Policy context

Cervical Cancer Prevention Policy

This section outlines the history and current context of Australian government policy relating to cervical cancer screening and human papillomavirus (HPV) immunisation. The implementation of the HPV Immunisation Program has influenced national screening policy. The Renewal of the National Cervical Screening Program commenced in 2011 and included a review of the evidence for screening tests and pathways, the screening interval and age range.^[1] Following this review, a renewed NCSP was implemented on 1 December 2017.

HPV vaccination

Three prophylactic HPV vaccines have been approved by the Therapeutic Goods Administration (TGA) for use in Australia. The quadrivalent HPV vaccine Gardasil was approved by the TGA in 2006 and is registered for use in women aged 9–45 years and males aged 9–26 years. The bivalent vaccine Cervarix was approved by the TGA in 2007 and is registered for use in women aged 10–45 years. In June 2015 Gardasil9 was registered for use in females aged 9–45 years and males aged 9–26 years.

National HPV Vaccination Program

In 2007 Australia commenced the National HPV Vaccination Program to deliver HPV vaccine (Gardasil) to adolescent girls via high schools. For the first two years of the program, the free vaccine was offered as a three-dose course to girls and women up to 26 years of age through schools, general practice and community health centres.

The National HPV Vaccination Program Register (NHVPR) monitors and reports HPV vaccine coverage. Based on data from the NHVPR, three-dose coverage in the school-based program ranged from 74% to 63% for girls aged 12 and 17 years in 2007, respectively.^[2] Three-dose coverage rates among young women who accessed the vaccine through community providers were 40% and about 31% for ages 18–19 years and 20–26 years, respectively (National HPV Vaccination Program 2017). Doses delivered through community providers are known to be under-reported to the NHVPR, and survey data suggest coverage in this age group may be 10-20% higher than register-based estimates.^[3] Vaccination coverage has increased in Australia over time, especially for the third dose.^[4] In 2016, National HPV vaccination data for girls turning 15 shows 78.6% had completed the full course of the HPV vaccine.^[2] While there is a lack of national vaccination data for Indigenous girls, lower vaccine uptake and completion have been observed in Queensland and Northern Territory.^[5]

In 2013 the National HPV Vaccination Program was extended to include boys aged 12-13, with a catch up program for boys aged 14-15 years delivered in 2013 and 2014. National HPV vaccination data for boys turning 15 in 2016 shows 72.9% had completed the full course of the HPV vaccine.^[2]

In 2018 Gardasil9 replaced Gardasil in the National HPV Vaccination Program. Gardasil9 is delivered as a two-dose (rather than a three-dose) course for individuals who receive dose one before the age of 15.

National Cervical Screening Program

Screening for cervical cancer was introduced in Australia on an ad hoc basis in the 1960s. Guidelines on cervical screening programs published in 1986 by the World Health Organization and the International Agency for Research on Cancer were used as a basis for a review of cervical screening in Australia, conducted on behalf of Australian Health Ministers Advisory Council.^[6] Following this review, cervical screening was organised into a structured program, known today as the National Cervical Screening Program (NCSP). The program was implemented in 1991 as a joint initiative of the Australian, State and Territory Governments.

The NCSP invited women aged 20–69 years to take a Pap test every two years. In 2018, 54.1% of eligible women aged 25-74 years participated in the NCSP.^[7] Participation was highest among women aged in their 40s and 50s.^[8] The rate has decreased slightly since 2004–2005 (when there was a change in methodology) from 59.4%. While national participation data are not available by Indigenous status, a state-wide linkage study from Queensland reported participation is at least 20 percentage points lower in Indigenous women than in non-Indigenous women.^[9] Screening participation also varies by socioeconomic status (47.5% versus 59.9% for women living in the most versus the least disadvantaged areas) and remoteness (50.7% for remote areas and 43.1% for very remote areas compared to 54.1% in major cities and 53.7% in inner regional areas).^[10]

The renewed National Cervical Screening Program

The renewed NCSP was implemented on 1 December 2017. The aim of the renewed NCSP is to ensure that all Australian women, HPV vaccinated and unvaccinated, have access to a cervical screening program that is acceptable, effective, efficient and based on current evidence and best practice. The changes to the program included:

an HPV test, that replaced the Pap test as the primary screening tool, with partial HPV genotyping and liquid-based cytology triage for HPV-positive women
the time between screening tests changed from every two to every five years
the age at which screening starts changed from 18 years to 25 years
a final HPV test is offered between the ages of 70–74 years rather than 69 years.

