jis590.full.pdf+html, viewed 28 October 2014. Victorian Cervical Cytology Registry Statistical Report 2013

>> 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)5 was established to support, monitor and evaluate the National HPV Vaccination Program. VCS Inc., which has operated the Victorian Cervical Cytology Registry (VCCR) for over 20 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 Pap test 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 precancers for women who had been completely vaccinated in the school-program, compared with unvaccinated women.6 These data indicate that the downward trend observed among young women within VCCR and national screening data can be ascribed to HPV vaccination.

1.5 DATA INCLUDED IN THIS REPORT This statistical report provides timely information about cervical screening in Victoria during 2013. In most cases the methodology and terminology used in VCCR reports are consistent with that published by the AIHW as part of reporting indicators for the National Cervical Screening Program.7 Participation rates This report includes information on participation rates for women aged 20 to 69 years in ten 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. The two year participation rates are also presented by Medicare Local, Department of Health region and Local Government Area. The number and proportion of Pap tests collected by nurses are presented in this report, by year and Department of Health region. Further information regarding Pap tests collected by nurses is available in the report â&#x20AC;&#x2DC;Evaluation of Pap tests collected by Nurses in Victoria during 2013â&#x20AC;&#x2122;, available on our website at http://www.vccr. org/data-research/statistical-reports/annual-nurse-reports

5 6 7 8 9 8

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. Cytology 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 Australiawide cytology codes that have been used since 1 July 2006 to correspond with the implementation of the NHMRC guidelines.8 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 2013 without an endocervical component is also presented. Histology reports The 2013 histology results in this report are as notified to the VCCR by 9 May 2014. The vast majority of histology reports are 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 2012 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 will be 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.9 The Reminder and Followup Protocol used by the VCCR in 2013 is shown in Appendix 2. Reminder letters are not sent to women whose VCCR records indicate a past history of hysterectomy or of cervical or uterine malignancy, or to women who are over 70 years of age and whose last Pap test was normal. Cervical cancer incidence and mortality Information on cervical cancer incidence and mortality is provided in this report courtesy of the Victorian Cancer Registry at the Victorian Cancer Council. Also included is a section examining the screening history of Victorian women diagnosed with invasive and micro-invasive cervical cancer during 2013.

The National HPV Vaccination Program Register website. http://www.hpvregister.org.au Gertig DM, Brotherton JML, Budd AC, Drennan K, Chappell G, Saville AM. Impact of a population-based HPV vaccination program on cervical abnormalities: a data linkage study. BMC Medicine 2013, 11:227. Australian Institute of Health and Welfare 2014. Cervical screening in Australia 2011-2012. Cancer series no.82. Cat. no. CAN 79. Canberra: AIHW. NHMRC Screening to prevent cervical cancer: guidelines for the management of asymptomatic women with screen-detected abnormalities, 2005. http://www.nhmrc.gov.au/publications/synopses/wh39syn.htm, viewed 28 October 2014. Ibid.

2. PARTICIPATION IN SCREENING

2.1 NUMBER OF PAP TESTS AND WOMEN SCREENED Table 2.1 shows data on the number of Pap tests registered and the number of women screened for each year of the VCCR’s operation. During 2013, a total of 600,769 Pap tests were registered from 571,558 women. From the previous year, this is a decrease of 1,601 Pap tests and 2,563 women screened.

2.2 PARTICIPATION BY AGE GROUP Method of calculating participation The participation of women estimated to be part of the Victorian Cervical Screening Program by age group is expressed as a percentage. This is determined by dividing the number of women screened by the number of women in the general population who are eligible for screening.

In interpreting the information in Table 2.1, it is important to • The number of women screened (numerator) is consider that, while it is recommended that women screen determined from the VCCR database. It is the number every two years, a small proportion of women in Victoria are of women resident in Victoria who had at least one Pap screened on an annual basis. Additionally, correct attribution of test in the time period of interest and have not had a Pap tests to the same woman over time is not always possible, hysterectomy according to information held by the VCCR. sometimes resulting in a possible over-estimation of women • The eligible population (denominator) is the number of recorded on the VCCR. However, over the last 10 years, 95% of women in the general population averaged for the time women with a Pap test record on the VCCR have had a Medicare period of interest, and adjusted to include only women number recorded. This has resulted in more complete recordwith an intact cervix. To determine this, the Victorian linkage of different episodes of care for women. female Estimated Resident Population (ERP)10 calculated by the Australian Bureau of Statistics (ABS) is averaged The VCCR is a voluntary “opt-off” registry; however, the over two years and then adjusted to exclude the proportion of women who are part of the screening program proportion of women estimated to have had a but decide to opt-off the VCCR is estimated to be fewer than hysterectomy using the known percentage of women 1%. Correlating VCS laboratory records with those held by who have not had a hysterectomy. Whilst VCCR the VCCR shows a ten year (2004-2013) opt-off rate of 0.38%. participation statistics produced prior to 2011 used Where a woman objects to her Pap test being registered, hysterectomy fraction estimates from the National the VCCR holds no information about that test. Health Survey,11 these data are no longer collected by Table 2.1: Number of Pap tests registered and number the ABS. In VCCR Statistical reports from 2011 onwards, of women screened in Victoria, 1990-20131. population data for the latest screening periods have been adjusted with hysterectomy estimates from Year Number of Pap tests Number of women analysis conducted by the AIHW using data from the registered screened National Hospital Morbidity Database (NHMD).12 This 1990 435,704 400,146 is consistent with the national approach. 1991 544,408 496,293 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013

540,472 570,602 622,987 588,788 617,180 584,830 618,484 602,397 572,039 577,174 579,177 571,600 587,958 585,320 572,730 585,549 565,651 584,265 573,836 572,129 602,370 600,769

494,873 522,319 562,235 529,269 559,620 533,521 569,851 557,253 531,778 542,400 540,649 532,417 550,142 549,635 540,676 557,363 538,222 556,483 547,436 545,781 574,121 571,558

It is important to appreciate that changes in the methods used to calculate participation impact upon the actual participation estimates. Hence comparisons in participation over time should be made with caution. Limitations of participation statistics As previously discussed, one limitation to these participation statistics is the imperfect record-linkage between multiple Pap tests from the same woman that could result in an overestimate of the number of women screened. 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.

Note 1 The number of Pap tests registered and women screened on the Registry as of 1 July 2014. 10 Australian Bureau of Statistics. 3101.0 – Australian Demographic Statistics,Dec 2013 (release date 19/6/14). 11 Australian Bureau of Statistics. 4364.0 – National Health Survey: Summary of Results, 2004-2005 (release date 27/2/2006). 12 Australian Institute of Health and Welfare 2014. Cervical screening in Australia 2011–2012. Cancer series no.82. Cat. no. CAN 79. Canberra: AIHW. Victorian Cervical Cytology Registry Statistical Report 2013

Participation in cervical screening by age group

Over the three year period from 2011-2013, the participation rate of Victorian women aged 20 to 69 years is estimated at 72.7%, a slight increase from the previous period of 2010-2012 (72.4%).

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 also highlights the five year estimated participation rate of 84% for 2009-2013, which is a slight increase from the previous period (83.9%).15 Three and five year participation rates for women aged 20 to 39 years decreased slightly from the previous period, whereas participation for women aged over 40 years demonstrated a slight increase.

There was a slight decrease in the one year screening rate from the previous year for women aged 20 to 69 years, at 32.3% in 2013, compared with 33.1% for 2012.13 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 2013.

Estimated two year participation over time

The two year screening rate (for the calendar years of 2012-2013) for women aged 20 to 69 years is estimated at 60.4%, which is a slight increase from 60% for the previous reporting period (2011-2012).14 During this two year period there was an increase in both the number of women screened and the eligible population compared with the previous two year period. The 20 to 29 year old cohort reported the lowest two year participation rate at 47.1% (the equivalent figure as reported for the previous period). The 50 to 59 year old cohort had the highest participation at 68.3% for the period of 2012-2013.

As seen in figure 2.2.1, there was a small decline over time for each age group between 2000-2001 and 2010-2011. In contrast, an increase in the number of women being screened in most age groups in the 2011-2012 and 2012-2013 periods has resulted in a slight increase in participation in women aged 40 years and over. Exceptions to this reversal of previous trends were seen in 20-29 year olds, for whom participation was relatively stable. Further breakdowns of this group into 20 to 24 and 25 to 29 years (refer to Figure 2.2.2) did not identify any differences between the groups over time. Compared to the previous period of 2011-2012 the 30 to 39 year age group experienced a slight decrease in participation during 2012-2013. It is likely that the introduction of a second reminder letter16 in 2013 is responsible for the improving participation in women aged 40 and over.

