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A LEADING pathologist has suggested plans to upgrade the National Cervical Screening Program could inadvertently lead to a fall in participation rates and a rise in invasive disease.
The Medical Services Advisory Committee (MSAC) has recommended raising the age to start screening from 18 to 25 years and replacing the current system of 2-yearly Pap tests with 5-yearly human papillomavirus (HPV) testing. (1)
The proposed changes are being considered by the federal Department of Health as part of the program’s scheduled renewal, and take into account the impact of widespread HPV vaccination and the evolution of HPV testing. The changes have strong support as being in line with the best available evidence.
However, Adjunct Professor Annabelle Farnsworth, medical director of Douglass Hanly Moir Pathology in Sydney, warned this week in an MJA editorial that “changing one aspect of a public health program may have unwanted consequences on another aspect”. (2)
Professor Farnsworth was commenting in light of new research published in the Journal confirming reports that there had been a decrease in participation in the screening program since the introduction of the HPV vaccine in Australia in 2007. (3)
The study of linked data from the Victorian Cytology Registry and the National HPV Vaccination Program Register found that over a 2-year period to 2011 vaccinated women aged 20‒24 years and 25‒29 years were significantly less likely to be screened than unvaccinated women (37.6% v 47.7% and 45.2% v 58.7%).
This was despite widespread patient education about the need for vaccinated women to have Pap smears as the vaccine does not prevent all HPV types that cause cervical cancer and cannot protect women already infected with HPV.
Professor Farnsworth suggested that raising the screening age could lead to a further fall in participation rates.
She noted that in England, changing the age to start screening from 21 to 25 years in an unvaccinated cohort in 2003 had been linked with a significant decrease in screening participation and a significant increase in cervical cancer in the 25‒29-year age group. (4)
Although UK researchers suggested an increase in HPV infections was to blame, Professor Farnsworth said changing the screening age may also have been a factor.
“It is hoped that in a vaccinated population [as in Australia today], raising the age for commencing cervical screening to 25 years will not have the same consequences as in England”, she said.
Professor Farnsworth also raised concerns about quality assurance measures under the proposed changes in Australia, predicting that as the number of cervical samples taken for cytological testing fell, fewer laboratories would be able to perform the tests optimally.
She said invalid HPV test results were “not rare”, saying that at her laboratory she had observed a 1% rate of invalid test results in 2013.
Professor Ian Hammond, chair of the Renewal Steering Committee for the National Cervical Screening Program, hit back at several aspects of the editorial, claiming Professor Farnsworth had misinterpreted the experience in England and mistakenly implied that MSAC had ignored issues of implementation.
“She fails to mention that the UK study found that screening women under the age of 25 years does not reduce the incidence of cervical cancer at ages 25‒29 years”, he told MJA InSight.
He noted that similar cancer trends were seen in Scotland and Wales over the period, indicating the impact of factors other than screening age.
Professor Hammond stood by the MSAC’s proposals, saying the current regimen of starting screening at 18 years of age and screening every 2 years was “too intensive when compared with other countries with similar outcomes”.
He agreed that it would be “very, very important that women do start being screened at age 25 in the new National Cancer Screening Program, and that there should be no significant delay”. This was why the MSAC had stressed that there should be an invitation and recall for 5-yearly HPV screening.
The authors of the MJA study also said their research emphasised the “imperative” to use direct invitations to commence screening.
They warned their results were likely to be limited by incomplete and unlinked data. However, they said this would not wholly explain their finding that vaccinated women were under-screened.
Dr Julia Brotherton, medical director of the National HPV Vaccination Program Register and a coauthor of the study, told MJA InSight she agreed that careful attention and commitment to organisation and quality assurance would be critical to the success of the program’s renewal.
However, she expressed confidence that this was achievable, saying “we have a long history of success in these areas”.
“Vaccination is undoubtedly superior to Pap testing in its ability to prevent those fortunately rare but rapidly occurring cervical cancers in very young women … but we do need both and our research is a call to action for young women who have not yet attended screening to find the time to do so.”
1. Australian Government: National Cervical Screening Program Renewal
2. MJA 2014: 201: 245-246
3. MJA 2014; 201: 279-282
4. J Med Screen 2012: 127-132
(Photo: BSIP / Science Photo Library)
The changes to the National Cervical Screening Program discrminate against people whose age at sexual initiation is younger than the mainstream Australian average of 17 years. For example, marginalised low socio-economic groups, including the much-researched ATSI populations, who additionally affected by an increased prevalence of other immunospuressant factors such as HTLV1 infection and carcinogenic cigarette smoking.See below for links to relevant articles.
Do the maths yourself. Given that the time taken to develop cervical cancer following a negative HPV test is 5-6 years by the MSAC’s own data, to apply the model to persons aged 12 – 13 years at age of first sexual intercourse, cervical/HPV screening should start at 18 years, rather than 25 years of age.
