vccr statistical report - 2012

STATISTICAL REPORT 2012

Editorial Committee:Associate Professor Dorota Gertig, VCCR Medical DirectorAssociate Professor Marion Saville, VCS Executive DirectorDr Julia Brotherton, Epidemiologist

Genevieve Chappell, VCCR ManagerBianca Barbaro,Senior Research Offi cerLesley Rowlands, Follow-up Manager Produced by: Tanya O’Farrell, Health Information Manager (Registry Operations)

Victorian Cervical Cytology RegistryPO Box 161, Carlton South, Victoria 3053 Telephone: (03) 8417 6816 Email: [email protected]: www.vccr.org

STATISTICAL REPORT 2012

The Victorian Cervical Cytology Registry

acknowledges the support of the Victorian Government

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CONTENTS

EXECUTIVE SUMMARY 6

1. INTRODUCTION 7 1.1 Background 71.2 Functions of the VCCR 71.3 National Policy: the NHMRC Guidelines for the Management of Asymptomatic Women with Screen Detected Abnormalities and Renewal of the Cervical Screening Program 71.4 The National HPV Vaccination Program 71.5 Data included in this report 8

2. PARTICIPATION IN SCREENING 92.1 Number of Pap tests and women screened 9 Table 2.1:NumberofPaptestsregisteredandnumberofwomenscreenedinVictoria,1990–2012. 92.2 Participation by Age Group 9 Table 2.2:Estimatedcervicalscreeningratesbyagegroupoveroneyear,twoyear, threeyearandfiveyearperiods. 10 Figure 2.2.1:Estimatedtwoyearcervicalscreeningratesbyagegroup,2000-01to2011-12. 11 Table 2.2.1: Estimatedtwoyearcervicalscreeningratesbyagegroup,2000-01to2011-12. 112.3 Participation by Area 12 2.3.1 Participation by Medicare Locals 13 Table 2.3.1: EstimatedtwoyearcervicalscreeningratesbyMedicareLocal,2010-2011

and2011-2012. 13Figure 2.3.1: EstimatedtwoyearcervicalscreeningratesbyMedicareLocal,2011-2012. 14

2.3.2 Participation by Department of Health Region 15 Table 2.3.2: EstimatedtwoyearcervicalscreeningratesbyDepartmentofHealthregion,

2010–2011and2011–2012. 15 Figure 2.3.2: EstimatedtwoyearcervicalscreeningratesbyDepartmentofHealthregion,2011–2012. 15 2.3.3 Participation by Local Government Area 16 Table 2.3.3: EstimatedtwoyearcervicalscreeningratesbyLocalGovernmentArea,

2010–2011and2011–2012. 16 Figure 2.3.3:EstimatedtwoyearcervicalscreeningratesbyLocalGovernmentArea,2011–2012. 182.4 Pap tests collected by Nurses 19 Table 2.4: ProportionofPaptestscollectedbynurses,2003–2012. 19 2.4.1 Proportion of Pap Tests Collected by Nurses by Department of Health Region 20 Table 2.4.1: Paptestsforwomenwithacervixcollectedbynurses,byDepartmentof Healthregion,2012. 20 Figure 2.4.1: ProportionofPaptestscollectedbynurses,byDepartmentofHealthregion,2012. 212.5 Closing the Data Gaps:Identifying Aboriginal and Torres Strait Islander People, and collecting country of birth and language spoken at home 22 Table 2.5 (a): ProportionofWomenScreenedbyAboriginalandTorresStraitIslanderOrigin. 22

Table 2.5 (b): ProportionofPapTestsbyPractitionerTypewithAboriginalandTorresStrait IslanderOriginInformationrecorded. 222.6 Frequency of Early Re-Screening 23

Table 2.6: SubsequentPaptestsovera21monthperiodforwomenwithanegativereportinFebruaryof2011. 23

Figure 2.6: Earlyre-screeningafteranegativePaptestreportinFebruary2011byagegroup. 23

VictorianCervicalCytologyRegistryStatistical Report 2012 5

3. CYTOLOGY REPORTS 243.1 Unsatisfactory Pap tests 243.2 Negative Pap tests 243.3 Pap tests without an endocervical component 24 Figure 3.3: PercentageofPaptestswithoutanendocervicalcomponent. 243.4 Pap tests with a squamous abnormality 25 Table 3.4: NumberandpercentofPaptestscollectedin2012withasquamousabnormality. 253.5 Pap tests with an endocervical abnormality 25 Table 3.5:NumberandpercentofPaptestscollectedin2012withanendocervicalabnormality. 253.6 Type of tests 25

4. HISTOLOGY REPORTS 26 Table 4: HistologyfindingsreportedtotheVCCRin2012. 26

5. HIGH-GRADE ABNORMALITY DETECTION RATES 27 Figure 5.1: Detectionrateofhigh-gradeintraepithelialabnormalities(histologically-confirmed)from

2009-2012per1,000screenedwomen. 27Figure 5.2: Trendsinhigh-gradecervicalabnormalities(histologically-confirmed)byage,2000–2012,VCCR. 27

6. CORRELATION BETWEEN CYTOLOGY AND HISTOLOGY REPORTS 28 Table 6.1: Correlationofsquamouscytologytothemostserioussquamoushistologywithin6months, womenaged20to69years,cytologytestsperformedin2011. 29 Table 6.2:Correlationofendocervicalcytologytothemostseriousendocervicalhistologywithin6months, womenaged20to69years,cytologytestsperformedin2011. 30

7. FOLLOW-UP AND REMINDER PROGRAM 31 Table 7: NumberoffirstandsecondreminderletterssenttowomenbytheVCCRin2012. 31

8. CERVICAL CANCER INCIDENCE AND MORTALITY IN VICTORIA 32 Figure 8.1: Age-standardisedincidenceandmortalityratesforalltypesofcervicalcancerinVictoria,1982–2012. 32 Figure 8.2: Age-standardisedincidencerates(ASR)forcervicalcancerbyhistologicalsubtypeinVictoria,1982–2012. 33 Figure 8.3: Age-specificincidenceratesofcervicalcancerbyhistologicalsubtypeinVictoria,2010–2012. 33

9. SCREENING HISTORY OF WOMEN DIAGNOSED WITH CERVICAL CANCER IN 2010 AND 2011 34 Table 9 (a): ScreeninghistoryofVictorianwomendiagnosedwithcervicalcancerfortheperiod 1January2010to31December2010. 34 Table 9 (b): ScreeninghistoryofVictorianwomendiagnosedwithcervicalcancerfortheperiod 1January2011to31December2011. 35

ACKNOWLEDGEMENTS 36LISTOFABBREVIATIONS 36GLOSSARYREFERENCES 37

APPENDIX1. CYTOLOGYCODINGSCHEDULE 38APPENDIX2.REMINDERANDFOLLOW-UPPROTOCOLUSEDDURING2012 39APPENDIX3.MAPOFMEDICARELOCALS 40APPENDIX3.MAPOFLOCALGOVERNMENTAREAS-MELBOURNE 41APPENDIX3.MAPOFLOCALGOVERNMENTAREAS-VICTORIA 42

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EXECUTIVE SUMMARY

1 BrothertonJ,FridmanM,MayC,ChappellG,SavilleM,GertigD.Early effect of the HPV vaccination programme on cervical abnormalities in Victoria, Australia: an ecological study.2011.Lancet.377:2085-20922 GertigDM,BrothertonJML,BuddAC,DrennanK,ChappellG,SavilleAM.Impact of a population-based HPV vaccination program on cervical abnormalities: a data linkage study.BMC Medicine 2013,11:227.

Aspartofthecervicalscreeningprogram,theVictorianCervicalCytologyRegistry(VCCR)playsanimportantroleinimprovingthescreeningparticipationofVictorianwomenbysendingreminderlettersandconductingresearchintounder-screening.In2012theVCCRintroducedasecondPaptestreminderletterforVictorianwomen,fundedbytheVictorianGovernment.OurevaluationshowedthatthisletterincreasedparticipationamongwomenoverdueforaPaptestby8.1%comparedtotheprevioustimeperiodbeforetheletterwasintroduced.Datainthisreportshowthatforthefirsttimeinoveradecadetherehasbeenasmallincreaseinscreeningparticipationacrossallagegroupswithanestimated60%twoyearparticipationfor2011-2012forwomeninthetargetagerangeof20to69yearscomparedwith59.2%inthepreviousperiodof2010-2011.ThecorrespondingsustainedincreaseinthenumberofwomenacrossallagegroupshavingPaptests,suggeststhatthisislikelyduetothesecondreminderletterinitiative.

However,substantialvariationexistsinscreeningratesbetweendifferentareasofVictoria,asrepresentedbyMedicareLocals,withthelowesttwoyearscreeningratefor2011–2012at53.2%andthehighestat67.6%.ThescreeningrateforVictorianDepartmentofHealthregionsrangedfrom56.6%to63.1%,whiletheestimatedtwoyearparticipationratebyLocalGovernmentArearangedfrom45.7%to75.5%.

Aspartofthefollow-upandreminderprogram,theVCCRregisteredatotalof602,367Paptestsin2012,representing574,123womenandsentover410,000follow-upandreminderletterstowomenandpractitioners.Morethan6,000abnormalPaptestswerefollowed-upbytheVCCRin2012.Almost120,000secondreminderlettersweresenttowomenandofthosesentafteranegativePaptest,24%hadasubsequentPaptestwithin3monthsofthereminder.

OfPaptestsrecordedbytheVCCRduringtheperiodofthisreport,adefinitehigh-gradesquamouscellabnormalitywaspresentin0.8%oftestsandanendocervicalabnormalitywasidentifiedinfewerthan0.1%oftests.Forthe3,653high-gradecytologytestsreported,2,911weresubsequentlyconfirmedwithhigh-gradehistologyonbiopsywithinasixmonthperiod.Thisrepresentsapositivepredictivevalueof79.7%andreflectsthehighqualityoflaboratoryreportinginVictoria.

OverthelastdecadetherehasbeenagradualincreaseintheproportionofPaptestscollectedbynurses.In2012thenumberofPaptestscollectedbynursesrepresented5.6%ofallPaptestscollectedinVictoriaandhighlightstheimportantrolenurseshaveintheCervicalScreeningProgram.

VCCRcontinuestoworkcloselywithProgramPartnerstoidentifygroupsinourcommunitythatarelesslikelytoscreen.CollectinginformationfromwomenattendingscreeningabouttheiridentificationasanAboriginalandTorresStraitIslander,theirCountryofBirthandtheLanguageSpokenatHomeiscriticalforunderstandingwhoparticipatesincervicalscreening.Theoverallpercentageofwomenscreenedin2012whohadtheirAboriginalandTorresStraitIslanderstatusrecordedbytheVCCRwas19.4%,forcountryofbirth14.5%andlanguagespokenathome15.2%.

Accordingtothemostrecentdata(2012)fromtheVictorianCancerRegistry,mortalityfromcervicalcancerinVictoriais1.1per100,000women.Thisisatremendousachievementandreflectsthesuccessoftheorganisedcervicalscreeningprogram,whichisunderpinnedbythePaptestregistries.Despitethissuccess,furthereffortsarenecessarytoimproveparticipationamongstunder-screenedwomenas77%ofVictorianwomenwhowerediagnosedwithinvasivecervicalcancerin2011hadneverhadaPaptest,orwerelapsedscreeners,priortotheircancerdiagnosis.

TheVCCRisleadingandcollaboratingonanumberofresearchactivitiesthatwilllikelyinfluencepolicyinitiativesincervicalscreening.CervicalabnormalityratesinthecohortofyoungwomenwhocommencedscreeningfollowingtheintroductionoftheNationalHPVVaccinationProgramin2007continuetobemonitoredinthisreport.FollowingthepublicationofVCCRdataintheLancetin2011,whichdocumentedthefirstdeclineinhigh-gradeabnormalitiesseeninavaccinatedpopulationinternationally1,histologically-confirmedhigh-gradeabnormalitieshavecontinuedtodeclineforwomenagedlessthan20yearsandinwomenaged20to24years.ThisyeartheVictorianCytologyService(VCS)andtheAustralianInstituteofHealthandWelfare(AIHW)havepublishedmoreworldfirstfindings,whichhavemeasuredHPVvaccineeffectivenessagainstcervicalabnormalitiesusingdataobtainedbylinkingtheVCCRwiththeNationalHPVVaccinationProgramRegister2.Thestudyfoundthatwomenvaccinatedintheschoolcohortsofthecatch-upprogram(aged12to17yearsin2007)attendingscreeninghavea48%lowerrateofhigh-gradeabnormalitiesthanunvaccinatedwomen.Aswomenvaccinatedatearlierages(theroutinevaccinationprogramisat12to13yearsofage)commencescreening,theimpactofthevaccineisexpectedtoincreasefurther.

Victorian Cervical Cytology Registry Statistical Report 2012 7

1. INTRODUCTION

3 NHMRC Screening to prevent cervical cancer: guidelines for the management of asymptomatic women with screen-detected abnormalities,2005. http://www.nhmrc.gov.au/publications/synopses/wh39syn.htm4 TabriziSN,BrothertonJML,KaldorJM,SkinnerSR,CumminsE,LiuB,BatesonD,McNameeK,GarefalakisM,GarlandSM.Fall in Human Papillomavirus Prevalence Following a National Vaccination Program.JInfectDis.2012;206(11):164551. Availableathttp://jid.oxfordjournals.org/content/early/2012/10/17/infdis.jis590.full.pdf+html

1.1 BACKGROUNDTheVictorianCervicalCytologyRegistry(VCCR)isoneofeightsuchregistriesoperatingthroughoutAustralia.EachStateandTerritoryoperatesitsownregister.VictoriawasthefirstStatetoestablishsucharegisterandcommencedoperationinlate1989afteramendmentstotheCancerAct1958.

ThePaptestRegistries,astheyarecommonlyknown,wereintroducedprogressivelyacrossAustraliathroughoutthe1990s.TheRegistriesareanessentialcomponentoftheNationalCervicalScreeningProgramandprovidetheinfrastructurefororganisedcervicalscreeningineachStateandTerritory.

TheVCCRisavoluntary“opt-off”confidentialdatabaseorregisterofVictorianwomen’sPaptestresults.LaboratoriesprovidetheVCCRwithdataonallPapteststakeninVictoria,unlessawomanchoosesnottoparticipate.