Table 2.2: Estimated cervical screening rates by age group over one year, two year, three year and five year periods. Age Group

20 to 29 yrs 30 to 39 yrs 40 to 49 yrs 50 to 59 yrs 60 to 69 yrs 20 to 69 yrs

% screened 2013 (1 year) 25.4% - 20 to 24 yrs - 25 to 29 yrs

% screened 2012-2013 (2 years) 47.1% 22.4% 28.2%

32.9% 36.1% 36.3% 33.1% 32.3%

% screened 2011-2013 (3 years) 60.5% 41.9% 52.0%

61.0% 67.5% 68.3% 62.9% 60.4%

% screened 2009-2013 (5 years) 79.6% 54.7% 66.0%

75.5% 80.5% 78.8% 70.3% 72.7%

Notes 1 The eligible female population is adjusted for the estimated proportion of women who have had a hysterectomy using hysterectomy fractions derived from the National Hospital Morbidity Database. 2 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. 3 Periods covered apply to calendar years.

13 Victorian Cervical Cytology Registry, Statistical Report 2012. Available from: http://www.vccr.org/data-research/statistical-reports 14 Ibid. 15 Ibid. 16 The second reminder letter provides a further prompt 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. 10

75.2% 83.8% 90.4% 89.5% 83.6% 71.2% 84.0%

Figure 2.2.1: Estimated two year cervical screening rates by age group, 2000-2001 to 2012-2013. 80

Participation rate (%)

70 60 50 40 30 20 10 0 ‡

‡ 2012-2013 ‡

Screening Period 20 - 29 yrs

30 - 39 yrs

40 - 49 yrs

50 - 59 yrs

60 - 69 yrs

20 - 69 yrs

Notes 1

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

Periods covered apply to calendar years.

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 2012-2013.

Participation rate (%)

70 60 50 Age Group

20 - 24 yrs

25 - 29 yrs

20 10 0 2003-2004

2004-2005

2005-2006

2006-2007

2007-2008

2008-2009

2009-2010

2010-2011

2011-2012

2012-2013

Table 2.2.1: Estimated two year cervical screening rates by age group, 2000-2001 to 2012-2013. Participation rate (%) 20-24 yrs

25-29yrs

20-29yrs

30-39yrs

40-49yrs

50-59yrs

60-69yrs

2000-2001*

56.0%

70.0%

74.0%

76.0%

58.0%

66.6%

2001-2002*

56.8%

67.0%

68.9%

69.7%

57.7%

64.4%

20-69yrs

2002-2003*

55.4%

66.4%

68.5%

70.0%

58.4%

63.9%

2003-2004*

48.5%

60.3%

54.4%

66.5%

69.5%

71.5%

60.3%

64.4%

2004-2005*

48.5%

60.2%

54.4%

67.4%

70.5%

71.9%

60.9%

65.0%

2005-2006 †

47.9%

58.7%

53.2%

66.3%

66.7%

68.8%

63.6%

63.4%

2006-2007 †

47.3%

58.1%

52.7%

65.4%

66.5%

69.6%

64.4%

63.1%

2007-2008 †

46.1%

56.3%

51.2%

64.5%

65.9%

69.3%

64.1%

62.3%

2008-2009 †

43.0%

54.0%

48.5%

63.7%

65.5%

69.4%

64.6%

61.3%

2009-2010 †

41.6%

52.4%

47.1%

62.6%

65.5%

69.9%

65.3%

60.7%

2010-2011 ‡

41.3%

51.7%

46.6%

61.1%

66.1%

59.7%

59.2%

2011-2012 ‡

41.7%

52.2%

47.1%

61.3%

66.9%

67.2%

61.6%

60.0%

2012-2013 ‡

41.9%

52.0%

47.1%

61.0%

67.5%

68.3%

62.9%

60.4%

Notes 1

* 2000-2001 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 and 2012-2013 population data has been adjusted using the National Hospital Morbidity Database (NHMD) hysterectomy fraction estimates (courtesy of the Australian Institute of Health and Welfare).

Periods covered apply to calendar years. Victorian Cervical Cytology Registry Statistical Report 2013

2.3 PARTICIPATION BY AREA Method of calculating participation

Limitations of participation statistics by area

The participation rate for age eligible women in cervical screening for Medicare Locals (ML), Department of Health (DH) regions and Local Government Areas (LGAs) is expressed as a percentage.

Small-area data (eg. DH regions, LGAs and Medicare Locals) are subject to greater measurement error than the data in sections 2.1 and 2.2. The main source of inaccuracy in the following tables are likely from:

• The numerator is the number of women by postcode who had at least one Pap test in the two year time period and who have not had a hysterectomy according to the information held by the VCCR.

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

• The denominator is the estimated number of women in each Postal Area17 adjusted to exclude the proportion of women estimated to have had a hysterectomy. The 2012-2013 data are adjusted by the hysterectomy fractions from the National Hospital Morbidity Database.18 The average female population over each two year period is used as the denominator. To calculate the estimated participation rates for areas, data by Australia Post postcodes and Postal Areas were mapped to LGAs and Medicare Locals using conversion files provided by the Victorian Department of Health and the Commonwealth Department of Health and Ageing respectively. The mapping of the 2012-2013 participation data for LGAs is based on concordances19 consistent with the ABS Australian Statistical Geography Standard (ASGS).20 Participation data by DH region are calculated as an aggregate of LGAs, while Medicare Locals were created based on the Commonwealth Department of Health Postcode to Medicare Local concordance file.21

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

17 ABS 2014, customized report. Data using 2011 postal boundaries: Victorian Female Estimated Resident Population by Postal Area at 30 June 2012 and 30 June 2013. 18 Australian Institute of Health and Welfare 2014. Cervical screening in Australia 2011–2012. Cancer series no.82. Cat. no. CAN 79. Canberra: AIHW. 19 2012 Postcode to LGA converter algorithm (based on 2011 Mesh Block boundaries) supplied by Victorian Department of Health and based on ABS Australian Statistical Geography Standard (ASGS) correspondence. 20 Australian Bureau of Statistics, 2011. Australian Statistical Geography Standard (ASGS): Volume 1 – Main Structure and Greater Capital City Statistical Areas, July 2011. Cat. No: 1270.0.55.001. 21 Australian Government Medicare Local Statistics, Boundary and Concordance files website. http://www.medicarelocals.gov.au/internet/medicarelocals/publishing.nsf/Content/digital-boundaries#.VBJ4fY09KmQ, viewed 28 October 2014. 12

2.3.1 Participation by Medicare Locals In 2011 the Australian Government established the Medicare Local 22 area network to replace the previous Divisions of General Practice. Participation rates for 2012-2013 have been calculated for the 17 Medicare Locals in Victoria, which are partially or entirely located within Victoria, using methods discussed at the beginning of Section 2.3. Table 2.3.1: Estimated two year cervical screening rates by Medicare Local, 2011-2012 and 2012-2013. Medicare Local Number ML201 ML202 ML203 ML204 ML205 ML206 ML207 ML208 ML209 ML210 ML211 ML212 ML213 ML214 ML215 ML216 ML217

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

2011-20121 % screened (95% CI)

2012-20131 % screened (95% CI)

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

57.0% (56.8%-57.3%) 65.3% (65.1%-65.5%) 53.8% (53.5%-54.1%) 56.8% (56.6%-57.1%) 59.1% (58.8%-59.3%) 62.9% (62.7%-63.1%) 63.3% (63.0%-63.6%) 57.1% (56.8%-57.3%) 60.3% (60.0%-60.6%) 64.0% (63.7%-64.4%) 57.5% (57.1%-57.9%) 62.7% (62.1%-63.3%) 61.7% (60.9%-62.5%) 63.4% (63.0%-63.8%) 59.0% (58.5%-59.4%) 68.2% (67.7%-68.7%) 60.7% (60.3%-61.0%)

Notes 1

2011-2012 and 2012-2013 data: postcodes mapped to Medicare Locals based on the Commonwealth Department of Health Postal Area to Medicare Local concordance file. Population data adjusted using estimated hysterectomy fractions from the AIHW National Hospital Morbidity Database.

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

Periods covered apply to calendar years.

22 www.medicarelocals.gov.au Victorian Cervical Cytology Registry Statistical Report 2013

Figure 2.3.1: Estimated two year cervical screening rates by Medicare Local, 2012-2013. % PARTICIPATION % PARTICIPATION

ML214

ML216

Less than 50%

ML215

50% - 55%

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

ML211

ML204

65% - 70%

60% - 65%

ML205

65% - 70%

ML201 ML206

Greater than 70%

Greater than 70% ML213

ML203

ML207

ML202 ML208

ML210 ML209

ML217 ML217

INSET: Melbourne andand surrounds INSET: Melbourne surrounds ML214

ML215

ML211

ML216

ML217 ML212 See Inset

ÂŻ

ML210

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.

