Cervical Screening Program Textbook

Cervical Screening
Handbook for providers of

Revised Edition June 2009
Medical Practitioner
Education
Cervical Screening
Program
Queensland
Queensland Cervical Screening Program Handbook for Providers of Medical Practitioner Education Acknowledgements
Medical
Practitioner
Education
CERVICAL
SCREENING HANDBOOK
FOR PROVIDERS OF
ACKNOWLEDGEMENTS
The production of the Cervical Screening Handbook for Providers of
Medical Practitioner Education in Queensland has been made possible
through the expert advice, guidance and support of the Queensland
Cervical Screening Program Medical Practitioner Training Project
Reference Group
The Queensland Cervical Screening Program would like to
acknowledge the following people for their contributions to the
development of the Handbook:
Dr Beris Joyner
Dr Caroline Harvey
Dr Glenda Nolan
Dr Jill Thistlethwaite
Dr Margaret Culpin
Dr Marie-Louise Dick
Dr Patricia Stuart
Dr Patrick Byrnes
Dr Tracey Chefns
Dr Vivienne OConnor
Ms Anna Voloschenko
Ms Jennifer Muller
Ms Kim Rogers
Ms Leane Christie
Ms Lisa Peberdy
PowerPoint Presentation:
Dr Kay Strom
Dr James Nicklin
Prof Ian Frazer
North Queensland Works Unit
The Cervical Screening Handbook for Providers of Medical Practitioner
Education was endorsed in July 2006 by the Queensland Cervical
Screening Program Quality Management Committee. The second
edition was endorsed by the Queensland Cervical Screening Program
Quality Management Committee on 9 April 2009.
Queensland Cervical Screening Program
Cancer Screening Services Unit
Population Health Queensland
PO Box 2368
Fortitude Valley BC QLD 4006
Telephone: (07) 3328 9467
Facsimile: (07) 3328 9487
ISBN 192 1021 500
June 2009
Page iv Queensland Cervical Screening Program Handbook for Providers of Medical Practitioner Education
FOREWORD
The second edition of the Cervical Screening Handbook for Providers
of Medical Education provides a review of current information
relating to cervical cancer incidence and mortality, participation
in cervical screening, Human Papillomavirus vaccination and new
technologies.
The second edition is produced in a CD format to facilitate wider
distribution and easy access for students and all those involved in
provision of medical education.
The second edition of the Handbook can be sighted or downloaded
from the Queensland Cervical Screening Program website:
www.health.qld.gov.au/cervicalscreening
Queensland Cervical Screening Program Handbook for Providers of Medical Practitioner Education Page 1
This Handbook has been conceived and produced to assist providers
of medical education in Queensland with information about all
aspects of cervical screening. The initiative for this project came from
the Queensland Cervical Screening Program Medical Practitioner
Education Project Reference Group whose task was to identify and
propose strategies to ensure that medical practitioners practising
in Queensland have access to appropriate training and continuing
education in the area of cervical screening. An extensive needs
analysis was conducted as part of this project to inform the scope
and presentation of this Handbook. The following content areas were
specied by the Reference Group as essential components that should
be included in any Medical Practitioner cervical screening education
program:
incidence , mortality and aetiology of cervical cancer including the
role of the Human papillomavirus (HPV) and other risk factors
principles of population health and screening including systematic
approaches to screening
health promotion and cervical screening
National Cervical Screening Policy for the prevention of
cervical cancer and the NHMRC Guidelines for the treatment of
asymptomatic women with screen detected abnormalities
cervical screening pathway
barriers affecting womens participation in regular cervical
screening
new technologies
clinical skills including basic theory and clinical experience in
performing a Pap smear, interaction and communication skills in
performing sensitive gynaecological examinations, interpretation
of cytology reports, follow-up and referral practices
quality assurance activities including principles of risk
management, recall and reminder systems, The Queensland Health
Pap Smear Register, interpreting quality assurance reports and
clinical audits.
Introduction
Cervical screening is a disease
prevention activity that ts
well into general practice.
This Handbook for providers
of medical education in
Queensland has been prepared
with this in mind.
Page 2 Queensland Cervical Screening Program Handbook for Providers of Medical Practitioner Education
To support registrars, supervisors and others who are involved in
medical education this Handbook has utilised the concepts of The
Royal Australian College of General Practitioners Training Programs
Five Domains of general practice which are:
1. Communication skills and the patient-doctor relationship
2. Applied professional knowledge and skills
3. Population health and the context of general practice
4. Professional and ethical role
5. Organisational and Legal Dimensions.
Table 1. This table illustrates how sections and learning objectives
in this Handbook t into the RACGP Curriculum framework.
The Handbook consists of ve sections. Each section has a Summary
of Information which gives a prcis of the section, lists key concepts
for inclusion in education programs and lists learning outcomes.
Supporting Information in each section contains a summary of
current information, references, additional readings and support
materials that can be used to develop education sessions. The variety
of materials contained in this Handbook can be adapted to many
modes of presentation or preferred method of delivery e.g. small
groups, lecture room delivery, self-directed or interactive learning.
Furthermore it is recognised that the target audience will be at
different levels of professional development such as medical students,
registrars and general practitioners, and internationally trained
medical graduates. The resource therefore has been designed to allow
for the educator to choose the materials which are most suitable to
the group that needs to be addressed.
PowerPoint presentations relevant to each chapter are provided to
assist with session preparation and presentation.
Domains of
General Practice
Handbook Sections as they relate to the Domains of General Practice
Communication Skills
and the Doctor-Patient
relationship
communlcallon skllls ncccssary lo crorm scnslllvc gynaccologlcal
examination such as a Pap smear (Section 4.1)
skllls lo undcrlakc cccllvc hcallh cducallon and hcallh romollon
within the context of cervical screening (Section 3)
skllls lo undcrlakc oorlunlsllc ccrvlcal scrccnlng Sccllon 8}
communlcallon wllh Aborlglnal and !orrcs Slrall lslandcr womcn,
lesbian women, women with disabilities and women from culturally and
linguistically diverse backgrounds ( Section 3.2)
barrlcrs accllng womcn's arllclallon ln rcgular ccrvlcal scrccnlng
(Section 3.2)
Applied professional
knowledge and skills
knowlcdgc o ccrvlcal scrccnlng lncludlng lhc hallonal Scrccnlng Pollcy
and screening pathway, NHMRC Guidelines (Sections 2.1,4.3,4.4)
skllls ln undcrlaklng lhc Pa smcar roccdurc Sccllon 4.2}
ncw lcchnologlcs Sccllon 4.}
cllnlcal dcclslon maklng on lhc basls o rcsulls rccclvcd Sccllon 4.8}
conllnully and lnlcgrallon o carc Sccllon 4.6}
Population health in
the context of General
Practice
rlncllcs o oulallon hcallh and oulallon scrccnlng Sccllons 2.1}
demographics, epidemiology and aetiology of cervical cancer ( Section1.1, 1.2)
dlscasc rcvcnllon and hcallh romollon ln conlcxl o ccrvlcal scrccnlng
eg participation in community based prevention and education strategies
( Section 3)
skllls ln advocacy and ln uslng communlly rcsourccs Sccllon 8}
the importance of a public health perspective in general practice (Section 3)
Professional and
Ethical role
rlsk managcmcnl Sccllon 6.1}
cullurc and valucs and lhclr lmacl on lhc lhcracullc rclallonshl
(Section 3.2)
allcnls rlghl Sccllons 4.1,4.2,4.6,6.8}
Table 1: Sections and learning objectives within the RACGP Curriculum framework.
Contents
Introduction
1
Contents
5
SECTION 1
Cervical Cancer Background Information
1.1 Cervical Cancer Incidence and Mortality
1.2 Aetiology of Cervical Cancer

7
15
SECTION 2
Population Screening for Cervical Cancer
2.1 Principles of Population Screening and the National
Cervical Screening Program

21
SECTION 3
Health Promotion in the Context of Cervical Screening
3.1 Health Promotion and Cervical Screening
3.2 Barriers Affecting Womens Participation in Regular Cervical
Screening

31
41
SECTION 4
Clinical Skills
4.1 Communication Skills Involved in Performing Sensitive
Gynaecological Examinations
4.2 The Pap Smear
4.3 Interpretation of Cytology Reports
4.4 Management of Screen Detected Abnormalities
4.5 Follow up and Referral
4.6 New Technologies
4.7 HPV Vaccination and HPV DNA Testing

51
57
63
71
75
81
87
SECTION 5
Quality Assurance Activities
5.1 Risk Management
5.2 Clinical Audits
5.3 The Queensland Health Pap Smear Register

93
99
105
RESOURCES
CD - Handbook, PowerPoint presentation and NHMRC
Screening to Prevent Cervical Cancer: Guidelines for the
Management of Asymptomatic Women with Screen Detected
Abnormalities
CD - Sensitive Examination Technique
Cervical
Cancer
Background
Information
SECTION 1
Key concepts
the demographics of cervical cancer and
cervical screening participation rates
recent state, national and world-wide
statistics relating to cervical cancer
incidence, morbidity and mortality
cervical screening participation rates of
women in Queensland
references for the most current statistics
and research regarding cervical cancer.
Learning outcomes
Participants of cervical screening courses
will be able to:
describe the cervical cancer incidence
and mortality in Queensland, Australia
and other parts of the world
recognise and explain the overall
in Queensland and the need for
improvement, particularly among
unscreened and under-screened women
identify the disproportionate burden
of disease experienced by Aboriginal
and Torres Strait Islander women in
Queensland
know the sources of current statistical
information relating to cervical
cancer incidence and mortality using
information technology.
Cancer of the cervix is a preventable and curable cancer if detected early. Research suggests that up
to 90% of the most common form of cervical cancer, squamous cell carcinoma, can be prevented if
women have a regular Pap smear every two years.
In Australia about $150 million a year is spent on preventing cervical cancer. Half of this is allocated to
screening and early detection activities, and the remainder for investigating and treating women with
screen detected abnormalities.
The lifetime probability of an Australian woman (to age 75 years) developing cervical cancer is 1 in183.
Invasive cervical cancer is virtually unknown in women under the age of 20 and is very rare before the
age of 25. Between the ages of 25 and 50 there is a rapid increase in the incidence of invasive cervical
cancer. For women of all ages incidence of cervical cancer was highest among women over 75 years
with peak incidence of 16.2 per100,000 in the 80-84 age group.
SUMMARY INFORMATION
Cervical Cancer
Background Information SECTION 1
Cervical Cancer
Background Information
Cancer of the cervix is the only cancer for which
the expected number of new cases in Australia
is projected to decrease even with the expected
ageing of the population. Squamous cell
carcinoma is the most frequent type of cervical
malignancy (80-85%) and has decreased in
incidence in Australia over the last twenty years.
It is most easily detected by the Papanicolaou
(Pap) smear.
1
Adenocarcinomas account for the
signicant minority of cervical cancers (22.4%).
The incidence of adenocarcinoma has remained
essentially unchanged since 1990 (2.2 per
100,000 in 2003)
1
and remains an outstanding
challenge. The inability to improve the statistics
for adenocarcinoma is generally attributed
to difculties of sampling glandular lesions
in the endocervical canal and difculties in
interpretation of cytologic abnormalities where
adenocarcinomas arise.
2

Recent state, national and world-wide
statistics relating to cervical cancer
incidence and mortality.
Queensland
In Queensland, cervical cancer was the 13th
most common cancer diagnosed in women
during 2006. In that year 186 Queensland
women were diagnosed with cancer of the cervix
and 60 women died as a result of this disease.
3
Over the last four available reporting periods
(2003, 2004, 2005, 2006) for the Queensland
Cervical Screening Program (QCSP) the
incidence of cervical cancer was 8.1, 7.4, 8.7 and
9.0 (per 100,000 women) respectively. However
SUPPORTING INFORMATION
the incidence of cervical cancer in Queensland
is higher than all other Australian States and
Territories with the exception of the Northern
Territory and Western Australia.
The reported number of incident cases of
cervical cancer in discrete rural and remote
Aboriginal and Torres Strait Islander communities
in Queensland between 1997 and 2002 was more
than twice the expected number for the general
Queensland population. The age-standardised
mortality rate in the period 2000-2004 was more
than four times higher in the Northern Territory,
South Australia, Queensland and Western
Australia (the only states where Indigenous
mortality data is of sufcient quality) then in
remaining states.
1
In previous studies, incidence
rates were ve time higher and mortality at least
13-fold higher in Aboriginal and Torres Strait
islander communities.
4

Mortality due to cervical cancer over the last
four available reporting periods (2003, 2004,
2005, 2006) was 2.0, 2.3, 2.0 and 2.7 (per
100,000 women) respectively.
3
In 2006 cervical
cancer was the 14
th
most common cause of
cancer death in Queensland women.
3
Mortality due to cervical cancer in Aboriginal
communities was 13.3% higher than the rest of
Queensland and in the Torres Strait Islands was
21.5 times higher.
4
Australia
The number of new cases of cervical cancer in
Australia has continued to decline. There were
734 new cases in Australia in 2006 compared
with 1,072 detected in 1989 prior to the start
of the National Cervical Screening Program.
Currently Australia has the second lowest
incidence rate of cervical cancer (9.1 women per
100,000 women) in the world.
8