TheVCCRworkscloselywiththeVictorianDepartmentofHealthandotherProgramPartnersincludingPapScreenVictoriawhichisresponsibleforthecommunicationsandrecruitmentprogramaimedatmaintainingthehighratesofparticipationofVictorianwomenintheNationalCervicalScreeningProgram.

1.2 FUNCTIONS OF THE VCCRTheVCCRfacilitatesregularparticipationofwomenintheNationalCervicalScreeningProgrambysendingreminderletterstowomenforPaptestsandbyactingasasafetynetforthefollow-upofwomenwithabnormalPaptests.

TheprimaryfunctionsoftheVCCRasspecifiedintheCancerAct1958are:

a) tofollow-uppositiveresultsfromcancertests,

b) tosendremindernoticeswhenpersonswhosenamesappearintheregisteraredueforcancertests,

c) subjecttoandinaccordancewiththeregulations,togiveaccesstotheregistertopersonsstudyingcancer;and

d) tocompilestatisticsand,iftheorganisationconsidersitappropriate,topublishthosestatisticsthatdonotidentifythepersonstowhomtheyrelate.

SecondaryfunctionsoftheRegistrieshavedevelopedonamoreregionalbasis.InVictoria,theroleoftheVCCRincludes:

• theprovisionoftheknownscreeninghistoryofawomantothelaboratorythatisreportingthecurrentPaptest,

• theprovisionofquantitativedatatolaboratoriestoassistwiththeirqualityassuranceprograms;and

• theprovisionofaggregatedatatotheAIHWsothattheNationalCervicalScreeningProgramcanbejudgedagainstanagreedsetofperformanceindicators.

1.3 NATIONAL POLICY: THE NHMRC GUIDELINES FOR THE MANAGEMENT OF ASYMPTOMATIC WOMEN WITH SCREEN DETECTED ABNORMALITIES AND RENEWAL OF THE CERVICAL SCREENING PROGRAMOn1July2006,theNationalHealthandMedicalResearchCouncil(NHMRC)Guidelines for the Management of Asymptomatic Women with Screen Detected Abnormalities(2005)3wereimplementedaroundAustralia.Themainchangestotheexistingguidelineswere:

• thechangeofterminologyforcytologyreportstotheAustralianModifiedBethesdaSystem2004,

• repeatPaptestsformostwomenwithlow-gradesquamousabnormalities,

• nottotreatbiopsyprovenlow-gradeorHPVlesions,

• toreferallwomenwithatypicalglandularcellsforcolposcopy,

• toreferallwomenwithapossiblehigh-gradelesionforcolposcopy;and

• touseHPVtestsandcytologyasatestofcureforwomentreatedforCINIIandCINIII.

TheVCCRparticipatesintheNationalSafetyMonitoringoftheNHMRCguidelines.Thecervicalscreeningprogramispresentlyundergoingarenewal,whichaimstoidentifythebestscreeningprogramforAustralianwomengivenrecentchangestoavailabletechnologyandtheimplementationoftheNationalHPVVaccinationProgram.Furtherinformationcanbefoundathttp://www.cancerscreening.gov.au/internet/screening/publishing.nsf/Content/ncsp-renewal

1.4 THE NATIONAL HPV VACCINATION PROGRAMTheNationalHPVVaccinationProgramcommencedinApril2007andisalreadyhavingasubstantialimpactontheprevalenceofHPVinfectionandcervicallesionsinvaccinatedcohorts4.Between2007and2009,12to26yearoldfemaleswereofferedthequadrivalentHPVvaccination(Gardasil)inanationalcatch-upprogramprovidedthroughschools,generalpracticeandothercommunityproviders.Since2009theprogramhasofferedroutinevaccinationthroughschoolsfor12to13yearoldgirlsand,from2013,vaccinationtoboysat12to13years,withatwoyearcatch-upprogramfor14to15yearoldboys.

ThePaptestRegistriesaroundAustraliaplayanimportantroleinmonitoringtheimpactofthevaccinationprogramonparticipationratesincervicalscreeningandoncervicalabnormalitiesandcancerinthelongterm.TheimportanceofcontinuingregularPaptestsforvaccinatedwomenisemphasisedaspartoftheNationalHPVVaccinationProgram.

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ofculturaldiversity,suchascountryofbirthandlanguagespokenathome.Informationontheproportionofwomenwhore-screenearlyisalsofeatured.

Cytology codingInformationprovidedonthecytologyreportofPaptestsispre-codedbythepathologylaboratorytotheCytologyCodingSchedule.Appendix1outlinestheAustralia-widecytologycodesthathavebeenusedsince1July2006tocorrespondwiththeimplementationoftheNHMRCguidelines.TheCytologyCodingScheduleallowsaPaptestreporttobesummarisedtoasixdigitnumericcodecoveringthetypeoftest,siteoftest,theresultforsquamouscells,theendocervicalcomponent,othernon-cervicalcells,andtherecommendationmadebythelaboratoryinregardtofurthertesting.DataarepresentedontheproportionofPaptestsclassifiedaccordingtotheirresultsasunsatisfactory,negative,squamousabnormalitypresentandendocervicalabnormalitypresent.ThepercentageofPaptestscollectedduring2012withoutanendocervicalcomponentisalsopresented.

Histology/colposcopy reportsThe2012histologyresultsinthisreportareasnotifiedby30June2013.Thevastmajorityofhistologyreportsarenotifiedbythistime.Whilereasonablycomprehensivenotificationoccursforhistologyreports,aproportionofcolposcopyonlyresultsarealsonotified,mosttypicallywhenahistologyreportisnotavailable.Dataincludedinthisreportexcludesresultsreportedfromacolposcopyreportalone(i.e.nolaboratoryreport).In2013,theVCCRimplementedroutinecollectionofdataoncolposcopiesperformedinVictoria.Thiswillassistwiththefollow-upofabnormalitiesandthemonitoringofcolposcopyquality.

Follow-up protocolTheVCCRReminderandFollow-upProtocolisbasedontheNHMRCGuidelines for the Management of Asymptomatic Women with Screen Detected Abnormalities.TheReminderandFollow-upProtocolusedbytheVCCRin2012isshowninAppendix2.ReminderlettersarenotsenttowomenwhoseVCCRrecordsindicateapasthistoryofhysterectomyorofcervicaloruterinemalignancy,ortowomenwhoareover70yearsofageandwhoselastPaptestwasnormal.

Cervical cancer incidence and mortality InformationoncervicalcancerincidenceandmortalityisprovidedinthisreportcourtesyoftheVictorianCancerRegistryattheVictorianCancerCouncil.AlsoincludedisasectionexaminingthescreeninghistoryofVictorianwomendiagnosedwithinvasiveandmicro-invasivecervicalcancerduring2010and2011.

5 TheNationalHPVVaccinationProgramRegisterwebsite.http://www.hpvregister.org.au6 GertigDM,BrothertonJML,BuddAC,DrennanK,ChappellG,SavilleAM.Impact of a population-based HPV vaccination program on cervical abnormalities: a data linkage study. BMC Medicine 2013,11:227.7 AustralianInstituteofHealthandWelfare2013.Cervical screening in Australia 2010-2011. CancerSeries76.Cat.no.CAN72.Canberra:AIHW

ANationalHPVVaccinationProgramRegister(theHPVRegister)5wasestablishedtosupport,monitorandevaluatetheNationalHPVVaccinationProgram.VCSInc,whichhasoperatedtheVictorianCervicalCytologyRegistryforover20years,wasengagedbytheDepartmentofHealthandAgeinginFebruaryof2008toestablishandmanagetheNationalHPVVaccinationProgramRegister.TheHPVRegisterreceivesdatafromallstatesandterritoriesandfromalltypesofvaccinationprovidersincludingLocalCouncils(whoinsomeStatesdelivertheschoolvaccinationprogram),GeneralPractitioners,nursesandotherimmunisationprovidersaroundAustralia.TheRegisterrecordsbasicdemographicinformationandinformationaboutdosesadministeredinAustralia.TheHPVRegistersupportstheprogrambysendingstatementsonvaccinationstatustoeligiblevaccinerecipientsandtheirproviders,andbyprovidingreportsandde-identifieddatatoapprovedprovidersandresearchers.LinkageofdataheldbytheHPVRegisterwithinformationheldbythePaptestandcancerregistrieswillbeacriticalcomponentofmonitoringandevaluatingtheimpactofvaccination.Thefirststudydemonstratingpopulation-basedeffectivenessoftheHPVvaccinationprogramwasrecentlypublishedbytheVCCR.Ade-identifieddatalinkagewasundertakenbetweentheNHVPRandtheVCCR,anddemonstrateda48%reductionontheratesofthemostseriouscervicalpre-cancersforwomenwhohadbeencompletelyvaccinatedintheschool-program,comparedwithunvaccinatedwomen6.

1.5 DATA INCLUDED IN THIS REPORT ThisstatisticalreportprovidestimelyinformationaboutcervicalscreeninginVictoriaduring2012.InmostcasesthemethodologyandterminologyusedinVCCRreportsisconsistentwiththatpublishedbytheAIHWaspartofreportingindicatorsfortheNationalCervicalScreeningProgram7.

Participation ratesThisreportincludesinformationonparticipationratesforwomenaged20to69yearsintenyearagegroupsandfiveyearagegroupsforthe20to29group.PopulationdatahasbeenadjustedtoexcludewomenwhohavehadahysterectomyusingmodelingcarriedoutbytheAIHWbasedontheNationalHospitalMorbidityDatabase.ThetwoyearparticipationratesarealsopresentedbyMedicareLocals,DepartmentofHealthregionandLocalGovernmentArea.ThenumberandproportionofPaptestscollectedbynursesispresentedinthisreport,byyearandDepartmentofHealthregion.FurtherinformationregardingPaptestscollectedbynursesisavailableinthereport‘Evaluation of Pap tests collected by Nurses in Victoria during 2012’,availableonourwebsiteathttp://www.vccr.org/stats.htmlTheParticipationinScreeningsectionalsoincludessomelimitedinformationontheidentificationofAboriginalandTorresStraitIslanderwomenandthecollectionofindicators

Victorian Cervical Cytology Registry Statistical Report 2012 9

2. PARTICIPATION IN SCREENING

Table 2.1:NumberofPaptestsregisteredandnumberofwomenscreenedinVictoria,1990–2012.1

Year

Number of Pap Tests registered

Number of women screened

2012 602,367 574,1232011 572,142 545,7952010 573,837 547,4402009 584,274 556,4982008 565,655 538,2292007 585,556 557,3712006 572,734 540,6812005 585,324 549,6422004 587,959 550,1482003 571,601 532,4182002 579,178 540,6532001 577,176 542,4022000 572,045 531,7871999 602,400 557,2571998 618,490 569,8581997 584,830 533,5251996 617,182 559,6251995 588,788 529,2701994 622,992 562,2431993 570,605 522,3221992 540,474 494,8751991 544,415 496,3011990 435,706 400,147

2.2 PARTICIPATION BY AGE GROUPMethod of calculating participation

TheparticipationofwomenestimatedtobepartoftheVictorianCervicalScreeningProgrambyagegroupisexpressedasapercentage.Thisisdeterminedbydividingthenumberofwomenscreenedbythenumberofwomeninthegeneralpopulationwhoareeligibleforscreening.

•Thenumberofwomenscreened(numerator)isdeterminedfromtheVCCRdatabase.ItisthenumberofwomenresidentinVictoriawhohadatleastonePaptestinthetimeperiodofinterestandhavenothadahysterectomyaccordingtoinformationheldbytheVCCR.

•Theeligiblepopulation(denominator)isthenumberofwomeninthegeneralpopulationaveragedforthetimeperiodofinterest,andadjustedtoincludeonlywomenwithanintactcervix.Todeterminethis,theVictorianEstimatedResidentPopulation(ERP)8collectedbytheAustralianBureauofStatistics(ABS)isaveragedandthenadjustedtoexcludetheproportionofwomenestimatedtohavehadahysterectomyusinghysterectomyfractions.WhilstVCCRparticipationstatisticsproducedpriortothe2011StatisticalReportusedhysterectomyfractionestimatesfromtheNationalHealthSurvey9,thesedataarenolongercollectedbytheABS.

2.1 NUMBER OF PAP TESTS AND WOMEN SCREENEDTable2.1showsdataonthenumberofPaptestsregisteredandthenumberofwomenscreenedforeachyearoftheVCCR’soperation.During2012atotalof602,367Paptestswereregisteredfrom574,123women.Fromthepreviousyear,thisisanincreaseof30,225Paptestsand28,328women.Since2003,95%ofwomenwithaPaptestrecordontheVCCRhaveaMedicarenumberavailable,andfrom1999theVCCRhasusedSSA-Name(matchingsoftware)inthelinkingofincomingteststopre-existingdataonthedatabase.Thishasresultedinmorecompleterecord-linkageofdifferentepisodesofcareforwomen.IninterpretingtheinformationinTable2.1,itisimportanttorealisethataproportionofwomeninVictoriaarescreenedonanannualbasis.TheVCCRisavoluntary“opt-off”registry;however,theproportionofwomenwhoarepartofthescreeningprogrambutdecidetoopt-offtheVCCRisestimatedtobefewerthan1%.CorrelatingVCSlaboratoryrecordswiththoseheldbytheVCCRshowsatenyear(2003-2012)opt-offrateof0.34%.WhereawomanobjectstoherPaptestbeingregistered,theVCCRholdsnoinformationaboutthattest.

8 AustralianBureauofStatistics.3101.0 –Australian Demographic Statistics, Dec 2012 (releasedate20/6/13)9 AustralianBureauofStatistics. 4364.0 – National Health Survey: Summary of Results, 2004-2005 (releasedate27/2/2006)10 AustralianInstituteofHealthandWelfare2013.Cervical screening in Australia 2010-2011.CancerSeries76.Cat.no.CAN72.Canberra:AIHW

Inthisandthepreviousreport,andconsistentwiththenationalapproach,thepopulationdataforthelatestscreeningperiodshavebeenadjustedwithhysterectomyestimatesfromanalysisconductedbytheAIHWusingdatafromtheNationalHospitalMorbidityDatabase(NHMD)10.Formoredetailsaboutthechangestomethodsrefertothe2011StatisticalReportathttp://www.vccr.org/stats.htmlItisimportanttoappreciatethatchangesinthemethodsusedtocalculateparticipationimpactupontheactualparticipationestimates.Hencecomparisonsinparticipationovertimeshouldbemadewithcaution.