2.3.2 Participation by Department of Health Region Victoria is divided into eight Department of Health (DH) 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 Department of Health region, 2011-2012 and 2012â&#x20AC;&#x201C;2013. Region Name

2011-20121 % screened (95% CI)

2012-20131 % screened (95% CI)

Barwon-South Western

62.6% (62.3%-62.9%)

63.6% (63.3%-63.9%)

Eastern Metropolitan

62.6% (62.5%-62.8%)

63.0% (62.9%-63.2%)

Gippsland

60.1% (59.7%-60.5%)

60.7% (60.3%-61.0%)

Grampians

57.6% (57.2%-58.0%)

58.6% (58.2%-59.0%)

Hume

62.6% (62.2%-62.9%)

63.2% (62.8%-63.5%)

Loddon Mallee

63.1% (62.8%-63.4%)

63.7% (63.3%-64.0%)

North & West Metropolitan

56.6% (56.5%-56.8%)

56.9% (56.7%-57.0%)

Southern Metropolitan

60.9% (60.8%-61.1%)

61.5% (61.3%-61.6%)

Notes 1

2011-2012 and 2012-2013 data: Participation data by DH region is calculated as an aggregate of LGAs. Postcode / Postal Areas mapped to LGA using a converter algorithm supplied by the Victorian Department of Health and based on ABS Australian Statistical Geography Standard (ASGS) 2011 correspondence data. Population data adjusted using estimated hysterectomy fractions from the AIHW National Hospital Morbidity Database.

Periods covered apply to calendar years.

Figure 2.3.2: Estimated two year cervical screening rates by Department of Health region, 2012-2013.

%%PARTICIPATION PARTICIPATION Less than 50% 50% Less than 50% - 55% 50% - 55% 55% - 60%

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

65% - 70%

Unincorporated Victoria

Greater than 70%

Unincorporated Victoria Loddon Mallee

Grampians

Barwon-South Western

Hume

North & West Eastern Metro Metro Southern Metro

Gippsland

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

Victorian Cervical Cytology Registry Statistical Report 2013

2.3.3 Participation by Local Government Area Within Victoria there are 79 Local Government Areas (LGAs). Using methods discussed at the beginning of Section 2.3, the estimated two year participation rates have been calculated. Table 2.3.3: Estimated two year cervical screening rates by Local Government Area, 2011-2012 and 2012-2013. DH region

LGA Code1

BarwonSouth Western

21750 21830 22410 22750 25490 26080 26260 26490 26730 21110 23670 24210 24410 24970 26980 27450 20740 20830 22110 23810 26170 26810 20260 20570 22490 22910 22980 23190 25150 25810 25990 26890 27630 20110 21010 22830 23350 24250 24850 24900 25620 26430 26670 26700 27170

Eastern Metropolitan

Gippsland

Grampians

Hume

LGA Colac-Otway Corangamite Glenelg Greater Geelong Moyne Queenscliffe Southern Grampians Surf Coast Warrnambool Boroondara Knox Manningham Maroondah Monash Whitehorse Yarra Ranges Bass Coast Baw Baw East Gippsland Latrobe South Gippsland Wellington Ararat Ballarat Golden Plains Hepburn Hindmarsh Horsham Moorabool Northern Grampians Pyrenees West Wimmera Yarriambiack Alpine Benalla Greater Shepparton Indigo Mansfield Mitchell Moira Murrindindi Strathbogie Towong Wangaratta Wodonga

2011â&#x20AC;&#x201C;20122 % screened (95% CI) 62.9% (61.6%-64.2%) 61.6% (60.1%-63.1%) 56.7% (55.3%-58.0%) 62.5% (62.1%-62.9%) 62.2% (60.8%-63.7%) 73.6% (70.4%-76.7%) 61.9% (60.4%-63.3%) 67.7% (66.6%-68.7%) 63.0% (62.0%-64.0%) 67.4% (67.0%-67.8%) 62.7% (62.3%-63.2%) 66.0% (65.5%-66.5%) 60.6% (60.0%-61.1%) 57.9% (57.5%-58.3%) 61.0% (60.6%-61.5%) 63.4% (62.9%-63.8%) 59.0% (57.9%-60.0%) 63.4% (62.5%-64.2%) 62.2% (61.3%-63.0%) 57.5% (56.8%-58.1%) 63.6% (62.5%-64.7%) 58.0% (57.1%-58.9%) 57.2% (55.3%-59.0%) 56.7% (56.2%-57.3%) 62.1% (60.7%-63.4%) 62.7% (61.2%-64.2%) 57.3% (54.7%-59.9%) 60.4% (59.1%-61.7%) 58.1% (57.0%-59.1%) 51.6% (49.8%-53.3%) 55.8% (53.5%-58.1%) 47.7% (44.5%-50.9%) 53.4% (51.0%-55.8%) 67.2% (65.6%-68.9%) 70.3% (68.8%-71.8%) 59.6% (58.8%-60.3%) 67.8% (66.3%-69.2%) 67.0% (65.0%-69.0%) 55.3% (54.3%-56.3%) 56.7% (55.5%-57.8%) 59.6% (58.0%-61.2%) 64.3% (62.4%-66.2%) 67.2% (64.8%-69.6%) 70.3% (69.2%-71.3%) 66.0% (65.0%-66.9%)

2012â&#x20AC;&#x201C;20132 % screened (95% CI) 62.2% (60.9%-63.5%) 63.1% (61.6%-64.6%) 57.7% (56.3%-59.0%) 63.3% (62.9%-63.7%) 63.8% (62.4%-65.3%) 74.7% (71.6%-77.8%) 62.3% (60.8%-63.8%) 68.3% (67.2%-69.3%) 65.3% (64.3%-66.2%) 67.2% (66.8%-67.6%) 62.9% (62.5%-63.4%) 66.4% (65.9%-66.9%) 61.6% (61.1%-62.2%) 58.1% (57.7%-58.5%) 61.0% (60.6%-61.5%) 65.0% (64.5%-65.5%) 60.4% (59.3%-61.4%) 64.9% (64.0%-65.7%) 62.3% (61.4%-63.2%) 58.0% (57.3%-58.7%) 63.6% (62.5%-64.7%) 57.5% (56.6%-58.4%) 55.4% (53.6%-57.3%) 57.1% (56.5%-57.7%) 63.1% (61.8%-64.4%) 61.8% (60.4%-63.3%) 57.6% (55.0%-60.3%) 62.0% (60.7%-63.3%) 62.2% (61.2%-63.2%) 52.0% (50.2%-53.7%) 56.9% (54.6%-59.2%) 54.5% (51.3%-57.7%) 54.9% (52.5%-57.3%) 68.4% (66.8%-70.0%) 71.0% (69.5%-72.5%) 60.3% (59.6%-61.0%) 70.9% (69.5%-72.2%) 66.4% (64.4%-68.4%) 56.0% (55.0%-57.0%) 56.8% (55.7%-58.0%) 61.8% (60.2%-63.4%) 64.1% (62.2%-65.9%) 68.8% (66.5%-71.2%) 70.3% (69.3%-71.4%) 65.9% (65.0%-66.8%)

DH region Loddon Mallee

North & West Metropolitan

Southern Metropolitan

LGA Code1

LGA

21270 21370 21670 22250 22620 23940 24130 24780 25430

Buloke Campaspe Central Goldfields Gannawarra Greater Bendigo Loddon Macedon Ranges Mildura Mount Alexander

2011â&#x20AC;&#x201C;20122 % screened (95% CI) 62.9% (60.5%-65.4%) 63.2% (62.2%-64.2%) 53.1% (51.4%-54.9%) 59.4% (57.5%-61.3%) 62.2% (61.6%-62.8%) 52.9% (50.7%-55.1%) 69.0% (68.2%-69.9%) 61.2% (60.4%-62.0%) 75.5% (74.2%-76.7%)

26610 20660 21180 21890 23110 23270 24330 24600 24650 25060 25250 25710 27070 27260 27350 20910 21450 21610 22170 22310 22670 23430 25340 25900 26350

Swan Hill Banyule Brimbank Darebin Hobsons Bay Hume Maribyrnong Melbourne Melton Moonee Valley Moreland Nillumbik Whittlesea Wyndham Yarra Bayside Cardinia Casey Frankston Glen Eira Greater Dandenong Kingston Mornington Peninsula Port Phillip Stonnington

59.9% (58.5%-61.2%) 65.1% (64.6%-65.6%) 54.6% (54.2%-55.0%) 59.0% (58.5%-59.4%) 60.4% (59.8%-61.0%) 53.6% (53.2%-54.0%) 56.7% (56.0%-57.3%) 45.7% (45.2%-46.2%) 51.7% (51.1%-52.2%) 61.1% (60.6%-61.7%) 58.5% (58.1%-59.0%) 71.5% (70.8%-72.1%) 55.3% (54.8%-55.7%) 49.6% (49.2%-50.1%) 66.2% (65.6%-66.7%) 73.9% (73.4%-74.4%) 57.2% (56.6%-57.9%) 57.3% (56.9%-57.6%) 55.2% (54.7%-55.7%) 64.2% (63.7%-64.6%) 54.6% (54.2%-55.1%) 61.3% (60.9%-61.8%) 63.0% (62.6%-63.5%) 62.9% (62.4%-63.4%) 66.6% (66.1%-67.1%)

