A voice for women's health

AWHC Submission on HPV Primary Screening October 2015

AWHC Submission on HPV Primary Screening

The National Screening Unit (NSU) requested submissions on the proposed changes to the National Cervical Screening Programme (NCSP).

1. Name 

Auckland Women's Health Council


2. Address

PO Box 99614, Newmarket, Auckland 1149

3. The modelling work done to date supports the preferred pathway as the one likely to achieve the greatest benefits. However, are there any other options that you believe the NCSP should investigate further?

Given that around 160 women in New Zealand are diagnosed with cervical cancer each year, and about 50 women die of cervical cancer, greater benefits for Maori, Pacific and Asian women are much more likely to be achieved by publicly funding cervical screening. It may even cost less than what is being proposed.

4. What further evidence and/or research should the NCSP consider to gain a comprehensive understanding of the impacts of proposed changes to the screening pathway?

Please provide links or references to any documents the NCSP should consider.
Email any relevant papers that the NCSP should consider to primaryhpv@moh.govt.nz.

The consultation document does not provide an accurate picture of the incidence of cervical cancer in NZ, nor the expected benefits of what is being proposed. The AWHC notes that NSU constantly refers to the incidence of cervical cancer in a global context which creates the impression that it is a big problem in New Zealand. It is misleading to provide international statistics on cervical cancer without stating the incidence of cervical cancer in New Zealand and the number of deaths.  In response to a question at one of the Auckland consultation meetings, one of the speakers referred to the potential of the new HPV test to bring about a 5% reduction in mortality from cervical cancer in New Zealand. This is an incredibly small benefit – one or two women per year – when considering the financial cost to the NCSP of implementing HPV screening.
The consultation document also does not clearly acknowledge that 80%-90% of women clear HPV infections within a couple of years without the need for any intervention or treatment. This is another important piece of information that people making a submission on the document needed, and that women having cervical screening need to understand when making an informed decision about HPV screening.  
When the National Cervical Screening Programme was established, many women who were told they had one of the three stages of cervical intraepithelial neoplasia believed they had cervical cancer. The AWHC fielded many phone calls from very distressed women who did not understand that CIN indicated the presence of abnormal cell changes but this did not mean they had cervical cancer.
The AWHC is therefore concerned that women who are told they have tested positive for hrHPV16 or hrHPV18 may interpret this to mean they are very likely to develop cervical cancer or even that they are already well down the pathway of developing cervical cancer.
The importance of the negative impact on women that information on their positive hrHPV status is likely to have cannot be overstated. Under the current screening pathway women clear HPV infections without being aware they have one. The proposed changes to the cervical screening pathway will result in far more women being identified as being potentially at risk of developing cervical cancer than the current screening pathway does. It is difficult to estimate what effect this will have on women, their commitment to keeping colposcopy appointments, etc.

5. Screening interval

Please comment on the proposal to routinely screen women every five years.·        
Are there any groups of women who may have a higher risk and require a shorter screening interval?

The move to a routine screen every five years may benefit some women but result in others turning up for cervical screening much less often, eg 7 – 10 years. A one-size fits all cervical screening programme that is based on HPV screening may not address the inequities that exist in the current screening programme.
Of course there are groups of women who have a higher risk of developing cervical cancer – those who cannot afford to pay for cervical screening and who do not have regular screening tests, eg Maori and Pacific and Asian women and those living in poverty.  These are the women that go on to develop cervical cancer. Unless HPV screening is publicly funded then this is unlikely to change.    

6. Age range for screening

Please comment on the potential change in age range for cervical screening from the current 20–69 years to 25–69 years.
Should there be an exit test for screening between the ages of 69 and 74 years?

Beginning cervical screening at 25 instead of 20 is a logical change given that the HPV vaccine is protecting an increasing number of women from the most common forms of HPV infections.
However, the NCSP’s educational resources must provide women with information on the very rare forms of aggressive cervical cancer that can occur, especially in young women, who may or may not have had the HPV vaccine and who go on to develop cervical cancer in their early 20s. The media carries many stories of such cases in which the families of the young women who have died subsequently embark on campaigns to lower the age at which cervical screening begins.
More information is needed before an exit screen is introduced for women between the ages of 69 and 74 years. What is the incidence of newly acquired HPV infections in older women?  Do older women take longer to clear an HPV infection than much younger women? Does cervical cancer develop more quickly in older women?

