No pap smears, just HPV tests

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The Australian government’s proposes changes in cervical cancer screening

The proposed changes in the Australian government’s renewed cervical cancer screening will improve early detention and save many lives.

The government has now indicated that from 1 December 2017, women aged 25 years or over who have not yet started cervical screening will receive an invitation to have the new cervical screening test.

The proposed changes would mean there will be no need to have a pap smear every two years. In this new program women will be offered a HPV test every 5 years from 25 until 70 years of age instead of a pap smear every two years from age of 18 to 69.

The National Cervical Screening Register will send an invitation to women to let them know they are due for their test and also remind women if they become overdue for their regular test.

Women already participating in the program will be invited to screen within three months of the date when they would have been due for their two-yearly Pap test.

Women between 70 and 74 years of age who have had a regular cervical screening test will be recommended an exit HPV test before leaving the National Cervical Screening Program.

Women older than 69 years of age who have never been screened or not had regular screening tests should have a cervical screening test if they request screening.

The pap smear detects cervical cancer in very early and pre-cancerous stages and since 1991 it has been the foundation of National Cervical Screening Program. So far it has significantly improved cervical cancer detection and has reduced cervical cancer rates in the Australia and in the world.

But some women experience anxiety about the speculum examination because of cultural issues or past sexual abuse which can force them not to have pap smear. It is more likely to happen in migrant women. In addition, lack of awareness of the screening program in their own country puts them at risk of underscreening.

The proposed changes are based on new knowledge of the role of HPV (Human Papilloma Virus) in cervical cancer as well as the availability of new technologies to detect the HPV virus and the success rate of the HPV vaccine.

These changes will further reduce the overall rate of cervical cancer cases and death by around 20%. In this new program, migrant women particularly who are never-screened or under-screened will be able to take a vaginal swab themselves which can be sent to the lab for testing. Though self-collected tests may not be as accurate as those taken by doctors it allows vulnerable migrant women to participate in the program and benefit from it.

In addition, Torres Strait Islanders and women from the aboriginal community, who have a four times higher cervical cancer death rate, can participate in this program. These changes may also save money of patients due to fewer visits to the GP and ultimately less referral to gynaecologists.

Out of 40 different HPV types which can cause infection in the genital tract of women, 14 HPV types are most likely to cause cancer of the cervix. Cancers develop when HPV fails to clear and persists in the cells for longer time. Out of theses 14, two types 16 and 18 are responsible for around 70 per cent of the cervical cancers.

If the new test detects HPV 16 and 18 infections, the pap smear will be analysed to look for abnormal cell changes, and if those are detected, women will be referred to specialists.

Women with an intermediate risk of HPV will have to repeat the test in 12 months.

Women with negative HPV can be reassured that their risk of developing cervical cancer within the next five years is very low. So, the retesting of HPV will be done after five years.

What is HPV?

HPV is a cancer-causing virus and is sexually transmitted infection. Most women get infected in early stages of active sexual life and in fact up to 80 per cent of the adults at some point of life will be infected. When infected it generally remains asymptomatic and majority of the time it clears off by its own. So, all those infected do not develop cancer but those fail to clear off HPV can develop cancer after few years-may be 10 years. In 2002, WHO estimated HPV caused 5.2 per cent of all cancers worldwide. On average, there are 1.3 cases of cervical cancer each year per 100,000 women aged 20-24 and 6.7 cases per 100,000 women aged 25-49.

Why are we screening at 25 rather than at 18?

Increasing the age from 18 to 25 has raised some concerns that cervical cancer can be missed in some younger women. But it is very unlikely because cervical cancer is rare in women less than 25 years of age and the old screening method has not reduced the mortality from cervical cancer in this age group. Though if there are symptoms women of any age should see their doctor. HPV infection and cell abnormalities are common in women less than 25 but a majority of the time it clears without any treatment. In fact, treatment of these abnormalities has put young women at risk of having pregnancy complication later in life.

The writer is a Senior Consultant Obstetrician & Gynaecologist, at Sunshine Hospital; Director at Western Specialist Centre, Werribee & St Albans; and Director; MyOBG at Werribee

 

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