2012â&#x20AC;&#x201C;20132 % screened (95% CI) 65.7% (63.2%-68.1%) 63.5% (62.6%-64.5%) 55.2% (53.4%-56.9%) 59.7% (57.8%-61.6%) 62.2% (61.6%-62.7%) 54.5% (52.3%-56.7%) 69.5% (68.7%-70.4%) 61.9% (61.1%-62.7%) 76.3% (75.1%-77.5%) 61.8% (60.5%-63.2%) 65.4% (64.9%-65.9%) 54.9% (54.4%-55.3%) 59.2% (58.7%-59.6%) 61.7% (61.1%-62.3%) 53.5% (53.1%-54.0%) 58.1% (57.5%-58.8%) 44.4% (43.9%-44.9%) 52.8% (52.3%-53.4%) 61.8% (61.3%-62.3%) 59.1% (58.7%-59.6%) 72.6% (71.9%-73.2%) 55.4% (54.9%-55.8%) 50.1% (49.7%-50.5%) 66.0% (65.5%-66.5%) 74.0% (73.5%-74.5%) 58.2% (57.6%-58.9%) 57.7% (57.4%-58.1%) 55.4% (54.9%-55.8%) 64.9% (64.5%-65.4%) 55.2% (54.7%-55.7%) 62.0% (61.5%-62.4%) 65.0% (64.5%-65.5%) 62.7% (62.2%-63.2%) 66.5% (66.0%-67.0%)

Notes 1

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

2 2011-2012 and 2012-2013 data: Postcode/ Postal Areas mapped to LGA using a converter algorithm supplied by the Victorian Department of Health and based on ABS Australian Statistical Geography Standard (ASGS) 2011 correspondence data. Population data adjusted using estimated hysterectomy fractions from the AIHW National Hospital Morbidity Database. 3 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. 4

Periods covered apply to calendar years.

Victorian Cervical Cytology Registry Statistical Report 2013

Figure 2.3.3: Estimated two year cervical screening rates by Local Government Area, 2012-2013.

% PARTICIPATION PARTICIPATION % Less than 50% Less than 50% 50% - 55%

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

Greater than 70%

65% - 70%

Unincorporated Victoria

Greater than 70%

Unincorporated Victoria

INSET: Melbourne and surrounds

See Inset

ÂŻ 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.

2.4 PAP TESTS COLLECTED BY NURSES The credentialling of nurses every three years to perform Pap tests recognises nurses’ expertise and dedication to the Victorian Cervical Screening Program. This process has been set in place to allow nurses to be accountable to the public and responsible for their individual practice while at the same time maintaining a standard of excellence. The credentialling program is coordinated by PapScreen Victoria. In this report, the Registry has included data on Pap tests where nurses are credentialled and funded by the Victorian Department of Health to be eligible for their own ‘practice number’ at VCS Pathology. Also included in this report are Pap tests from nurses using private pathology services. These nurses provide Pap test data to PapScreen Victoria, which is then provided to VCCR for analysis. During 2013, a total of 38,012 Pap tests were collected and reported to the Registry by 437 credentialled nurses. This number represents 6.3% of all Pap tests collected in Victoria during 2013. This figure reflects the significant growth in the role of nurses in cervical screening, with the proportion of Pap tests performed by nurses having steadily increased over the years from an initial reported figure of 0.8% (5,170 tests) in 1996. Table 2.4 shows the number and proportion of Pap tests collected by nurses over the last 10 years.

Table 2.4: Proportion of Pap tests collected by nurses, 2004-2013. Year

Number of Pap tests collected by nurses

% of all Victorian Pap tests

2013

38,012

6.3%

2012

33,875

5.6%

2011

31,613

5.5%

2010

28,546

5.0%

2009

25,594

4.4%

2008

21,668

3.8%

2007

18,651

3.2%

2006

16,035

2.8%

2005

14,375

2.5%

2004

13,100

2.2%

Nurse Pap test data highlight the increasingly important role that nurses have in the delivery of the Victorian Cervical Screening Program, particularly in relation to the increasing number of Pap tests collected by nurses in recent years and the high quality of their tests. As observed in recent years, Pap tests collected by nurses are more likely to have an endocervical component, which is considered to be a reflection of test quality.23 General Practice and Community Health settings remain the main types of practices where nurses collect Pap tests (83.3% of practice types in 2013).24 During 2013, 40.2% of the Pap tests collected by nurses were from women over 50 years of age compared with 32.5% collected by other provider types in Victoria during this period.25

23 VCCR Evaluation of Pap tests collected by Nurses in Victoria during 2013 report, p. 8. Available from: http://www.vccr.org/data-research/statistical-reports/annual-nurse-reports 24 Ibid p. 4. 25 Ibid p. 6. Victorian Cervical Cytology Registry Statistical Report 2013

2.4.1 Proportion of Pap tests collected by nurses by Department of Health Region Data on Pap tests collected by nurses were analysed by Department of Health (DH) region.26 The following table and figure show that the rural DH regions had a higher proportion of tests collected by nurses, for women with a cervix, than those within metropolitan Melbourne. Between 2012 and 2013 the proportion of Pap tests collected by nurses increased across the BarwonSouth Western, Eastern Metropolitan, Gippsland and Southern Metropolitan regions. The largest changes between 2012 and 2013 were for the Barwon-South Western region (0.7% increase) and the Loddon Mallee region (1.0% decrease).

Table 2.4.1: Pap tests for women with a cervix collected by nurses, by Department of Health region, 20131. Region name

Number of Pap tests collected by nurses in 20132

Number of nurses in region in 2013 3

% Pap tests in region collected by nurses in 2012

% Pap tests in region collected by nurses in 2013

Barwon-South Western

4,069

10.7%

11.4%

Eastern Metropolitan

2,318

2.1%

2.2%

Gippsland

2,517

9.9%

10.5%

Grampians

3,835

19.7%

19.1%

Hume

3,559

14.8%

14.3%

Loddon Mallee

6,620

23.2%

22.2%

North & West Metropolitan

6,899

4.1%

3.9%

Southern Metropolitan

3,237

2.0%

2.3%

Notes 1

The 4,558 Pap tests from nurses using private pathology services are not included in these statistics as postcode is not collected.

2 Excludes 326 post-hysterectomy Pap tests, 6 interstate postcodes, 68 women where postcode was missing or not able to be matched and 4,558 Pap tests submitted to PapScreen Victoria where postcode data is not collected. 3 Excludes eight nurses whose postcode could not be matched, 36 nurses who do not collect postcode data when submitted to PapScreen Victoria and one nurse who performed only one Pap test on a woman who did not have a cervix.

26 VCCR Evaluation of Pap tests collected by Nurses in Victoria during 2013 report, p 7. Available from: http://www.vccr.org/data-research/statistical-reports/annual-nurse-reports 20

Figure 2.4.1: Proportion of Pap tests collected by nurses, by Department of Health region, 2013.

% PARTICIPATION Less than 5% 5% - 10%

% PARTICIPATION Less than 5%

10% - 15%

5% - 10%

15% - 20%

10% - 15%

Greater than 20% Unincorporated Victoria

15% - 20% Greater than 20%

Unincorporated Victoria Loddon Mallee

Grampians

Barwon-South Western

Hume

North Eastern & West Metro Metro Southern Metro

Gippsland

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

Victorian Cervical Cytology Registry Statistical Report 2013

2.5 CLOSING THE DATA GAPS: IDENTIFYING ABORIGINAL AND TORRES STRAIT ISLANDER PEOPLE, AND COLLECTING COUNTRY OF BIRTH AND LANGUAGE SPOKEN AT HOME Data from the AIHW has shown that Aboriginal and Torres Strait Islander women are five times more likely to die of cervical cancer than non-Aboriginal and Torres Strait Islander women.27 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.28 Women from Culturally and Linguistically Diverse (CALD) backgrounds have also been identified as an under-screened group.29 Strategies for engaging with Aboriginal and Torres Strait Islander and CALD women, and increasing participation, are a priority for the Victorian Department of Health as outlined in the Victorian Public Health and Well Being Plan 2011-2015 and the previous governments’ Victorian Cancer Action Plan (2008-2011). Where provided by practitioners, laboratories, and directly by women through updates of personal information, the VCCR will record if a woman has identified as an Aboriginal or Torres Strait Islander person, as well as her country of birth and language spoken at home, as indicators of cultural diversity.