Cervical cancer is the 19th most common cause
of cancer mortality in Australian women, and
accounted for 224 deaths in 2006. The age
standardised mortality from cervical cancer
halved between 1991 and 2005 from 4.0 deaths
per 100,000 to 1.9 per 100,000. During the same
period, for women aged 20-69 years, the rate fell
from 4.0 per 100,000 to 2.0 per 100,000 women.
1

There are variations in mortality rates from
cervical cancer between metropolitan, regional
and rural areas within Australia. Although
overall death rates from cervical cancer have
reduced, higher rates in remote and rural areas
are observed. The 2000-2003 age standardised
mortality rate was 2.4 per 100,000 for remote
areas, 2.5 per 100,000 for regional areas
compared with 1.9 per 100,000 in metropolitan
areas.
1
The cervical cancer mortality rate in Australia
for Aboriginal and Torres Strait Islander
women is higher than for non-Indigenous
women. During the period 2001-2004 the age
standardised mortality rate for cervical cancer
for Aboriginal and Torres Strait Islander women
aged 20-69 years was more than four times
the rate for non-Indigenous women, at 9.9 per
100,000 as compared to 2.1 per 100,000 for non
indigenous women.
1
World Wide
Cervical cancer has a major impact on womens
lives worldwide, particularly in developing
countries where it is a leading cause of death
among women.
5
The world age-standardised incidence rate of
cervical cancer is 16.2 women per 100,000
women and the mortality rate is 9.0 per
100,000.
6
This makes cervical cancer the second
most common cancer affecting women after
breast cancer and the third most common cause
of cancer mortality in women worldwide. The
incidence and mortality rates from cervical
cancer however vary from country to country.
According to the latest global estimates, 493,000
new cases of cervical cancer occur each year
among women and 275,000 women die of the
disease annually.
6 7
This represents nearly 10% of
all cancers in women. Four out of ve new cases,
and a similar proportion of deaths, occur in
developing countries where screening programs
are not established. The hardest-hit regions are
among the worlds poorest including Central and
South America, the Caribbean and sub-Saharan
Africa. Because the disease progresses over
many years, an estimated 1.4 million women
worldwide are living with cervical cancer, and
two to ve times more women (up to 7 million
women worldwide) may have precancerous
conditions.
5
The lack of effective screening and
treatment strategies is a major reason for higher
cervical cancer rates in developing countries
compared with countries with screening
programs.
Cervical Cancer
Cervical Screening Participation in
Australia
The National Cervical Screening Program
was established as a joint initiative of the
Commonwealth, State and Territory governments
in 1991.
Participation in the National Cervical Screening
Program is measured by two-year participation
rates. In 2006-2007 participation in cervical
screening of Australian women aged 20-69
was 61.5%.1 For the rst time in 2005-2007
the Australian Institute of Health and Welfare
reported three and ve year participation rates.
Nationally the participation rates for women
aged 20-69 years were 74% over three years and
86.4% over 5 years.
1

In 2006-2007 two year participation rates by
geographical regions were 62.5% for major
cities, 61.2% for inner regional, 58.9% for
outer regional 53.6% for remote locations and
54% for very remote areas. Cervical Screening
participation by women from the highest level
of socio-economic status was 71.5% while
57.3% of women from the lowest level of
socio-economic status participated in cervical
screening.
1
Cervical Screening Participation Rates
in Queensland
The state-wide participation rate for the target
age group of women aged 20 to 69 years in
2006-2007 was 59.3% This is the second lowest
participation rate after the Northern Territory
and below the Australian rate of 61.5% (2006-
2007).
1
There are several factors that may have
contributed to this;
The geographical distribution of the
population throughout Queensland
A rapidly growing Queensland population
and subsequent increase in the population of
women eligible for screening
A shortage of general practitioners(GPs),
particularly female GPs in rural and remote
areas
Decreased numbers of GPs who bulk bill
The relatively high number of international
medical graduates in rural and remote areas,
many of whom are from countries where
there is no organised population screening
and therefore there are limited opportunities
for training.
The percentage of women in Queensland
who are Aboriginal and Torres Strait Islander
women whose uptake rates are low in some
areas.
The unscreened and underscreened groups in
Queensland reect those identied nationally.
The groups that are particularly underscreened
are:
Women over 50 years of age
Women living in rural and remote areas
Women from Culturally and Linguistically
Diverse backgrounds
Aboriginal and Torres Strait Islander women.
Cervical Cancer in the future
Despite successful screening programs and
recently introduced HPV immunisation programs,
cervical cancer will continue to exist though it
may be classied as a rare cancer. Special care
however will need to be taken to ensure that
most marginalised and dispossessed women in
our society are immunised, screened and treated.
Cervical Cancer
Additional Reading
Jelfs P. (1995) Cervical Cancer in Australia.
Australian Institute of Health and Welfare. Cancer
Series Number 3, Canberra. (Chapter 3).
Australian Institute of Health and Welfare (2005)
Cancer Incidence Projections Australia 2002 to 2011.
Australian Association of Cancer Registries. Cat. No
CAN 25 Canberra. (Executive Summary and relevant
tables that relate to Incidence and Mortality for
cervical cancer).
The Cancer Council Australia (2007) National Cancer
Prevention Policy 2007-2009. Camperdown NSW.
(Document can be downloaded: www.cancer.org.au)
Zhang X, Condon J, Denpsey K and Garling L. (2008)
Cancer Incidence and Mortality, Northern Territory
1991-2005. Department of Health and Families
Darwin.
Supporting Material
PowerPoint Presentation 1.1: Cervical Screening
Presentations: Part 2 Section of the Handbook.
References
1. Australian Institute of Health and Welfare
(AIHW) (2009) Cervical Screening in Australia
2006-2007, AIHW, Canberra.
2. Mitchell H, Hocking J and Saville M
(2003) Improvement in protection against
Adenocarcinoma of the Cervix Resulting from
Participation in Cervical Screening. Cancer 99:
336-341.
3. Queensland Cancer Registry (2009) Cancer in
Queensland, Incidence and Mortality 1982-2006,
Queensland. The Cancer Council Queensland,
Queensland Health, Brisbane.
4. Coory M, Fagan P Muller J and Dunn N (2002)
Participation in cervical cancer screening
by women in rural and remote Aboriginal
communities in Queensland. Medical Journal of
Australia, 177. 544-547
5. Ashford Land Collymore Y (2005) Preventing
cervical Cancer Worldwide. Population Reference
Bureau. Washington DC, USA.
6. Ferlay J (2002) Cancer Incidence, Mortality and
Prevalence Worldwide. GLOBOCAN 2002, Lyon,
France.
7. Huh WK, Kendrick JE, Alvares RD (2007) New
advances in vaccine technology and improved
cervical cancer prevention. Obstetrics and
Gynaecology.109: 1187-1192.
8. Australian Government, National Health and
Medical Research Council (2005) Screening
to prevent cervical cancer: Guidelines for the
management of asymptomatic women with
screen detected abnormalities. Canberra.
The aetiology of cervical cancer is important in understanding the disease and its prevention. Recent
advances in knowledge and understanding of Human papillomavirus (HPV) and its role in cervical
abnormalities and cervical cancer have led to a changed understanding of the aetiology of cervical
cancer.
Key concepts
the aetiology of cervical cancer
HPV and its role in the development of
cervical cancer
other risk factors implicated in the
development of cervical cancer
Learning outcomes
will be able to:
describe the aetiology of cervical cancer
discuss HPV and explain the role it plays
in the development of cervical cancer
list the risk factors for the development
of cervical cancer in eligible women.
SUMMARY INFORMATION
1.2 The Aetiology of Cervical Cancer
Cervical Cancer
Cervical Cancer
Human Papillomavirus
There is overwhelming evidence that Human
papillomavirus (HPV) is necessary for the
development of cervical cancer.
1,2,3,4,5
Research
using sensitive methods to detect HPV,
demonstrate that over 99.7% of cervical cancers
test positive for HPV DNA.
6
Furthermore,
the National Institute of Health Consensus
Conference on Cervical Cancer concluded that
cervical cancer is unique in that it is the rst
solid tumour to be shown to be virally induced
in essentially every case.
7

More than 200 types of HPV have been identied
of which almost 40 affect the genital tract. HPV
types are classied as high risk (oncogenic) or
low risk (non-oncogenic). Only high risk types of
HPV have been associated with cervical cancer.
There are over 15 high risk genital HPV types
however, infection with HPV 16 is responsible
for over 50% of cervical cancers and HPV 18 for
an additional 20% of cancers.
8,9
Infection with
high risk genital HPV is almost always sexually
transmitted.
10
Low risk HPV types include types 6 and 11, which
are linked to approximately 90% of genital warts
cases and around 10% of low grade cervical
abnormalities.
9

HPV infection is very common in the early years
of a womens sexual activity and is an extremely
common infection.
11
The peak prevalence of
HPV infection occurs in women in their early
20s. Women have a 50% chance of becoming
infected with HPV after one episode of
unprotected sexual intercourse.
11
A productive
infection of HPV in the cervix often manifests
itself as a low grade squamous intraepithelial
lesion (LSIL) but can also lead to high grade
squamous changes (HSIL).
Cervical cancer however is a rare outcome of
HPV infection. The modal age of rst infection
(LSIL) with high risk genital HPV is between
15 and 25 years.
12
More than 95% of women
who acquire a genital HPV infection clear
the infection within 3 years and the median
clearance time varies between 8 to 14 months.
It is persistent HPV infection that may lead to
the development of high-grade abnormalities
and infections persisting beyond three years are
unlikely to resolve spontaneously, however some
women can have HPV infection for a lifetime
without developing cervical cancer.
11

It has also been demonstrated that the
prevalence of HPV in the community is extremely
high, especially among young women; however
the modal age of diagnosis with cervical cancer
in unscreened women varies between 35 and
50. Less than 0.2% of cervical cancers occur in
women under 25 years of age.
11
The lifetime risk
of cervical cancer, given infection with high risk
HPV, varies across geographical regions from 1 in
15 to 1 in 100.
11
In Australia the lifetime risk of
a woman developing cervical cancer is about 1
in183.
12
Whilst persisting infection of the cervix with a
high-risk HPV is necessary for the development
of cervical cancer, it is not sufcient alone.
10

