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Cervical cancer screening

12. Screening in Aboriginal and Torres Strait Islander women

Clinical question

GUIDELINE UPDATES - This guideline was last updated 8/16/2018

UPCOMING GUIDELINES - This guideline was updated and comes into practice on 7/1/2022Download PDF

Background

Cervical cancer incidence and mortality rates are higher among Aboriginal and Torres Strait Islander women than non-Aboriginal and Torres Strait Islander women.[1]

The current National Cervical Screening Program (NCSP) does not make separate policy recommendations for Aboriginal and Torres Strait Islander women. Limited available evidence on participation in cervical screening by Aboriginal and Torres Strait Islander women suggests that they are under-screened.[2] The Australian Government Department of Health recognises that there are cultural, linguistic and physical barriers to cervical screening for these women.[2]

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Evidence

Systematic review evidence

The systematic literature search identified no randomised or pseudorandomised controlled trials that examined modified screening strategies for Aboriginal and Torres Strait Islander women, compared with the strategy recommended for the general population: primary human papillomavirus (HPV) test-based screening with partial genotyping every 5 years for women aged 25–69 years, immediate referral to colposcopy for women with a positive oncogenic HPV (16/18) test result, and cytology triage for women with a positive oncogenic HPV (not 16/18) test result.

The search strategy and inclusion and exclusion criteria are described in detail in the Technical report.

General literature review evidence

In the absence of any direct evidence from the systematic review, a general review of the literature was performed to identify current evidence-based clinical practice guidelines for cervical screening, and studies evaluating screening strategies, for Aboriginal and Torres Strait Islander women.

No relevant evidence-based clinical practice guidelines based on systematic reviews of evidence were identified. No studies were found that directly compared alternative screening strategies for Aboriginal and Torres Strait Islander women.

A general literature search was also conducted to quantify the relative risk of and burden of cervical cancer among women of Aboriginal and Torres Strait Islander descent, compared with the general Australian female population. The search strategies and findings are described in detail in the Technical report.

The literature review made the following findings:

A national retrospective study found that, between 1998 and 2005, the age-standardised incidence rate for cervical cancer was 2.7 times higher (95% confidence interval 2.2–3.2) for Aboriginal and Torres Strait Islander women (20 per 100,000) than for non-Aboriginal and Torres Strait Islander women (7 per 100,000).[3] In 2005–2009, the age-standardised incidence rate of cervical cancer slightly improved, at 2.3 times higher for Aboriginal and Torres Strait Islander women as for non-Aboriginal and Torres Strait Islander women.[1] Chapter 1. Cervical cancer in Australia shows incidences of cervical cancer and cervical cancer outcomes by Indigenous status. See also the tables in the literature review report.

There are no current national data on screening participation by Aboriginal and Torres Strait Islander women. This is primarily because Aboriginal and Torres Strait Islander status is not recorded on pathology forms (the primary source of data for Pap test registers).[4][2] It is expected that the renewal of the NCSP will provide an opportunity to correct this situation. This will require a coordinated strategy involving primary health care, pathology practices, and the National Cancer Screening Register (NCSR).

National data from primary healthcare organisations funded by the Department of Health to provide services to Aboriginal and Torres Strait Islander people show that, in December 2013, 32% of the Aboriginal or Torres Strait Islander women who were regular clients of these services had undergone a cervical screening test in the previous 2 years, 40% had been tested in the previous 3 years, and 46% had been tested in the previous 5 years.[2] However, these records may not capture screening visits if clients had undergone screening outside their usual primary healthcare organisation.[2]

A cross-sectional study reported that the age-adjusted prevalence of oncogenic HPV genotypes was similar for Aboriginal or Torres Strait Islander women and non-Aboriginal and Torres Strait Islander women, both overall and in each age group (31.3% versus 30.0% respectively, overall).[5] The prevalence of HPV 16/18 was also similar in each age group for Aboriginal or Torres Strait Islander women and non-Aboriginal and Torres Strait Islander women, however oncogenic HPV (not 16/18) types were more common in Aboriginal or Torres Strait Islander women aged 31–40 (35.0%) than in non-Aboriginal and Torres Strait Islander women the same age (22.5%).[5] The prevalence of HPV DNA (including oncogenic and non-oncogenic types) was higher for Aboriginal and Torres Strait Islander women than for non-Indigenous women when standardised to the general Australian population (47.5% versus 41.5%). However this finding was driven by differences in the prevalence of low-risk (non-oncogenic) HPV genotypes (28.7% versus 24.8%), and confidence intervals overlapped in both cases.[5]