See HPV DNA testing for more information on the HPV test.

The renewed NCSP will provide an opportunity to increase screening rates with the option of self-collection of HPV samples for under-screened and never-screened women. Self-collection technologies have proven to be highly acceptable to women and have the potential to improve screening participation rates among under-screened women (see HPV self-collection).

National HPV Surveillance Plan

In 2013, Communicable Diseases Network Australia endorsed the HPV surveillance plan developed after the Australian Government announced an extension of the National HPV Vaccination Program to include males.^[11] The surveillance objectives included infection monitoring and cancer endpoints. The Australian Government has funded the IMPACT study to monitor the prevalence of HPV genotypes in the Australian population and evaluate the effectiveness of the National HPV Vaccination Program.

References

Medical Services Advisory Committee. National Cervical Screening Program Renewal: Evidence review. Canberra: Department of Health; 2013 Nov. Report No.: MSAC application no. 1276. Available from: http://www.cancerscreening.gov.au/internet/screening/publishing.nsf/Content/E6A211A6FFC29E2CCA257CED007FB678/$File/Review%20of%20Evidence%20notated%2013.06.14.pdf.
National HPV Vaccination Program Register. Coverage Data. [homepage on the internet] Melbourne: Victorian Cytology Service; [cited 2017]. Available from: http://www.hpvregister.org.au/research/coverage-data.
Brotherton JM, Liu B, Donovan B, Kaldor JM, Saville M. Human papillomavirus (HPV) vaccination coverage in young Australian women is higher than previously estimated: independent estimates from a nationally representative mobile phone survey. Vaccine 2014 Jan 23;32(5):592-7 Available from: http://www.ncbi.nlm.nih.gov/pubmed/24316239.
Brotherton JM, Winch KL, Bicknell L, Chappell G, Saville M. HPV vaccine coverage is increasing in Australia. Med J Aust 2017 Apr 3;206(6):262 Available from: http://www.ncbi.nlm.nih.gov/pubmed/28359009.
Brotherton JM, Murray SL, Hall MA, Andrewartha LK, Banks CA, Meijer D, et al. Human papillomavirus vaccine coverage among female Australian adolescents: success of the school-based approach. Med J Aust 2013 Nov 4;199(9):614-7 Available from: http://www.ncbi.nlm.nih.gov/pubmed/24182228.
National Health and Medical Research Council. Screening to prevent cervical cancer: guidelines for the management of asymptomatic women with screen-detected abnormalities. Canberra: Commonwealth of Australia; 2005 Available from: http://www.nhmrc.gov.au/_files_nhmrc/publications/attachments/wh39.pdf.
Australian Institute of Health and Welfare. National cancer screening programs participation data. Canberra: AIHW; 2020 May 28 [cited 2020 Jun 5] Available from: https://www.aihw.gov.au/reports/cancer-screening/national-cancer-screening-programs-participation/contents/national-bowel-cancer-screening-program.
Australian Institute of Health and Welfare. National cancer screening programs participation data. Canberra: AIHW; 2019 Jul 11 [cited 2019 Jul 19]. Report No.: Cat. no: CAN 114. Available from: https://www.aihw.gov.au/reports/cancer-screening/national-cancer-screening-programs-participation/contents/summary.
Whop LJ, Garvey G, Baade P, Cunningham J, Lokuge K, Brotherton JM, et al. The first comprehensive report on Indigenous Australian women's inequalities in cervical screening: A retrospective registry cohort study in Queensland, Australia (2000-2011). Cancer 2016 May 15;122(10):1560-9 Available from: http://www.ncbi.nlm.nih.gov/pubmed/27149550.
Australian Institute of Health and Welfare. National cervical screening program monitoring report 2019. Canberra: AIHW; 2019 [cited 2020 Jun 5]. Report No.: Cancer series no. 125. Cat. no.132. Available from: https://www.aihw.gov.au/getmedia/fcacac12-cd05-4325-88bc-5529a61b53f3/aihw-can-132.pdf.aspx?inline=true.
HPV Surveillance Working Group of the Communicable Diseases Network Australia. Human Papillomavirus (HPV) Surveillance Plan – an integrated approach to monitoring the impact of HPV vaccine in Australia. Canberra: Communicable Diseases Network Australia of Australian Health Protection Principal Committee, Australian Government Department of Health; 2013 Dec Available from: http://www.health.gov.au/internet/main/publishing.nsf/content/e5b543ce209e55c3ca257f48001d65ef/$file/hpv-surveillance-plan.pdf.