Limitations of participation statisticsOnelimitationtotheseparticipationstatisticsistheimperfectrecord-linkagebetweenmultiplePaptestsfromthesamewomanthatcouldresultinanoverestimateofthenumberofwomenscreened.Inaddition,wheresiteofspecimeninformationisnotreportedtotheRegistrywhenaPaptestistakenfromawomanwithoutacervix,thewomanwillbeincorrectlyincludedinthenumerator.

1 ThenumberofPaptestsregisteredandwomenscreenedontheRegistryasat30September2013.

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Participation in cervical screening by age group Table2.2showstheestimatedcervicalscreeningratesbyagegroupforone,two,threeandfiveyearperiods,withthepopulationdataadjustedwithestimatedhysterectomyratesfromtheNHMD11.Therewasaslightincreaseintheoneyearscreeningratefromthepreviousyearforwomenaged20to69years,at33.1%in2012,comparedwith31.8%for201112.Althoughtherewasanincreaseintheeligiblescreeningpopulationin2012,theincreaseinparticipationwasaresultofalargerincreaseinthenumberofwomenwhowerebeingscreened.Thetwoyearscreeningrate(forthecalendaryearsof2011–2012)forwomenaged20to69yearsisestimatedtobe60.0%,whichisaslightincreasefrom59.2%13forthepreviousreportingperiod(2010–2011).Asobservedwiththeoneyearparticipationdata,theslightincreaseisduetoagreaterincreaseinthenumberofwomenscreenedthanintheeligiblepopulation.Thistrendwasobservedamongallagegroups.The20to29yearoldcohortreportedthelowestparticipationat26.3%,comparedtothe40to49and50to59yearoldcohorts,eachwith36.9%.Theincreaseinoneyearparticipationandtoalesserextenttwoyearparticipation,acrossallagegroupscoincideswiththeimplementationofthesecondreminderletterbytheVCCRinJune2011.Theevaluationofthesecondreminderlettershowedanincreaseof8.1%(2,308women)whencomparingthesameperiodbefore(Jun-Dec2009)andaftertheimplementation(Jun-Dec2011)14.Agreaterimpactontwoyearparticipationisexpectednextyearasafulltwoyearsofthesecondreminderprojectwillbeincluded.

Overthethreeyearperiodfrom2010-2012,theparticipationrateofVictorianwomenaged20to69yearswasestimatedat72.4%,aslightincreasefromthepreviousperiodof2009-2011(72.0%).Table2.2alsohighlightsthefiveyearestimatedparticipationrateof83.9%for2008-2012,whichisaslightdecreasefromthepreviousperiod(84.1%)15.Threeandfiveyearparticipationratesforwomenaged20to39yearsdecreasedfromthepreviousperiod,whereasparticipationforwomenagedover40yearsincreased16.

Estimated two year participation over timeAsseeninfigure2.2.1,therewasasmalldeclineovertimeforeachagegroupbetween2000-2001and2010-2011;howeveranincreaseinthenumberofwomenbeingscreenedineachagegroupinthemostrecent2011-2012periodhasresultedinaslightincreaseinparticipationacrossallagegroups.ThedeclineinparticipationevidentinpreviousyearsisareflectionofthegrowingVictorianpopulation,refiningofthemethodtodeterminetheparticipationstatisticsincludingmoreprecisehysterectomyfractions;andinsomeinstancesactualdeclinesinthenumberofwomenscreened.Typicallywomenaged40to49yearsand50to59yearshavethehighesttwoyearscreeningratesandwomenaged20to29yearshavethelowestscreeningrate.Thistrendtowardsdecreasingparticipationinyoungwomenhasalsobeenseennationallyandinternationally17.

11 Ibid. 12 VictorianCervicalCytologyRegistry,Statistical Report 2011.Availableat:http://www.vccr.org/stats.html13 Ibid.14 Ibid.15 Ibid.16 Ibid.17 LancuckiL,FenderM,KoukariA,LyngeE,MaiVetal.A fall-off in cervical screening coverage of younger women in developed countries. 2010:JMed Screen.17:91-6

Age Group

% screened2012

(1 year)

% screened2011-2012(2 years)



20to29yrs 26.3% 47.1% 60.6% 80.1% - 20 to 24 yrs 23.2% 41.7% 54.7% 75.7% - 25 to 29 yrs 29.3% 52.2% 66.2% 84.4%30to39yrs 33.8% 61.3% 75.8% 90.9%40to49yrs 36.9% 66.9% 80.0% 89.0%

50to59yrs 36.9% 67.2% 77.8% 82.8%60to69yrs 33.3% 61.6% 68.8% 69.8%20 to 69 yrs 33.1% 60.0% 72.4% 83.9%

Table 2.2:Estimatedcervicalscreeningratesbyagegroupoveroneyear,twoyear,threeyearandfiveyearperiods.

Notes

1. Theeligiblefemalepopulationisadjustedfortheestimatedproportionofwomenwhohavehadahysterectomyusinghysterectomy fractionsderivedfromtheNationalHospitalMorbidityDatabase.2. Thetableprovidesthepercentageofwomenscreenedasaproportionoftheeligiblefemalepopulation(cruderate).Womenscreened onlyincludeswomenwhohavenothadahysterectomyaccordingtoinformationheldbytheVCCR.3. Periodscoveredapplytocalendaryears.

11Victorian Cervical Cytology Registry Statistical Report 2012

Participation %

20-69yrs 20-29yrs 30-39yrs 40-49yrs 50-59yrs 60-69yrs

2000-2001* 66.6% 56.0% 70.0% 74.0% 76.0% 58.0%

2001-2002* 64.4% 57.0% 67.0% 69.0% 70.0% 58.0%

2002-2003* 63.9% 55.0% 66.0% 69.0% 70.0% 58.0%

2003-2004* 64.4% 54.0% 67.0% 70.0% 72.0% 60.0%

2004-2005* 65.0% 54.4% 67.4% 70.5% 71.9% 60.9%

2005-2006 † 63.4% 53.2% 66.3% 66.7% 68.8% 63.6%

2006-2007 † 63.1% 52.7% 65.4% 66.5% 69.6% 64.4%

2007-2008 † 62.3% 51.2% 64.5% 65.9% 69.3% 64.1%

2008-2009 † 61.3% 48.5% 63.7% 65.5% 69.4% 64.6%

2009-2010 † 60.7% 47.1% 62.6% 65.5% 69.9% 65.3%

2010-2011 ‡ 59.2% 46.6% 61.1% 66.1% 66.1% 59.7%

2011-2012 ‡ 60.0% 47.1% 61.3% 66.9% 67.2% 61.6%

0

10

20

30

40

50

60

70

80

Par

ticip

atio

n ra

te (%

)

Time Period

20 - 29 yrs 30 - 39 yrs 40 - 49 yrs 50 - 59 yrs 60 - 69 yrs 20 - 69 yrs

‡ ‡

Figure 2.2.1: Estimated two year cervical screening rates by age group, 2000-01 to 2011-12.

Notes

1. The graph provides the percentage of women screened as a proportion of the eligible female population (crude rate). Women screened only includes women who have not had a hysterectomy according to information held by the VCCR. The eligible female population is adjusted for the estimated proportion of women who have had a hysterectomy using hysterectomy fractions as indicated by the symbols *, † and ‡; which are outlined in further detail below. 2. Periods covered apply to calendar years.

* 2000-2001 to 2004-2005 data has been adjusted using the 2001 National Health Survey hysterectomy fractions estimates.

† 2005-2006 to 2009-2010 data has been adjusted using the 2004-05 National Health Survey hysterectomy fractions estimates.

‡ 2010-2011 and 2011-2012 data has been adjusted using the National Hospital Morbidity Database (NHMD) hysterectomy fraction estimates (courtesy of the Australian Institute of Health and Welfare).

Table 2.2.1: Estimated two year cervical screening rates by age group, 2000-01 to 2011-12.

12

Otheradditional(butprobablylesser)sourcesofmeasurementerrorderivefrom:

•theproportionofVictorianPaptestsreportedbylaboratoriesoutsideofVictoriawhicharenotreportedtotheVCCR(thiswillmainlyaffectareaslocatedontheVictoria/NewSouthWalesandVictoria/SouthAustraliaborders);and,

•thedifferencesbetweentheAustraliaPostpostcodesusedtoreportscreeningnumbersaccordingtoaddressdatagivenbythewoman(usedasthenumeratorincalculatingparticipation)andtheABSPostalAreasforwhichpopulationstatisticsareavailable(usedasthedenominator).ItisimportanttonotethatalthoughtherearecommonalitiesbetweenpostcodesandPostalAreas,theyarenotexactmatchesandtheirboundariescandiffer.TheunderlyingreasonforthedifferencesintheseboundariesisthattheABSPostalAreaswerecreatedspecificallyforCensuspurposesanddisseminatingstatistics,whilepostcodesaredesignedtodistributemail.

Whencomparingparticipationrateestimatesbygeographicalarea,itshouldalsobenotedthatthesearecruderatesi.e.theyhavenotbeenage-adjusted.Thereforeareaswitholderpopulationswillhaveapparentlyhigherscreeningratesthanareaswithahighpopulationofyoungwomenbecauseofthestrongcorrelationbetweenageandscreeningrates.

18 ABS2012,customizedreport.Datausing2011postalboundaries:VictorianFemaleEstimatedResidentPopulationbyPostalAreaat30June2010and30June2011.19 AustralianInstituteofHealthandWelfare2013.Cervical screening in Australia 2010-2011.Cancerseries76.Cat.No.CAN72.Canberra:AIHW20 2012PostcodetoLGAconverteralgorithm(basedon2011MeshBlockboundaries)suppliedbyVictorianDepartmentofHealthandbasedonABSAustralianStatisticalGeographyStandard(ASGS)correspondence.21 AustralianBureauofStatistics,2011.AustralianStatisticalGeographyStandard(ASGS):Volume1–MainStructureandGreaterCapitalCityStatisticalAreas,July2011.Cat.No:1270.0.55.001.22AustralianGovernmentMedicareLocalBoundaryandConcordanceFileswebsite.

http://www.medicarelocals.gov.au/internet/medicarelocals/publishing.nsf/Content/digital-boundaries,cited4October2013.

2.3 PARTICIPATION BY AREAMethod of calculating participation

TheparticipationrateforageeligiblewomenincervicalscreeningforMedicareLocals(ML),DepartmentofHealth(DH)regionsandLocalGovernmentAreas(LGAs)isexpressedasapercentage.

•ThenumeratoristhenumberofwomenbypostcodewhohadatleastonePaptestinthetwoyeartimeperiodandwhohavenothadahysterectomyaccordingtotheinformationheldbytheVCCR.

•ThedenominatoristheestimatednumberofwomenineachPostalArea18adjustedtoexcludetheproportionofwomenestimatedtohavehadahysterectomy.The2011–2012dataareadjustedbythehysterectomyfractionsfromtheNationalHospitalMorbidityDatabase19.Theaveragefemalepopulationovereachtwoyearperiodisusedasthedenominator.

Tocalculatetheestimatedparticipationratesforareas,mappingofdatabyAustraliaPostpostcodesandPostalAreastoLGAsandMedicareLocalswasdoneusingconversionfilesprovidedbytheVictorianDepartmentofHealthandtheCommonwealthDepartmentofHealthandAgeingrespectively.

Themappingofthe2011–2012participationdataforLGAsisbasedonconcordances20consistentwiththenewABSAustralianStatisticalGeographyStandard(ASGS)21.ParticipationdatabyDHregionarecalculatedasanaggregateofLGAs,whileMedicareLocalswerecreatedbasedontheCommonwealthDepartmentofHealthPostcodetoMedicareLocalconcordancefile22.

Limitations

Small-areadata(eg.DHregions,LGAsandMedicareLocals)aresubjecttogreatermeasurementerrorthanthedatainsections2.1and2.2.ThemainsourceofinaccuracyinthefollowingtablesisderivedfromapplyingthenationalhysterectomyfractionstotherelativelysmallfemalepopulationresidentinthePostalAreas.


2.3.1 Participation by Medicare Locals

In2011theAustralianGovernmentestablishedthenewMedicareLocal23areanetworktoreplacethepreviousDivisionsofGeneralPractice,toplanandfundcommunity-basedprimarycareacrossAustralia.Participationratesfor2010-2011and2011-2012werecalculatedforthe17MedicareLocalsinVictoriawhicharepartiallyorentirelylocatedwithinVictoria.UsingmethodsdiscussedatthebeginningofSection2.3,theestimatedtwoyearparticipationrateshavebeencalculatedfortheseareas.

MedicareLocal

Number

Medicare Local Name

2010-20111 % screened (95% CI)

2011-20121 % screened (95% CI)

ML201 InnerNorthWestMelbourne 56.7%(56.4%-57.0%) 57.2%(57.0%-57.5%)ML202 Bayside 64.5%(64.3%-64.7%) 65.0%(64.8%-65.2%)ML203 SouthWesternMelbourne 52.4%(52.0%-52.8%) 53.2%(52.8%-53.5%)ML204 MacedonRangesandNorthWesternMelbourne 55.4%(55.1%-55.7%) 55.9%(55.6%-56.1%)ML205 NorthernMelbourne 58.1%(57.9%-58.3%) 59.0%(58.8%-59.2%)ML206 InnerEastMelbourne 62.1%(61.9%-62.3%) 62.8%(62.6%-63.0%)ML207 EasternMelbourne 61.8%(61.5%-62.0%) 62.4%(62.1%-62.6%)ML208 SouthEasternMelbourne 56.0%(55.7%-56.2%) 56.5%(56.2%-56.7%)ML209 Frankston-MorningtonPeninsula 58.9%(58.5%-59.2%) 59.2%(58.9%-59.6%)ML210 Barwon 62.2%(61.9%-62.5%) 63.3%(62.9%-63.6%)ML211 Grampians 55.5%(55.1%-55.9%) 56.8%(56.4%-57.2%)ML212 GreatSouthCoast 60.7%(60.2%-61.3%) 61.2%(60.6%-61.7%)ML213 LowerMurray 58.7%(57.9%-59.5%) 61.4%(60.6%-62.1%)ML214 Loddon-Mallee-Murray 60.7%(60.3%-61.1%) 62.8%(62.4%-63.3%)ML215 GoulburnValley 56.3%(55.8%-56.7%) 58.3%(57.8%-58.8%)ML216 Hume 65.5%(65.0%-66.0%) 67.6%(67.1%-68.1%)ML217 Gippsland 59.7%(59.4%-60.1%) 60.1%(59.8%-60.5%)

Table 2.3.1:EstimatedtwoyearcervicalscreeningratesbyMedicareLocal,2010-2011and2011-2012.