Other factors have been found to be positively
1.2 The Aetiology of Cervical Cancer
associated with a womens risk of persistent HPV
infection and these include smoking (amount,
duration and age at which smoking commenced)
and immunosuppression. Progression to cervical
cancer has been positively associated with age
at diagnosis (over 30 years of age) and the size
and extent of the cervical lesion.
12,13,14
There is
evidence that cervical cancer may progress more
rapidly in women infected with HPV if they are
also oral contraceptive users. Oral contraceptives
have not been found to increase the incidence
of preinvasive cervical cancer, however there has
been a signicant association found between the
use of oral contraceptives and cervical cancer
which increases with duration of use suggesting
a promoting effect rather than carcinogenic
action
15,16,18
.
In recent years cervical infection with high risk
HPV DNA has been linked to the development
of most cervical adenocarcinomas and has been
identied in the majority of lesions labelled as
adenocarcinoma in situ.
Cervical cancer
There are two main types of cervical cancer.
These are squamous cell carcinoma and
adenocarcinoma. The most common form of
cervical cancer is squamous cell carcinoma
which starts in the squamous cells of the cervix.
Adenocarcinoma is much less common and
occurs in glandular cells. The Pap smear has
lead to a decrease in the number of women
with squamous cell cervical cancer, but it is not
designed or able to detect glandular changes
so the rate of glandular or adenocarcinoma
in Australia has not decreased since the
introduction of an organised approach to
cervical screening.
Squamous cell cervical cancers almost always
arise in the transformation zone and it is
therefore very important cells are taken from the
transformation zone during a Pap smear, as this
is the region most likely to undergo changes.
15,16
Because the Pap smear is able to detect
premalignant squamous cell changes and there
is a prolonged time period (approximately 10
years) before the majority of changes progress to
invasive cancer, regular two-yearly Pap smears
are an effective test for the screening and early
detection of cervical abnormalities.
Cervical Cancer
References
1. Hulka B (1982) Risk factors for cervical cancer.
Journal of Chronic Diseases 35: 5-11.
2. Villa L (1997) Human Papilloma viruses and
cervical cancer. Advances in Cancer Research
71:321-42.
3. Turek L, Smith E (1996) The genetic program of
genital human Papilloma viruses in infection
and cancer. Obstetrics and Gynaecology Clinics
of North America 23(4) 735-58.
4. Park T, Fijiwara Hand Wright T (1995). Molecular
biology of cervical cancer and its precursors.
Cancer 76: 1902-13.
5. Walboomers J , Meijer C (1997) Do HPV-Negative
cervical carcinomas exist. Journal of Pathology
181: 253-54.
6. National Institutes of Health Consensus
Development Conference Statement on Cervical
Cancer (1997) Gynaecologic Oncology 66:351-61.
7. Bosch F (2000) Clinical cancer and HPV: a
worldwide perspective. In: 4th International
Multidisciplinary Congress, Eurogin 2000, Paris
France.
8. Ho GY, Bierman R, Beardsley L, Chang CJ, and
Burk RD (1998) Natural history of cervicovaginal
Papillomavirus infection in young women. New
England Journal of Medicine 338(7): 423-28.
9. Wain G ( 2008) HPV Vaccines and the Australian
Human Papilloma virus(HPV) Vaccination
Program. Cancer Forum.32:2;96-98.
10. Fairley CK, Tabrizi SN, McNeil JJ, Chen S, Borg AJ
and Garland SM (1993) Is HPV always sexually
acquired? Medical Journal of Australia 159(11-
12): 724-26.
11. Frazer I. Presentation at Wartfest on 07/02/2006,
at Princess Alexandra Hospital , Brisbane.
12. Schiffman M and Kjaer SK (2003) Chapter
2: Natural History of anogenital human
Papillomavirus infection and neoplasia. Journal
of the National Cancer Institute Monographs
(31):14-19.
13. Thomas D Ray r and World Health Organisation
Collaborative Study of Neoplasia and Steroid
Contraceptives (1996) American Journal of
Epidemiology144(3); 281-89.
Medical Research Council (2005) Screening to
Prevent Cervical Cancer: Guidelines for the
Management of Asymptomatic Women with
Screen Detected Abnormalities. Australian
Government, National Health and Medical
Research Council. Canberra.
15. Hammond I (2006) The Queensland Cervical
Screening Program Update. QSCP Queensland
Health, Brisbane.
16. International Collaboration of Epidemiological
Studies of Cervical Cancer (2007) Comparison
of risk factors for invasive squamous cell
carcinoma and adenocarcinoma of the cervix:
collaborative reanalysis of the individual data
on 8,097 women with squamous cell carcinoma
and 1,374 women with adenocarcinoma from
12 epidemiological studies. International Cancer
Journal February 15; 120(4):885-91.
17. Lalonde ABand Reid R (2008) Position Statement.
Birth Control Pill and Cancer. Council of the
Society of Obstetricians and Gynaecologists
of Canada.Current Opinion in Obstetrics and
Gunaecology16:1; 27-29.
18. Hannaford PC, Sivasubramaniam S, Elliott AM,
Angus V Ivarsen and L,Lee A J (2007) Cancer risk
among users of oral contraceptives: cohort data
from the Royal College of General Practitioners
contraception study. British Medical Journal
Online
Additional Readings
Commonwealth Department of Health and Family
Services (1998) Screening for the Prevention of
Cervical Cancer Australian Government, Canberra.
National Health and Medical Research Council (2005)
Screening to Prevent Cervical Cancer: Guidelines
for the Management of Asymptomatic Women
with Screen Detected Abnormalities Australian
Government, Canberra. (Chapter 2)
(This document can be sited or downloaded from
NHMRC website: http://www.nhmrc.gov.au/
publications/synopses/wh39syn.htm
Supporting Material
PowerPoint Presentation 1.2: The Aetiology of
Cervical Cancer. Part 2 Section of the Handbook CD.
Population
Screening
for Cervical Cancer
SECTION 2
Key concepts
population screening in the context of
cervical screening
the cervical screening pathway
the National Cervical Screening Policy
Pap smear guidelines for women in
special circumstances.
Learning outcomes
will be able to:
explain the core components of a
screening program
outline the principles of cervical
screening in the context of population
health
discuss the role of medical practitioners
in the cervical screening pathway
identify the cervical screening target
group and the frequency of screening
according to the National Cervical
Screening Policy
explain the recommendations for
screening women under special
circumstances.
Signicant reductions in morbidity and mortality from invasive cervical cancer have occurred in
countries and communities which have developed an organised approach to cervical screening and
have ensured a high proportion of eligible women have been screened regularly.
The implementation of an organised, population based cervical screening program in Australia has
been a successful public health program that has resulted in signicant reductions in cervical cancer
incidence and mortality.
SUMMARY INFORMATION
Population Screening
for Cervical Cancer
SECTION 2
Population Screening for Cervical
Cancer
Cervical cancer is the second most common
cancer among women worldwide, with almost
half a million new cases each year.
1
Prevention
of cervical cancer centers on screening for
abnormalities using the Pap smear, named
after Dr George Papanicolaou. Dr Papanicolaou
began the study of vaginal cytology in humans
in 1920. Upon examination of a slide made
from a patients vaginal uid he discovered that
abnormal cancer cells could be observed under
a microscope. The Pap smear was not accepted
by the scientic community until the early 1950s
when large scale screening began in America.
This resulted in a historic drop in the incidence
of cervical cancer among American women.
Systematic cervical screening during the 1960s
sharply reduced cervical cancer in Iceland and
Finland which contrasted to a slow but steady
increase of cervical cancer in Norway.
2
In 1990,
Miller concluded that screening using the Pap
smear plus adequate follow up therapy led to
major reductions in cervical cancer incidence
and mortality rates.
3

In 1998, the World Health Organization (WHO)
published guidelines outlining the essential
elements of population screening programs.
4

WHO advised that a number of factors should
be taken into account when the adoption of any
screening technique is being considered:
sensitivity: the effectiveness of a test in
detecting a cancer in those who have the
disease
specicity: the extent to which a test gives
negative results in those that are free of the
disease
positive predictive value: the extent to
which subjects have the disease in those that
give a positive test result
negative predictive value: the extent to
which subjects are free of the disease in
those that give a negative test result
acceptability: the extent to which those
for whom the test is designed agree to be
tested.
4
In addition WHO outlined that the success of
screening programes depends on a number of
fundamental principles:
the target disease should be a common form
of cancer, with high associated morbidity or
mortality
effective treatment, capable of reducing
morbidity and mortality, should be available
test procedures should be acceptable, safe,
and relatively inexpensive.
4

WHO has identied specic criteria that need
to be considered before a screening program is
instituted as a part of a national cancer control
program:
the condition to be detected is of public
health importance
the natural history of the condition is
understood and there is an unsuspected but
detectable (pre-clinical) stage
for Cervical Cancer
there is an ethical, acceptable, safe and
effective procedure for detecting the
condition at a sufciently early stage to
permit intervention
there are ethical, acceptable, safe and
effective preventive measures or treatments
for the condition when it is detected at an
early stage
there is sufcient political will, and it is
feasible to carry out the relevant screening,
diagnostic and intervention practices in
a population-based manner with existing
resources or with resources that could be
obtained during the planning period
adoption and implementation of the
screening, diagnostic and intervention
practices will strengthen the development
of the health system and overall societal
development in a manner consistent with the
principles of primary health care
the cost of screening and intervention is
warranted and reasonable compared with
alternative uses of resources.
4
In October 2008, Australian Health Ministers
Advisory Council Screening Subcommittee
released Population Based Screening Framework
document.
13
The purpose of the document is
to inform decision makers on the key issues
to be considered when assessing potential
screening programs in Australia. The framework
is underpinned by the principles of access and
equity, fundamental elements to all population
screening programs, and is intended to provide
guidance and inform judgement.
National Cervical Screening Program in
Australia
The major goals of the National Cervical
Screening Program which was introduced in
1991 are to reduce incidence and mortality of
cervical cancer in women. Cervical screening
using the Pap smear detects abnormalities of the
cervix at an early stage and medical intervention
can avert the possible progression to cervical
cancer.
For the National Cervical Screening Program to
be successful it is essential that it reaches all
women who are eligible. Regular participation
in cervical screening is the key to the prevention
of cervical cancer and as such is the primary
indicator used in monitoring the success of the
program.
In Australia the Pap smear became available in
the 1960s. For more than 20 years screening
was provided in an opportunistic manner,
without a coherent national approach. Women
were frequently provided with inconsistent
and conicting messages. This resulted in
unnecessary frequent screening of women at
low risk, and failure to reach women at high risk.
Moreover it was expensive and its effectiveness
could not be measured.
5
As a result of the success of an organised
approach to cervical screening in Nordic
countries, the Australian Health Ministers
Advisory Council (AHMAC) commissioned a
review of cervical screening in 1988. Subsequent
evaluation and pilot projects funded by the
for Cervical Cancer
Commonwealth found that Australia was
preventing only 50% of all cases of cervical
cancer when up to 90% of the most common
form a cervical cancer, squamous cell carcinoma
was believed possible with a systematic
approach.
2
The Commonwealth then established
a new program called Organised Approach to
the Prevention of Cancer of the Cervix in 1991.
5

In 1995 this was renamed the National Cervical
Screening Program which aims to reduce
avoidable deaths from cervical cancer by:
encouraging women at risk to have a Pap
smear every two years
improving accessibility and reliability of
services for the provision and testing of Pap
smears
optimising the management of women with
screen detected abnormalities
improving monitoring and evaluation.
Cervical screening in Australia does not operate
through a separate dedicated screening and
assessment service. Screening services are
provided as part of the mainstream health
services, with the great majority of Pap smears
provided in the general practice setting.
The National Cervical Screening Program has
national and state and territory components.
Although policy is usually decided at the
national level, coordination of screening activity
happens at the state and territory level.
also overseen the establishment of Pap Smear
Registers in each state and territory. These are
condential databases of Pap smear results
for the purposes of issuing reminder letters to
women when their Pap smear is overdue and
providing a safety net for the follow-up of
women with abnormal Pap smears. The registers
also provide information to laboratories, in
the form of screening histories, to assist in the
reporting of current tests, and quantitative data
to manage quality assurance activities.
The implementation of an organised, population
based cervical screening program in Australia
is one of the most successful public health
programs of its time.
6
It has been estimated that
cervical screening saves over 1,200 women from
developing cervical cancer each year.
7
The Cervical Screening Pathway
The organised approach to cervical screening
encompasses more than the provision of Pap
smears and is reected in the cervical screening
pathway. It is essential that all aspects of the
screening pathway are of high quality and
function correctly for the population benet of
cervical screening to be realised. The interface
between screening services and treatment
services is critically important and requires a
partnership approach between government,
non-government and private sector services, to
ensure that the desired cancer control outcomes
are achieved.
8
Recruitment of Women
Community development processes and effective health promotion
strategies to recruit unscreened and underscreened women into the
cervical screening program.
Monitor participation in cervical screening.
Screening Intervals
Know which women require Pap smears, as set out in the National
Policy.
Give women information about cervical cancer prevention.
Recognise barriers to regular screening.
Have a reminder system to ensure women are screened regularly.
Inform women about the role and function of the Queensland Health
Pap Smear Register
Pap Smear Provision
Ensure quality of Pap smears provided.
Reporting of Pap Smears
Ensure feedback and monitoring of Pap smear quality assurance.
Follow-up of Results
Have an efcient system for notifying results to women, identifying
abnormal results and recalling women.
Negative Smear
Routine screening every two
years.
Reminder systems.
Abnormal Smear
Provide information to women.
Manage and refer as per
guidelines protocols.
The steps of the cervical screening pathway are:
for Cervical Cancer
Cervical Screening in Special
Circumstances
Pap smears guidelines for women with special
circumstances are included in the NHMRC
guidelines: Screening to Prevent Cervical
Cancer: Guidelines for the Management of
Asymptomatic Women with Screen Detected
Abnormalities.
9
In these circumstances
the interval between Pap smears and
recommendations relating to Pap smears
differ as these women are not participating in
population screening given their risk prole.
The National Cervical Screening Policy is a
key part of the Cervical Screening Pathway
and recommends the following:.
Routine screening with Pap smears
should be carried out every two years
All women aged 20 to 69 years who have
ever been sexually active have a Pap
smear every two years.
Pap smears may cease at the age of 70
years for women who have had two
negative Pap smears within the last ve
years. Women over 70 years who have
never had a Pap smear, or who request a
Pap smear, should be screened.
This policy applies only to women without
symptoms that could be due to cervical
pathology. Women with a past history of
high grade cervical lesions, or who are
being followed up for previous abnormal
smears should be managed in accordance
with the NHMRC guidelines: Screening to
Screen Detected Abnormalities.
9