VCCR is working closely with Program Partners including the Department of Health, PapScreen Victoria and VCS Pathology to improve the identification of Aboriginal and Torres Strait Islander women and the ongoing collection and reporting of CALD data to the Registry. VCS Pathology continues to work with nurses who collect Pap tests, to support and encourage the identification of Aboriginal and Torres Strait Islander women and the recording of this information on the VCS Pathology Request Forms. Of all practitioner types, nurses have the highest rate of reporting these data, with 96.8% of Pap tests collected during 2013 including this information. Table 2.5.2 shows the 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: Proportion of Pap Tests by Practitioner Type with Aboriginal and Torres Strait Islander status information recorded, 2013. Practitioner Type

Aboriginal and Torres Strait Islander Women

General Practitioner

In 2013 the overall percentage of women screened who had their Aboriginal and/or Torres Strait Islander status recorded by the VCCR was 21.8% (n= 124,964). Table 2.5.1 shows the number of women by their identification as an Aboriginal or Torres Strait Islander person, and the proportion for those whom data was collected.

Hospital

Table 2.5.1: Reporting of Aboriginal and Torres Strait Islander status of women during 2013. Status

Aboriginal

Number

% of those with status collected (124,964)

1,134

0.91%

Torres Strait Islander

0.03%

Aboriginal & Torres Strait Islander

151

0.12%

Not Aboriginal & Torres Strait Islander

123,637

98.94%

< 0.01%

Total number of women with status reported

124,964

100%

Number of women where status was not reported

446,594

Declined to answer

Number

77,452

16.3%

1,449

19.4%

Nurse

36,808

96.8%

Obstetrician & Gynaecologist

15,621

20.1%

518

23.3%

Other

Culturally and Linguistically Diverse (CALD) women In 2013 the overall percentage of women screened who had a country of birth recorded by the VCCR was 17.4%. The most common countries of birth outside of Australia were Vietnam, England, New Zealand, United Kingdom (includes Channel Islands and Isle of Man),30 China, India, Italy, Philippines, Greece and Malaysia. The overall percentage of women screened during 2013 who had language spoken at home recorded was 18.1%. The most common languages reported, other than English, were Vietnamese, Greek, Italian, Mandarin, Arabic, Chinese (not elsewhere classified), Spanish, Cantonese, French and Maltese.

27 Australian Institute of Health and Welfare, Cervical cancer rates at all-time low media release http://www.aihw.gov.au/media-release-detail/?id=10737420434, viewed 28 October 2014. 28 Council of Australian Governments, Closing the Gap in Indigenous Disadvantage website. https://www.coag.gov.au/closing_the_gap_in_indigenous_disadvantage, viewed 28 October 2014. 29 Mullins R Anti Cancer Council Victoria, Evaluation of the impact of PapScreen’s Campaign on Culturally and Linguistically Diverse (CALD) Women, 2006. Available here: http://www.cancervic.org.au/downloads/cbrc_research_papers/Cervical_cancer_research/06rep_rm_eval_PapScreen_campaign_ CALD_women.pdf 30 United Kingdom (includes Channel Islands and Isle of Man) is assigned when the Country of Birth is not further specified. 22

2.6 FREQUENCY OF EARLY RE-SCREENING

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 VCCR within 36 months of the index Pap test were excluded. This is in line with the national reporting of indicators by the AIHW for the same period and is also consistent with the NHMRC Guidelines. Table 2.6 shows the number of subsequent Pap tests over a 21 month period for women who received a negative Pap test report in February of 2012. These data show that 87.3% of women aged 20 to 69 years who had a negative Pap test in February 2012 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 Pap tests, indicating a decreasing rate of early re-screening. As seen in Figure 2.6, some variation in early re-screening occurs by age group. The graph shows the proportion of women, by age group, who had early re-screening after a negative Pap test report in February 2012.

Table 2.6: Subsequent Pap tests over a 21 month period for women with a negative test in February of 2012. Number of subsequent Pap tests since February 2012

No further tests

87.3%

12.2%

0.4%

< 0.1%

< 0.01%

5 or more

< 0.01%

Figure 2.6 : Percentage of women by age group who re-screened early after a negative Pap test in February 2012. 16 14 Early re-screening (%)

While the Australian screening policy recommends screening every two years after a negative Pap test report, a proportion of women are screened more frequently. A small level of early re-screening can be justified on the basis of a past history of abnormality.

12 10 8 6 4 2 0 20-29 yrs

30-39 yrs

40-49 yrs

50-59 yrs

60-69 yrs

Age Group

Victorian Cervical Cytology Registry Statistical Report 2013

3. CYTOLOGY REPORTS

Cytology reports received by the VCCR are coded according to the 2006 Cytology Coding Schedule (refer to Appendix 1). From this coding, Pap test results are categorised into the broader groups of unsatisfactory, negative, having no endocervical component, and having a squamous abnormality or endocervical abnormality. These groupings are consistent with the cytology result types reported to the AIHW for the national indicators for the same period. For this analysis, the results of 591,495 Pap tests from any provider type were considered. These include Pap tests which were collected during 2013, from women of any age, but exclude post-hysterectomy smears (also referred to as vault smears).

3.3 PAP TESTS WITHOUT AN ENDOCERVICAL COMPONENT 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 2013 by the VCCR, 159,037 were recorded as not having an ECC present in the specimen. This equates to 26.9% of Pap tests. As illustrated in Figure 3.3, the proportion of Pap tests without an ECC has gradually increased from 19.7% in 2004 to 26.9% in 2013 (p < 0.0001).

3.1 UNSATISFACTORY PAP TESTS An unsatisfactory Pap test result is defined as having: â&#x20AC;˘ unsatisfactory squamous cells (SU) and unsatisfactory endocervical cells (EU); or â&#x20AC;˘ unsatisfactory squamous cells (SU) and no endocervical cells (E0) or no endocervical abnormality (E1). Of Pap test results received during 2013 by the VCCR, 15,931 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. 31

3.2 NEGATIVE PAP TESTS A negative Pap test result is defined as having squamous cells with no abnormality (S1) and no endocervical cells (E0) or no endocervical abnormality (E1). Of the Pap test results received during 2013 by the VCCR, 534,092 were recorded as having a negative result. This equates to 90.3% of Pap tests.

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. Rates of histologically-confirmed highgrade cervical abnormality (HGA) and cancer in women with negative Pap tests with and without an ECC were estimated. Women 18 to 69 years with at least two Pap tests between 1 January 2001 and 31 December 2010 with the first test in that period (index smear) showing no abnormality were eligible. The incidence rate of histologically-confirmed HGA was significantly lower following ECC- tests than after ECC+ tests (adjusted IRR: 0.69, 95% Confidence Interval (CI) 0.62-0.77), particularly at older ages (interaction between ECC status and age, p=0.001). In contrast, the overall rate of invasive cancer was not significantly different after ECCthan after ECC+ tests (IRR: 1.27, 95% CI 0.90-1.77). This study confirms that women without ECC had a lower rate of confirmed HGA and no significant increase in the rate of invasive cervical cancer following ECC- tests. This study does not support differential (accelerated) follow-up in women with a negative test without an endocervical component. 32

Figure 3.3: Percentage of Pap tests without an endocervical component, 2004-2013.

Percentage

25 20 15 10 5 0 2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

Year 31 National Pathology Accreditation Advisory Council (NPAAC) 2006. Performance Measures for Australian Laboratories Reporting Cervical Cytology, Canberra: Department of Health and Ageing. 32 Sultana F, English DR, Simpson JA, Canfell K, Gertig DM, Saville M. 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. 24

3.4 PAP TESTS WITH A SQUAMOUS ABNORMALITY

3.5 PAP TESTS WITH AN ENDOCERVICAL ABNORMALITY

As seen in table 3.4, the number of Pap tests collected during 2013 with a squamous cell abnormality (an abnormality of possible low-grade lesion or worse) was 41,105, which equates to 6.9% 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 0.7% in 2013.

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.

Table 3.4: Number and percent of Pap tests collected in 2013 with a squamous abnormality. Squamous Cell Code

Number of Pap tests

% of Pap tests

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

21,275

3.6%

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

10,917

1.9%

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

4,522

0.8%

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

4,274

0.7%

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

< 0.1%

Squamous carcinoma (S7)

< 0.01%

The following table shows the proportion of Pap tests for 2013 where an endocervical abnormality was detected. Pap tests which are known to have been collected posthysterectomy are excluded. For 2013, the total number of Pap tests with an endocervical abnormality (atypical endocervical cells of uncertain significance or worse) was 551, 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 2013 with an endocervical abnormality. Endocervical Component Code

Number of Pap tests

% of Pap tests

Atypical endocervical cells of uncertain significance (E2)

276

< 0.1%

Possible high-grade endocervical glandular lesion (E3)

166

< 0.1%

Adenocarcinoma in situ (E4)

< 0.1%

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

< 0.01%

Adenocarcinoma (E6)

< 0.01%

3.6 TYPE OF TESTS As per the Cytology Coding Schedule (Appendix 1), the VCCR records the type of Pap test taken; that is, conventional cytology (A1), liquid-based specimen (A2) or combination (A3). During 2013 the proportion of liquid-based tests was 4.0% of all tests reported to the Registry. Nearly all of these tests were â&#x20AC;&#x153;split samplesâ&#x20AC;?, where the conventional Pap smear is accompanied by the liquid-based specimen. Very small numbers were liquid-based specimens only (0.2%).