Notes

1. 2010-2011and2011-2012data:PostcodesmappedtoMedicareLocalsbasedontheCommonwealthDepartmentofHealthPostalAreatoMedicare Localconcordancefile.PopulationdataadjustedusingestimatedhysterectomyfractionsfromtheAIHWNationalHospitalMorbidityDatabase.

2. Thetableprovidesthepercentageofwomenscreenedasaproportionoftheeligiblefemalepopulation(cruderate).Womenscreenedonlyincludes womenwhohavenothadahysterectomyaccordingtoinformationheldbytheVCCR.

3. Periodscoveredapplytocalendaryears.

23 www.medicarelocals.gov.au

14

Figure 2.3.1:EstimatedtwoyearcervicalscreeningratesbyMedicareLocal,2011-2012.

Medicare Local boundaries have been truncated where they overlap the Victorian border. This includes the Lower Murray (ML 213), Loddon–Mallee-Murray (ML 214), and Hume (ML 216) Medicare Locals. Refer to Appendix 3 for a map of Medicare Locals which have not been truncated at the border.


Figure 2.3.2:EstimatedtwoyearcervicalscreeningratesbyDepartmentofHealthregion,2011-2012.

2.3.2 Participation by Department of Health Region

VictoriaisdividedintoeightDepartmentofHealth(DH)regions,withfiveinruralVictoriaandthreecoveringmetropolitanMelbourne.UsingmethodsdiscussedatthebeginningofSection2.3,thetwoyearparticipationrateshavebeencalculated.

Region Name 2010-20111

% screened (95% CI)2011-20121

% screened (95% CI)

BarwonSouthWestern 61.8%(61.5%-62.1%) 62.6%(62.3%-62.9%)

EasternMetropolitan 62.0%(61.8%-62.1%) 62.6%(62.5%-62.8%)

Gippsland 59.7%(59.4%-60.1%) 60.1%(59.7%-60.5%)

Grampians 56.3%(55.9%-56.7%) 57.6%(57.2%-58.0%)

Hume 60.6%(60.2%-61.0%) 62.6%(62.2%-62.9%)

LoddonMallee 61.0%(60.7%-61.3%) 63.1%(62.8%-63.4%)

NorthernWestMetropolitan 56.0%(55.8%-56.1%) 56.6%(56.5%-56.8%)

SouthernMetropolitan 60.5%(60.3%-60.6%) 60.9%(60.8%-61.1%)

Table 2.3.2:EstimatedtwoyearcervicalscreeningratesbyDepartmentofHealthregion,2010–2011and2011–2012.

Notes

1. 2010–2011and2011-2012data:ParticipationdatabyDHregioniscalculatedasanaggregateofLGAs.Postcode/PostalAreasmappedtoLGAusing aconverteralgorithmsuppliedbytheVictorianDepartmentofHealthandbasedonABSAustralianStatisticalGeographyStandard(ASGS)2011correspondencedata.PopulationdataadjustedusingestimatedhysterectomyfractionsfromtheAIHWNationalHospitalMorbidityDatabase.



Unincorporated Victoria refers to the areas within Victoria which are not administered by incorporated local government bodies.

16

DH region LGA Code1 LGA 2010–20112 % screened (95% CI)

2011–20122 % screened (95% CI)

Barwon South West

21750 Colac-Otway 66.4%(65.1%-67.6%) 62.9%(61.6%-64.2%)

21830 Corangamite 57.8%(56.3%-59.3%) 61.6%(60.1%-63.1%)

22410 Glenelg 57.1%(55.7%-58.4%) 56.7%(55.3%-58.0%)

22750 GreaterGeelong 61.1%(60.7%-61.5%) 62.5%(62.1%-62.9%)

25490 Moyne 61.1%(59.6%-62.6%) 62.2%(60.8%-63.7%)

26080 Queenscliffe 69.5%(66.2%-72.8%) 73.6%(70.4%-76.7%)

26260 SouthernGrampians 61.9%(60.4%-63.3%) 61.9%(60.4%-63.3%)

26490 SurfCoast 67.4%(66.4%-68.5%) 67.7%(66.6%-68.7%)

26730 Warrnambool 63.6%(62.6%-64.6%) 63.0%(62.0%-64.0%)

Eastern Metropolitan

21110 Boroondara 67.0%(66.6%-67.4%) 67.4%(67.0%-67.8%)23670 Knox 62.4%(61.9%-62.8%) 62.7%(62.3%-63.2%)24210 Manningham 65.1%(64.6%-65.7%) 66.0%(65.5%-66.5%)24410 Maroondah 60.9%(60.4%-61.5%) 60.6%(60.0%-61.1%)24970 Monash 57.2%(56.8%-57.7%) 57.9%(57.5%-58.3%)26980 Whitehorse 60.1%(59.6%-60.5%) 61.0%(60.6%-61.5%)27450 YarraRanges 61.8%(61.4%-62.3%) 63.4%(62.9%-63.8%)

Gippsland 20740 BassCoast 60.0%(58.9%-61.1%) 59.0%(57.9%-60.0%)20830 BawBaw 61.4%(60.5%-62.3%) 63.4%(62.5%-64.2%)22110 EastGippsland 61.9%(61.1%-62.8%) 62.2%(61.3%-63.0%)23810 Latrobe 56.4%(55.8%-57.1%) 57.5%(56.8%-58.1%)26170 SouthGippsland 62.8%(61.6%-63.9%) 63.6%(62.5%-64.7%)26810 Wellington 59.6%(58.7%-60.5%) 58.0%(57.1%-58.9%)

Grampians 20260 Ararat 50.4%(48.6%-52.2%) 57.2%(55.3%-59.0%)20570 Ballarat 56.1%(55.5%-56.7%) 56.7%(56.2%-57.3%)22490 GoldenPlains 61.5%(60.1%-62.8%) 62.1%(60.7%-63.4%)22910 Hepburn 65.3%(63.8%-66.8%) 62.7%(61.2%-64.2%)22980 Hindmarsh 52.4%(49.8%-54.9%) 57.3%(54.7%-59.9%)23190 Horsham 58.0%(56.6%-59.3%) 60.4%(59.1%-61.7%)25150 Moorabool 54.9%(53.9%-56.1%) 58.1%(57.0%-59.1%)25810 NorthernGrampians 53.4%(51.6%-55.2%) 51.6%(49.8%-53.3%)25990 Pyrenees 52.6%(50.3%-55.0%) 55.8%(53.5%-58.1%)26890 WestWimmera 44.9%(41.8%-48.0%) 47.7%(44.5%-50.9%)27630 Yarriambiack 54.5%(52.1%-56.9%) 53.4%(51.0%-55.8%)

Hume 20110 Alpine 68.8%(67.2%-70.4%) 67.2%(65.6%-68.9%)21010 Benalla 67.6%(66.1%-69.1%) 70.3%(68.8%-71.8%)22830 GreaterShepparton 57.0%(56.2%-57.7%) 59.6%(58.8%-60.3%)23350 Indigo 66.0%(64.6%-67.5%) 67.8%(66.3%-69.2%)24250 Mansfield 65.8%(63.8%-67.8%) 67.0%(65.0%-69.0%)24850 Mitchell 54.0%(53.0%-55.0%) 55.3%(54.3%-56.3%)24900 Moira 54.2%(53.1%-55.4%) 56.7%(55.5%-57.8%)25620 Murrindindi 57.2%(55.6%-58.8%) 59.6%(58.0%-61.2%)26430 Strathbogie 63.9%(62.0%-65.8%) 64.3%(62.4%-66.2%)26670 Towong 63.9%(61.5%-66.4%) 67.2%(64.8%-69.6%)26700 Wangaratta 67.3%(66.2%-68.4%) 70.3%(69.2%-71.3%)27170 Wodonga 64.3%(63.3%-65.2%) 66.0%(65.0%-66.9%)

2.3.3 Participation by Local Government Area

WithinVictoriathereare79LocalGovernmentAreas(LGAs).UsingmethodsdiscussedatthebeginningofSection2.3,

theestimatedtwoyearparticipationrateshavebeencalculated.

Table 2.3.3: EstimatedtwoyearcervicalscreeningratesbyLocalGovernmentArea,2010–2011and2011–2012.


DH region LGA Code1 LGA 2010–20112 % screened (95% CI)

2011–20122 % screened (95% CI)

Loddon Mal ee

21270 Buloke 62.7%(60.3%-65.2%) 62.9%(60.5%-65.4%)

21370 Campaspe 58.7%(57.7%-59.6%) 63.2%(62.2%-64.2%)

21670 CentralGoldfields 49.2%(47.5%-51.0%) 53.1%(51.4%-54.9%)

22250 Gannawarra 57.0%(55.1%-58.9%) 59.4%(57.5%-61.3%)

22620 GreaterBendigo 61.0%(60.4%-61.6%) 62.2%(61.6%-62.8%)

23940 Loddon 53.5%(51.2%-55.7%) 52.9%(50.7%-55.1%)

24130 MacedonRanges 68.4%(67.6%-69.2%) 69.0%(68.2%-69.9%)

24780 Mildura 58.8%(57.9%-59.6%) 61.2%(60.4%-62.0%)

25430 MountAlexander 72.9%(71.6%-74.2%) 75.5%(74.2%-76.7%)

Northern & Western Metropolitan

26610 SwanHill 55.6%(54.3%-56.9%) 59.9%(58.5%-61.2%)20660 Banyule 64.2%(63.7%-64.7%) 65.1%(64.6%-65.6%)21180 Brimbank 54.5%(54.1%-54.9%) 54.6%(54.2%-55.0%)21890 Darebin 57.7%(57.2%-58.1%) 59.0%(58.5%-59.4%)23110 HobsonsBay 58.0%(57.4%-58.6%) 60.4%(59.8%-61.0%)23270 Hume 52.3%(51.9%-52.8%) 53.6%(53.2%-54.0%)24330 Maribyrnong 54.9%(54.4%-55.6%) 56.7%(56.0%-57.3%)24600 Melbourne 45.6%(45.1%-46.1%) 45.7%(45.2%-46.2%)24650 Melton 51.6%(51.0%-52.1%) 51.7%(51.1%-52.2%)25060 MooneeValley 60.8%(60.3%-61.3%) 61.1%(60.6%-61.7%)25250 Moreland 57.2%(56.8%-57.7%) 58.5%(58.1%-59.0%)25710 Nillumbik 71.3%(70.6%-71.9%) 71.5%(70.8%-72.1%)27070 Whittlesea 54.8%(54.3%-55.2%) 55.3%(54.8%-55.7%)

Southern Metropolitan

27260 Wyndham 49.3%(48.8%-49.7%) 49.6%(49.2%-50.1%)27350 Yarra 65.4%(64.9%-66.0%) 66.2%(65.6%-66.7%)20910 Bayside 72.6%(72.1%-73.1%) 73.9%(73.4%-74.4%)21450 Cardinia 56.4%(55.8%-57.1%) 57.2%(56.6%-57.9%)21610 Casey 56.8%(56.4%-57.1%) 57.3%(56.9%-57.6%)22170 Frankston 55.4%(54.9%-55.9%) 55.2%(54.7%-55.7%)22310 GlenEira 63.1%(62.6%-63.6%) 64.2%(63.7%-64.6%)22670 GreaterDandenong 54.3%(53.8%-54.8%) 54.6%(54.2%-55.1%)23430 Kingston 61.5%(61.0%-61.9%) 61.3%(60.9%-61.8%)25340 MorningtonPeninsula 62.1%(61.6%-62.6%) 63.0%(62.6%-63.5%)25900 PortPhillip 63.4%(62.9%-63.9%) 62.9%(62.4%-63.4%)26350 Stonnington 65.5%(65.0%-66.0%) 66.6%(66.1%-67.1%)

Notes

1. RefertoAppendix3formapsshowingLocalGovernmentAreacodes.

2. 2010–2011and2011-2012data:Postcode/PostalAreasmappedtoLGAusingaconverteralgorithmsuppliedbytheVictorianDepartmentofHealthand basedonABSAustralianStatisticalGeographyStandard(ASGS)2011correspondencedata.Populationdataadjustedusingestimatedhysterectomy fractionsfromtheAIHWNationalHospitalMorbidityDatabase.



l

18

% PARTICIPATIONLess than 50%

50% - 55%

55% - 60%

60% - 65%

65% - 70%

Greater than 70%

Unincorporated Victoria

INSET: Melbourne and surrounds

Figure 2.3.3: EstimatedtwoyearcervicalscreeningratesbyLocalGovernmentArea*,2011–2012.


*NotethatmapsshowingVictorianLGAcodesareprovidedinAppendix3.


Table 2.4: Proportion of Pap tests collected by nurses, 2003–2012.

2.4 PAP TESTS COLLECTED BY NURSES ThecredentiallingofnurseseverythreeyearstoperformPaptestsrecognisesnurses’expertiseanddedicationtotheVictorianCervicalScreeningProgram.Thisprocesshasbeensetinplacetoallownursestobeaccountabletothepublicandresponsiblefortheirindividualpracticewhileatthesametimemaintainingastandardofexcellence.ThecredentiallingprogramiscoordinatedbyPapScreenVictoria.

During2012,atotalof33,875PaptestswerecollectedandreportedtotheRegistryby416credentiallednurses.Thisnumberrepresents5.6%ofallPaptestscollectedinVictoriaduring2012.Thisfigurereflectsthesignificantgrowthintheroleofnursesincervicalscreening,withtheproportionofPaptestsperformedbynurseshavingsteadilyincreasedovertheyearsfromaninitialreportedfigureof0.8%(5,170tests)in1996.Table2.4showsthenumberandproportionofPaptestscollectedbynursessince2003.