Symptomatic women: it is important to
remember that a woman with any abnormal
symptoms (irregular bleeding or discharge)
does not come under the National Cervical
Screening Policy as this only applies to
asymptomatic women. In such situations a
Pap smear may be collected as part of the
investigative workup that could include
referral for further investigation.
The National Cervical Screening Policy is
under consideration in the light of new
evidence pertaining to the natural history
of human papilloma virus and its role
in the development of cervical cancer.
Furthermore introduction of the HPV
vaccine and new technologies for detecting
cervical abnormalities may lead to changes
to National Cervical Screening Policy in the
near future
The National Cervical Screening Policy
Cervical Screening in Pregnancy
Queensland Health has a Policy and Protocol
for Cervical Screening in Pregnancy. It states a
Pap smear should be offered to every woman
booking for antenatal care who has not had
cervical screening within the past two years,
and to any woman with a history of abnormal
symptoms or treatment of cervical abnormalities
who has not been followed up in accordance
with national guidelines.
It is recommended that Pap smears be offered to
women where appropriate to at least 28 weeks
of pregnancy and in selected other women into
their third trimester, if it appears likely that they
may have difculty presenting for screening in
the post natal period.
Pap smears have not been associated with an
increased rate of miscarriage or pre-term labour.
If a woman is concerned and is reluctant to
agree to have a Pap smear, the provider should
emphasise to the woman the importance of
having a Pap smear performed at an early
date in the post-natal period (no earlier than
12 weeks). It is also recommended that every
woman with unexplained bleeding in early
pregnancy should have her cervix visualised via a
speculum to ensure that unexpected malignancy
is not the cause.
The Queensland Health has developed a Policy
and Protocol for Cervical Screening in pregnancy
which can be found on the website
The Policy outlines the Pap smear procedure to
follow for a pregnant woman.
6
Cervical Screening after Hysterectomy
A hysterectomy is the surgical removal of the
uterus. Hysterectomies may be performed
because of abnormal bleeding, prolapse, benign
tumours such as broids, damage to the uterus
during childbirth or surgical procedures, or
because of cancer. As well as removing the
uterus, the surgeon will usually remove the
cervix, and in some cases the ovaries and
fallopian tubes.
10
Whether a woman needs to have a Pap smear
following hysterectomy depends on:
whether she still has a cervix
why the hysterectomy has been performed
whether the Pap smear was negative before
the surgery.
When the cervix was removed during the
operation, a woman MAY need to have Pap
smears from the vault (top) of the vagina if:
the hysterectomy was performed because
of cancer of the uterus, cervix, ovaries or
fallopian tubes, or abnormal cells were found
at the time of surgery
it is not known why the hysterectomy was
performed
the woman had abnormal Pap smears in the
past
the woman did not know if she had
previously had abnormal Pap smears
for Cervical Cancer
the woman is taking medication which
suppresses the immune system, eg cortisone
prescribed for asthma or arthritis
the woman was exposed to the drug Diethyl-
stilboestrol before she was born.
If a woman has a subtotal hysterectomy, where
the cervix is not removed and is present then the
normal screening regime applies.
Guidelines for Immunosuppressed Women
Immunosuppressed women are at increased
risk of developing a persistent productive HPV
infection that may develop into cervical cancer.
9

Women may be immunosuppressed because
of HIV infection or the effect of drugs, such as
those used to prevent rejection of transplanted
organs/tissues or the treatment of autoimmune
diseases such as systemic lupus erythematosus,
ulcerative colitis or asthma. Immunosuppressed
women have a 20% increased risk of
intraepithelial neoplasia (compared with
less than 5% for general population).
9
The
management of these women is complex and
should be carried out in specialist centres.
Guidelines for women exposed in utero to
diethylstilboestrol (DES)
DES was given to pregnant women between
1940 and 1970 to provide luteal support to
those with previous poor pregnancy outcome.
9

Although DES exposure in utero rarely leads
to vaginal adenocarcinoma, vaginal adenosis
occurs in 45% of these women and structural
abnormalities are present in 25%.
11
DES-exposed
women should be offered annual cytological
screening and colposcopic examination of
both the cervix and vagina with a clinician
experienced in colposcopy of the lower genital
tract. Screening should begin at any time at the
womans request and continued indenitely.
Symptomatic women
It is important to remember that a woman with
any abnormal symptoms (irregular bleeding or
discharge) does not come under the National
Cervical Screening Policy as this only applies to
asymptomatic women. In such situations a Pap
smear may be taken as part of the investigative
workup that would include referral for further
investigation.
References
1. Ferlay J (2000) GLOBOCAN 2000: Cancer
incidence mortality and prevalence worldwide.
Lyon. IARC Cancer Base No5.
2. Hakama M (1982) Trends in the incidence of
cervical cancer. In Magnus K, ed. Trends in
cancer incidence. Washington DC, Hemisphere.
3. Miller (1990) Report of the workshop of the UICC
project on evaluation of screening for cancer.
International Journal of Cancer 46: 761-69.
4. World Health Organization (2002) National
Cancer Control Programmes, Policies and
Managerial Guidelines. World Health
Organization, Geneva.
5. Australian Health Ministers Advisory Council
(AHMAC) (1991) Cervical Cancer Screening
Evaluation Committee Cervical Cancer Screening
in Australia: Options for Change.
Additional Readings
Hakama M, Miller AB, Day NE (eds) (1986) Screening
for Cancer of Uterine Cervix. International Agency
for Research on Cancer, France.
Wilson J, Junger G, (1968) Principles and Practice of
Screening for Diseases. World Health Organisation,
Geneva. (Chapter 2).
World Health Organisation (2002) Cervical Cancer
Screening in Developing Countries. A Report of WHO
Consultation. World Health Organisation, Geneva.
(Chapter 2).
Commonwealth Department of Health and Family
Services (1998) Screening for the Prevention of
Cervical Cancer Australian Government, Canberra.
Supporting Materials
PowerPoint Presentation 2.1: Principals of Population
Screening and the National Cervical Screening
program .Presentation, Handbook CD
Resources that contain Queensland Healths Policy
and Protocols for Cervical Screening in Special
Circumstances are found on the website
For more detailed information relating to National
Cervical Screening Program see Australian
Government Department of Health and Ageing
website: www.cervicalcreening.gov.au
Population Based Screening Framework document:
www.cancerscreening.gov.au
The Queensland Health Policy and Protocol for
Cervical Screening in Pregnancy. This resource can
be found on the Queensland Cervical Screening
Program website:
6. Australian Institute of Health: Prevention
Program Evaluation Series No.2. QGPS, Canberra.
7. Mitchell HS (2003) How much cervical cancer is
being prevented? Medical Journal of Australia,
178-298.
8. Commonwealth Department of Health and
Family Services (1998) Screening for the
Prevention of Cervical Cancer Australian
Government, Canberra.
9. National Health and Medical Research
Council (2005) Screening to Prevent Cervical
Cancer: Guidelines for the Management of
Abnormalities. Australian Government, Canberra.
10. Queensland Cervical Screening Program (2006)
Queensland Health Policy and Protocol for
Cervical Screening in Pregnancy. Queensland
Health , Brisbane.
11. Queensland cervical Screening Program (2000)
Are Pap Smears Necessary after Hysterectomy?
12. Hacker NF (2000) Vaginal Carcinoma In:
Practical Gynaecologic Oncology, 3rd Edition
Berke JS and Hacker NF (eds.) Lippincott Williams
and Wilkins, Philadelphia.
13. Australian Health Ministers Advisory Council
Screening Subcommittee (2008) Population
Based Screening Framework. Commonwealth of
Australia.
Health
Promotion
in the Context of
Cervical Cancer
SECTION 3
Health Promotion in
the Context of Cervical Screening
Key concepts
factors inuencing womens participation
in cervical screening
key principles of the Ottawa Charter
of Health Promotion in the context of
cervical screening
evidence-based cervical screening health
promotion activities for general practice
advocacy and networking skills in the
promotion of cervical screening in
general practice
cervical screening practice incentive
payments
the availability of relevant health
promotion resources.
Learning outcomes
will be able to:
discuss the barriers affecting womens
participation in cervical screening
describe the key principles of the Ottawa
Charter for Health Promotion and
identify cervical screening prevention
and education activities
identify strategies for promoting
participation in cervical screening
including opportunistic and systematic
cervical screening in medical settings
identify and network with other medical
practitioners and health care providers
in the community who are involved in
the provision of information or services
relevant to cervical screening.
Regular participation in cervical screening is the key to prevention of cervical cancer. In the context
of general practice, cervical screening is an important component of the womens health care. Medical
practitioners have a signicant health promotion role to play in inuencing a womans decision to
participate in cervical screening. This not only requires the clinical knowledge necessary to perform
the Pap smear, but also knowledge of cultural, religious, spiritual, economic, geographical and socio-
political inuences that can play a part in womens participation in regular screening.
SUMMARY INFORMATION
SECTION 3
Health Promotion in
Health Promotion provides a framework for
action in public health practice which recognises
that inequalities in health are embedded in
the way society lives and works, economically,
politically and culturally. It is perhaps best
described as a philosophy that supports the
development of policy for the planning and
delivery of health care services and recognises
the importance of looking at health from a
holistic perspective. Over the years the concept
of public health has changed and expanded
as the views of physicians and health planners
have widened from an early focus on hygiene to
encompass the prevention of disease.
1
Perhaps
the most signicant recent evolution in the
public health movement was the development
of and commitment to the Ottawa Charter for
Health Promotion which was developed at an
international conference on Health Promotion
held in Ottawa, Canada in 1986. The Ottawa
Charter denes health promotion as the process
of enabling individuals and communities to
increase control over the determinants of health
and thereby improve their health.
2

To reach a state of complete physical, mental
and social well-being, an individual or group
must be able to identify and recognise goals that
satisfy their needs including coping with the
environment. Health is seen as a part of everyday
life and not the objective of living. The Ottawa
Charter emphasizes the importance of using an
all inclusive approach to the planning of public
health policies and health promotion practice.
The Key Principles of the Ottawa Charter are:
build public policies that support health
create supportive environments
strengthen community action
develop personal skills
reorient health services.
To facilitate effective and efcient health
promotion in the ve areas mentioned above,
the Charter urges the development and
application of advocacy, mediation and enabling
skills to ensure that all people are empowered
to gain greater control over their lives and
subsequently their health.
The role of general practitioners in health
promotion has been recognised in The Future
of general practice.
3
Five specic strategies are
proposed to encourage General Practitioners
to be more active in health promotion. These
strategies are:
Supporting opportunistic health promotion
which is about identifying risk factors in
a patient if they exist, and encouraging
preventive action if one is available. As Ellis
and Leeder
4
point out the opportunity to
introduce appropriate preventive action to
80 million health consultations a year is too
good to waste. In the context of cervical
screening, the GP can identify women
who are unscreened or underscreened and
encourage them to participate in cervical
screening.
Improving education and information
dissemination to general practitioners
about health promotion. This relates to
the provision of appropriate and relevant
information when it becomes available
through a variety of sources such as
newsletters, conferences, update meetings,
publications etc. For example disseminating
information to women about cervical
screening and the Pap Smear Register.
Increasing and improving the use of
record systems in general practice for the
purpose of health promotion. Recall and
reminder systems can be used to encourage
womens participation in cervical screening
and increase participation rate in screening
of eligible women.
Making health targets more relevant to
general practice. This includes involving
general practitioners in local planning and
participation in specic health promotion
activities.
Providing support for general practitioners
who want to be involved in population
health promotion. This may involve provision
of specially designed literature for patients,
participation in health promotion campaigns
and other relevant activities. For example GP
can display and distribute literature about
all aspects of cervical screening during an
organised cervical screening campaign, or
just keep the information in the surgery and
distribute it when needed.
Strategies for Promoting Participation
in Cervical Screening
Straton notes four categories of strategies for
promoting participation in screening:
(i) individual invitations (call and recall)
(ii) improvement of opportunistic screening
(iii) provision of special/acceptable and
accessible screening services
(iv) community and media based health
education programs.
5
Individual invitation call and recall
Approximately 30% of women say that
forgetting is one of the main reasons they do
not keep up to date with regular smears.
6
Most
of these women also believe that Pap smear is
worth while yet may require prompting to do so.
General Practice has been recognised as a major
focal point of screening service in Australia as
approximately 80% of Pap smears are provided
by GPs.
4
Reminder, call and recall systems set
up by individual GPs have been successful in
increasing screening rates.
7

There are many systems in place throughout
Australia. Some GPs employ direct mail
system that targets all eligible women in a
specic target population, while others send
out individualised invitations using data from
electoral rolls, population registers, district
registers, registers of cytology or general practice
age-sex registers.
Health Promotion in
Research has shown that GPs who employ a
systematic approach within their practices
generally were younger, had larger practices,
were predominantly rural, employed a Practice
Nurse and had a positive attitude towards the
efcacy of screening. It has also been found that
offering an appointment time when initially
inviting women for screening made them more
likely to have a smear.
8
The majority of general practices have reminder
systems in place to encourage women to have
regular Pap smears before their smear is due.
These practices do not rely on the Pap Smear
Register to remind women when they are
overdue but use this as a back-up. Setting up
a reminder service is not difcult. The RACGP
patient record system has the provision for
recording recall dates on the cover of womens
le. There are also software programs which can
assist in this.
8
Improving opportunistic screening
Opportunistic prevention (screening) is dened
as the identication of risk factors and the
provision of an appropriate intervention during
any medically related consultation, regardless of
presenting symptoms.
9
There are limitations to
opportunistic screening. The greatest limitation
with relying on opportunistic screening is that
only women who visit the health service have
their screening history assessed. Usually those
least likely to attend the practice are those that
are least likely to be screened.
10

