1 THE NEW CERVICAL CANCER SCREENING PROGRAMThe Renewal THE NEW CERVICAL CANCER SCREENING PROGRAM

2 CERVICAL CANCER 4th most common cancer in women worldwide

3 CERVICAL CANCER 4th most common cancer in women worldwide>250,000 deaths/year

4 CERVICAL CANCER 4th most common cancer in women worldwide>250,000 deaths/year 85% of cervical cancer incidence and mortality occurs in less developed countries

5 CERVICAL CANCER 4th most common cancer in women worldwide>250,000 deaths/year 85% of cervical cancer incidence and mortality occurs in less developed countries – limited or no screening

6 CERVICAL CANCER Incidence

7 CERVICAL CANCER Mortality

8 CERVICAL CANCER In our regionAustralia: Incidence - 5 per 100,000 women Mortality - 2 per 100,000 women Melanesia (PNG, Vanuatu, Fiji) : Incidence - 33 per 100,000 women (x7) Mortality - 20 per 100,000 women (x10)

9 FIJI – Nurse training VIA

10 Screening room

11 Sterilising equipment

12 VANUATU HPV vaccination & testing

13 Cold chain challenges

14 THE IMPORTANCE OF SCREENING80% of women with cervical cancer are either under- screened, or have never been screened

15 CERVICAL CANCER SCREENING in AUSTRALIACurrent National Cervical Cancer Screening Program since 1991 Women aged yrs 2 yearly Pap tests State/Territory based Registers

16 THE PAP TEST

17 CERVICAL CANCER SCREENING in AUSTRALIACurrent Hugely successful – 50% reduction in cervical cancer incidence and mortality

18 SO WHY CHANGE??

19 Online petition shows women want to know moreSO WHY CHANGE?? Online petition shows women want to know more The past week saw 70,000 people (so far) sign an online petition opposing the changes to the cervical screening program. The person behind the petition said she was motivated by “concern and worry”, because “[she] didn’t know about it and no one seemed to know about it”, and because “[she’d] love someone to be able to get down on our level and explain the testing”. Responses to her petition indicated widespread concern about safety of the new starting age and the wider screening interval. In addition, women perceived the renewed program as a cutback – that less screening is being driven by cost-savings rather than the availability of a better test.

20 SO WHY CHANGE?? 1. LIMITATIONS of CURRENT TESTINGReductions in cervical cancer incidence and mortality have plateaued over the last 10 years Current program has had no impact on certain groups – women < 25 years, subgroups of cancers (adenocarcinomas)

21 SO WHY CHANGE?? 2. INCREASED KNOWLEDGEThe role of HPV in cervical lesions and cancer (causes >99% of cancer, most HPV infections will regress within 18 months) Pathogenesis of cervical cancer (most cancers take years to develop)

22 HPV HPV causes >99% of cervical cancerOver 200 genotypes of HPV, 40 affect ano-genital tract High risk HPV: 16,18,31,33,35,39,45,51,52,56,58,59,68,73,82

23 HPV Anal cancer – 90% Vaginal cancer – 70% Penile cancer – 50%Vulvar cancer – 40% Head and neck/orophayngeal cancers – 13 – 72%

24 HPV

25 HPV Over 80% of HPV infections will clear within months

26 HPV Persistent infection with high-risk HPV is the most important risk factor for cervical cancer

27 SO WHY CHANGE?? 3. NEW TECHNOLOGIES HPV DNA testLiquid based cytology & computer-assisted image analysis

28 SO WHY CHANGE?? 3. NEW TECHNOLOGIES HPV DNA testMuch higher sensitivity compared with Pap smears (95% v 55%): better test High negative predictive value (>99%), allowing for longer screening interval

29 SO WHY CHANGE?? 4. NATIONAL HPV VACCINATION PROGRAM3 dose quadrivalent vaccination (Gardasil): HPV 6,11,16,18 2007 – girls (12-26yrs), 2013 – girls and boys (12-13 years) Coverage with 3 doses: around 70-80% 86% reduction in HPV 16,18,6,11 92% reduction in genital warts 45% reduction in low grade lesions 85% reduction in high grade lesions

30 WHAT IS THE CHANGE? Renewal 5 yearly screening Based on HPV DNA testWomen 25 – 74 yrs Option for self-collected sample (for never screened or under-screened women) National Register

31 HPV test Identical procedure to Pap test - sample from SC junction using cervical sampler, spatula +/- cytobrush Then sample is placed in liquid based medium HPV DNA testing (with partial genotyping) is performed If positive for oncogenic HPV type, reflex liquid based cytology (LBC) is performed on the same sample

32 SCREENING PATHWAY

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43 SCREENING PATHWAY

44 Self collected swab Dry flocked swab inserted into vaginaCannot perform LBC on sample Medicare rebate for “never or under screened women” If +ve HPV 16/18 – refer for colposcopy If +ve for oncogenic HPV (not 16/18) – invite back for reflex LBC under direct vision Sensitivity 88% – better than Pap, not as good as physician collected sample

45 SPECIAL CASES Pregnancy Immune-deficient/HIV DES in uteroSymptomattic women (any age) History childhood sexual abuse/first sexual activity <14 yrs

46 NATIONAL REGISTER Operated by Telstra HealthBowel Cancer Screening & Cervical Cancer Screening Legislative Framework: - National Cancer Screening Register Act 2016 - Others: Privacy Act 1988, Cybercrimes Act 2001 etc FAQ: Content/National-Cancer-Screening-Register

47 NATIONAL REGISTER Single electronic recordSend out invitations, reminders, and FOBT kits Allow practitioners access to patients records/results through medical software Upload data to Register through medical software Allow patients to access screening record/results

48 TRANSITIONING TO THE NEW PROGRAMWomen who: are aged 25+ years will be invited into the new program 2 years after their last Pap test have had a Pap test below the age of 25 will be invited into the program at the routine screening age of 25 (explanatory letter to be sent by National Register)

49 TRANSITIONING TO THE NEW PROGRAMWomen who: are in follow-up for LSIL should have co-test (HPV + LBC) at next scheduled follow-up; refer for colposcopy if + for any oncogenic HPV type; if negative return to 5- yearly screening have been treated for HSIL (CIN2/3) in the pre-renewal program should start or continue Test of Cure (annual co-test until 2 consecutive negatives) have been treated for adenocarcinoma in situ will have annual co-testing (HPV and LBC) indefinitely

50 TRANSITIONING TO THE NEW PROGRAMcal_cancer/Screening

51 THE NEW SCREENING PROGRAMWe have a BETTER TEST

52 THE NEW SCREENING PROGRAMWe have a BETTER TEST

53 THE NEW SCREENING PROGRAMWe have a BETTER TEST It will further reduce rates of cervical cancer (additional 20% reduction) - Increased detection of adenocarcinoma

54 THE NEW SCREENING PROGRAMThe better test means we can SAFELY SCREEN LESS OFTEN - So we allow women adequate time to clear the virus themselves (much like the common cold)

55 THANK YOU