NursePaptestdatahighlighttheincreasinglyimportantrolethatnurseshaveinthedeliveryoftheVictorianCervicalScreeningProgram,particularlyinrelationtotheincreasingnumberofPaptestscollectedbytheminrecentyearsandthehighqualityoftheirtests.Asobservedinrecentyears,Paptestscollectedbynursesaremorelikelytohaveanendocervicalcomponent,whichisconsideredtobeareflectionoftestquality.GeneralPracticeandCommunityHealthsettingsremainthemaintypesofpracticeswherenursescollectPaptests(85.5%ofpracticetypesin2012).

During2012,39.2%ofthePaptestscollectedbynurseswerefromwomenover50yearsofagecomparedwith30.1%collectedbyotherprovidertypesinVictoriaduringthisperiod24.

Year Number of Pap tests collected

by nurses

% of all Victorian Pap tests

2012 33,875 5.6%

2011 31,613 5.5%

2010 28,546 5.0%

2009 25,594 4.4%

2008 21,668 3.8%

2007 18,651 3.2%

2006 16,035 2.8%

2005 14,375 2.5%

2004 13,100 2.2%

2003 11,494 2.0%

24 VCCR Evaluation of Pap tests collected by Nurses in Victoria during 2012report.Refertowww.vccr.org/stats.html

20

Table 2.4.1:Paptestsforwomenwithacervixcollectedbynurses,byDepartmentofHealthregion,2012.

2.4.1 Proportion of Pap tests collected by nurses by Department of Health RegionDataonPaptestscollectedbynurseswereanalysedbyDepartmentofHealth(DH)region.ThefollowingtableandfigureshowthattheruralDHregionshadahigherproportionoftestscollectedbynurses,forwomenwithacervix,thanthosewithinmetropolitanMelbourne.TheproportionofPaptestscollectedbynursesincreasedacrossBarwonSouthWest,EasternMetropolitan,LoddonMalleeandtheNorthernandWesternMetropolitanregions.ThelargestincreasesintheproportionofPaptestscollectedbynurseswereseenintheLoddonMallee(3.4%)andBarwonSouthWestregions(0.9%)25.

Region name Number of Pap tests collected

by nurses1

Number of nurses in each

region2

% Pap tests in region collected

by nurses

BarwonSouthWest 3,915 55 10.7%

EasternMetropolitan 2,324 32 2.1%

Gippsland 2,365 31 9.9%

Grampians 4,046 29 19.7%

Hume 3,878 54 14.8%

LoddonMallee 7,046 70 23.2%

Northern&WesternMetropolitan 7,168 101 4.1%

SouthernMetropolitan 2,738 37 2.0%

25 Ibid.

1 Excludes345post-hysterectomyPaptestsand50womenwhosepostcodewasmissingornotabletobematched.2 Excludessevennurseswhosepostcodecouldnotbematched.



Figure 2.4.1:ProportionofPaptestscollectedbynurses,byDepartmentofHealthregion,2012.

22

VCCRisworkingcloselywithProgramPartnersincludingtheDepartmentofHealth,PapScreenVictoriaandVCSPathologytoimprovetheidentificationofAboriginalandTorresStraitIslanderwomenandtheongoingcollectionofCALDdatatotheRegistry.

VCSPathologycontinuestoworkwithnurseswhocollectPaptests,tosupportandencouragetheidentificationofAboriginalandTorresStraitIslanderwomenandtherecordingofthisinformationontheVCSPathologyRequestForms.NursePractitionershavethehighestproportionofanypractitionertype,94.1%,ofPaptestswherethisinformationwasreported.Table2.5(b)showstheproportionofPaptestsbypractitionertypewhereAboriginalandTorresStraitIslanderinformationwasrecordedinthewoman’srecord.

2.5 CLOSING THE DATA GAPS: IDENTIFYING ABORIGINAL AND TORRES STRAIT ISLANDER PEOPLE, AND COLLECTING COUNTRY OF BIRTH AND LANGUAGE SPOKEN AT HOME

DatafromtheAIHW26hasshownthatAboriginalandTorresStraitIslanderwomenarefivetimesmorelikelytodieofcervicalcancerthannon-AboriginalandTorresStraitIslanderwomen.Thenational“ClosingtheGap”strategyisacommitmentbyallAustralianGovernmentstoovercomedisadvantageandimprovethelivesandhealthoutcomesofAboriginalandTorresStraitIslanderpeople27.

WomenfromCulturallyandLinguisticallyDiverse(CALD)backgroundshavealsobeenidentifiedasanunder-screenedgroup28.StrategiesforengagingwithAboriginalandTorresStraitIslanderandCALDwomen,andincreasingparticipation,areapriorityfortheVictorianDepartmentofHealthasoutlinedintheVictorianPublicHealthandWellBeingPlan2011-2015andthepreviousgovernments’VictorianCancerActionPlan(2008-2011).

Whereprovidedbypractitioners,laboratories,anddirectlybywomenthroughupdatesofpersonalinformation,theVCCRwillrecordifawomanhasidentifiedasanAboriginalandTorresStraitIslanderpersonaswellashercountryofbirthandlanguagespokenathomeasindicatorsofculturaldiversity.

Aboriginal and Torres Strait Islander Women

In2012theoverallpercentageofwomenscreenedwhohadtheirAboriginalandTorresStraitIslanderoriginrecordedbytheVCCRwas19.4%.Table2.5(a)showsthenumberandproportionofwomenbytheiridentificationasanAboriginalandTorresStraitIslanderperson.

Status No. %Aboriginal 1052 0.2%

TorresStraitIslander 41 0.0%

Aboriginal&TorresStraitIslander

172 0.0%

NotAboriginal&TorresStraitIslander

110,336 19.2%

NotCollected 462,508 80.6%

DeclinedtoAnswer 14 0.0%

TOTAL 574123 100.0%

Practitioner Type No. %GeneralPractitioner 67259 14.0%

Hospital 1122 15.1%

NursePractitioner 31865 94.1%

Obstetrician&Gynaecologist 14473 18.4%

Other 359 15.4%

Table 2.5 (a): ProportionofWomenscreenedbyAboriginalandTorresStraitIslanderOrigin.

Table 2.5 (b): ProportionofPapTestsbyPractitionerTypewithAboriginalandTorresStraitIslanderOriginInformationrecorded.

26 AustralianInstituteofHealthandWelfareOctober31st2011http://www.aihw.gov.au/media-release-detail/?id=1073742043427 AustralianGovernment,DepartmentofSocialServices,http://www.dss.gov.au/our-responsibilities/indigenous-australians/programs-services/closing-the-gap28 MullinsRAntiCancerCouncilVictoria,2006EvaluationoftheimpactofPapScreen’sCampaignonCulturallyandLinguisticallyDiverse(CALD)Women http://www.cancervic.org.au/downloads/cbrc_research_papers/Cervical_cancer_research/06rep_rm_eval_PapScreen_campaign_CALD_women.pdf29UnitedKingdom(includesChannelIslandsandIsleofMan)isassignedwhentheCountryofBirthisnotfurtherspecified.

Culturally and Linguistically Diverse Women

In2012theoverallpercentageofwomenscreenedwhohadaCountryofBirthrecordedbytheVCCRwas14.5%.ThemostcommoncountriesofbirthoutsideofAustraliawereVietnam,England,NewZealand,UnitedKingdom(includesChannelIslandsandIsleofMan)29,China(excludesSARSandTaiwan),India,Italy,Philippines,GreeceandMalaysia.

TheoverallpercentageofwomenscreenedwhohadLanguageSpokenatHomerecordedwas15.2%.Themostcommonlanguagesreported,otherthanEnglish,wereVietnamese,Italian,Greek,Mandarin,Chinese(notelsewhereclassified),Arabic,Spanish,Cantonese,TurkishandMaltese.


2.6 FREqUENCY OF EARLY RE-SCREENINGWhiletheAustralianscreeningpolicyrecommendsscreeningeverytwoyearsafteranegativePaptestreport,aproportionofwomenarescreenedmorefrequently.Asmalllevelofearlyre-screeningcanbejustifiedonthebasisofapasthistoryofabnormality.

Inlate2000,theNationalCervicalScreeningProgramadoptedthefollowingdefinitionofearlyre-screening:

Early re-screening is the repeating of a Pap test within 21 months of a negative Pap test report, except for women who are being followed up in accordance with the NHMRC guidelines for the management of cervical abnormalities.

Thisdefinitionrecognisesthatsomere-screeningmayoccuropportunisticallybetween21and24monthsafteranegativePaptestreportandthismaybecost-effective.

Todeterminehowmanywomenaretrulyscreenedearly,womenwithapriorcytologicalorhistologicalabnormalityrecordedbytheVCCRwithin36monthsoftheindexPaptestwereexcluded.ThisisinlinewiththenationalreportingofindicatorsbytheAIHWforthesameperiodandisalsoconsistentwiththeNHMRCGuidelines.

Table2.6showsthenumberoffurtherPaptestsovera21monthperiodforwomenwhoreceivedanegativePaptestreportintheFebruaryof2011.Thedatashowthat86.4%ofwomenaged20to69yearswhohadanegativePaptestinFebruary2011hadnofurthertestswithinthenext21months.

Thisdataiscomparablewiththatprovidedinthe2009,2010and2011StatisticalReports,howevernotwithpriorreports,asthemethodofdeterminingthepercentagenowexcludeswomenwhohaveanabnormalitywithin36monthsoftheirnegativeindexPaptest.

AsseeninFigure2.6,somevariationinearlyre-screeningoccursbyagegroup.Thegraphshowstheproportionofwomen,byagegroup,whohadearlyre-screeningafteranegativePaptestreportinFebruary2011.

Figure 2.6 :Earlyre-screeningafteranegativePaptestreportinFebruary2011byagegroup.

0

2

4

6

8

10

12

14

16

Per

cent

age

of e

arly

re-

scre

enin

g

20-29 yrs 30-39 yrs 40-49 yrs 50-59 yrs 60-69 yrs

Table 2.6:SubsequentPaptestsovera21monthperiodforwomenwithanegativereportinFebruaryof2011.

Number of subsequent Pap tests since February 2011 Percent

Nofurthertests 86.4%

1 13.0%

2 0.5%

3 < 0.1%

4 < 0.01%

5ormore < 0.01%

24

3. CYTOLOGY REPORTS

Cytology reports received by the VCCR are coded according to the 2006 Cytology Coding Schedule (refer to Appendix 1). From this coding, Pap test results are categorised into the broader groups of unsatisfactory, negative, having no endocervical component, and having a squamous abnormality or endocervical abnormality. These groupings are consistent with the cytology result types requested by the AIHW for the reporting of national indicators for the same period.

For this analysis, the results of 593,119 Pap tests from any provider type were considered. These include Pap tests which were collected during 2012, from women of any age, but not post-hysterectomy smears (also referred to as vault smears).

3.1 UNSATISFACTORY PAP TESTSAnunsatisfactoryPaptestresultisdefinedashaving:

• unsatisfactorysquamouscells(SU)andunsatisfactoryendocervicalcells(EU);or

• unsatisfactorysquamouscells(SU)andnoendocervicalcells(E0)ornoendocervicalabnormality(E1).

OfPaptestresultsreceivedduring2012bytheVCCR,14,700wererecordedashavinganunsatisfactoryresult.Thisequatesto2.5%ofPaptests.TheNationalPathologyAccreditationAdvisoryCouncil(NPAAC)Performance measures for Australian laboratoriesreporting cervical cytology(NPAAC2006)includesarecommendedstandardfortheproportionofspecimensreportedasunsatisfactoryasbetween0.5%and5.0%ofallspecimensreported30.

3.2 NEGATIVE PAP TESTSAnegativePaptestresultisdefinedashavingsquamouscellswithnoabnormality(S1)andnoendocervicalcells(E0)ornoendocervicalabnormality(E1).

OfthePaptestresultsreceivedduring2012bytheVCCR,538,455wererecordedashavinganegativeresult.Thisequatesto90.8%ofPaptests.

3.3 PAP TESTS WITHOUT AN ENDOCERVICAL COMPONENTThepresenceofendocervicalcellswithinaPaptestspecimenisconsideredtobeareflectionoftestquality.PaptestsidentifiedasnotcontaininganendocervicalcomponentarecodedashavingaresultofE0fortheendocervicalcellresult.

OfthePaptestresultsreceivedduring2012bytheVCCR,153,123wererecordedasnothavinganendocervicalcomponentpresentinthespecimen.Thisequatesto25.8%ofPaptests.

AsillustratedinFigure3.3,theproportionofPaptestswithoutanendocervicalcomponenthasgraduallyincreasedfrom19.7%in2004to25.8%in2012(p<0.001).Thisincreasehasalsobeenseenatanationallevel.ThereasonforthedeclineinPaptestswithanendocervicalcomponentisunclear.Itislikelytobemulti-factorial,andamoredetailedanalysisofthesetrendsisbeingcompletedbytheVCCR.

30 AustralianInstituteofHealthandWelfare2013.Cervical screening in Australia 2010-2011.Cancerseries76.Cat.no.CAN72.Canberra:AIHW.

Figure 3.3: PercentageofPaptestswithoutanendocervicalcomponent.

0

5

10

15

20

25

30

Per

cent

age

2004 2005 2006 2007 2008 2009 2010 2011 2012

Year

3.4 PAP TESTS WITH A SqUAMOUS ABNORMALITYTable3.4showsthattheproportionofPaptestswithasquamouscellabnormality(withanabnormalityofpossiblelow-gradelesionorworse)in2012was39,621whichequatesto6.7%ofallPaptestsfortheyear.

Adefinitehigh-gradeabnormality(i.e.high-gradelesionwithorwithoutpossiblemicro-invasionorinvasion,invasivesquamouscellcarcinoma)wasreportedin0.8%ofallPaptestsfor2012.

3.5 PAP TESTS WITH AN ENDOCERVICAL ABNORMALITYThepresenceofendocervicalcellswithinaPaptestspecimenisnecessaryforthedetectionandreportingofglandularabnormalitiesincludingatypicalcells,possiblehigh-gradelesions,endocervicaladenocarcinomainsituandadenocarcinoma.

ThefollowingtableshowstheproportionofPaptestsfor2012whereanendocervicalabnormalitywasdetected.Paptestswhichareknowntohavebeencollectedpost-hysterectomyareexcluded.