Recommended steps to encourage cervical
screening have been developed from published
accounts of the success of the opportunistic
approach in general practice.
11
The steps are:
identify women at risk opportunistically
check what the woman understands
offer a Pap smear during the consultation or
make another appointment
offer written information or recommend a
website.
Providing special/acceptable and accessible
services to women
One of the most important components of
successful cervical screening is providing women
with acceptable and accessible services.
5
This
includes the provision of accessible services in
a variety of settings to promote access eg GP
practice, hospital and special womens health
clinics in rural and remote settings.
Registered Nurse Pap Smear Providers
For some time registered nurses have made
a signicant contribution to the Queensland
Cervical Screening Program.
12
They have been
recognised as an important complementary
service provider especially for their role in
accessing women who have never had a
Pap smear or who do not have regular Pap
smears. Registered nurses have consistently
demonstrated that they provide accessible,
high quality services that women are highly
satised with.
13
Queensland Registered Nurse
Pap Smear Providers (RN PSP) undertake
specic training in cervical screening that is
accredited with the Royal College of Nursing
Australia Inc and are deemed competent in
meeting the National Standards for Nurse Pap
Smear Providers.
14
RN PSPs presently practice
in a variety of settings and include, Mobile
Womens Health Nurses, Sexual Health Nurses,
Remote Area Nurses, Practice Nurses and nurses
working in organisations such as Family Planning
Queensland, community-controlled Aboriginal
and Torres Strait Islander medical services and
the Department of Defence Medical centres.
Practice Nurse Pap Smear Providers
In January 2005, Medicare Item Numbers
10998/9 were issued for cervical screening
consultations provided by Practice Nurses (PNs)
in regional and remote areas, provided the PN
has completed an accredited program. This
action has provided the opportunity for RNs
working in General Practice to provide cervical
screening services for women attending General
Practice.
The benets of a Practice Nurse providing Pap
smears in general practice include:
increased access to female Pap smear
providers
increased capacity of General Practice to
offer cervical screening
increased capacity to establish and monitor
recall and reminder systems
increased capacity for general practitioners
to offer consultations for clients with
complex health needs.
Community Based Media and Health Education
Programs
Community and media based programs have
been an integral part of raising the prole of
cervical cancer on the public health agenda.
Television and radio have been the most popular
and thoroughly evaluated media and have the
potential to reach large numbers of women as
well as target specic groups.
15
Greater longevity
of the message is achieved through the use
of written material, such as newspapers and
magazine articles.
Community development strategies such as Pap
smear clinics, educational talks, morning teas,
distribution of brochures, posters, reminder
cards and other relevant information are some
of the strategies that can be used to increase
participation.
16
Cervical Screening Practice Incentives
In 2001-2002 the Australian Government
Federal provided money over four years to
increase cervical screening participation rates
and improve the early detection of cervical
abnormalities, thereby aiming to reduce deaths
from cervical cancer. The implementation of
this initiative supports and builds on the existing
National Cervical Screening Program (NCSP) by
recognising the role of general practitioners as
the primary providers of cervical screening as
well as targeting higher risk groups of women.
Funding has continued beyond 2005 following
an evaluation of the Cervical Screening Practice
Incentive payments (PIP).
Health Promotion in
The Cervical Screening Incentive has three
components:
1. Sign On Component
(Practice Incentive Payment -PIP)
To be eligible for the sign on payment, PIP
practices are required to register for the Cervical
Screening Incentive. The sign on payment
recognises that practices may incur up-front
costs in terms of both time and resources in
preparing for the cervical screening incentive. In
signing on practices agree:
to participate in the cervical screening
incentive scheme
to have practice details provided to the
State/Territory Cervical Screening Registers
to receive information from the Registers and
consider strategies they propose to improve
the level and quality of participation in the
NCSP, and
that the State/Territory Cervical Screening
Registers can provide information about the
aggregate number of women screened in
the practice to HIC for the calculation of the
outcome incentive payment.
2. Service Incentive Payment (SIP-Cervical)
GPs working in PIP practices receive a service
incentive payment (SIP-Cervical) for screening
women between 20 and 69 years who have not
had a Pap smear within the last four years as
these women are classied as high risk.
3. Outcomes Component
A further payment through the PIP is made to
practices that reach target levels of cervical
screening for their female clients aged 20 to 69.
In May 2006, 91.7% of practices in Australia
were signed on to participate in these activities
(Medicare Australia 2006).
Further information about practice incentive
payments can be obtained from the PIP enquiry
line on 1800 222 032 or via
http://www.medicareaustralia.gov.au.
The Medical Benets Scheme (MBS
Items)
MBS items (10994 and 10995) apply to Pap
smear and preventive checks provided by a
practice nurse on behalf of general practitioner.
Item number 10994 can be used by all practices
and applies to female patients of any age, while
item number 10995 is available only to GPs
participating in the Practice Incentive Program
(PIP) and generates a Service Incentive Payment
(SIP). Item 10995 applies when a Pap smear is
provided from a woman between the ages 20-69
who has not had a Pap smear in the last four
years.
MBS item numbers (10998, 10999) apply to Pap
smears provided by Practice Nurses in regional,
rural and remote areas. Both items are for
Pap smears provided by the Practice Nurse on
behalf of a GP. Item 10998 applies to a Practice
Nurse who provides a Pap smear for a woman
on behalf of the GP, while item number 10999
References
1. Ferlay J (2000) GLOBOCAN 2000: Cancer
incidence mortality and prevalence worldwide.
Lyon. IARC CancerBase No5
2. Hakama M (1982) Trends in the incidence of
cervical cancer.In Magnus K, ed. Trends in cancer
incidence. Washington DC, Hemisphere.
3. Miller (1990) Report of the workshop of the UICC
project on evaluation of screening for cancer.
International Journal of Cancer 46: 761-69.
4. National Cancer Control Programmes, Policies
and managerial guidelines (2002). World Health
Organization, Geneva.
5. Straton, JAY (1994) Recruitment for Cervical
Screening: a review of literature. Australian
Government Publishing Service, Canberra
6. Australian Health MinistersAdvisory Council
(AHMAC) (1991) Cervical Cancer Screening
Evaluation Committee Cervical Cancer Screening
in Australia: Options for Change. Australian
Institute of Health: Prevention Program
Evaluation Series No.2. QGPS, Canberra
7. Jelfs P (1995) Cervical Cancer in Australia.
Australian Institute of Health and Welfare:
Cancer Series No3. AIHW, Canberra.
8. Pritchard DA,Straton JAY, LeSeur H, Hyndman
J(1994) Cervical Screening in general practice.
Department of General Practice University of
WA.
9. Stott N ,and Davis R (1979) The exceptional
potential in each primary care consultation.
Journal Royal College of General Practice.
29:201-05
applies when a Pap smear is provided by a
Practice Nurse for a woman who has not had a
Pap smear in the last four years and is between
20 and 69 years old.
In order to be eligible for claims there are
conditions attached. These conditions relate to
qualications and training, quality assurance
and medical indemnity. In addition Pap smears
provided by a Practice Nurse on behalf of a
GP count towards the PIP practices outcome
component.
Further information is available by calling
13 21 50 or the Medicare Australia website:
http://www.medicareaustralia.gov.au/
medicareinitiatives
Availability of Health Promotion
Resources
The National and Queensland Cervical Screening
Programs produce and publish cervical screening
resources for women and health professionals.
These resources can be viewed on the
Queensland Cervical Screening Program website
www.health.qld.gov.au/cervicalscreening. They
can be downloaded or ordered directly from the
website free of charge.
Cancer Council Queensland also has literature
for women and those affected by cervical cancer.
This information can be obtained by telephoning
the HelpLine on 13 11 20
Health Promotion in
10. Shelley J. (1992) Encouraging women to
participate in Pap smear screening. Campaign
Unit, Commonwealth Department of Health
Housing and Community Services. Canberra.
11. Brett T (1992) Opportunistic cervical screening
among 50-70 year olds: a prospective study in
general practice. Australian Family Physician
21: 1781-84.
12. Cancer Screening Services Unit, Population
Health Branch (2008) Queensland Cervical
Screening Program Phase 4 State Plan 2007-
2011. Queensland Health, Brisbane
13. Kirk M, Hoban E, Dunne A and Manderson L
(1998) Barriers to and Appropriate Delivery
Systems for Cervical Cancer Screening in
Indigenous Communities in Queensland.
Australian Centre for International and Tropical
Health and Nutrition., University of Queensland,
Brisbane.
Community Services (1997) Standards of
Practice in Making Quality Visible National
Standards for Nurse Pap Smear Providers.
15. Mitchell H (1993) Pap smears collected by nurse
practitioners: comparison to smears collected by
medical practitioners. Oncology Nursing Forum
20(5): 807-810.
16. Byles J, Sanson-Fisher R (1996) Mass mailing
campaign to promote screening for cervical
cancer: do they work, and do they continue to
work? Australian and New Zealand Journal of
Public Health 20(3): 254-60.
17. Byrnes P,McGoldrick C,Crard and M,Peers M
(2007) Cervical Screening in General Practice.
Strategies for improving participation. Australian
Family Physician 36: 3;183-192.
Additional Readings
The Cancer Council Australia 2007. National Cancer
Prevention Policy 2007-09. NSW: The Cancer Council
Australia.
Straton JAY (1996) Recruitment for cervical
screening. A review of the literature. National
Cervical Screening Program. Australian Government
Publishing Service (Refer to pages 4-29).
Womens Cancer Screening Services (2002)
Queensland Cervical Screening Program Phase
3, State Plan 2002-2006 Queensland Health,
Queensland.
OConnor, M.L, and Parker, E. (1995) Health
promotion, principles and practice in the Australian
context. Allen and Unwin Pty Ltd. St Leonards, NSW
2065 Australia (Chapter 1 and Chapter 10).
Egger, G., Spark, R., Donovan ,R., (1999) Health
promotion strategies and methods. Second Edition.
The Mc Graw- Hill Companies Sydney Australia.
(Chapters 1 and 2).
Nutbeam D, Harris E. (2004) A practical guide to
health promotion theories. McGraw-Hill Sydney
Australia Pty Ltd. (Chapters 3, 5 and 6).
PowerPoint Presentation 3:2 Cervical Screening
Presentations Part 2 Section of the Handbook CD.
Pap Smear Prompt and Reminder Cards.
The Queensland Cervical Screening Program produces
Pap smear prompt and reminder cards which are
available free of charge. These can be ordered
directly from the website: www.health.qld.gov.au/
cervicalscreening. This resource can be used in two
ways, rstly it can be given to women at the time
of the Pap smear to identify the month and year
that their next Pap smear is due. Alternately, it can
be given as a prompt card to encourage and remind
women who are identied as being due for a Pap
smear and choose not to have the test performed
at the time to make an appointment to have a Pap
smear performed. Similar prompt cards and fridge
magnets have been developed for Aboriginal and
Torres Strait women.
r Providers of Medical Practitioner Education
There are numerous barriers to regular participation in cervical screening that have been identied in
the literature. Many of these barriers are complex and interrelated. Appreciation of the complexity of
these barriers is important as it can lead to the provision of appropriate services and thus increase the
rate of participation of eligible women in cervical screening.
Key concepts
barriers affecting womens participation
in cervical screening
cervical screening for women with
special needs including lesbian women ,
women with disabilities, Aboriginal and
Torres Strait Islander women and women
from culturally and linguistically diverse
backgrounds (CALD).
Learning outcomes
will be able to:
know the cervical screening
participation rates and know how to
access them
discuss the invasive and sensitive nature
of cervical screening and gynaecological
examination
understand that cervical screening is an
invasive and sensitive gynaecological
examination
identify factors and barriers affecting
womens participation in cervical
screening
describe and understand the
complexities and interactions that relate
to the barriers to cervical screening.
SUMMARY INFORMATION
3.2 Barriers Affecting Womens Participation in Regular Cervical Screening
Health Promotion in
Cervical Cancer
Cervical Screening Participation Rates
It is essential for the success of the National
Cervical Screening Program that it reaches all
women who are eligible. Regular participation
in cervical screening is the key to the prevention
of cervical cancer and as such is the primary
indicator used in monitoring the success of
the program. The current policy is that women
should participate in screening once every
two years, and participation is measured by
rates. The participation rate in Queensland is
calculated as a count of the participation of
eligible women aged 20 to 69 who have had a
Pap smear within a two-year period and who
choose to be registered on the Queensland
Health Pap Smear Register (PSR) as a proportion
of the eligible population. Women who choose
not to have their details sent or who choose to
have their details removed from PSR are unable
to be counted and therefore, are excluded from
the rate.
In Queensland the state-wide participation rate
for the target age group of women aged 20 to
69 years in 2006-2007 was 59.3%. This is the
second lowest participation rate of all the States
and Territories and below the latest available
Australian rate of 60.6% (2005/2006).
1

