Understanding the renewed National Cervical Screening Program

Resources References Online activity

In December 2017, the National cervical screening program (NCSP) changed:

Summary of changes to the National Cervical Screening Program

New

Current national cervical screening program

(commenced 1 December 2017)

Old

Superseded program

(1991–November 2017)

Sample

Cervical sample collected with plastic spatula, broom brush or cytobrush combination, transferred into the liquid-based medium

Both HPV test and cytology (if needed) are performed from single liquid sample

Cervical sample collected via wooden or plastic spatula, transferred onto glass slide for cytology

Women could opt for additional LBC

Test

‘Cervical screening test’ = two parts:

1. HPV test (with partial genotyping)

2. Reflex LBC (HPV-positive samples only)

Pap test (Papanicolaou smear)

Women could opt for additional LBC

Cancer marker(s) detected

Infection with oncogenic HPV (indicates potential for progression to high-grade lesion)

Abnormal cells on cytology

Abnormal (pre-cancerous) cells

Cytology test

LBC (performed only when oncogenic HPV detected)

Pap test (Papanicolaou smear)

HPV test

Nucleic acid test to detect HPV oncogenic types

Types 16 or 18 are specifically identified (partial genotyping)

Not part of primary screening test

Target screening§ population

Women aged 25–74 years who:

  • have a cervix
  • have ever been sexually active with a man or woman
  • are HPV vaccinated or unvaccinated.

Women aged 18–69 years

Starting age

25*

18, or 1–2 years after first sexual activity

Stopping age*

Exit testing at age 70–74

69

Transition to renewed NCSP

First test when next due for Pap test (eg 2 years after last Pap test for women with normal screening history)

N/A

Screening cycle

Every 5 years

Every 2 years

MBS items

73070, 73071, 73072, 73073, 73074, 73075, 73076

Previous items ceased

Information to include on pathology request form to ensure correct test and fee

Test requested and relevant clinical information (determined by presentation, clinical context, sample type, test type) – GPs can follow instructions online or on poster#

Do not write ‘Pap test’

Aboriginal and Torres Strait Islander status (if woman identifies as Aboriginal or Torres Strait Islander)

N/A

HPV: human papilloma virus; LBC: liquid-based cytology; MBS: Medicare Benefits Scheme; N/A: non-applicable

§ the HPV test (in combination with liquid-based cytology) is also used in the investigation of symptoms suggesting cervical cancer (eg vaginal pain or bleeding) in women of any age with an intact cervix.

* for general target population (appropriate age may vary for special subgroups). An earlier test can be considered for women who experienced sexual activity before age 14 and immune-deficient women

# Australian Government Department of Health. Pathology test guide for cervical and vaginal testing (poster).

Human papilloma virus (HPV) test is now the primary screen

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For a summary of the rationale for changes to the NCSP, see the fact sheet.

Self-collection is available as a second-line option

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This option is intended to encourage participation in screening by women who are unwilling or unable to visit their GP for a cervical screening test.


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Clinician-collected samples are preferable to self-collected samples, because a self-collected vaginal sample can only be tested for HPV, not cervical cytology. If oncogenic HPV types are detected on a self-collected sample, the woman will need to visit her GP, who will collect a cervical sample and submit a new pathology request for an LBC test only.[2]

Pathology reports and indications for colposcopy have changed

What the pathology report will contain

HPV test results are reported as one of following categories:

  • HPV 16/18 detected
  • oncogenic HPV (not 16/18) detected
  • oncogenic HPV not detected
  • unsatisfactory.

LBC test results are reported as negative, unsatisfactory LBC, or a specified abnormality (squamous or glandular).


LBC report categories

Negative

Squamous abnormalities:

  • possible low-grade squamous intraepithelial lesion (pLSIL)
  • low-grade squamous intraepithelial lesion (LSIL)
  • possible high-grade squamous intraepithelial lesion (pHSIL)
  • high-grade squamous intraepithelial lesion (HSIL)
  • squamous cell carcinoma

Glandular abnormalities:

  • atypical endocervical cells of undetermined significance
  • atypical glandular cells of undetermined significance
  • possible high-grade glandular lesion
  • endocervical adenocarcinoma in situ
  • adenocarcinoma

Unsatisfactory LBC

The pathology laboratory will issue a combined report, which includes the HPV result, LBC test result (if performed), and the overall screening risk rating for each woman. Reports include management recommendations as one of four actions.[1]

Cervical screening report

Cervical screening result

Management recommendation

Low risk of significant cervical abnormality

Rescreen in 5 years

Intermediate risk of significant cervical abnormality

Repeat HPV test in 12 months

Higher risk of significant cervical abnormality

Refer to specialist for colposcopy

Unsatisfactory

Retest in 6 weeks

When to refer a woman for colposcopy

The appropriate follow-up in response to the each of the possible results of a cervical screening test are set out in the pathway for GP follow-up to a cervical screening test report.