7. Referrals to colposcopy (for clinicians)

If the number of referrals to colposcopy increased temporarily, how would it impact on the capacity and timeliness of colposcopy service delivery?
What would be the best way to limit any such impact?

How important is it to your clinical practice to have a cytology result for the women you see at colposcopy? 
The current DNA rate is of concern and many DHBs are currently not meeting their colposcopy targets. Increasing the referrals to colposcopy would exacerbate the problem for both the women and the colposcopy services.

8. Screening equity

Please comment on suggested strategies for eliminating inequalities in screening.

The most important strategy for eliminating inequalities in screening is to publicly fund cervical screening and thus bring it into line with other screening programmes in New Zealand, but this strategy is not included in the consultation document.  
If the government is serious about improving access to cervical screening for Maori, Pacific and Asian women then it will ensure that these women are able to access free screening.
Other inequities in cervical screening
Women with physical and sensory impairments have to overcome a number of obstacles to screening. These include:

  • Access to disabled parking close to those doctors who have their practices in shopping or shared parking areas
  • Getting into those clinics which  don’t have ramps for wheelchairs
  • Some clinics don’t have accessible toilets, or beds that go up and down.


9. Self sampling

Who should self-sampling be offered to?
What is the best way for women to test themselves (eg, at home or at a clinic)?
If a woman tests positive for HPV during self-sampling, she will need either follow-up cytology or referral to colposcopy. What do you think the uptake of follow-up for a positive test would be?
What issues do you see with self-sampling?

Self sampling should be offered to all women.
The best way is for many women to test themselves may be at home, especially for those for whom transport is an issue. Others may prefer to test themselves at a clinic. Women should have a choice, and self sampling must be free of charge to the women.
Another possibility for the future is for NSU to negotiate with LabTest to play a role in increasing access.  The NSU could do the invitation and recall (the population register would be necessary for that), with LabTest providing easy access to HPV testing, and ISPs managing the conversations and follow up with women who then are advised to go for further tests at colposcopy.  This would mean there was no need for the General Practices with their wide range of consultation fees to be involved.  This would only be for diagnostic purposes in the event of symptoms that need investigation.
One of the issues with self-sampling is that the uptake of follow-up for a positive test is likely to be much lower than the NSU expects, and as already noted significantly increase the DNA rates above what they already are.

10. Invitation and recall to screening

What should be taken into account when re-designing the NCSP-Register for HPV primary screening?
What is the most reliable way of systematically inviting women into the programme and recalling them at the appropriate time?
Whose role should it be to invite and recall women into screening?

The NCSP Register will need to be redesigned to meet the rapidly changing IT environment and be accessible to GPs and other screening providers to enable them to check both the screening history and the HPV vaccine status of their patients. Women will presumably also have access to this information via their patient portals.
The responsibility of inviting and recalling women into the programme should remain with the NSU. All regions must have a cervical screening co-ordinator to oversee and report on the operation of cervical screening in their region.

11. Cervical screening workforce

Smear takers: What information do you need to confidently engage with your patients if HPV primary screening is introduced?
Cytopathology workforce: How do we retain gynaecological cytopathology professionals (existing cytopathologists, and anatomical pathology registrars) and maintain their expertise in the long term?
Cytoscientists and cytotechnicians: What can we do to maintain a gynaecological cytology workforce in the period before HPV primary screening is introduced?
What should we do to ensure New Zealand has an adequate number of expert gynaecological cytology staff in the long term?
Histology and molecular biology staff: Does the molecular biology workforce have any additional training requirements?
How much capacity do histology laboratories have to process a 10–30 percent increase in gynaecological histology specimens?
Regional coordination, and invitation and recall staff: What is the best way to ensure you are well informed about the changes resulting from HPV primary screening?

Well before HPV screening is introduced all the cervical screening workforce issues must be clearly identified and strategies implemented to ensure that the problems identified in the consultation document do not adversely impact on women’s access to cervical screening, as well as the cervical screening programme’s ability to provide the services.

12. Do you have any other feedback?

The importance of accurate information being provided to women about cervical screening and the proposed benefits and drawbacks of HPV screening cannot be overstated.
The NSU does not have a good track record of providing women with evidence-based information on the risks of screening programmes, and this must change before a new primary screening test is introduced that has the potential to turn many thousands of well women into anxious patients who think they are in imminent danger of developing cervical cancer.

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