The Queensland Cervical Screening Program
provides annual participation rates by
Queensland Health Service Districts, statistical
local areas and general practice divisions. These
reports are available on the website:
http://www.health.qld.gov.au/cervicalscreening/
health_professionals/stat_info.asp
Barriers Affecting Womens
Participation in Cervical Screening
A review of the literature indicates numerous
barriers to cervical screening.
2
Many of the
identied barriers are complex and inter-related:
Lauver
3
identied three types of barriers to
cervical screening participation these were: (1)
practitioner related barriers (2) system related
barriers (3) client related barriers.
1. Practitioner related barriers
These barriers include concerns about client
embarrassment, lack of time and lack of
discussion about screening between practitioner
and client. General practitioners are well
placed to provide cervical screening to clients
in terms of their large female client base,
however barriers are reected by ndings
such as those documented by Cockburn et al.
4

These authors state, One of the disappointing
ndings of the study, therefore, is the number
of GPs who apparently take few smears or none
at all. This nding is reinforced by Bowman,
Redman, Reid and Sanson-Fisher who state,
While general practitioners perceive themselves
as the most appropriate providers of cervical
screening, some currently are providing a less-
than-adequate service to their patients.
5
Time
and the pressures to restrict the duration of
consultations are listed as signicant barriers to
opportunistic screening in general practice.
6

Gender of the practitioner has also been
identied as a practitioner related barrier.
Studies have indicated that many women
3.2 Barriers Affecting Womens Participation in Regular Cervical Screening
prefer a female practitioner to provide cervical
screening.
6,7,8
This is particularly relevant for
Aboriginal and Torres Strait Islander women and
women from CALD.
8,9

Other practitioner related barriers identied
include qualications of the practitioner, time
available, interpersonal skills, comfort levels and
knowledge.
10
2. System related barriers
These include barriers such as accessibility of
services in relation to location (the service is
hard to get to), timing (many women work or
care for children during ofce hours when most
services are offered) and cost to the client of
screening tests.
Other identied system related barriers include
the presence or absence of reminder systems and
bulk billing.
10
The introduction of Registered Nurse Pap Smear
Providers (RN PSPs) is one strategy aimed at
improving the acceptability and accessibility
of services. RN PSPs as mentioned in Section
3.1 have been described as providing accessible
services especially to at risk groups, including
remote, older and CALD women.
11
However, there appears to be a need for
greater promotion of the role as identied in
a cross-sectional survey of clients attending a
large metropolitan Family Planning Clinic in
Queensland highlighting a lack of awareness and
uncertainty about the role of RN PSPs.
12
3. Client-related barriers
These are associated with psycho social factors
such as beliefs, norms and affect regarding
screening.
3
Client related barriers have been
specically identied for Australian women and
were described under three broad categories
by the Cervical Cancer Screening Evaluation
Steering Committee.
These were:
womens knowledge, attitudes and beliefs
about cervical screening
womens perceptions of Pap smear services
other reasons, such as forgetting or
inadequate time.
13
In Australia, surveys have shown that ...while
many women have a favourable attitude
towards screening, many perceive the test to be
embarrassing, uncomfortable, painful or anxiety
provoking.
14

External factors such as the media, mixed
messages and guilt may also impact on a
womans attitude towards a screening program.
15
Cockburn
14
surveyed older women (aged 40
years and over) to explore barriers to screening
and found two major barriers were anticipated,
embarrassment and the perception that they
were too busy. This was a recurring theme in
the literature with Jirojwong, Maclennan and
Manderson nding; embarrassment and fear of
the diagnosis inhibited regular screening among
Thai women in Brisbane.
16
Health Promotion in
Fear was identied by Seamark as an additional
factor impacting on why women do not
participate in cervical screening programs.
17
He
describes fear from two perspectives. The rst
is fear of the actual test that it may hurt or be
embarrassing, the second is fear of the result and
the lurking possibility of cancer. This was also
the nding from a Scottish study of womens
views of the Pap smear.
7

Cockburn found that lack of knowledge of
cervical screening frequency and purpose is a
signicant barrier for older women who often
perceived the test to be for cancer and as they
were asymptomatic, they did not believe the test
was needed.
14
Cultural factors may play some
part in this misunderstanding. The link between
cervical cancer and HPV, a sexually transmitted
infection may also increase resistance to
screening.
17
Research conducted in the United Kingdom
revealed that thirty-eight women (sixty-two
percent of the sample) refused a Pap smear
for inappropriate reasons.
18
The reasons cited
included:
had lived with same partner throughout
adult life
were not the type of woman to get this
disease
had not had intercourse for many years.
Other client-related barriers which have been
identied include issues such as the availability
of child care and access to a female practitioner.
7, 8, 17, 19

Another important predictor of cervical
screening behaviour is regularity and consistency
of care.
20,21
In their study of sociodemographic
predictors among White, Black and Hispanic
women, Selvin and Brett stress the importance
of targeting preventive care messages directly
at women who do not have a regular source
of care. Often these women do not attend for
preventive care because they do not feel unwell
and in some cases are unaware of screening
procedures and programs.
Cervical Screening and Women from
Culturally and Linguistically Diverse
(CALD) Backgrounds
It needs to be realised that the concept of
screening is often outside the traditional views
of healing and health beliefs of women from
many cultures.
18, 22
Poor understanding of or
confusion about the Pap smear procedure among
women from CALD backgrounds are potential
obstacles to cervical screening. Because cancer
is viewed in some cultures as a predestined
and probably incurable disease, some women
typically do not wish to know if they have
cancer and are reluctant to discuss the topic.
2

Some believe that only God can save them
from cancer and that cancer can be induced
by talking or thinking about it.
24
Ansell, Lacey
and Whitman argue that if access is difcult or
restricted, participation in screening by CALD
women is adversely affected. Further, familiarity
with the medical system is a strong predictor of
participation in cervical screening.
25
As CALD women represent a diversity of cultures
and beliefs, the most acceptable organised
attempts to recruit CALD women involve the
use of female Pap smear providers and bilingual
educators who have received support from
their community through a process of active
networking and consultation.
26
Aboriginal and Torres Strait Islander
Women
Aboriginal and Torres Strait Islander women
experience a higher incidence and mortality
from cervical cancer than other Australian
women especially if they live in rural and remote
communities.
27
It has been suggested that it is
due to several causes:
poor socio-economic conditions
late presentation of cervical cancer and its
precursors
lack of adequate medical services and
personnel particularly in rural and remote
areas
a general lack of awareness of preventive
behaviour such as screening that can reduce
the risk of developing cervical cancer
the presence of co-morbidities may predict
poorer treatment outcomes in respect to
cancer treatment and survival.
28
Aboriginal and Torres Strait Islander women
have been shown to share many concerns of
non-Indigenous women about Pap smears, such
as shyness and lack of knowledge about Pap
smears. Studies have shown that Aboriginal
and Torres Strait Islander women also have
culturally specic beliefs about their anatomy,
the function of screening and their approach to
health and prevention of illness.
27
The specic
beliefs which are considered as barriers to
screening among Aboriginal and Torres Strait
Islander women are:
cervical screening is womens business and
should not be discussed with others
Pap smears should be performed by women
providers
the association between cervical cancer and
sexually transmitted infections adds to the
stigma of screening and shame - in small
communities, a woman with cervical cancer
may be shunned or rejected
women often have pre-existing health
problems such as diabetes and renal disease
and screening is not of high priority.
It has been shown however that most barriers to
screening can be overcome by the development
and implementation of culturally appropriate
screening programs involving trained staff who
acknowledge the existence of barriers mentioned
above. The provision of special clinics and
mobile screening clinics staffed with female
Pap smear providers and Aboriginal and Torres
Strait Islander liaison ofcers/health workers
are essential in increasing the participation of
Aboriginal and Torres Strait Islander women in
cervical screening.
Health Promotion in
Women with Special Needs
A key factor in reducing mortality from cervical
cancer is to recruit all eligible women into
the cervical screening program. To maximise
recruitment, it is important to accommodate
women with special needs including lesbian
women and women with disabilities.
For women with special needs, physical access to
general practitioners including distance from the
surgery, lack of female Pap smear providers, poor
transport, lack of child care, difculties getting
time off work and nancial problems are just as
relevant and may be even more so.
Depending on the nature of the disability
however, cervical screening may be difcult to
perform in general practice consulting rooms.
It is important to know that some women with
upper motor neurone lesions may be at increased
risk for autonomic hyperreexia during pelvic
examinations. Special guidelines have been
published to assist in the provision of Pap smears
for women with disabilities.
19
Research has shown that lesbians are less likely
to have regular Pap smears than heterosexual
women. Many health care providers and
patients share the false assumption that because
lesbians are not currently sexually active with
men, they are not at risk for developing cervical
cancer. As a result of this misinformation,
lesbians may avoid medical services and health
care providers may give incorrect advice so that
lesbian women are under screened. However,
lesbians, like all women, need regular Pap smears
if they have been exposed to risks associated
with acquiring HPV.
29