National data are not available on HPV vaccine coverage in Aboriginal and Torres Strait Islander girls. In Queensland and the Northern Territory, HPV vaccination rates during the catch-up program (girls aged 12–17 years in 2007) were lower among Aboriginal and Torres Strait Islander girls, compared with non-Aboriginal and Torres Strait Islander girls, but the magnitude of the difference and patterns were different between the two jurisdictions. In Queensland there was only a marginal difference in the percentage of girls who started the course (4%) but the completion rates were lower amongst Aboriginal and Torres Strait Islander girls such that there was a 15% lower three dose coverage rate overall. In contrast in the Northern Territory, Aboriginal and Torres Strait Islander girls were less likely to start the course but amongst those who did the completion rate was identical, resulting in an overall 9% lower three dose coverage rate. These data suggest that any barriers to commencement and completion of HPV vaccination courses may vary for Indigenous people living in different parts of Australia. Coverage data have not been published for Aboriginal and Torres Strait Islander girls vaccinated after 2008.[6]

A national ecological study reported that the reduction in hospital admissions involving a diagnosis of genital warts in the first 4 years after the inception of the National HPV Vaccination Program was similar in young Aboriginal or Torres Strait Islander women and non-Aboriginal and Torres Strait Islander women (86.7% versus 76.1%; 95% confidence intervals overlapped).[7]

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Synthesis

Current evidence does not support the use of a more intensive screening strategy for Aboriginal and Torres Strait Islander women. To date, the NCSP has not been successful in reducing the incidence and mortality of cervical cancer among Aboriginal and Torres Strait Islander women. More effective strategies are needed to increase their participation in the NCSP. Strategies for improving equity, accessibility, effectiveness and cultural sensitivity of cervical screening services for Aboriginal and Torres Strait Islander women should be explored. Data collection systems should be improved to ensure that accurate data for Aboriginal and Torres Strait Islander women are available for inclusion in the NCSR.

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Recommendations

Consensus-based recommendation
REC12.1: Cervical Screening for Aboriginal and Torres Strait Islander women
Aboriginal and Torres Strait Islander women should be invited and encouraged to participate in the NCSP and have a 5-yearly HPV test, as recommended for all Australian women.
Practice point
REC12.2: Invitations to screen for Aboriginal and Torres Strait Islander women
Specific efforts should be made to maximise delivery of invitations to Aboriginal and Torres Strait Islander women.
Practice point
REC12.3: Cervical screening services for Aboriginal and Torres Strait Islander women
Specific efforts should be made to provide screening, diagnostic and treatment services that are accessible and culturally appropriate to Aboriginal and Torres Strait Islander women.
Practice point
REC12.4: Data collection and recording Aboriginal and Torres Strait Islander status
Healthcare professionals should ask all women whether they identify as Aboriginal or Torres Strait Islander, and a woman’s Aboriginal and Torres Strait Islander status should be recorded on the pathology request form in accordance with the ABS classification and standards.

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Benefits and harms

In the absence of evidence to support specifically tailored screening protocols for Aboriginal and Torres Strait Islander women, participation in the NCSP is expected to reduce rates of cervical cancer among Aboriginal and Torres Strait Islander peoples.

Invitations to participate in screening may cause unnecessary anxiety for some Aboriginal and Torres Strait Islander women if they have not received adequate education and explanation about cervical cancer and its link with HPV infection. Culturally sensitive education should be implemented to minimise this potential harm.

See Chapter 5. Benefits, harms and cost-effectiveness of cervical screening in the renewed National Cervical Screening Program (NCSP).

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Health system implications of these recommendations

Clinical practice

Healthcare professionals who provide screening services for Aboriginal and Torres Strait Islander women need to be able to allocate enough time to provide education about screening and encouragement to participate in the program.

Improved resources for cervical screening for Aboriginal and Torres Strait Islander women should be made available.

For all women who present for cervical screening the healthcare professional should ascertain the woman’s Aboriginal and Torres Strait Islander status and record this on the pathology request form and it is anticipated that this data will be collected by the National Cancer Screening Register.