Demographers please watch for a rise in cervical cancer incidence, in at-risk demographic goups, following the 2016 introduction of the new National Cervical Cancer Screening Program. Also I suggest tracking the incidence and prevalence of anal cancer and tonsillar cancer. These are two other types of cancer associated with persistent infection with oncogenic subtypes of HPV.
http://www.sswahs.nsw.gov.au/services/sgog/Dysplasia_Guide.html
http://www.health.gov.au/internet/main/publishing.nsf/Content/ohp-bbvs-atsi
https://www.mja.com.au/journal/2007/186/10/attitudes-and-behaviours-young-indigenous-people-townsville-concerning
Clinical Pathologists study disease relating to patients, and so are in a position to influence clinical management.
I value the input of Clinical Pathologists.
Models from the UK and Finland do not apply to Australia, because we have a significant scattered rural population , (which includes Aboriginal and CALD women) who are underscreened
Rural areas have a lower participation in school-based vaccination programmes including HPV vaccination.
I am not aware of any programme to follow-up school children who miss the school-based vaccinations, including HPV vaccination.
Sadly, there is no requirement for children whose parents or ‘carers’ are in receipt of Centrelink benefits for supposedly “supporting” or “caring’ for these Centelink-supported children to have any preventive health care .
I agree with Anonymous regarding mobile populations, changing addresses, mobile telephones.
No-one has mentioned that the Pap smear is part of a well-woman’s health check, where contraception, STD screening,BP , BMI, skin check, smoking cessation, lifestyle issues are addressed.
Nor has anyone raised the high rate of termination of pregnancy in Australia- a reflection of the high rate of unprotected sexual intercourse, exposure to STDs including strains fo HPV, some of which are not preventable.
We seem to have a problem in this country following the evidence, it means we end up doing excess biopsies/over-treating too many women. Over-treatment can damage the cervix and can lead to premature babies, c-sections etc. Serious over-screening simply means more false positives/excess biopsies/over-treatment. It’s concerning to think Finland has had their 7 pap test program, 5 yearly from 30 to 60, since the 1960s. Their results: the lowest rates of cc in the world and they refer FAR fewer women for biopsies and treatments. Women here are still being told to have 26 (or more) pap tests.
So I was pleased to see things might change, but disappointed to see we’ll probably stay with excess. 5 yearly HPV primary tests from 25 to 74. (too early and too many tests (10 or 11 when 5 or 6 is enough)) The new program recommended by the Dutch Health Council is 5 HPV primary tests (or self-testing) at 30,35,40,50 and 60 and only the roughly 5% who are HPV+ will be offered a 5 yearly pap test. You don’t have to do much research to see that HPV testing before age 30 is not a good idea, it means about 40% of young women WILL be HPV+ We also, know these infections usually clear within a year or two.
Evidence based programs don’t offer pap testing before age 30. The cancer is rare before 30 and these early cases occur whether you pap test or not. No country has shown a benefit in terms of incidence or mortality from cc in women under 30, despite cervical screening, but young women produce the most false positives. I also, fear our HPV+ women will be sent straight for colpscopy/biopsy, when they should simply be offered a pap test. These programs MUST be independently assessed/monitored, putting women and the evidence first.
In response to Dr Bradford’s comment, pathologists ARE doctors who care for the patients referred to them! Every day, as a gynaecological pathologist, I am intimately involved in the clinical management of dozens of women who have had a Pap smear or some type of gynaecological procedure. To imply that Annabelle Farnsworth or any other pathologist cannot take a leading role or make decisions in their area of expertise is quite extraordinary!
I would like to correct Jenny Bradford’s statement.
My resignation 10 years ago as Vice Chair of the NHMRC Guidelines Review committee and the subsequent publicity were because I did not believe that the management recommendations about to be endorsed by the committee were appropriate.
My resignation prompted a new, thorough review of the scientific evidence, resulting in the final management recommendations which in fact reflected my original position.
Although it was not an easy process I believe that the right outcome was achieved and the safety of women was assured.
Five years is too long between tests. In my extended family all the young women are tested every 2 years My niece,vaccinated, then 24, had a test result CIN 11. My daughter,28, not vaccinated due to immune system dysfunction (myalgic encephamyelitis) had an abnormal smear after 2 years and six months lates CIN 111.No history of cancers either side of the family. What would have happened with a five year gap?
I agree with the comments made by Professor Anabelle Farnsworth. There is a significant cohort of young women who engage in sexual intercourse and may have started being sexually active at a very young age (i.e. underage) who are at a high risk of acquiring high oncogenic strains of HPV, even prior to being vaccinated, and may not indicate this, if they present for vaccination. Also, at the present time, I understand the vaccine does not cover all possible strains of the virus. The effects on cytology laboratories is also of concern with regard to maintenance of screening skills with lower numbers of Pap smears being screened. We have excellent screeners in this country and these are skills which need to be maintained.
Five years is a long time between tests. I would like to know how invitation and recall letters and follow up letters are going to find a highly mobile population of young women who change their abode, email address and mobile phone numbers frequently.
Pathologists are not clinicians, and therefore should not be making clinical decisions. They can advise, but the final decision must stay with the doctors who care for patients.
Dr Farnsworth has very publically dissented once before from clinician decisions regarding cervical cancer screening – on the front page of the Sydney Morning Herald. On that ocasion, the clinicians stuck to their guns, and the outcome was a succes for women.
This time around, I am sure there will be a similar positive outcome.