For2012,thetotalnumberofPaptestswithanendocervicalabnormality(atypicalendocervicalcellsofuncertainsignificanceorworse)was505,whichequatestofewerthan0.1%ofallPaptestsfortheyear.


Table 3.5:NumberandpercentofPaptestscollectedin2012withanendocervicalabnormality.

Endocervical Component Code Number of Pap tests

% of Pap tests

Atypicalendocervicalcellsofuncertainsignificance(E2)

239 0.1%

Possiblehigh-gradeendocervicalglandularlesion(E3)

166 0.1%

Adenocarcinomainsitu(E4) 77 0.1%

Adenocarcinomainsituwithpossiblemicro-invasion/invasion(E5)

10 0.01%

Adenocarcinoma(E6) 13 0.01%

Table 3.4:NumberandpercentofPaptestscollectedin2012withasquamousabnormality.

Squamous Cell Code Number of Pap tests

% of Pap tests

Possiblelow-gradesquamousintraepitheliallesion(LSIL)(S2)

19,091 3.2%

Low-gradesquamousintraepitheliallesion(LSIL)(S3)

11,371 1.9%

Possiblehigh-gradesquamousintraepitheliallesion(HSIL)(S4)

4,496 0.8%

High-gradesquamousintraepitheliallesion(HSIL)(S5)

4,521 0.8%

High-gradesquamousintraepitheliallesion(HSIL)withpossiblemicro-invasion/invasion(S6)

88 0.1%

Squamouscarcinoma(S7) 54 0.01%

3.6 TYPE OF TESTSInJuly2006,theVCCRbeganrecordingthetypeofPaptesttaken;thatis,conventionalcytology,liquid-basedspecimenorcombination.During2012theproportionofliquid-basedtestswas4.0%ofalltestsreportedtotheRegistry.Nearlyallofthesetestswere“splitsamples”wheretheconventionalPapsmearisaccompaniedbytheliquid-basedspecimen.Verysmallnumberswereliquid-basedspecimensonly(0.2%).

4. HISTOLOGY REPORTS

ThissectiondescribesthehistologyreportsthatwerenotifiedtotheVCCRduring20121.Althoughthereportingofhistologyresultsisnotmandatory,themajorityofallrelevantcervicalbiopsiesarereportedtotheVCCR.AllcancersarenotifiedtotheVictorianCancerRegistrybylaboratories,hospitalsandtheVCCR.

In2012,therewere20,630histologyreportsrelatingtothecervixreceivedbytheVCCR.Thefollowingtableshowsthedistributionofhistologyfindingsfor2012.

NotethatthedatapresentedinTable4includesallhistologyreportsreceivedbytheVCCR,andisnotrestrictedtothemostseverereportforawoman.

Table 4: HistologyfindingsreportedtotheVCCRin2012.

Histology findings Number (%)

Endocervicalabnormality

Carcinomaofthecervix–other2 15 ( 0.1%)

Adenosquamouscarcinoma 4 ( 0.1%)

Endocervicaladenocarcinoma,invasive 51 (0.2%)

Endocervicaladenocarcinoma,micro-invasive 4 ( 0.1%)

High-gradecarcinomainsitu/adenocarcinomainsitu 68 (0.3%)

High-gradeendocervicalabnormality,adenocarcinomainsitu 114 (0.6%)

High-gradeendocervicalabnormality,endocervicaldysplasia 11 ( 0.1%)

Endocervicalatypia 0 (0.0%)

Squamousabnormality

Squamouscellcarcinoma,invasive 106 (0.5%)

Squamouscellcarcinoma,micro-invasive 25 (0.1%)

High-gradesquamousabnormality,CINIII 2,922 (14.2%)

High-gradesquamousabnormality,CINII 2,136 (10.4%)

High-gradesquamousabnormality,CINnototherwisespecified 241 (1.2%)

Low-gradesquamousabnormality 3,373 (16.3%)

Benignchanges/normal 11,302 (54.8%)

Unsatisfactory 258 (1.3%)

TOTAL 20,630 (100%)

26

1 ThenumberofHistologyReportsnotifiedtotheVCCRasat30June2013.2 Carcinomaofthecervix–other:includessmallcellcarcinomaandothermalignantlesions

(mayincludetumoursofnon-epithelialorigin).


5. HIGH-GRADE ABNORMALITY DETECTION RATES

Figure5.2showstherateofhistologically-confirmedhigh-gradecervicalabnormalitiesbyyearsince2000,foryoungwomen(<20,20-24,25-29)andthose30+yearsofage.32Thepreviouslynoteddecline,followingtheNationalHPVVaccinationProgram,inwomenunder20yearsofageiscontinuing,withanearhalvingoftherateof11casesper1,000womenscreenedin2006downto6casesper1,000in2012(p<0.001).Ratesinwomen20to24yearshavebeendecliningsince2010;howevertherehasbeenasteadyriseindetectionratesfor25to29yearoldwomenoverthelast10years.

TheVCSandtheAIHWhaveundertakenananalysisofde-identifiedlinkeddatafromtheVCCRandtheNHVPRtodeterminewhetherthedeclinesobservedinhigh-gradeabnormalityratesamongstyoungwomen(aged12to17yearsin2007)sincethevaccinationprogramareduetovaccination.Theanalysisconfirmedthatvaccinatedwomenattendingscreeninghavea48%lowerrateofhigh-gradeabnormalitiesthanunvaccinatedwomen,afteradjustingforage,socioeconomicstatusandareaofresidence(HazardRatio0.72(95%CI0.58-0.91)forreceiptofanynumberofdosesofHPVvaccine).ThisisthefirstinternationalevidenceoftheeffectivenessofHPVvaccinationinpreventinghigh-gradecervicalabnormalitiesinapopulation.33

In2012theoverallrateofhistologically-confirmedhigh-gradeabnormalitiesdetectedinVictoriaforwomenaged20to69yearswas7.65per1,000womenscreened.31Figure5.1illustratesthedetectionrateofhistologically-confirmedhigh-gradeintraepithelialabnormalitiesper1,000screenedwomenfortheyears2009-2012byfiveyearagegroup.Thegraphclearlyillustratesthatyoungerwomenhaveamuchhigherrateofhigh-gradeabnormalities,resultingfromhighratesofincidentHPVinfectionfollowingtheonsetofsexualactivity,thanolderwomen.Notablehoweveraretheyearonyeardeclinesintherateintheyoungestwomen(aged20to24years),correspondingtotheimplementationoftheHPVvaccinationprogrambetween2007-2009.Historicallythisagegrouphashadthehighestratesofabnormalitiesbutfrom2009theratehasbeenhigheramongst25to29yearolds.Since2008theratein20to24yearoldshasfallenfrom21.1(notshowninfigure)to15.3per1,000in2012(p<0.001)(2009=18.7;2010=17.9;2011=15.8).Theyoungestvaccinatedwomen,whoarelesslikelytohavebeenpreviouslyexposedtohigh-riskHPVtypesthroughsexualactivity,arenowcommencingcervicalscreening.AccordingtotheNationalHPVVaccinationProgramRegister,Victorianwomenaged15to19yearsin2012haveanotifiedthree-dosevaccinecoverageof72.6%andthoseaged20to24yearshaveanotifiedcoverageof52.9%(NHVPR,unpublisheddata).

Figure 5.2:Trendsinhigh-gradecervicalabnormalities(histologically-confirmed)byage,2000-2012,VCCR.

20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69yrs yrs yrs yrs yrs yrs yrs yrs yrs yrs

Age group

Rat

e pe

r 1,

000

scre

ened

wom

en

0

2

4

6

8

10

12

14

16

18

20

20112012

20102009

Rat

e pe

r 1,

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ened

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en

Year

0

5

10

15

20

25

30

<20 yrs 20-24 yrs 25-29 yrs 30+ yrs

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012

Figure 5.1:Detectionrateofhigh-gradeintraepithelialabnormalities(histologically-confirmed)from2009-2012per1,000screenedwomen.

Histology findings Number (%)

Endocervicalabnormality

Carcinomaofthecervix–other2 15 ( 0.1%)

Adenosquamouscarcinoma 4 ( 0.1%)

Endocervicaladenocarcinoma,invasive 51 (0.2%)

Endocervicaladenocarcinoma,micro-invasive 4 ( 0.1%)

High-gradecarcinomainsitu/adenocarcinomainsitu 68 (0.3%)

High-gradeendocervicalabnormality,adenocarcinomainsitu 114 (0.6%)

High-gradeendocervicalabnormality,endocervicaldysplasia 11 ( 0.1%)

Endocervicalatypia 0 (0.0%)

Squamousabnormality

Squamouscellcarcinoma,invasive 106 (0.5%)

Squamouscellcarcinoma,micro-invasive 25 (0.1%)

High-gradesquamousabnormality,CINIII 2,922 (14.2%)

High-gradesquamousabnormality,CINII 2,136 (10.4%)

High-gradesquamousabnormality,CINnototherwisespecified 241 (1.2%)

Low-gradesquamousabnormality 3,373 (16.3%)

Benignchanges/normal 11,302 (54.8%)

Unsatisfactory 258 (1.3%)

TOTAL 20,630 (100%)

31 NotethatthemethodusedtocalculatetherateofhighgradeabnormalitieshasbeenupdatedtobeconsistentwiththeAIHWindicator4.2(AustralianInstituteofHealthandWelfare2013.Cervical screening in Australia 2010-2011.Cancerseries76.Cat.no.CAN72.Canberra:AIHW).Thereforeratesareslightlydifferenttothosepresentedinpreviousreports.

32 Ibid.33 GertigDM,BrothertonJML,BuddAC,DrennanK,ChappellG,SavilleAM.Impact of a population-based HPV vaccination program on cervical abnormalities: a data linkage study. BMC Medicine 2013,11:227.

28

6. CORRELATION BETWEEN CYTOLOGY & HISTOLOGY REPORTS

Tables6.1and6.2showthecorrelationbetweencytologyresultsandhistologyfindings.Thecorrelationisrestrictedtocytologyperformedin2011whereasubsequenthistologytestwasreportedwithinsixmonths.Ifmultiplehistologyresultswerereportedthemostsevereresultisused.Colposcopyreports,withouthistologicalconfirmation,havebeenexcludedfromthisanalysis.

Ininterpretingthisinformation,itisimportanttorememberthatonlyaminorityoflow-gradecytology(atypiaandCINI)isfurtherinvestigatedbycolposcopyorbiopsy,andanevensmallerpercentageofnegativecytologyreportsarefollowedbycolposcopyorbiopsy.Womenwhohaveabiopsyarelikelytobeanatypicalsubsetofthewholegroupofwomenwithnegativeorlow-gradecytologyreports.

ThecorrelationdatapresentedusestheCytologyCodingScheduleimplementedinJuly2006whichisbasedontheAustralianModifiedBethesdaSystemof2004(refertoAppendix1).EachPaptestisassignedasummarycode(negative,low-grade,glandular,possiblehigh-gradeandhigh-grade)basedonspecificcriteriaofthesquamous,endocervicalandother/non-cervicalcodes.Thecorrelationusesthisclassificationforcytology.

ThehistologyclassificationandmethodofcorrelationpresentedisconsistentwiththeAIHWnationalreportingindicators.Itisbasedonthetest,notthewoman,andthedataincludeswomenaged20to69years.ItalsoincludestherecordsofwomenwhoresideoutsideofVictoriabuthavedatarecordedontheVCCR.

Whereadefinitehigh-gradesquamouscytologyresultwasreported,79.7%(2911/3653)ofwomenweresubsequentlydiagnosedwithhigh-gradehistologyatbiopsy(includinghigh-gradeCINnototherwisespecified,CINII,CINIIIandmicro-invasiveandinvasivesquamouscarcinoma).Thisfigurerepresentsthepositivepredictivevalueofahigh-gradecytologyreportforhigh-gradehistology.TheNationalPathologyAccreditationAdvisoryCouncil(NPAAC)performancestandardsrequirethatnotlessthan65%ofcytologyspecimenswithadefinitehigh-gradeepithelialabnormalityisconfirmedonhistologywithinsixmonthsashavingahigh-gradeabnormalityorcancer34.

WomenwithaPaptestreportof‘atypicalendocervicalorglandularcellsofuncertainsignificance’haveglandular(orendocervical)cellsontheirsmearwhich,intheopinionofthereportingpathologist,appearunusualbutarenotsufficientlyabnormaltojustifyamoresignificantdiagnosis.Unfortunatelythereisoverlapinthecellularfeaturescausedbybenign,inflammatorychanges(byfarthemostcommoncause)andmoresignificantprocessessuchaspre-cancer(occasionally)andcancer(rarely).TheNHMRCGuidelines35

recommendcolposcopyasaninitialevaluationbecauseoftheriskofinvasivecancer36.Ofthe26cytologyreportsof‘atypicalendocervicalorglandularcellsofundeterminedsignificance’,2weresubsequentlydiagnosedwithinvasiveormicro-invasivecancer(wherehistologywasavailablewithinsixmonthsafterthecytologyresult).

Therewerenocasesofcervicalcancerreportedonhistologywithin6monthsofalow-gradesquamouscytologyin2011(Table6.1).

34 NationalPathologyAccreditationAdvisoryCouncil(NPAAC)2006.Performance Measures for Australian Laboratories Reporting Cervical Cytology,Canberra:DepartmentofHealthandAgeing.

35 NHMRC Screening to prevent cervical cancer: guidelines for the management of asymptomatic women with screen-detected abnormalities,2005 http://www.nhmrc.gov.au/publications/synopses/wh39syn.htm36 Appendix 8. Outcome after a cytological prediction of glandular abnormality in 1999.AuthorDrHeatherMitchell.ScreeningtopreventCervicalCancer Guidelinesforthemanagementofasymptomaticwomenwithscreendetectedabnormalities.

AvailablefromtheNHMRCwebsitewww.nhmrc.gov.au/_files_nhmrc/publications/attachments/wh39.pdf


Table 6.1: Correlation1ofsquamouscytologytothemostserioussquamoushistologywithin6months,womenaged20to69years,cytologytestsperformedin2011.

