Cervical Screening in Australia

In December 2017, the Pap smear program in Australia was replaced by the new Cervical Screening Program.
With the Pap smear, a swab or brush of the cervix was spread on a slide and the cells were examined for abnormalities.
Now, there is still a swab of the cervix but it is sent for virus testing instead – specifically Human Papillomavirus (HPV). This is called the ‘Cervical Screening Test’ or CST for short.
If HPV is detected, the cells are then looked at in the same sample. The result guides recommendations for follow-up.

The Pap smear program has been quite successful and reduced the cervical cancer rate significantly since the program’s formal introduction in 1991.
However, some cancers are still being missed.
Also, the rate of cervical cancer has plateaued in the last 10 years – can we do better?
Detection will be even harder when the prevalence of abnormal cell changes and cancer falls due to the cervical cancer vaccine – and we need a screening test that will still perform well, even with low prevalence.
HPV testing has a high negative predictive value (so a negative result is very reassuring) and a high detection rate for high grade abnormality. It is the better test.

– HPV testing, not Pap smears
– Every 5 years (not every 2 years)
– Starting age 25 (previously 18 or first sexual intercourse)
– Exit of program 70-75 years old after a negative CST
– Possibility of ‘self-testing’

– Human Papillomavirus or HPV is a small double-stranded DNA virus
– There are hundreds of types but only some are associated with cancer
– It is transmitted by direct contact (usually sexual contact)
– Several types including HPV types 1, 2, and 4 cause common warts and plantar warts
– HPV types 6 and 11 are associated with genital warts
– HPV types 16 and 18 have historically caused about 70% of cervical cancers – and seem to be more likely to cause abnormal cell changes
– There are another 12 or so HPV types tested for in the CST that have also been associated with cervical cancer

The CST result will look something like this:

NAME etc
CST – reason (eg. routine test)
HPV 16 Not detected
HPV 18 Not detected
HPV (not 16/18) Detected
Cytology negative
Endocervical component present

HPV 16/18 detected
If HPV 16 and/or 18 is detected, then the recommendation is for referral to a gynaecologist for a colposcopy. This is because HPV 16 and 18 have a higher association with abnormal cell changes and cervical cancer.

HPV (not 16/18) detected or HPV Other detected
In this example, one of the other 12 HPV types has been detected.
It is not important which type as it is unknown if having one type causes more cancer than another type in this group. But these are still ‘high risk’ HPV types that can cause cancer.

Because HPV has been detected, the cells in the same sample have been analysed and, in this example, are ‘negative’.

With this result, the recommendation would be to repeat the CST in 12 months.

Repeat CST in 12 months
If the HPV is still detected, then the recommendation would be referral to a gynaecologist for colposcopy. This is because persisting HPV can cause abnormal cell changes that may not be picked up by the CST and requires visual inspection and targeted sampling/biopsy (which is what colposcopy is about).

If the repeat CST in 12 months is negative, then it is back to ‘routine’ screening, which is every 5 years. It is very likely HPV is not ‘cleared’ but is just ‘dormant’ and can re-activate at another time.

Cytology not negative but LSIL or HSIL
Cytology can also be LSIL or HSIL. LSIL is when the cells in the sample only have low grade changes. There is a high chance (about 70%) of LSIL resolving spontaneously so the recommendation is repeat CST in 12 months.
HSIL refers to high grade abnormalities and are far less likely to resolve and more likely to persist or go on to cancer – the recommendation is referral to a gynaecologist for a colposcopy.

Very likely not.
If you have HPV detected on your CST, even though all the HPV types tested can cause cancer, just having the virus does not mean you have cancer.
It is thought that having one of the high risk HPV types and having an active infection of it for a long time (years) results in abnormal cell changes. Over more years, these cell changes become cancer. But the hope is that with regular screening, we will catch it at the early cell change stage – or, with the CST, at the HPV active infection stage so we know when to watch closely.

Colposcopy is an examination very much like having a ‘Pap smear’, except the cervix is looked at with a colposcope.
A speculum (the duck-bill thing) is inserted into the vagina and the cervix is inspected by a colposcope.
The colposcope is basically binoculars with a light.
Fine details on the cervix can be seen much better than with the naked eye.
If there are any abnormalities seen, a biopsy is recommended – the biopsy is a little pinch of tissue, 1-3mm long. Some people feel a little pinch, some have no sensation at all.
Silver nitrate or Monsels is used on the biopsy site to stop bleeding.
It is recommended to avoid anything vaginally for at least 48 hours to prevent infection.

Male partners do not need to be tested (as there is no test) and no precautions are required (they probably already carry HPV).
Much less commonly, HPV can cause head and neck cancers and cancers of male genitals. But these can also be non-HPV related. In contrast to cervical cancer where HPV is involved in more than 99% of the cases, if not close to 100%.

It is unknown when you acquired HPV.
It is very likely that HPV is never truly ‘cleared’ and that it becomes ‘dormant’ for long periods of time and then becomes ‘active’ at times.
HPV is detected when it is active. HPV is not detected or negative when the virus is inactive or ‘dormant’.
It is likely that things that lower the immune system such as smoking, extreme stress, certain medications, etc make it more likely that HPV is active.
So it doesn’t mean that your partner has been unfaithful!

The interval between persistent HPV infection and development of cervical cancer is on average about 10-15 years.
It is very unlikely cervical cancer will develop in the five years after a negative result.
More than 90% of women with cervical cancer either didn’t have any screening or last had screening more than 5-10 years before.

Short answer: too bad.
Long answer: it will not be possible. The shift away from Pap smears has meant there are now fewer expert cytologists to interpret the Pap smears so the results will not be as good as they once were.
Better get with the program – the new Cervical Screening Program.

Because the vaccine does not cover all the high risk HPV types.
The original Gardasil only covered HPV types 16 and 18 (and types 6 and 11 but those caused genital warts).
The new nonavalent vaccine covers nine HPV types but there are still types not covered.
The good news is that we are already seeing the decrease in HPV infection in those covered by the cervical cancer vaccine – there has been a noticeable decline in genital warts such that it is now rarely seen.
The vaccine is only preventative and not curative – so is best given prior to first sexual intercourse.