Suggestions for general practitioners to
improve the screening rates of women with
special needs:
remain vigilant and offer cervical screening
to women with special needs
explain the importance of Pap smears and
what is involved in the procedure
ascertain whether the woman is comfortable
with the setting where a Pap smear is
provided and with the Pap smear provider
make arrangements for informing the
woman of her results and what they mean in
a way that they can understand
provide information on diagnosis and
management options if they arise in relevant
ways.
References
1. National Cervical Screening Program (2005)
Cervical Screening in Australia. Australian
Government, Cat No. CAN 26 Australian Institute
of Health and Welfare. Canberra.
2. Forbes, C., Jepson, R., Martin-Hirsch, P (2004)
Interventions targeted at women to encourage
the uptake of cervical screening (Review): The
Cochrane Collaboration. John Wiley & Sons, Ltd.
3. Lauver DR and Kane J (1992) A Motivational
Message, External Barriers. Cancer Detection and
Prevention 23 (3) 254-264.
4. Cockburn J, White V Hirst S and Hill D (1992)
Barriers to Cervical Screening in Older Women
Australian Family Physician 21: 973-78.
5. Byles JE, Redman S, Sanson Fisher R and Boyle C
(1995) Effectiveness of two Direct-mail
Strategies to Encourage Women to Have Cervical
(Pap) Smears. Health Promotion International 10:
5-16.
6. Heywood A, Firman D & Ring I (1996) Factors
Associated with Pap Smear Taking in General
Practice: Focusing Public Health Initiatives.
Australian & New Zealand Journal of Public
Health 20(3): 260-265.
7. McKie L (1993) Womens views of the cervical
smear test: implications for nursing practice
women who have not had a smear test.
Journal of Advanced Nursing 18: 972-979.
8. Mak D (1997) Why do(nt) aboriginal women
have Pap smears? Australian Family Physician
26(6): 763.
9. Kirk M, Hoban E, Dunne A and Manderson L
(1998) Barriers to, and appropriate delivery
systems for, cervical cancer screening in
Indigenous communities in Queensland. A
report to Queensland Health. Queensland Health
Department.
10. Bell J & Ward J (1998) Cervical screening: linking
practice, policy and research in womens health.
Cancer Forum 22: 6-11.
11. Womens Cancer Screening Services (2002)
Queensland Cervical Cancer Screening State Plan
2002-2006. Queensland Health, Queensland.
12. Christie, L., Gamble, J and Creedy, DK (2005)
Womens views of registered nurses on
Papanicolau Smear providers: A pilot study.
Contemporary Nurse 20 (2) 159-168.
13. Commonwealth Department of Human Services
and Health, (1995) Report of the Evaluation of
Steering Committee. The Interim Evaluation of
the Organised Approach to Preventing Cancer
of the Cervix 1991-1995. Australian Government
Printing Service, Canberra.
14. Hill D, White V, Borland R & Cockburn J (1991)
Cancer-related beliefs and behaviours in
Australia. Australian Journal of Public Health
15(1): 14-23.
15. Harokopos, V., McDermott, R (1996) Cervical
Cancer Screening: Benets and Barriers. Journal
of Health Education 27(6) 351-6.
16. Jirojwong, S., Maclennan, R., Manderson, L (2001)
Health Beliefs & Pap Smears among Thai women
in Brisbane, Australia. Asia-Pacic Journal of
Public Health 13 (1)20-23.
17. Seamark C (1996) Why women do not present
for cervical smears - observations from general
practice. The British Journal of Family Planning
22: 50-52.
18. Doyle Y (1991) A survey of cervical screening
in London District, including reasons for non
attendance, ethnic responses and views on the
quality of service. Social Sciences and Medicine.
19. NSW Cervical Screening Program (2003)
Preventative Womens Health Care for Women
with Disabilities. Guidelines for General Practice.
Sydney.
Health Promotion in
20. Selvin E., Brett, M (2003) Breast and Cervical
Cancer Screening: Socio-demographic Predictors
among White, Black and Hispanic Women.
American Journal of Public Health 93 (4) 618-23.
21. Brett T (1992) Opportunistic cervical screening
among 50-70 Year Olds: a Prospective Study in
General Practice. Australian Family Physician 21:
1781-84.
22. Hoare T (1996) Breast screening and ethnic
minorities. British Journal of Cancer 74: S38-
S41.
23. Ling G et al (1996) Reducing the incidence and
mortality from cervical cancer. Medical Journal
of Australia 164(5): 318-19.
24. Gifford SM (1991) Culture and the provision of
preventive health care: Implication for medical
education. Cancer Forum 15: 73-80.
25. Ansell D, Lacey L Whitman S, Chen E and Phillips
CA (1994) Nurse delivered intervention to
reduce barriers to breast and cervical screening
in Chicago inner city clinics. Public Health
Reports 109: 104-111.
26. Wilcox LS and Mosher WD (1993) Factors
associated with obtaining Health Screening
among women of reproductive age. Public
Health Reports 108: 76-86.
27. Jelfs P (1995) Cervical Cancer in Australia.
Australian Institute of Health and Welfare
Cancer Series Number 3, Australian Government
Publishing Service, Canberra.
28. Valery P, Coory M, Stirling J & Green A (2006)
Cancer diagnosis, treatment, and survival in
Indigenous and non-Indigenous Australians: A
matched cohort study.
The Lancet 367, 1842-1848.
29. Rankow ET and Tossaro T (1998) Cervical cancer
risk and Papanicolaou screening in sample of
lesbian and bisexual women. Journal of Family
Practice 47(2): 139-43.
Additional Readings
Royal College of Obstetricians and Gynaecologists
(2002) Gynaecological Examinations: Guidelines for
Specialised Practice. London. (This resource can be
viewed and downloaded from the website, www.
rcog.org.uk).
Hill D, Borland R & Cockburn J (1991) Cancer-related
beliefs and behaviours in Australia. Australian
Journal of Public Health 15(1): 14-23.
Straton J (1994) Recruitment for Cervical Screening.
A review of literature. National Cervical Screening
Program, Australian Government Publishing Service,
Canberra.
PowerPoint Presentation 3:2 Barriers Affecting
Womens participation in Cervical Screening:
Part 2 Section of the Handbook CD.
Clinical
Skills
SECTION 4
4.1 Communication skills involved in performing sensitive
gynaecological examinations
Key concepts
communication skills involved in
performing sensitive gynaecological
procedures
appropriate communication of issues
regarding decision making relevant to
cervical screening
sensitive communication of abnormal
Pap smear results to a woman who has
undergone cervical screening.
Learning outcomes
Participants of cervical screening
courses will:
explain the procedure and its purpose and
limitations to a woman
discuss the cultural, social, psychological
and emotional factors involved in a
womans choice to have a Pap smear
perform a Pap smear with sensitivity and
care, providing a positive experience for
the woman that allows her to understand
the process and procedure
obtain consent at all stages of the
consultation
offer a chaperone or companion for the
woman
communicate Pap smear results
effectively and sensitively
describe the sensitive issues that surround
communication of abnormal Pap smear
results to a woman.
The Pap smear is a sensitive gynaecological examination, therefore it is important to ensure that
women participating in cervical screening are physically and psychologically comfortable during the
procedure. This information requires the use of appropriate interaction and communication skills
which include cultural and language awareness as well as sensitivity to possible barriers to screening
that may be present.
Clear information in a format most accessible for the woman herself should be provided to
convey what the woman needs to do and what will occur before, during and after the procedure.
Communicating Pap smear results, especially abnormal results also requires specic skills and
sensitivities to ensure effective communication occurs. The importance of obtaining consent at all
stages in the consultation and offering the presence of a chaperone if relevant, contributes to the
empowerment of the woman.
Clinical Skills
SUMMARY INFORMATION
SECTION 4
4.1 Communication skills involved in performing sensitive
gynaecological examinations
Clinical Skills
Communication at the Time of the
Pap Smear
The Pap smear has been described as an
intimate sensitive examination which involves
invasion of personal space. Embarrassment
has been shown to be a signicant barrier that
discourages women from having a Pap smear.
The procedure produces anxiety as it is physically
uncomfortable and the examination position
itself has been described as imposing directly
upon traditional values such as modesty and
respectability irrespective of culture, colour or
creed.
1
The way that the Pap smear provider
communicates with a woman has an inuence
on how she feels about the procedure and
whether she is likely to return for regular Pap
smears.
The following communication strategies may
assist in ensuring the woman feels safe and does
not experience pain during the procedure:
Commence the consultation with a warm
personal greeting before the examination
begins to put the woman at ease and reduce
anxiety.
The woman should be invited to describe
whether she has had a previous Pap
smear and any concerns relating to the
examination.
Explore previous Pap smear experiences and
if a woman expresses concerns these should
be discussed further prior to commencing
the examination.
The Pap smear provider should describe
the benets of regular cervical screening
including that it is a preventive measure to
detect changes in the cervix that if detected
early can be treated before developing into
cervical cancer.
The Pap Smear Register should also be
discussed at this time to ensure women
are aware their results will be forwarded
automatically to the register (unless she
chooses to opt-off at this stage).
The woman also should be advised of the
limitations of the Pap smear, the benets of
participating in regular cervical screening
and the importance of returning if she
experiences any abnormal symptoms such as
abnormal bleeding.
The Pap smear provider should offer to
explain the procedure to a woman prior to
commencing the examination. Anatomical
models or diagrams are useful for this and
showing women the specimen collection
devices and speculum can also reduce
anxiety. This also enables the Pap smear
provider to ascertain the level of a womans
understanding of the procedure.
The woman should be advised that the
procedure can be stopped at any stage at her
request. Empowering a woman with a stop
signal can signicantly reduce anxiety and
discomfort as women who are tense tend to
tighten their pelvic muscles which can also
make the procedure more difcult. This can
assist in reducing a womans vulnerability
A tissue should be offered at the end of the
procedure to wipe away any lubricant and
a place to dispose of it should be provided
close to the examination couch. A panty
liner or pad should also be available in case
she experiences spotting.
Further discussion of any abnormality
that might have been observed, when the
result will be available and how this can
be obtained should be discussed after the
woman is dressed and has returned to the
consulting desk.
If there is a language or a cultural barrier it
may be necessary to determine the womans
literacy and cultural values and if needed use the
services of a translator/interpreter (Telephone
Interpreter Service 13 14 50) or an appropriate
community health worker in the area.
Communication of Pap Smear Results
The initial communication of an abnormal result
is likely to create anxiety and in some women
a desire for more information. Many women
respond to the identication of an abnormality
on their Pap smear by concluding they have
cancer, rather than a treatable pre-cursor lesion.
2

About 18% of women with an abnormal result
reported in one study that they did not know
what the result meant.
3
and fear during the procedure. It is also
important to warn a woman about visceral
sensations she may experience during the
procedure and that she may experience
spotting after the procedure.
The woman should be offered a chaperone
or accompanying person to be present if she
wishes. The issue of chaperones needs to be
considered in the context of protection of
the doctor-patient relationship. Chaperoning
can be considered a risk management
strategy as it may protect the doctor from
allegations of inappropriate behaviour and
misconduct, or from misconduct by the
patient.2,3. Some hospitals have a policy
regarding presence of chaperone during
gynaecological examinations.
Consent to proceed with the examination
should be requested before the woman
undresses and once she is lying on the couch.
It is important that privacy is maintained
at all times. The examination should be
performed in a private room and a curtain
should be available to allow the woman
to undress and position herself on the
examination table. A covering sheet should
also be provided and clear directions about
what clothing to remove should be discussed.
Some women prefer to be involved in the
process and nd the offer of a mirror to be
able to see the cervix empowering.
Human Papillomavirus
When discussing abnormal Pap smear results
with a woman it is necessary to discuss HPV.
It has been demonstrated that some women
do not associate cervical cancer with HPV and
have low levels of awareness about this virus. It
has been shown, that some women experience
a range of negative emotions when told they
have HPV so this subject needs to be addressed
with sensitivity and tact, especially as HPV is a
sexually transmitted infection.
4
Women who
have been diagnosed with HPV have been found
to experience:
a negative impact on well-being
anxiety, worry, upset, shock, distrust, fear of
cancer, guilt/blame
intrusive thoughts, somatic symptoms, stigma
relating to having a sexually transmitted
infection (STI), disclosure concerns
concerns about transmission or reinfection
by partner.
4
The key information that women want to
know about HPV includes:
HPV viral types
avoid the use of the word warts when
discussing HPV
implications for sexual relationship
prevalence, latency, regression
treatment and management
implications for cancer risk and fertility.
4
produced a brochure for women: The link
between Cervical Cancer and HPV that can be
used to assist with communicating these issues
to women.
It has also been demonstrated that the clinicians
communication style affects womens responses
to being told about HPV. Women preferred
direct communication rather than a letter and
reassurance and minimisation of the seriousness
of the infection.
4
Clinical Skills
References
1. Mitchell H (1993) Pap Smears Collected by the
Nurse Practitioners. Oncology Nurses Forum
20(5): 807-10.
2. http://medicalboardvic.org.au/content.php
Accessed 30 January 2007
3. Howarth, G. Chaperone use in medical practice.
Available at: www.medpharm.co.za/safp/2003/
mar/chaperone.html
4. Towler B, Irwing L and Shelley J (1993) The
Adequacy of management of women with
CIN2/3 Pap Smear Abnormalities. Medical
Journal of Australia 159: 523-28.
5. Schiels MJ, Sanson-Fisher R, Haplin Sand
Redman S (1994) Notication and follow-up of
Pap Test Results: Current Practices and Womens
Preferences. Preventive Medicine 23: 276-83.
6. Mc Caffrey K, Waller J, Forrest S, Cadman L,
Szarewski A and Wardle J (2004) Testing Positive
for Human Papillomavirus in Routine cervical
Screening: Examination of Psychosocial Impact.
BJOG: an International Journal of Obstetrics and
Gynaecology;111: 1437-43.
Additional Readings
National Health and Medical Research Council (2005)
Screening to Prevent Cervical Cancer: Guidelines
for the Management of Asymptomatic Women
with Screen Detected This document can be sited
or downloaded from NHMRC website: http://www.
nhmrc.gov.au/publications/synipses/wh39syn.htm
Chapter 10.
Kelaher M et al. (1997) The Impact of Culture and
Ethnicity on cervical screening in Queensland.
University of Queensland, Brisbane.
Commonwealth Department of Human Services
and Health (1994) Making the Pap Smear Better
Report of the Steering Group of Quality Assurance in
Screening for the Prevention of Cancer of the Cervix.
Canberra.
Department of Health, Housing. Local Government
and Community Services (1991) Screening to Prevent
Cancer of the Cervix. Canberra.
Straton J (1994) Recruitment for Cervical Screening.
A review of literature. National Cervical Screening
Program. Australian Government Publishing Service,
Canberra.
PowerPoint Presentation 4.1: Communication skills;
The link between cervical cancer and HPV (human
papilloma virus) brochure can be viewed on www.
cancerscreening.gov.au or ordered from Queensland
Cervical Screening Program website www.health.qld.
gov.au/cervicalscreening
Clinical Skills
4.2 The Pap smear
Key concepts
the sensitivity and specicity of the Pap
smear
the importance of good Pap smear
technique
equipment used in providing a Pap
smear
steps in performing a Pap smear.
Learning outcomes
will be able to:
explain and understand the limitations
of the Pap smear
describe the basic techniques involved in
providing a Pap smear
identify equipment necessary to obtain
a sample.
Collecting an adequate sample of cells from the cervix is crucial to obtaining a satisfactory Pap
smear. An optimal cytological sample of the cervix includes epithelium from the transformation zone,
the squamous ectocervix distal to it and the columnar endocervix proximal to it using appropriate
specimen collection devices.
To ensure that an optimal specimen is obtained, adequate clinical training is required.
SUMMARY INFORMATION
Clinical Skills
4.2 The Pap smear
Accuracy of screening tests
The Pap smear is a cytological test designed to
detect abnormal cervical cells. It is also a test
with inbuilt limitations. Even in the most highly
trained and experienced hands false negative
and a smaller number of false positive results
will sometimes occur. Causes of false negative
results include screening and interpretation
errors. False negatives also result from sampling
errors, where the actual lesion is not sampled or
is not transferred from the sampling device to
the slide or vial.
There are two critical components that
determine the tests accuracy: sensitivity and
specicity.
Sensitivity is the probability that the test is
positive, given that the person has the disease.
Specicity is the probability that the test
is negative, given that the person does not
have the disease. The Pap smear is generally
considered to be a very specic test for high
grade lesions or cancer, but only moderately
sensitive.
High specicity means that cytology correctly
identies a high proportion of women who do
not have high-grade lesions or cancer. Australian
Health Technology Advisory Committee (AHTAC)
reported an average specicity of 69% and
an average sensitivity of 58% in 28 studies
evaluating the accuracy of the Pap smear as a
screening test.
1
Other studies have placed the
specicity of the Pap smear as being as high
as 80-95% for CIN 1 lesions or worse. This
highlights the importance of regular screening
since the occurrence of a false negative is
uncommon and there is every chance that the
abnormality will be picked up at the next smear.
It has been estimated that regular two-yearly
screening prevents an adverse outcome from
many false negatives and will prevent at least
90 percent of cervical cancers in the screened
population.
1
The importance of good Pap smear
collection technique
The objective of a Pap smear is to sample cells
from the transformation zone of the cervix. This
is the site at which the cell abnormalities which
precede the development of squamous cell
carcinoma of the cervix are usually found. The
quality of the Pap smear sample depends on the
technique used and the adequacy of equipment.
Health professionals who provide Pap smears
should be trained in both the theoretical aspects
of screening and clinical tuition that includes
appropriate communication skills to ensure that
all aspects of cervical screening are covered.
What is a satisfactory Pap smear?
There is consensus amongst cytologists that a
satisfactory Pap smear should:
contain sufcient cellular material sampled
from the transformation zone
be appropriately xed to ensure a good state
of preservation
in a Pap smear include the use of bivalve
rather than a Simms speculum, ensuring
adequate visualisation of the cervix and the
transformation zone where possible and using an
appropriate device to sample the endocervix.
4