Victorian Cervical Cytology Registry Statistical Report 2013

4. HISTOLOGY REPORTS

This section describes the histology reports that were notified to the VCCR during 2013. Although the reporting of histology results is not mandatory, the majority of all relevant cervical biopsies are reported to the VCCR. All cancers are notified to the Victorian Cancer Registry by laboratories, hospitals and the VCCR. In 2013, there were 21,183 histology reports relating to the cervix received by the VCCR. The following table shows the distribution of histology findings for 2013. Note that data presented in Table 4 include 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 2013. Histology finding1

Squamous abnormality

Squamous cell carcinoma, invasive

0.4%

Squamous cell carcinoma, micro-invasive

0.1%

High-grade squamous abnormality, CIN III

2,763

13.0%

High-grade squamous abnormality, CIN II

2,029

9.6%

203

1.0%

High-grade squamous abnormality, CIN not otherwise specified Low-grade squamous abnormality

Endocervical abnormality

Number

3,369

15.9%

Adenosquamous carcinoma

< 0.1%

Endocervical adenocarcinoma, invasive

0.2%

Endocervical adenocarcinoma, micro-invasive

< 0.1%

High-grade carcinoma in situ / adenocarcinoma in situ

0.3%

High-grade endocervical abnormality, adenocarcinoma in situ

0.5%

High-grade endocervical abnormality, endocervical dysplasia

0.1%

Endocervical atypia

< 0.1%

12,180

57.5%

273

1.3%

21,183

100%

Carcinoma of the cervix â&#x20AC;&#x201C; other2 Benign changes / normal Unsatisfactory TOTAL Notes

The number of histology reports notified to the VCCR as at 9 May 2014.

Carcinoma of the cervix â&#x20AC;&#x201C; other: includes small cell carcinoma and other malignant lesions (may include tumours of non-epithelial origin).

5. HIGH-GRADE ABNORMALITY DETECTION RATES

In 2013 the overall rate of histologically-confirmed highgrade abnormalities detected in Victoria for women aged 20 to 69 years was 7.33 per 1,000 women screened.33 Figure 5.1 illustrates the detection rate of histologicallyconfirmed high-grade intraepithelial abnormalities per 1,000 screened women for each year from 2009 to 2013 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. Notable in these data are the yearon-year declines in the rate for the youngest women (aged 20 to 24 years), corresponding to the implementation of the HPV vaccination program between 2007 and 2009. Historically this age group had the highest rates of abnormalities but from 2009 the rate has been higher amongst 25 to 29 year olds. Since 2008, the rate in 20 to 24 year olds has fallen from 21.1 (not shown in figure) to 13.5 per 1,000 in 2013 (p < 0.0001) (2009=18.7; 2010=17.9; 2011=15.8; 2012=15.3). The youngest vaccinated women, who are less likely to have been infected with high-risk HPV types through sexual activity, are now commencing cervical screening (18 year old women in 2013 were aged 12 in 2007, the first year of the HPV vaccination program). Interestingly, following an underlying trend of increases in incidence, the high-grade detection rate for 25 to 29 year old women for 2013 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). 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.

According to the National HPV Vaccination Program Register, Victorian women aged 15 to 19 years in 2013 have a notified three-dose vaccine coverage of 72.7%, those aged 20 to 24 years have a notified coverage of 57.7% and those aged 25 to 29 years have a notified coverage of 32.2% (NHVPR, unpublished data). Figure 5.2 shows the rate of histologically-confirmed highgrade cervical abnormalities 34 by year since 2000, for young women (< 20 years, 20 to 24 years, 25 to 29 years) and those 30+ years of age. The previously noted decline (following the implementation of the National HPV Vaccination Program between 2007-2009) in women under 20 years of age is continuing, with the rate more than halving from 11 cases per 1,000 women screened in 2006 down to 5 cases per 1,000 in 2013 (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. The VCS and the AIHW undertook an analysis of de-identified linked data from the VCCR and the NHVPR to determine whether the declines observed in high-grade abnormality rates amongst young women (aged 12 to 17 years in 2007) since the vaccination program are due to vaccination. The analysis confirmed that, through to the end of 2011, vaccinated women attending screening had a significantly lower rate of high-grade abnormalities than unvaccinated women, after adjusting for age, socioeconomic status and area of residence (Hazard Ratio 0.72 (95%CI 0.58-0.91) for receipt of any number of doses of HPV vaccine). This was the first international evidence of the effectiveness of HPV vaccination in preventing high-grade cervical abnormalities in a population. 35 Figure 5.2: Trends in high-grade cervical abnormalities (histologicallyconfirmed) by age, 2000-2013, as recorded on the VCCR.

Figure 5.1: Detection rate of high-grade intraepithelial abnormalities (histologically-confirmed) from 2009-2013 per 1,000 screened women. 2009 2010 2011 2012 2013

Rate per 1,000 screened women

18 16 14 12 10 8 6

Rate per 1,000 screened women

5 0

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013

Year

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

Age Group

<20 yrs

20-24 yrs

25-29 yrs

30+ yrs

Note 1 30+yrs includes all women aged 30 years or older and is not restricted to 30-69 years.

33 Note that the method used to calculate the rate of high-grade abnormalities is consistent with the AIHW indicator 4.2 (Australian Institute of Health and Welfare 2014. Cervical screening in Australia 2011â&#x20AC;&#x201C;2012. Cancer series no.82. Cat. no. CAN 79. Canberra: AIHW). 34 Ibid. 35 Gertig DM, Brotherton JML, Budd AC, Drennan K, Chappell G, Saville AM. Impact of a population-based HPV vaccination program on cervical abnormalities: a data linkage study. BMC Medicine 2013, 11:227.

Victorian Cervical Cytology Registry Statistical Report 2013

6. CORRELATION BETWEEN CYTOLOGY & HISTOLOGY REPORTS Tables 6.1 and 6.2 show the correlation between cytology results and histology findings. The correlation is restricted to cytology performed in 2012 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, for squamous and endocervical abnormalities. The histology classification and method of correlation presented is consistent with the AIHW national reporting indicators. It is based on the test, not the woman, and these data include women aged 20 to 69 years. They also include the records of women who reside outside of Victoria but have data recorded on the VCCR.

There was one case of micro-invasive cervical cancer reported on histology within six months of a low-grade squamous cytology in 2012, and none of invasive cervical cancer (Table 6.1). 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 NHMRC Guidelines 37 recommend colposcopy as an initial evaluation because of the risk of invasive cancer. 38 Of the 28 cytology reports of ‘atypical endocervical or glandular cells of undetermined significance’, five of those who underwent histological evaluation were subsequently diagnosed with invasive cancer (where histology was available within six months after the cytology result).

Where a definite high-grade squamous cytology result was reported, 78.7% (2,999/3,811) of women were subsequently diagnosed with high-grade histology at biopsy (including high-grade CIN not otherwise specified, CINII, CINIII and micro-invasive and invasive squamous carcinoma). This figure represents the positive predictive value of a highgrade 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 is confirmed on histology within six months as having a high-grade abnormality or cancer. 36

36 National Pathology Accreditation Advisory Council (NPAAC) 2006. Performance Measures for Australian Laboratories Reporting Cervical Cytology, Canberra: Department of Health and Ageing. 37 NHMRC Screening to prevent cervical cancer: guidelines for the management of asymptomatic women with screen-detected abnormalities, 2005. http://www.nhmrc.gov.au/publications/synopses/wh39syn.htm, viewed 28 October 2014. 38 Mitchell HS. Outcome after a cytological prediction of glandular abnormality. Aust NZJ Obstet Gynaecol. 2004 Oct;44(5):436-40. 28

Table 6.1: Correlation of squamous cytology to the most serious squamous histology within six months, women aged 20 to 69 years, for cytology tests performed in 20121. Cytology Prediction (based on squamous cell code) Negative2

Possible Low-Grade

Low-Grade

Possible High-Grade3

High-Grade4

High-Grade with possible micro-invasion / invasion5

SCC5

Histology finding

Squamous Abnormality

Negative HS01

3,626

78.7%

1,598

51.4%

808

32.6%

920

29.4%

396

10.4%

2.8%

5.6%

Low-grade abnormality HS02

750

16.3%

1,089

35.0%

1,199

48.4%

679

21.7%

416

10.9%

4.2%

0.0%

High-grade abnormality CIN not otherwise specified HS03.1

0.3%

1.0%

1.3%

1.9%

1.8%

1.4%

0.0%

High-grade abnormality CIN II HS03.2

123

2.7%

242

7.8%

311

12.5%

630

20.2%

866

22.7%

5.6%

0.0%

High-grade abnormality CIN III HS03.3

1.9%

149

4.8%

128

5.2%

821

26.3%

2,005

52.6%

62.0%

19.4%

Squamous Cell Carcinoma â&#x20AC;&#x201C; micro-invasive HS04.1

0.1%

0.0%

< 0.1%

0.1%

0.5%

4.2%

13.9%

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

< 0.1%

0.0%

0.3%

1.1%

19.7%

61.1%

4,605

100%

3,110

100%

2,479

100%

3,124

100%

3,811

100%

Totals Notes

1 The correlation excludes diagnosis based on colposcopic impression alone. 2

Negative cytology: no abnormal squamous cells or only reactive changes.