1 Thecorrelationexcludesdiagnosisbasedoncolposcopicimpressionalone2 Negativecytology:noabnormalsquamouscellsoronlyreactivechanges3 Possiblehigh-gradecytology:includespossiblehigh-gradesquamousintraepitheliallesion4 High-gradecytology:includeshigh-gradesquamousintraepitheliallesion5 HGPlus:includeshigh-gradesquamousintraepitheliallesionwithpossiblemicro-invasion/invasion

Cytology Prediction

Histology fi nding

HG: High-Grade LG: Low-Grade SQ: Squamous

Negative2 Possible Low-Grade

Low-Grade Possible High-Grade3

High-Grade4 High-Grade Plus5

SCC

S1 S2 S3 S4 S5 S6 S7

Squ

amou

sA

bnor

mal

ity

NegativeHS01

3,236 76.3% 1406 51.6% 670 31.4% 996 31.6% 354 9.7% 3 5.4% 1 3.0%

LGSQabnormalityHS02

776 18.3% 936 34.3% 1042 48.9% 672 21.3% 388 10.6% 2 3.6% 0 0.0%

HGSQabnormalityCINNOSHS03.1

16 0.4% 25 0.9% 26 1.2% 65 2.1% 55 1.5% 0 0.0% 3 9.1%

HGSQabnormalityCINIIHS03.2

126 3.0% 224 8.2% 270 12.7% 629 19.9% 865 23.7% 9 16.1% 0 0.0%

HGSQabnormalityCINIIIHS03.3

85 2.0% 134 4.9% 124 5.8% 780 24.7% 1944 53.2% 26 46.4% 10 30.3%

SQCellCarcinoma–micro-invasiveHS04.1

1 <0.1% 0 0.0% 0 0.0% 6 0.2% 24 0.7% 4 7.1% 1 3.0%

SQCellCarcinoma–invasiveHS04.2

2 <0.1% 0 0.0% 0 0.0% 5 0.2% 23 0.6% 12 21.4% 18 54.5%

Totals 4242 100% 2725 100% 2132 100% 3153 100% 3653 100% 56 100% 33 100%

30

Table 6.2: Correlation1ofendocervicalcytologytothemostseriousendocervicalhistologywithin6months,womenaged20–69years,cytologytestsperformedin2011.

1 Thecorrelationexcludesdiagnosisbasedoncolposcopicimpressionalone2 Endocervicaladenocarcinoma–invasive:includesadenocarcinomaandembryonal/clearcellcarcinoma3 Carcinomaofthecervix–other:includessmallcellcarcinomaandothermalignantlesions(mayincludetumoursofnon-epithelialorigin)4 Glandularcytology:includesatypicalglandularcellsofuncertainsignificance(E2)5 Possiblehigh-gradecytology:includespossiblehigh-gradeendocervicalglandularlesion

Cytology Prediction

Histology fi nding

HG: High-Grade

Negative Atypical Endocervical

cells of uncertain signifi cance4

Possible High-Grade5

Adenocarcinoma in situ (AIS)

AIS with possible

micro-invasion /invasion

Adenocarcinoma

E1 E2 E3 E4 E5 E6

End

ocer

vica

lAbn

orm

alit

y

NegativeHE01

1736 95.5% 8 30.8% 3 6.5% 0 0.0% 0 0.0% 0 0.0%

EndocervicalAtypiaHE02

0 0.0% 0 0.0% 0 0.0% 0 0.0% 0 0.0% 0 0.0%

HGEndocervicalAbnormality,EndocervicalDysplasiaHE03.1

4 0.2% 1 3.8% 1 2.2% 0 0.0% 0 0.0% 0 0.0%

HGEndocervicalAbnormality,AdenocarcinomainsituHE03.2

24 1.3% 13 50.0% 26 56.5% 28 50.9% 3 42.9% 1 12.5%

HGCarcinomainsitu/AdenocarcinomainsituHE03.3

36 2.0% 2 7.7% 9 19.6% 14 25.5% 0 0.0% 0 0.0%

EndocervicalAdenocarcinoma–micro-invasiveHE04.1

0 0.0% 0 0.0% 1 2.2% 1 1.8% 0 0.0% 0 0.0%

EndocervicalAdenocarcinoma–invasive2

HE04.2

11 0.6% 1 3.8% 6 13.0% 12 21.8% 4 57.1% 7 87.5%

AdenosquamousCarcinomaHE04.3

5 0.3% 1 3.8% 0 0.0% 0 0.0% 0 0.0% 0 0.0%

Carcinomaofthecervix–Other3HE04.4

2 0.1% 0 0.0% 0 0.0% 0 0.0% 0 0.0% 0 0.0%

Totals 1818 100% 26 100% 46 100% 55 100% 7 100% 8 100%


7. FOLLOW UP & REMINDER PROGRAM

The VCCR Reminder and Follow-up Protocol (refer to Appendix 2) adheres to the 2006 NHMRC Guidelines. As part of the follow-up service provided by VCCR, a total of 410,680 follow-up and reminder letters were mailed to women and practitioners in 2012.

Second reminder letters were implemented as part of the routine correspondence of the VCCR in June 2011 and are printed in-house on a weekly basis for mail-out. The implementation costs and outcomes of the first seven months of the second reminder initiative were evaluated and published in an interim report37. Based upon the positive outcomes of the interim evaluation, the Department of Health has extended the funding for the second reminder initiative until June 2014. The following is a summary of the VCCR follow-up activities during 2012.

First Reminders to Women

Between1January2012and31December2012,270,989firstreminderlettersweresenttowomeninthecategoriesshowninTable7.

Ofthe258,047reminderssentafteranegativePaptest,103,634(40%)womenhadasubsequentPaptestwithinthreemonthsofthedateofthereminder.

Second Reminders to Women

Between1January2012and31December2012;117,460secondreminderlettersweresenttowomen,inthecategoriesshowninTable7.

Ofthe112,469reminderssentafteranegativePaptest;26,974(24%)womenhadasubsequentPaptestwithinthreemonthsofthedateofthereminder.

Table 7: NumberoffirstandsecondreminderletterssenttowomenbytheVCCRin2012.

Follow-up

During2012,theVCCRsentout1,854questionnairestopractitionersseekingfurtherinformationafterahighgradeabnormalityonPaptestand4,493afteralow-gradeabnormality.Thesequestionnairesarepartofthefollow-upofabnormaltestsandseekinformationoncolposcopyorbiopsytoalterthefollow-upintervalaccordingly.TheVCCRalsosentout12,406reminderletterstopractitioners,followinglow-gradeorunsatisfactoryPaptests.

Duringtheyear,802womenwithahigh-gradeabnormalityrequiredfurtherfollow-upbytheVCCRasnofurtherinformationhadbeenreceivedby5.5monthsaftertheirPaptest.Forthesewomen,atleastonephonecalltothepractitionerwasmadetoascertainfollow-up,withmanyrequiringadditionalcalls.In345cases,theRegistrysentletterstothesewomen,mostlybyregisteredmailtoensurethattheywereawareoftheirabnormality.Forwomenwhohadlow-gradeabnormalitiesrequiringfurtherinvestigation,onwhomtheVCCRhadnotreceivedfollow-upinformation;2,178lettersweresenttothesewomenin2012.TheVCCRfollowedup151non-cervicalabnormalitieswithletterstothepractitionersseekinginformationaboutfurtherinvestigations.

Pap test report category First Reminders Second Reminders

High-gradewithsubsequentbiopsy 1,180 402

High-gradenosubsequentPaptestby12months 158 68

Low-grade-withsubsequentbiopsyorcolposcopy 1,674 612

Low-grade-previoustestabnormalorfluctuatingabnormality 800 329

Low-grade–over30withnonegativecytologyinprevious3years 504 227

Low-grade–allotherwomen 5,534 2,005

Negativewithpreviousabnormal 25,033 10,823

Negative 233,014 101,646

Unsatisfactorywithpreviousabnormal 120 40

Unsatisfactory 2,972 1,308

37 Interim evaluation report of Second Reminder, VCCR. PreparedbyLesleyRowlands,GenevieveChappellandDorotaGertig,April2012

8. CERVICAL CANCER INCIDENCE & MORTALITY IN VICTORIA

Thegreatestimpactofthecervicalscreeningprogramhasbeenonsquamouscellcarcinomaofthecervix,withage-standardisedincidenceratesdecliningfrom6.3per100,000womenin1989to2.7per100,000in2012.Thisisamarginalincreasefromanincidencerateof2.0in2010and2.2in2011per100,000women.Incidenceratesformicro-invasivecancerhaveincreasedslightlysince2000;andin2012were1.1per100,000womenscreened(2010:1.2and2011:1.1).Cervicalscreeningislesseffectiveforthedetectionofadenocarcinomas39,whichnowrepresentalargerproportionofallcancersduetothesuccessoftheprograminreducingtheincidenceofsquamouscancers.ItisanticipatedthatHPVvaccinationprogramswillreducethefutureincidenceofadenocarcinomas.

Figure8.3showstheage-specificincidenceratesofcervicalcancerbyhistologyandage,groupedoverthethreeyearperiodof2010to2012.Theage-specificincidenceofinvasivesquamouscervicalcancerincreasesinthe30to34yearoldagegrouptopeakatage45to49years,followedbyasubsequentpeakinwomenagedintheirearly70s.Micro-invasivecervicalcancerpeaksataround30yearsofageanddeclinessteadilythereafter.

38 FerlayJ,ShinHR,BrayF,FormanD,MathersCandParkinDM.GLOBOCAN2008v2.0,Cancer Incidence and Mortality Worldwide: IARC CancerBaseNo.10[Internet].Lyon,France:InternationalAgencyforResearchonCancer;2010.Availablefrom:http://globocan.iarc.fr39 NHMRC Screening to prevent Cervical Cancer: guidelines for the management of asymptomatic women with screen-detected abnormalities,2005 http://nhmrc.gov.au/publications/synopses/whj39syn.htm

Theaimofthecervicalcancerscreeningprogramistoreducetheincidenceofandmortalityfromcervicalcancer.DataoncancerincidenceandmortalityarecollectedbytheVictorianCancerRegistryandnotificationsarecompulsoryfromlaboratories,hospitalsandtheVCCR.

Figure8.1showstheincidenceandmortalityratesfromcervicalcancerinVictoriafrom1982to2012.Theincidenceofcervicalcancerhasdeclineddramaticallysincethe1980s,withaconsiderabledeclinefromthemid1990s.Therewasaplateauinincidencein2000andtheratehasremainedrelativelystablesincethattimeatbetween4and5per100,000women.Aslightincreasehasbeennotedin2012,astheincidencerateforcervicalcancerwas5.7per100,000women(2010:5.0and2011:4.9).

ThemortalityfromcervicalcancerinVictoriahasdeclinedgraduallyovertimeandsince2002hasbeenaround1.0per100,000women,whichisamongthelowestintheworld38.Themortalityrateforalltypesofcervicalcancerin2012was1.1per100,000Victorianwomen(2010:1.3and2011:1.1).

Figure8.2showstheage-standardisedincidenceratesforcervicalcancerbyhistologicalsubtypeovertime.

IncidenceMortality

Year

Rat

e pe

r 10

0,00

0 w

omen

(age

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ndar

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d to

the

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ld S

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1982

1983

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1992

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2003

2004

2005

2006

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2011

2012

Source:ThursfieldV,FarrugiaH.CancerinVictoria:StatisticsandTrends2011.CancerCouncilVictoria,Melbourne2012.

32

Figure 8.1:Age-standardisedincidenceandmortalityratesforalltypesofcervicalcancerinVictoria,1982–2012.


Othercervicalcancersarecomprisedofallothertypes,includingadenocarcinomas.Source:Unpublisheddata,VictorianCancerRegistry,CancerCouncilVictoria.

Figure 8.2:Age-standardisedincidencerates(ASR)forcervicalcancerbyhistologicalsubtypeinVictoria,1982–2012.

Othercervicalcancersarecomprisedofallothertypes,includingadenocarcinomas.Source:Unpublisheddata,VictorianCancerRegistry,CancerCouncilVictoria.

Figure 8.3: Age-specificincidenceratesofcervicalcancerbyhistologicalsubtypeinVictoria,2010–2012.

1982

1983

1984

1985

1986

1987

1988

1989

1990

1991

1992

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3434

9. SCREENING HISTORY OF WOMEN DIAGNOSED WITH CERVICAL CANCER IN 2010 AND 2011

AccordingtotheVictorianCancerRegistry(VCR),183Victorianwomenwerediagnosedwithcervicalcancerin2010and185womenin2011(January1–December31).Thescreeninghistoriesofwomenwithhistologically-confirmedinvasiveandnon-invasivecervicalcancerrecordedontheVictorianCervicalCytologyRegistry(VCCR)isoutlinedbelow.

Cervical Cancer Diagnoses in 2010Ofthe183womendiagnosedwithcervicalcancerin2010,77werediagnosedwithinvasivesquamouscellcarcinoma,38withmicro-invasivesquamouscellcancerand68withothertypesofinvasivecervicalcancer(includingadenocarcinoma,smallcellcarcinoma,mixedadenosquamousadenocarcinomaandcarcinosarcomas/sarcomas)40.Ofthesewomendiagnosedwithcervicalcancer,137werealsorecordedontheVCCR,andthusascreeninghistorywasavailableforreview.

Cervical Cancer Diagnoses in 2011Ofthe185womendiagnosedin2011,83werediagnosedwithinvasivesquamouscellcarcinoma,36withmicro-invasivesquamouscellcancerand66withothertypesofinvasivecervicalcancer41.

Table 9 (a): ScreeninghistoryofVictorianwomendiagnosedwithcervicalcancerfortheperiod1January2010to31December2010.

Screening History

Invasive Squamous cell carcinoma

Number (%)

Other invasive cervical cancer

Number (%)Invasive

Sub-TotalMicro-invasive

Sub-Total

Invasive & Micro-invasive

Total

A.Neverscreened 38 49% 35 51% 73 50% 18 47% 91 50%

B.Lapsedscreeners(lastscreengreaterthan2.5years)

23 30% 18 26% 41 28% 11 29% 52 28%

C.Adequatelyscreened(lastscreenwithin2.5years)

10 13% 12 18% 22 15% 7 18% 29 16%

D.Delayeddiagnosis 6 8% 3 4% 9 6% 2 5% 11 6%

E.Noteligible1 0 0% 0 0% 0 0% 0 0% 0 0%

Total 77 100% 68 100% 145 100% 38 100% 183 100%

Ofthesewomendiagnosedwithcervicalcancer,113withaninvasivecancerdiagnosisand26withamicro-invasivediagnosiswerealsorecordedontheVCCRandthusascreeninghistorywasavailableforreview.