Referral to colposcopy is recommended for women in the ‘higher risk’ category:[1]

  • Women with a positive oncogenic HPV (16/18) test result should be referred for colposcopic assessment, regardless of the LBC findings:[1]

– If the report includes a prediction of pHSIL/HSIL, the woman should be referred for colposcopic assessment, ideally within 8 weeks.

– If the report is invasive cancer (squamous, glandular or other), the woman should be referred to a gynaecological oncologist or gynaecological cancer centre for urgent evaluation, ideally within 2 weeks.

  • Women with a positive oncogenic HPV (not 16/18) test result and a LBC prediction of pHSIL/HSIL or any glandular abnormality, should be referred for colposcopic assessment at the earliest opportunity, ideally within 8 weeks.[1]
  • Women with HPV (any type) still detected 12 months after HPV was detected at a previous screening test should be referred for colposcopic assessment.[1]

Special screening approaches apply to some groups of women

Special screening approaches apply to the following groups (see the rules and exceptions):


Pregnant women

Routine antenatal and postpartum care should include a review of the woman’s cervical screening history.

Pregnant women who are due or overdue for screening should be screened while pregnant.[1] Women can be safely screened at any time during pregnancy using a cytobroom (not a cytobrush or combi-brush, as these are more likely to cause bleeding).[1]

Self-collection of a vaginal sample is not recommended.[1]


Women exposed to diethylstilbestrol (DES)

Women exposed to DES in utero should be offered an annual co-test and colposcopic examination of both the cervix and vagina indefinitely.[1]

Women who experienced early sexual activity or have been victims of sexual abuse in childhood

For women who experienced first sexual activity before age 14 (including women who were sexually abused as children), and who had not received the HPV vaccine before sexual debut, a single HPV test between ages 20 and 24 years can be considered on an individual basis.[1]


Immuno-deficient women

Immune-deficient women should be screened every 3 years instead of every 5 years.[1]

Special screening processes also apply to women who have opted for self-collected samples.


Self-collected samples

If no oncogenic HPV is detected on a self-collected sample, the woman will be invited to re-screen in 5 years and should be advised to have a clinician-collected sample at that time.[1]

If oncogenic HPV type 16/18 is detected on a self-collected sample, the woman should be referred straight to colposcopy without collecting a cervical sample.[1]

If HPV (not 16/18) is detected on a self-collected sample, the woman will be advised to visit her GP as soon as possible to have a cervical sample collected for LBC.[1]


Screening strategy: rules and exceptions[1]

Rule

Exceptions

Cervical screening test every 5 years

Every 3 years for immune-deficient women

Cervical screening starts at age 25 years

Can be considered between age 20 and 24 on individual basis for women with:

  • immune deficiency > 5 years (regardless of HPV vaccination status)
  • sexual debut before age 14 and before HPV vaccination.

Women who have ever been sexually active should have regular cervical screening tests until age 75 years

A woman can stop screening if:

  • no oncogenic HPV is detected at a screening test at age 70–74 years
  • she has had a hysterectomy for benign disease (eg menorrhagia, uterine fibroids or utero-vaginal prolapse) and cervical pathology was normal.

If you would like to do some short case studies on this topic, you can enrol in the Understanding the renewed National Cervical Screening Program activity on gplearning. Completion of the online activity is worth 2 CPD Activity points.

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Additional resources

RACGP resources

For more information on developing and consolidating your communication skills, including communication in difficult situations such as breaking bad news, please refer to the gplearning Communication skills in general practice Active Learning Module.

Fact sheet: Rationale for changes to the National Cervical Screening Program


Links to external resources


Resources for patients

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References

  1. Cancer Council Australia Cervical Cancer Screening Guidelines Working Party (2017). National Cervical Screening Program: Guidelines for the management of screen-detected abnormalities, screening in specific populations and investigation of abnormal vaginal bleeding. Sydney: Cancer Council Australia.
  2. Australian Government Department of Health. Quick reference guide – self-collected vaginal sample for HPV test. [web page]
  3. Aminisani N, Armstrong BK, Canfell K (2012). Cervical cancer screening in Middle Eastern and Asian migrants to Australia: a record linkage study. Cancer Epidemiology, 36, e394-400.
  4. Australian Institute of Health and Welfare (2017). Cervical screening in Australia 2014–2015. Cancer series no. 105. Cat. no. CAN 104. Canberra: AIHW.
  5. Anderson, JO, Mullins, RM, Siahpush M, Spittal MJ, Wakefield M (2009). Mass media campaign improves cervical screening across all socio-economic groups. Health education research, 24, 867-75.
  6. Australian Government Department of Health. Changes to the National Cervical Screening Program (NCSP) for Healthcare providers [factsheet].

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