Possible high-grade cytology: includes possible high-grade squamous intraepithelial lesion.

High-grade cytology: includes high-grade squamous intraepithelial lesion.

SCC: Squamous cell carcinoma.

Victorian Cervical Cytology Registry Statistical Report 2013

Table 6.2: Correlation of endocervical cytology to the most serious endocervical histology within six months, women aged 20 to 69 years, for cytology tests performed in 20121. Cytology Prediction Negative

Atypical Endocervical cells of unknown significance5

Possible High-Grade6

AIS2

Histology finding

Endocervical Abnormality

Negative HE01

AIS2 with Adenocarcinoma possible micro-invasion / invasion E5

1,884

94.5%

25.0%

8.7%

0.0%

Endocervical Atypia HE02

0.0%

High-grade Endocervical Abnormality, Endocervical Dysplasia HE03.1

0.3%

0.0%

1.6%

0.0%

High-grade Endocervical Abnormality, AIS2 HE03.2

1.4%

42.9%

54.3%

50.8%

12.5%

14.3%

High-grade Carcinoma in situ / AIS2 HE03.3

2.3%

14.3%

19.6%

18.0%

37.5%

0.0%

Endocervical Adenocarcinoma – micro-invasive HE04.1

0.1%

0.0%

6.6%

12.5%

14.3%

Endocervical Adenocarcinoma – invasive3 HE04.2

0.9%

17.9%

15.2%

21.3%

37.5%

57.1%

Adenosquamous Carcinoma HE04.3

0.2%

0.0%

2.2%

1.6%

0.0%

Carcinoma of the cervix – Other4 HE04.4

0.4%

0.0%

14.3%

1,994

100%

Totals Notes

1 The correlation excludes diagnosis based on colposcopic impression alone.

AIS: Adenocarcinoma in situ.

Endocervical adenocarcinoma – invasive: includes adenocarcinoma and embryonal/clear cell carcinoma.

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

Glandular cytology: includes atypical glandular cells of uncertain significance (E2).

Possible high-grade cytology: includes possible high-grade endocervical glandular lesion.

7. FOLLOW UP & REMINDER PROGRAM

The VCCR Reminder and Follow-up Protocol (refer to Appendix 2) adheres to the 2006 NHMRC Guidelines. As part of the follow-up service provided by VCCR, a total of 410,544 follow-up and reminder letters were mailed to women and practitioners in 2013. 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 2012 to 30 June 2013, the Department of Health has extended the funding for the second reminder initiative until June 2015. The following is a summary of the VCCR follow-up activities during 2013. First Reminders to Women Between 1 January 2013 and 31 December 2013, 275,187 first reminder letters were sent to women in the categories shown in Table 7. Of the 261,640 reminders sent after a negative Pap test, 108,506 (41%) women had a subsequent Pap test within three months of the date of the reminder. Second Reminders to Women

Follow-up During 2013, the VCCR sent out 1,788 questionnaires to practitioners seeking further information after a high-grade abnormality on Pap test and 4,692 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 13,362 reminder letters to practitioners, following low-grade or unsatisfactory Pap tests. During the year, 758 women with a high-grade abnormality required further follow-up by the VCCR as no further information had been received by 5.5 months after their Pap test. For these women, at least one phone call to the practitioner was made to ascertain follow-up, with many requiring additional calls. In 359 cases, the Registry sent letters to these women, mostly by registered mail to ensure that they were aware of their abnormality. In 2013, 8,701 Victorian women had a high-grade abnormality reported on one or more of their Pap tests, 7,725 (89%) of whom were followed up with colposcopy and/or biopsy within the following six to nine months. A further 677 (8%) women with high-grade abnormalities predicted on their Pap tests in 2013 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, 2,269 letters were sent to these women in 2013. The VCCR followed up 167 non-cervical abnormalities with letters to the practitioners seeking information about further investigations.

Between 1 January 2013 and 31 December 2013, 111,962 second reminder letters were sent to women, in the categories shown in Table 7. Of the 106,585 reminders sent after a negative Pap test, 25,683 (24%) women had a subsequent Pap test within three months of the date of the reminder. Table 7: Number of first and second reminder letters sent to women by the VCCR in 2013.

Most recent Pap test report category High-grade with subsequent biopsy High-grade no subsequent Pap test by 12 months Low-grade – with subsequent biopsy or colposcopy

First Reminders

Second Reminders

1,161

452

134

1,726

643

Low-grade – previous test abnormal or fluctuating abnormality

779

301

Low-grade – over 30 with no negative cytology in previous 3 years

583

289

Low-grade – all other women

5,738

2,045

Negative with previous abnormal

24,669

10,402

Negative

236,971

96,183

144

3,282

1,528

Unsatisfactory with previous abnormal Unsatisfactory

Victorian Cervical Cytology Registry Statistical Report 2013

8. CERVICAL CANCER INCIDENCE & MORTALITY IN VICTORIA The aim of the cervical cancer screening program is to reduce the incidence of and mortality from cervical cancer. Data on cancer incidence and mortality are collected by the Victorian Cancer Registry and notifications are compulsory from laboratories, hospitals and the VCCR. During 2013, 168 cases of cervical cancer (all types) were reported to the Victorian Cancer Registry, and 43 Victorian women died due to cervical cancer. Figure 8.1 shows the incidence and mortality rates from cervical cancer in Victoria from 1982 to 2013. 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 was followed by a subsequent decline to 4.3 per 100,000 women during 2013. 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. 39 The mortality rate for all types of cervical cancer in 2013 was 1.0 per 100,000 Victorian women (2011: 1.1 and 2012: 1.1).

Figure 8.2 shows the age-standardised incidence rates for cervical cancer by histological subtype over time. The greatest impact of the cervical screening program has been on squamous cell carcinoma of the cervix, with age-standardised incidence rates declining from 6.3 per 100,000 women in 1989 to 1.5 per 100,000 in 2013. Incidence rates for micro-invasive cancer have increased slightly since 2000; and in 2013 were 1.3 per 100,000 women screened (2010: 1.2, 2011: 1.1 and 2012: 1.1). Cervical screening is less effective for the detection of adenocarcinomas, 40 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 2011 to 2013. The age-specific incidence of invasive squamous cervical cancer increases in the 30 to 34 year old age group to peak at age 45 to 49 years, followed by a subsequent peak in women aged in their early 70s. Micro-invasive cervical cancer peaks at around 30 years of age and declines steadily thereafter.

Figure 8.1: Age-standardised incidence and mortality rates for all types of cervical cancer in Victoria, 1982-2013.

Rate per 100,000 women

(age-standardised to the World Standard Population)

Incidence Mortality

10 8 6 4 2

19 8 19 2 83 19 8 19 4 8 19 5 86 19 8 19 7 8 19 8 8 19 9 9 19 0 9 19 1 92 19 9 19 3 9 19 4 95 19 9 19 6 9 19 7 9 19 8 99 20 0 20 0 0 20 1 0 20 2 0 20 3 0 20 4 0 20 5 0 20 6 0 20 7 08 20 0 20 9 1 20 0 1 20 1 1 20 2 13

Year Source: Thursfield V, et al. Cancer in Victoria: Statistics and trends 2013. Cancer Council Victoria, Melbourne 2014.

39 GLOBOCAN 2012: Estimated Cancer Incidence, Mortality and Prevalence Worldwide in 2012, online analysis. http://globocan.iarc.fr/Pages/online.aspx, viewed 28 October 2014. 40 NHMRC Screening to prevent cervical cancer: guidelines for the management of asymptomatic women with screen-detected abnormalities, 2005. http://www.nhmrc.gov.au/publications/synopses/wh39syn.htm, viewed 28 October 2014. 32

Figure 8.2: Age-standardised incidence rates for cervical cancer by histological subtype in Victoria, 1982-2013.

Rate per 100,000 women

(age-standardised to the World Standard Population)

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

7 6 5 4 3 2 1

19 8 19 2 83 19 8 19 4 8 19 5 8 19 6 8 19 7 88 19 8 19 9 9 19 0 9 19 1 92 19 9 19 3 9 19 4 95 19 9 19 6 97 19 9 19 8 99 20 0 20 0 0 20 1 02 20 0 20 3 0 20 4 0 20 5 06 20 0 20 7 08 20 0 20 9 1 20 0 1 20 1 12 20 13

Year Other cervical cancers are comprised of all other types, including adenocarcinomas. Source: Thursfield V, et al. Cancer in Victoria: Statistics and trends 2013. Cancer Council Victoria, Melbourne 2014.

