In 2022, Can­cer Aus­tralia esti­mates 942 new cas­es of cer­vi­cal can­cer will be diag­nosed in Aus­tralia. Cer­vi­cal can­cer is twice as preva­lent in Aus­tralian Abo­rig­i­nal women and they are three times more like­ly to die from the dis­ease than their non-Indige­nous coun­ter­parts. Also, more cas­es will be diag­nosed in rur­al and remote areas in Aus­tralia (Can­cer Aus­tralia, 2022). 

Cur­rent­ly, only 63 per cent of eli­gi­ble peo­ple in Aus­tralia are up to date with the cer­vi­cal screen­ing sched­ule rec­om­mend­ed by the Nation­al Cer­vi­cal Screen­ing Pro­gram (Can­cer Coun­cil, 2022). In response to tar­get­ing under­screened groups, the Aus­tralian Gov­ern­ment intro­duced a par­tial update to the cer­vi­cal screen­ing guide­lines result­ing in increased eli­gi­bil­i­ty of self-col­lec­tion for HPV test­ing. This will not only result in less inva­sive test­ing but pro­vide a way for­ward to increas­ing test­ing in under-screened groups, some of whom reside in region­al and remote Aus­tralia (Can­cer Coun­cil Aus­tralia, 2022). 

Up until recent­ly, attend­ing a health ser­vice for cer­vi­cal screen­ing meant an inva­sive clin­i­cian-led pro­ce­dure which could be uncom­fort­able and dif­fi­cult for peo­ple with a trau­ma his­to­ry. A recent study found embar­rass­ment, fear of results, lack of time and lack of female prac­ti­tion­ers as rea­sons for lack of par­tic­i­pa­tion (Nagendi­ram A et al 2019). Oth­er stud­ies cite his­to­ries of sex­u­al abuse and trau­ma as a bar­ri­er (Cad­man L, 2012).

Cou­ple these research find­ings with the lim­it­ed avail­abil­i­ty of appoint­ments in GP prac­tices and fly in/​fly out clin­ics in remote regions, and it is easy to see how clin­i­cian-col­lect­ed cer­vi­cal screen­ing tests get pushed to the back­burn­er, result­ing in under-screened populations. 

Offer­ing self-col­lec­tion, which is con­trolled by the patient, could increase test­ing rates and is seen as a game chang­er in the fight to elim­i­nate cer­vi­cal can­cer in Aus­tralia by 2035 (ACPCC, 2022).

Eli­gi­bil­i­ty criteria

These new guide­lines do not replace the need for for­mal cer­vi­cal screen­ing train­ing offered by sex­u­al health teach­ing organ­i­sa­tions through­out Aus­tralia. To offer cer­vi­cal screen­ing to patients, clin­i­cians should first com­plete cer­vi­cal screen­ing train­ing which will be informed by the Nation­al Cer­vi­cal Screen­ing Pro­gram guide­lines (Can­cer Coun­cil Aus­tralia, 2022). 

Under­tak­ing the train­ing will alert clin­i­cians to the var­i­ous cri­te­ria for who should be offered self-col­lec­tion screening. 

Main­ly, peo­ple who do not have symp­toms of con­cern between the ages of 25 – 74 who have ever been sex­u­al­ly active can be offered self-col­lec­tion test. Exam­ples of symp­toms of con­cern are abnor­mal, post-menopausal and inter­men­stru­al bleed­ing as well as pain or abnor­mal dis­charge. These peo­ple would not qual­i­fy for self-col­lec­tion but instead would be offered a clin­i­cian-col­lect­ed sam­ple as fur­ther inves­ti­ga­tions are required and a co-test (cytol­ogy) should be ordered to detect any cel­lu­lar changes. Co-tests can­not be ordered from a self-col­lect­ed swab and must be ordered through a clin­i­cian-col­lect­ed cer­vi­cal sample.

Flocked swabs

One of the com­mon con­cerns with the self­col­lec­tion method is whether the test­ing is as reli­able and accu­rate as clin­i­cian-col­lect­ed sam­ples. A recent meta-analy­sis found that the sen­si­tiv­i­ty and speci­fici­ty of HPV test­ing to detect CIN2+ in self-col­lect­ed sam­ples were sim­i­lar to those for clin­i­cian-col­lect­ed sam­ples when using val­i­dat­ed PCR-based HPV assays (Can­cer Coun­cil, 2022). 

Self-col­lec­tion HPV tests are obtained using a flocked swab which is high­ly resilient and can with­stand very hot and cold tem­per­a­tures, as well as last­ing for up to 28 days once the swab is collected. 

This robust fea­ture of the test is what is most attrac­tive to rur­al and remote clin­i­cians who are logis­ti­cal­ly iso­lat­ed from test­ing facilities.

The resilience of the swab also allows prac­ti­tion­ers in rur­al and remote areas to test oppor­tunis­ti­cal­ly in their clin­ics, rather than wait­ing for ded­i­cat­ed clin­ics, which are often set up on a fort­night­ly basis and are booked solid­ly with more imme­di­ate issues. This will hope­ful­ly result in the reduc­tion of cer­vi­cal can­cer cas­es in rur­al and remote Aus­tralia and the World Health Organisation’s goal to erad­i­cate cer­vi­cal can­cer by 2035 will hope­ful­ly be met.

Ref­er­ences

Aus­tralian Cen­tre for the Pre­ven­tion of Cer­vi­cal Can­cer (2022), Let’s Elim­i­nate Cer­vi­cal Can­cer by 2035, Australia’s Nation­al Cer­vi­cal Can­cer Elim­i­na­tion Strat­e­gy | acpcc​.org​.au, cit­ed 18/9/22

The Aus­tralian Gov­ern­ment (2022), Can­cer Aus­tralia, Cer­vi­cal can­cer in Aus­tralia sta­tis­tics | Can­cer Aus­tralia, cit­ed 18/9/22.

Can­cer Coun­cil Aus­tralia (2022), Nation­al Cer­vi­cal Screen­ing Pro­gram, Cer­vi­cal can­cer screen­ing | Can­cer Coun­cil, cit­ed 18/9/22.

Can­cer Coun­cil (2022) Updat­ed guide­lines pre­pare health pro­fes­sion­als for cer­vi­cal screen­ing ​‘game-chang­er’ | Can­cer Coun­cil, cit­ed 18/9/22

Can­cer Coun­cil, (2022) Self-col­lect­ed vagi­nal sam­ples | Can­cer Coun­cil. Cit­ed 18/9/22

Cad­man L, Waller J, Ash­down-Barr L, et al Bar­ri­ers to cer­vi­cal screen­ing in women who have expe­ri­enced sex­u­al abuse: an explorato­ry study Jour­nal of Fam­i­ly Plan­ning and Repro­duc­tive Health Care 2012;38:214 – 220. 

Nagendi­ram A, Bougher H, Banks J, Hall L, Heal C. Aus­tralian women’s self-per­ceived bar­ri­ers to par­tic­i­pa­tion in cer­vi­cal can­cer screen­ing: A sys­tem­at­ic review. Health Pro­mot J Aus­tr. 2020 Sep;31(3):343 – 353. doi: 10.1002/hpja.280. Epub 2019 Aug 7. PMID: 31353682. https://pubmed. ncbi​.nlm​.nih​.gov/​3​1​3​5​3682/