New Changes To Cervical Screening

Program 2017Dr DONALD ANGSTETRA Bsc(Med) | MBBS |

FRANZCOGObstetrician & Gynaecologist

Advanced Gynaecological Laparoscopic Surgeon | Gold Coast University Hospital

Visiting Medical Officer | Gold Coast Private HospitalSenior Lecturer | Griffith University

About me…

National Cervical Screening Program Introduced 1991 2-yearly pap smear test Asymptomatic women who have

been sexually active Age 18-69yo

CURRENT Cervical Screening in Australia

Cervical Cancer in Australia Cervical cancer − last 20 years

1991-2002 − Incidence & mortality rates ~50% > 2002 − Rates have plateau

Incidence of Cervical ca 9/100,000 Mortality rate 2/100,000

Pre-NCSP

National Screening program Introduced in 1991

National Screening program Introduced in 1991

Cervical Cancer in Australia

Pre-NCSP

So why change??

New Knowledge of HPV infection and Cervical Ca New technologies

HPV DNA typing Liquid Based Cytology (LBC) Computer Assisted Image Analysis

The National HPV Vaccination Program − Prevalence of HPV in community 2007 – Girls (12-13 year old) 2013 – Boys

New Evidence - appropriate screening age ranges and ‘optimal’ intervals

Proposed New Cerical Screening Program

Replace “Pap Smear” with HPV DNA test Genotyping HPV16, 18 +/- 45 IF +ve HPV DNA test will undergo further triaging -> Reflex liquid based cytology

Entry age of 25; Exit HPV test at age 70-74 vaccinated and unvaccinated women

Increases screening interval from 2yrs 5yrs

HPV Self-Collection “Never screened” & “Under-Screened” population

Registry – Invitation, Call & Recall

Patient Participation

Will 5yr interval increase OR decrease participation? 2008-2012 Patient participation (age 20-69)

2yr interval – 57.7%3yr interval – 70.2%5yr interval – 83.3%

Proposed NCSP Algorithm

Safe More effective

Aim to further Cervical ca by additional 15% More cost-effective

What does this mean for the Clinician?

Collect sample from cervix If HPV +ve Reflex cytology

Clinician will receive a report with HPV status (+/- genotype) Cytology (if HPV +ve) Single recommendation

HPV and Cervical Cancer

Double stranded DNA virus 100 different genotypes HPV infection is necessary, though not sufficient, for

development Cervical ca HPV 16 & 18 ~70% of all Cervical ca

80% lifetime risk of acquiring HPV Majority infections are cleared within 2yrs

HPV and Cervical Cancer

Cervical Ca - rare outcome of infection

Natural progression of High Grade abnormalities over 1-25 years Common Diagnosis of HSIL 25-29 yo; Cervical Ca 44-49 yo

CIN2 CIN3Regression 43% 32%Persistence 35% 56%Progression 5% >12%

HPV DNA Testing

Currently use HPV DNA testing NOT a diagnostic tool “Test of cure” for post treated High Grade lesion

Can be requested any times, But NO Medicare rebate ($80-$100)

Order of TEST is IMPORTANT Applying More sensitive test first (HPV DNA)

Negative Predictive Value (NPV of >99%) Reduce number of False Negatives

Applying More specific test second (LBC) Good Positive Predictive Value Reduce number of False Positives

unnecessary referral and follow-up

WHY Combined HPV DNA Test + Reflex LBC?

Incidence of Cervical Cancer in <25yo

~2.3/100,000 (rare) NO effect on incidence of Cervical Ca Increased risk of future pregnancy HPV vaccination

HPV Vaccination & Abnormal Cervical Screening

2006 vs 2011: Decline high grade in

<20 & 20-24

HPV Vaccination Program & Genital Warts

women

men

Improving Participation – SELF COLLECTION

20% did not participate in screening Victorian Cervical Cytology Register

In 2009, 80% invasive Ca had never been screened OR lapsed screeners

ATSI 2x incidence of Cervical Ca 4x mortality rate in comparison to non-indigenous

Self-Collection participation rates

A Paradigm Shift? Changing Perspective

By using HPV DNA as primary diagnostic tool Disease no longer cytological / histological

diagnosis BUT Sexually Transmitted Infection

Altered patient perception -> stigma?

TAKE HOME MESSAGE

Procedure for collecting sample remains the same

5-year screening ONLY applies to women with negative results Women with HPV +ve will require further investigation and closer monitoring

SYMPTOMATIC women (post coital bleeding, intermenstrual bleeding) need investigation The ‘NEW’ NCSP applies only to asymptomatic women

HPV vaccinated women will still require screening

Questions?

http://www.goldcoastwomencare.com.au