Figure 8.3: Age-specific incidence rates of cervical cancer by histological subtype in Victoria, 2011-2013.

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

Rate per 100,000 women

10 8 6 4 2 0 0-4 yrs

5-9 yrs

10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84 85+ yrs yrs yrs yrs yrs yrs yrs yrs yrs yrs yrs yrs yrs yrs yrs yrs

Age Group Other cervical cancers are comprised of all other types, including adenocarcinomas. Source: Thursfield V, et al. Cancer in Victoria: Statistics and trends 2013. Cancer Council Victoria, Melbourne 2014.

Victorian Cervical Cytology Registry Statistical Report 2013

9. SCREENING HISTORY OF WOMEN DIAGNOSED WITH CERVICAL CANCER IN 2012

A. never screened (coverage failure), B. lapsed screening: with more than two and a half years between the cancer diagnosis and the ultimate Pap test, C. adequately screened (screening failure): with less than two and a half years between the cancer diagnosis and the ultimate Pap test, D. delayed diagnosis: eg. no colposcopy and/or biopsy recorded [biopsy, management or treatment failure], E. other 4

According to the Victorian Cancer Registry (VCR), 213 Victorian women were diagnosed with cervical cancer in 2012 (January 1-December 31). Of these women, 106 were diagnosed with invasive squamous cell carcinoma, 37 with micro-invasive squamous cell cancer and 70 with other types of invasive cervical cancer (including adenocarcinoma, small cell carcinoma, mixed adenosquamous adenocarcinoma and carcinosarcoma/ sarcoma). 41 During 2012, 168 women were recorded on the Victorian Cervical Cytology Registry (VCCR) as having a histologicallyconfirmed invasive or micro-invasive cervical cancer, with 143 having an invasive cancer diagnosis (squamous or other type) and 25 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. 42 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:

Table 9: Screening history of Victorian women diagnosed with cervical cancer for the period 1 January 2012 to 31 December 2012. Screening History

Invasive squamous cell carcinoma Number %

A. N ever Screened

44%

Other invasive cervical cancer Number % 33

47%

Invasive sub-total Number % 80

45%

Micro-invasive Number % 20

54%

Invasive and micro-invasive Number % 100

47%

Never Screened, recorded on the VCCR

33%

17%

27%

22%

26%

Never Screened, estimated to not be recorded on VCCR2

11%

30%

19%

32%

21%

B. Lapsed Screeners

39%

24%

33%

19%

31%

Lapsed Screener, > 2.5 yrs

Lapsed Screener, > 3.5 yrs

Lapsed Screener, > 5.5 yrs

14%

11%

13%

11%

Lapsed Screener, > 10 yrs Lapsed Screener, > 18 months

C. A dequately Screened (last screen within 2.5 years)

13%

23%

17%

22%

18%

D. Delayed Diagnosis

E. Other

106

100%

176

100%

213

100%

Total Notes

1 Woman recorded on the VCCR but has no screening history prior to diagnosis (ie: within six months of diagnosis). 2

Estimated remaining number of women, not accounted for on the VCCR (ie: VCR-VCCR).

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

Other: symptomatic woman, not followed up.

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

Table 9 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 2012, 80 (45%) 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 58 women (33%) 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 58 women who are lapsed screeners, 23 (40%) did not have a screening test within ten years of their diagnosis.

Taken together, the data above for “never screened” women and “lapsed screeners” indicate that, for invasive cervical cancers diagnosed during 2012:

• 8 3% of women with invasive squamous cell cancer had no screening history or had a lapsed screening history.

• 71% 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, 30 (17%) women 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. Just over half of these women 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), seven (4%) women appear to have had a delayed diagnosis or management failure on the limited information available to the VCCR.

Victorian Cervical Cytology Registry Statistical Report 2013

ACKNOWLEDGEMENTS

The production of this report would not be possible without the co-operation of the staff of the pathology laboratories of Victoria, the staff of the VCCR and the Victorian Cytology Service Information & Communication Technology team. Very sincere thanks are extended to the members of all these groups. In particular, special thanks go to the dedicated VCCR staff for their collection of high-quality information and the provision of an excellent service for women and health practitioners. The figures on incidence and mortality from cervical cancer were kindly provided by the Victorian Cancer Registry at the Cancer Council Victoria. We would like to thank Vicky Thursfield and Helen Farrugia for their assistance in providing these data.

LIST OF ABBREVIATIONS ABS:

Australian Bureau of Statistics

AIHW:

Australian Institute of Health and Welfare

CIN:

Cervical Intraepithelial Neoplasia

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 Inc.

GLOSSARY 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. Cervix – The neck of the uterus (womb), located at the top of the vagina. Colposcopy – A detailed examination of the lower genital tract with a magnifying instrument called a colposcope. This method of non-invasive evaluation allows the clinician to more accurately assess a cytologic abnormality by focusing on the areas of greatest abnormality and by sampling them with a biopsy to obtain a tissue diagnosis. Cytology – The microscope evaluation of a sample of cells obtained from a tissue (or body 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 (Australian Institute of Health and Welfare, 2008. Australia’s health 2008. Cat. no. AUS 99. Canberra: AIHW, p 557) 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 – 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 tests (or smear) – Simple procedure in which a number of cells are collected from the cervix, smeared onto a microscope slide and sent to a laboratory for cytological examination to look for changes that might lead to cervical cancer. Named after the test’s inventor, Dr Papanicolaou. Pathology – Laboratory-based study of disease, as opposed to clinical examination of systems. 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.

43 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 HMRC Screening to prevent cervical cancer: guidelines for the management of asymptomatic women with screen-detected abnormalities, 2005. http://www.nhmrc.gov.au/publications/synopses/wh39syn.htm, viewed 28 October 2014. Victorian Cervical Cytology Registry Statistical Report 2013

RECOMMENDATION

CYTOLOGY

SPECIMEN

APPENDIX 1. CYTOLOGY CODING SCHEDULE

Type

AØ Not stated

A1 Conventional smear

A2 Liquid based specimen

A3 Conventional and liquid based specimen

Site

BØ Not stated

B1 Cervical

B2 Vaginal

B3 Other gynaecological site

Squamous Cell

Endocervical

Other/Non-cervical

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

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

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

E-

Not applicable: vault smear / previous hysterectomy

No other abnormal cells

Possible low-grade squamous intraepithelial lesion (LSIL)

EØ

No endocervical component

Atypical endometrial cells of uncertain significance

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

Endocervical component present. No abnormality or only reactive changes

Atypical glandular cells of uncertain significance – site unknown

Possible high-grade squamous intraepithelial lesion (HSIL)

Atypical endocervical cells of uncertain significance

Possible endometrial adenocarcinoma

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

Possible high-grade endocervical glandular lesion

Possible high-grade lesion – non-cervical

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

Adenocarcinoma in situ

Malignant cells – uterine body

Squamous carcinoma

Adenocarcinoma in situ with possible microinvasion / invasion

Malignant cells – vagina

Adenocarcinoma

Malignant cells – ovary

Malignant cells – other

RØ

No recommendation

Repeat smear 6 months

Referral to specialist

Repeat smear 3 years

Repeat smear 6-12 weeks

Other management recommended

Repeat smear 2 years

Colposcopy / biopsy recommended

Symptomatic-clinical management required

Repeat smear 12 months

Already under gynaecological management

– –

All other women

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

All other women

Yes

–

Previous smear also abnormal or fluctuating low-grade abnormality

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

–

Yes

subsequent Biopsy or colposcopy other circumstances Yes –

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

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

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

victorian cervical cytology registry acknowledges the support of the victorian government

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

Unsatisfactory

Negative

Low-grade squamous abnormality

cytology report High-grade squamous abnormality or any glandular abnormality

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

APPENDIX 2. REMINDER AND FOLLOW-UP PROTOCOL USED DURING 2013

Victorian Cervical Cytology Registry Statistical Report 2013

May 2013 VCCR-Pub-19 V10

APPENDIX 3. MAP OF MEDICARE LOCALS

ML215 ML211

ML216

ML204 ML205

ML203 ML213

ML201 ML206

ML207

ML202 ML208

ML210

ML217 ML209

INSET: Melbourne and surrounds

ML214

Medicare Locals Victoria

ML216 ML215

ML211

See Inset

ML212

ML210

ML217

APPENDIX 3. MAP OF LOCAL GOVERNMENT AREAS – MELBOURNE

Victorian Cervical Cytology Registry Statistical Report 2013

APPENDIX 3. MAP OF LOCAL GOVERNMENT AREAS – VICTORIA