AnauditwasconductedonthescreeninghistoriesofwomenrecordedontheVCCRwithcervicalcancerbasedoncriteriausedinotherinternationalstudies42.Thefollowingcategorieswereused,andallscreeningtestswithin6monthsofdiagnosiswereexcluded(asitisassumedtheseledtothediagnosis):

A. Never screened (coverage failure),B. Lapsed screening: with more than two and a half years

between the cancer diagnosis and the ultimate Pap test,C. Adequately screened (screening failure): with less than

two and a half years between the cancer diagnosis and the ultimate Pap test,

D. Delayed diagnosis: eg. no colposcopy and/or biopsy recorded [biopsy, management or treatment failure],

E. Not eligible: Women over the age of 70 years and no longer eligible for the screening program1.

40 Unpublisheddata,VictorianCancerRegistry,CancerCouncilVictoria41 Ibid. 42 SasieniP,AdamsJ,CuzickJ.Benefi ts of cervical screening at different ages: evidence from the UK audit of screening histories.2003. BrJCancer.89(1):p.88-93.


1 Womenover70yearsandwithanegativescreeninghistoryareoutsidetheeligiblerangeforthescreeningprogram.RefertotheNationalCervical ScreeningProgramatwww.cancerscreening.gov.au

A. Women with no previous screening historyTheneverscreenedcategoryincludeswomenwhowereontheVCRandeithernotrecordedontheVCCR(37womenin2010and36womenin2011);andthusitisassumedtheywereneverscreened,orwererecordedontheVCCRbuttheirfirstPaptestwaswithin6monthsofdiagnosis(36womenin2010and37womenin2011).AproportionofthoseunknowntotheVCCRmayhavebeenscreenedinterstateoroverseas,orhaveopted-offtheRegistry.

B. Women with a lapsed screening history AccordingtotheVCCRrecords,therewere41women(28%)ineachof2010and2011thatwerecategorizedaslapsedscreeners.ThisisdefinedaswomenwithnorecordofaPaptestwithintwoandahalfyearsoftheircancerdiagnosis(butmorethansixmonthspriortodiagnosis)inaccordancewiththecurrentNationalscreeningpolicyrecommendationoftwoyearlyscreening.Theproportionofsquamousinvasivecancersforwhichtherewaseithernoscreeninghistoryoralapsedscreeninghistorywas79%in2010and81%in2011.Forglandularinvasivecancers,itwas77%in2010and71%in2011.

9. SCREENING HISTORY OF WOMEN DIAGNOSED WITH CERVICAL CANCER IN 2010 AND 2011

Table 9 (b): ScreeninghistoryofVictorianwomendiagnosedwithcervicalcancerfortheperiod1January2011to31December2011.

Screening History

Invasive Squamous cell carcinoma

Number (%)

Other invasive cervical cancer

Number (%)

Invasive

Sub-Total

Micro-invasive

Sub-Total

Invasive & Micro-invasive

Total

A.Neverscreened 43 52% 30 45% 73 49% 19 53% 92 50%

B.Lapsedscreeners(lastscreengreaterthan2.5years)

24 29% 17 26% 41 28% 11 31% 52 28%

C.Adequatelyscreened(lastscreenwithin2.5years)

11 13% 12 18% 23 15% 4 11% 27 15%

D.Delayeddiagnosis 4 5% 7 11% 11 7% 2 6% 13 7%

E.Noteligible1 1 1% 0 0% 1 1% 0 0% 1 1%

Total 83 100% 66 100% 149 100% 36 100% 185 100%

Invasive Cervical Cancers.

Tables 9(a) and 9(b) classify the screening history of women diagnosed with invasive cervical cancer into one of the following four groups:

C. Women with an adequate screening historyOfthewomendiagnosedwithcervicalcancer,22(15%)womenin2010and23(15%)womenin2011havebeenassessedashavinganadequatescreeninghistorywithatleastonePaptestbetweensixmonthsandtwoandahalfyearspriortotheircancerdiagnosis.Overhalfofthesewomeninboth2010and2011werediagnosedwithglandularcervicalcancers,whicharehardertodetectthroughcervicalscreening.

D. Women with a delayed diagnosisOfthewomendiagnosedwithfranklyinvasivesquamouscervicalcancer,9(6%)womenin2010and11(7%)womenin2011appeartohavehadadelayeddiagnosisormanagementfailureonthelimitedinformationavailabletotheVCCR.Paptestsarenotveryeffectiveatdetectionofadenocarcinoma,duetothedifficultyofsamplingtheendocervicalcanal,hencedelayeddiagnosismayplayaroleindetectionofthesecancers.

ACKNOWLEDGEMENTS

LIST OF ABBREVIATIONS

Theproductionofthisreportwouldnotbepossiblewithouttheco-operationofthestaffofthepathologylaboratoriesofVictoria,thestaffoftheVCCRandtheICTteam.Verysincerethanksareextendedtothemembersofallthesegroups.Inparticular,specialthanksgotothededicatedVCCRstafffortheircollectionofhigh-qualityinformationandtheprovisionofanexcellentserviceforwomenandhealthpractitioners.

ThefiguresonincidenceandmortalityfromcervicalcancerwerekindlyprovidedbytheVictorianCancerRegistryattheCancerCouncilVictoria.WewouldliketothankVickyThursfieldandHelenFarrugiafortheirassistanceinprovidingthesedata.

ABS: Australian Bureau of Statistics

AIHW: Australian Institute of Health and Welfare

ASR: Age-Standardised Rate (per 100,000 Victorian women standardised to World Standard Population)

CIN: Cervical Intraepithelial Neoplasia

ERP: Estimated Resident Population

HPV: Human Papillomavirus

HSIL: High-grade squamous intraepithelial lesion

ICT: Information and Communication Technology

LSIL: Low-grade squamous intraepithelial lesion

NHMRC: National Health and Medical Research Council

NHVPR: National HPV Vaccination Program Register

NPAAC: National Pathology Accreditation Advisory Council

PPV: Positive Predictive Value

SCC: Squamous Cell Carcinoma

VCCR: Victorian Cervical Cytology Registry

VCR: Victorian Cancer Registry

VCS: Victorian Cytology Service Inc.

36


GLOSSARY REFERENCES 43

Immunisation–Inducingimmunityagainstinfectionbytheuseofanantigentostimulatethebodytoproduceitsownantibodies(AIHW (2008) Australia’s Health 2008, Cat. No. AUS 99. AIHW, Canberra)

Incidence–Thenumberofnewcases(forexample,ofanillnessorevent)occurringduringagivenperiod

Intraepithelial lesion–Lesionconfinedtothesurfacelayerofthecervix

Invasive Cancer–Atumourwhosecellshavethepotentialtospreadtonearbyhealthyornormaltissueortomoredistantpartsofthebody

Lesion–Alterationofsurfacetissue,causedbyinjuryordisease

Malignant–Abnormalitiesincellsortissuesconsistentwithcancer

Micro–invasive squamous cell carcinoma (micro–invasive cancer)–Alesioninwhichthecancercellshaveinvadedjustbelowthesurfaceofthecervix,buthavenotdevelopedanypotentialtospreadtoothertissues

National Cervical Screening Program –Australia-widesystematicapproachtocervicalscreeningbasedonsoundinternationalscientificevidence,theaimofwhichistoreducetheincidenceandmortalityratesforcervicalcancer

Opportunistic screening–TakingPapsmearswhenawomanvisitsherGPforanotherreason

Pap Tests (or Smear)–Simpleprocedureinwhichanumberofcellsarecollectedfromthecervix,smearedontoamicroscopeslideandsenttoalaboratoryforcytologicalexaminationtolookforchangesthatmightleadtocervicalcancer.Upto90%accurateandthebestwaytopreventsquamouscervicalcancer.Namedafterthetest’sinventor,DrPapanicolaou

Pathology–Laboratory-basedstudyofdisease,asopposedtoclinicalexaminationofsystems

Screening –Testingofallpeopleatriskofdevelopingacertaindisease,eveniftheyhavenosymptoms.Screeningtestscanpredictthelikelihoodofsomeonehavingordevelopingaparticulardisease

Squamous cells –Thinandflatcells,shapedlikesoftfishscales.Theylinetheoutersurfaceofthecervix(ectocervix).Theymeetwithcolumnarcellsinthesquamo-columnarjunction.AbnormalitiesassociatedwithsquamouscellsarethemostlikelyabnormalitiestobepickedupbyPaptests

Squamous cell carcinoma–Acarcinomaarisingfromthesquamouscellsofthecervix

Adenocarcinoma–Ararecanceraffectingthecervix,butinvolvingthecolumnarcellsratherthanthesquamouscells.Thecolumnarcellsareinvolvedinglandularactivity.AdenocarcinomahasadifferenttypeandrateofprogressionandisnotsooftenpickedupinaPaptest

Atypia–Abnormalityinacell(toalowerdegreethandysplasia)

Biopsy of the Cervix–Removalofasmallpieceofthecervixforexaminationunderamicroscope

Carcinoma in Situ–Cancercellsthatarerestrictedtothesurfaceepithelium.Theabnormalcellsareevidentthroughouteachofthelayersoftheepitheliumbuttheyhavenotextendedintoother,deepertissueorsurroundingareas

Cervix–Theneckoftheuterus(womb),locatedatthetopofthevagina

Colposcopy–Adetailedexaminationofthelowergenitaltractwithamagnifyinginstrumentcalledacolposcope.Thismethodofnon-invasiveevaluationallowsthecliniciantomoreaccuratelyassessacytologicabnormalitybyfocusingontheareasofgreatestabnormalityandbysamplingthemwithabiopsytoobtainatissuediagnosis

Cytology–Themicroscopeevaluationofasampleofcellsobtainedfromatissue(orbodyfluid)duringproceduressuchasPaptests.Thesampledoesnotpermitevaluationoftheunderlyingstructureofthetissueoforigin (cf. histology)

Dysplasia-Abnormalappearance,developmentorgrowthpatternsofcells

Endocervix–Internalcanaloftheuterinecervixanditsepithelium,notusuallyvisibleoninspectionofthecervix

Glandular Lesion–Lesioninvolvingthecolumnarcellsofthecervix,whichproducemucusandhavebothadifferentappearanceandadifferentfunctionfromthesquamouscells

Histology–Themicroscopestudyoftheminuteanddetailedstructureandcompositionoftissues

Human Papillomavirus–Groupofvirusesthatcancauseinfectionintheskinsurfaceofdifferentareasofthebody,includingthegenitalarea.Theviruscancausevisiblegenitalwarts.SometypescancausetheabnormalcellchangeswhicharedetectedonaPaptestandwhichcansometimescausecancer.

Hysterectomy–Referstothesurgicalprocedurewherebyallorpartoftheuterusisremoved

Hysterectomy Fraction–Theproportionofwomenwhohavehadtheiruterusremovedbyhysterectomy

43 Unlessotherwiseindicated,alldefinitionshavebeensourcedfromthefollowingpublications:AustralianInstituteofHealthandWelfare2013.Cervical screening in Australia 2010-2011.Cancerseries76.Cat.no.CAN72.Canberra:AIHWNHMRC Screening to prevent cervical cancer: guidelines for the management of asymptomatic women with screen-detected abnormalities, 2005.http://www.nhmrc.gov.au/publications/synopses/wh39syn.htm

38

APPENDIX 1.CYTOLOGYCODINGSCHEDULE

S Squamous Cell E Endocervical O Other/Non-cervical

SU Unsatisfactoryforevaluatione.g.poorcellularity,poorpreservation,celldetailobscuredbyinflammation/blood/degeneratecells

EU Duetotheunsatisfactorynatureofthesmear,noassessmenthasbeenmade

OU Duetotheunsatisfactorynatureofthesmear,noassessmenthasbeenmade

S1 Cellnumbersandpreservationsatisfactory.Noabnormalityoronlyreactivechanges

E- Notapplicable:vaultsmear/previoushysterectomy

O1 Nootherabnormalcells

S2 Possiblelow-gradesquamousintraepitheliallesion(LSIL)

EØ Noendocervicalcomponent O2 Atypicalendometrialcellsofuncertainsignificance

S3 Low-gradeLSIL(HPVand/orCINI) E1 Endocervicalcomponentpresent.Noabnormalityoronlyreactivechanges

O3 Atypicalglandularcellsofuncertainsignificance-siteunknown

S4 Possiblehigh-gradesquamousintraepitheliallesion(HSIL)

E2 Atypicalendocervicalcellsofuncertainsignificance

O4 Possibleendometrialadenocarcinoma

S5 High-gradesquamousintraepitheliallesion(HSIL)(CINII/CINIII)

E3 Possiblehigh-gradeendocervicalglandularlesion

O5 Possiblehigh-gradelesion-non-cervical

S6 High-gradesquamousintraepitheliallesion(HSIL)withpossiblemicroinvasion/invasion

E4 Adenocarcinomainsitu O6 Malignantcells-uterinebody

S7 Squamouscarcinoma E5 Adenocarcinomainsituwithpossiblemicroinvasion/invasion

O7 Malignantcells-vagina

E6 Adenocarcinoma O8 Malignantcells-ovary

O9 Malignantcells–other

CYT

OLO

GY

Type AØNotstated A1Conventionalsmear A2Liquidbasedspecimen A3Conventionalandliquidbasedspecimen

Site BØNotstated B1Cervical B2Vaginal B3OthergynaecologicalsiteSPEC

IMEN

RØ Norecommendation R4 Repeatsmear6months R8 Referraltospecialist

R1 Repeatsmear3years R5 Repeatsmear6-12weeks R9 Othermanagementrecommended

R2 Repeatsmear2years R6 Colposcopy/biopsyrecommended

RS Symptomatic-clinicalmanagementrequired

R3 Repeatsmear12months R7 AlreadyundergynaecologicalmanagementR

ECO

MM

EN

DAT

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APPENDIX 3. MAPOFLOCALGOVERNMENTAREAS-MELBOURNE

42

APPENDIX 3.MAPOFLOCALGOVERNMENTAREAS–VICTORIA

APPENDIX 3. MAPOFLOCALGOVERNMENTAREAS–VICTORIA

vccr statistical report - 2012

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