Resourcing

There may be too few nurses or Aboriginal health workers adequately trained as cervical screening test providers. Training more personnel will have cost implications. There is evidence from Queensland that the introduction of LBC for cervical screening in a remote high-risk population (mainly Aboriginal and Torres Strait Islander people) led to a reduction in the rate of unsatisfactory smears.[8] In the Renewed program it anticipated that this benefit will be continued.

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Barriers to implementation

Due to the transient nature of some Aboriginal and Torres Strait Islander women they may not receive an invitation to participate in the NCSP if their mailing address has changed.

Aboriginal and Torres Strait Islander women may refuse the invitation for cultural reasons or a lack of understanding about cervical cancer and its prevention. Education about HPV testing and prevention of cervical cancer is very important, and should be delivered in culturally sensitive and appropriate ways, by people in whom these women have confidence.

Aboriginal and Torres Strait Islander women, especially those in rural and remote areas, often use the services of nurses and Aboriginal Health workers who are trained cervical screening test providers. The aim is to provide the most appropriate service for individual women. Workers and women can be facing multiple barriers to providing cervical screening including other health and social issues that may be a priority during an appointment. Most importantly, it can take time for workers to build trust and educate women about the need for screening.[9]


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Discussion

Unresolved issues

Data regarding Indigenous status are not currently routinely collected by the Cervical Screening Registers and this prevents the accurate assessment of cervical screening issues in Aboriginal and Torres Strait Islander women. The Renewed NCSP aims to collect these data.

Future research priorities

Strategies to improve recruitment of Aboriginal and Torres Strait Islander women should be developed, implemented and evaluated. Consideration could be given to the development and evaluation of culturally appropriate information to support the invitation to screen. More research is required to determine why cervical screening participation in some specific communities in the Northern Territory and Queensland is higher than in others, and to translate the approaches of the more highly screened communities to the wider Aboriginal and Torres Strait Islander population.


Author(s):

References

  1. Australian Institute of Health and Welfare. The health and welfare of Australia’s Aboriginal and Torres Strait Islander peoples 2015. Cat. no. IHW 147. Canberra: AIHW; 2015 Available from: http://www.aihw.gov.au/WorkArea/DownloadAsset.aspx?id=60129551281.
  2. Australian Institute of Health and Welfare. Cervical screening in Australia 2012–2013. Cancer series no. 93. Cat. no. CAN 91. Canberra: AIHW; 2015 Available from: http://www.aihw.gov.au/WorkArea/DownloadAsset.aspx?id=60129550872.
  3. Zhang X, Condon JR, Rumbold AR, Cunningham J, Roder DM. Estimating cancer incidence in Indigenous Australians. Aust N Z J Public Health 2011 Oct;35(5):477-85 Available from: http://www.ncbi.nlm.nih.gov/pubmed/21973255.
  4. Whop LJ, Cunningham J, Condon JR. How well is the National Cervical Screening Program performing for Indigenous Australian women? Why we don't really know, and what we can and should do about it. Eur J Cancer Care (Engl) 2014 Nov;23(6):716-20 Available from: http://www.ncbi.nlm.nih.gov/pubmed/25238027.
  5. Garland SM, Brotherton JM, Condon JR, McIntyre PB, Stevens MP, Smith DW, et al. Human papillomavirus prevalence among indigenous and non-indigenous Australian women prior to a national HPV vaccination program. BMC Med 2011 Sep 13;9:104 Available from: http://www.ncbi.nlm.nih.gov/pubmed/21910918.
  6. 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.
  7. Smith MA, Liu B, McIntyre P, Menzies R, Dey A, Canfell K. Fall in genital warts diagnoses in the general and indigenous Australian population following implementation of a national human papillomavirus vaccination program: analysis of routinely collected national hospital data. J Infect Dis 2015 Jan 1;211(1):91-9 Available from: http://www.ncbi.nlm.nih.gov/pubmed/25117753.
  8. Shield PW, Nolan GR, Phillips GE, Cummings MC. Improving cervical cytology screening in a remote, high risk population. Med J Aust 1999 Mar 15;170(6):255-8 Available from: http://www.ncbi.nlm.nih.gov/pubmed/10212646.
  9. Peters K. Politics and patriarchy: barriers to health screening for socially disadvantaged women. Contemp Nurse 2012 Oct;42(2):190-7 Available from: http://www.ncbi.nlm.nih.gov/pubmed/23181371.

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