The Pap smear procedure
Equipment used to collect a Pap smear
There are a number of different sampling
instruments that are used in performing a Pap
smear. These instruments include:
Ayres Spatula to collect ectocervical cells
(this device should be used in conjunction
with a device to collect endocervical cells, eg
Cytobrush)
Cytobrush to collect endocervical cells (this
device should be used in conjunction with a
device to collect ectocervical cells, eg Ayres
spatula)
Cervex sampler to collect both ectocervical
and endocervical cells*.
5
*In some cases it may be appropriate to use a
Cytobrush in conjunction with a Cervex sampler.
Steps in collecting a Pap smear
The steps for collecting a Pap smear are
contained in the booklet, Screening for the
Prevention of Cervical Cancer which is available
from the National Cervical Screening Program,
call 13 15 56.
have clearly visible cellular material which is
not obscured by blood or inammatory cells.
2

If unsatisfactory the laboratory report will state
why and will provide recommendations on
when the Pap smear should be repeated and any
treatment, for example, local oestrogens, that
may assist in increasing the quality of the repeat
Pap smear.
In relation to sufciency of cellular material
sampled, an unsatisfactory Pap smear has been
dened as a smear that contains fewer than
10,000 well visualised endocervical cells and/
or squamous epithelial cells (or 5,000 for liquid
based preparations).
3

There has been much debate about the
presence of endocervical cells in the Pap smear.
Endocervical cells are a good indicator that
the transformation has been sampled and it
is recommended that a practitioners smears
should have an endocervical component in at
least 85% of the smears they collect.
4
However,
it is more important that the practitioner is
certain that they have visualised and sampled
the transformation zone. If this is the case then
the Pap smear does not need to be repeated if
no endocervical cells are present as there may be
physiological factors that reduce the ability to
sample the endocervix such as cervical stenosis.
The proportion of smears containing an
endocervical component is highest in young
women and it decreases with age of a woman.
Practitioner-related factors that inuence the
likelihood of endocervical cells being present
References
1. Australian Health Technology Advisory
Committee (1998) Review of automated and
semi-automated cervical screening devices,
Commonwealth of Australia, Canberra.
and Health (1994) Making the Pap Smear
Better Report of the Steering Group of Quality
Assurance in Screening for the Prevention
of Cancer of the Cervix. Commonwealth
Department of Human Services and Health,
Canberra.
Family Services (1998) Screening for the
Prevention of Cervical Cancer, Australian
5. Royal College of Obstetricians and
Gynaecologists (2002) Gynaecological
Examinations: Guidelines for Specialist Practice
London. Website www.rcog.org.uk
Clinical Skills
Additional Readings
Commonwealth of Australia, Commonwealth
Department of Health and Family Services(2005)
titled Screening for the Prevention of Cervical
Cancer at www.cancerscreening.gov.au
PowerPoint Presentation 4.2 Part 2 Section of the
Handbook CD.
Also view separate CD titled Sensitive Examination
Technique in the DVD case.
Clinical Skills
Understanding the Pap smear result is crucial to the provision of cervical screening. Changes to the
terminology for Pap smears came into effect in July 2006 with the implementation of the NHMRC
Guidelines for the Management of Asymptomatic Women with Screen-detected Abnormalities.
1

In addition, the Pap smear provider can assist the cytologist to interpret the Pap smear and the
pathologist to make appropriate recommendations for individual women by including appropriate
information on the Pap smear request form.
SUMMARY INFORMATION
Key concepts
Australian Modied Bethesda System
(AMBS) 2004 terminology
the Pap smear report
common Pap smear results
common information to include on the
Pap smear request form.
Learning outcomes
will be able to:
understand and explain Pap smear
reports in the context of new
terminology
interpret a Pap smear report
complete a Pap smear request form with
the appropriate relevant information
required by the laboratory.
Australian Modied Bethesda System
(AMBS) 2004 terminology
The terminology for the reporting of cervical
cytology was changed in July 2006 to be closer
to the internationally accepted Bethesda
system allowing meaningful interpretation
of international research data. It was also
recognised that there was poor reproducibility
for distinguishing between the subtypes
(Nonspecic minor change (NSMC), HPV and
Cervical intraepithelial neoplasia 1 (CIN 1) of
low grade cytology and that this low grade
report mostly represents the changes of a
productive HPV infection in squamous cells.
1

The terminology for cervical histology, however,
remains unchanged. Therefore intraepithelial
lesions conrmed histologically will still
be reported according the Systematised
Nomenclature of Medicine (SNOMED) terms, i.e.
CIN 1, 2 and 3 etc.
1
The Australian Modied Bethesda System 2004
is outlined in the table below which highlights
the comparison with previous terminology.
New Australian NHMRC terminology AMBS 2004 1994 Australian NHMRC terminology
Squamous abnormalities
Possible low-grade squamous
intraepithelial lesion (possible LSIL)
Low-grade epithelial abnormality
Low-grade squamous intraepithelial lesion (LSIL) Low-grade epithelial abnormality
Possible high-grade squamous
lesion (possible HSIL)
Inconclusive, possible high-
grade squamous abnormality
High-grade squamous intraepithelial lesion (HSIL) High-grade epithelial abnormality
Squamous cell carcinoma High-grade epithelial abnormality
Glandular abnormalities
Atypical endocervical cells of
undetermined signicance
Atypical glandular cells of
Possible high-grade glandular lesion
Inconclusive, possible high-
grade glandular abnormality
Endocervical adenocarcinoma in situ High-grade epithelial abnormality
Adenocarcinoma High-grade epithelial abnormality
Clinical Skills
Table 2: Terminology of Cervical Abnormalities
The Pap smear report
The Pap smear provider will usually receive
the Pap smear result within two to 14 days
depending upon where the specimen was
collected and where it was examined.
Pap Smear Report Forms
Pap smear report forms differ in their format
however, they contain similar information. The
information on a Pap smear report includes:
Specimen:
Identies the site of the cytology samples.
Possible explanations are:
Slide Pap Smear - Cervical
Slide Pap Smear - Vault
This section will also note whether it is a
conventional Pap smear sample or a Thin Prep
sample.
Result:
Identies if the result is negative or abnormal.
Possible results include:
Negative for Intraepithelial Lesion or
malignancy
Possible Low-Grade Squamous Intraepithelial
Lesion
Low-Grade Squamous Intraepithelial Lesion
Possible High-Grade Squamous Lesion
High-Grade Squamous Intraepithelial Lesion
Unsatisfactory
Specic diagnosis:
A more detailed description of the result is given
in this section of the report. Along with the
report on the presence or absence of any cellular
abnormality, the coexisting presence of specic
microorganisms may be given. This part of the
report also includes a comment on the presence
or absence of an endocervical component.
Recommendations:
These are according to the current NHMRC
guidelines. For example, a negative smear
result from women who has no symptoms or
history of cervical pathology would have a
recommendation of: Repeat in 2 years.
Common Pap smear results
About one in every ten Pap smear results will
have a comment or indicate some kind of
problem. Many of these are not serious, and
most cell changes in the cervix are not due to
cancer.
Unsatisfactory Pap Smears
Sometimes the Pap smear report will indicate
that the sample was unsatisfactory. This may
happen for a variety of reasons:
the cells may be obscured by blood or
inammation / mucous
there may not be enough cells on the sample
to give an accurate assessment
the cells may be atrophic and difcult to
interpret
the smear may not have been properly
prepared, or
the slide may have been broken during
transit to the laboratory.
If any of these problems occur, a woman
will be asked to have another Pap smear in
approximately six to 12 weeks. This allows time
for the cells of the cervix to be renewed so that
there will be sufcient cells available to obtain a
satisfactory sample.
An atrophic smear can be difcult for the
cytologist to interpret. Atrophic Pap smears are
often seen in post-menopausal and post natal-
women, particularly if they are breastfeeding.
These Pap smears result from decreased
oestrogen levels. It is recommended that if the
Pap smear is unsatisfactory due to atrophic
changes, the woman has a repeat Pap smear in 3
months after being treated with local oestrogen.
Clinical Skills
Inammatory Pap Smears
Sometimes a Pap smear will show signs of
inammation. This may be caused by an
infection caused by a micro-organism such as
Candida Albicans or Trichomonas. Sometimes the
cause of the inammation may be detected by
the Pap smear; however additional investigations
should be undertaken to identify and treat the
cause.
Squamous and Glandular Abnormalities
There are two types of cervical abnormalities:
squamous and glandular which are described in
Table 3.
Important information to include on
the Pap smear Request Form
The following information will assist the
laboratory to interpret the Pap smear and make
recommendations that are appropriate for each
womans specic history. These include:
medical record number
name (previous surname if applicable)
date of birth
address
date of Pap smear
collector
date of the last Normal Menstrual Period
(LNMP)
site: cervical or vaginal vault
hormonal therapy: Hormone Replacement
Therapy, Oral Contraceptive Pill, Implanon,
Depo Provera etc
hysterectomy
abnormal history of symptoms* such as post
coital bleeding (PCB) and intermenstrual
bleeding (IMB)
abnormal or suspicious appearance of the
cervix*
pregnancy (gestation)
Aboriginal and Torres Strait Islander status.
*NOTE: the Pap smear may be part of the
investigations for abnormal symptoms or
appearances and in itself does not provide a
diagnosis for signs or symptoms that should
be explored further. A normal Pap test can be
obtained in the presence of an invasive cancer.
Histology results
Prior to the introduction of the NHMRC
guidelines in 2006, abnormal Pap smear results
were described as cervical intraepithelial
neoplasia (CIN) under the 1994 Australian
NHMRC endorsed terminology. From 3 July 2006
cytology results are reported using the Australian
Modied Bethesda System 2004 and will
incorporate terminology such as LSIL and HSIL.
CIN may be reported on cytology results under
Specic Diagnosis and CIN will continue to be
used to report histological cervical cell changes.
CIN is graded into CIN 1 (mild), CIN 2 (moderate)
and CIN 3 (severe) cervical cell changes.
Terms used in describing results What it means
Squamous abnormalities
Possible low-grade squamous intraepithelial
lesion (Possible LSIL)
Non-specic minor squamous cell changes
Low-grade squamous intraepithelial lesion
(LSIL)
A low grade squamous abnormality of the cervix
consistent with HPV infection
Possible high-grade squamous lesion
(Possible HSIL)
Changes that suggest, but fall short of a high-grade
squamous intraepithelial lesion or SCC
High-grade squamous intraepithelial lesion
(HSIL)
High grade pre-cancerous change consistent with
CIN2, CIN3
Squamous cell carcinoma The presence of cancer in the squamous cells
Glandular abnormalities
Atypical endocervical cells of undetermined
signicance
Non-specic minor cell changes in endocervical cells
Atypical glandular cells of
Non-specic minor cell changes in glandular cells
Possible high grade glandular lesion
Changes that suggest, but fall short of,
adenocarcinoma in situ or adenocarcinoma
Endocervical adenocarcinoma in situ
Adenocarcinoma in situ (abnormal cells are
restricted to the surface epithelium)
Adenocarcinoma
High grade abnormality affecting the glandular or
columnar cells of the cervix (adenocarcinoma)
(Source. Queensland Health Fact Sheet, Cervical Screening Program 2000)
Table 3: Types of Cervical Abnormalities
References
PowerPoint Presentation 4.3 Interpretation of
Cytology Reports. Part 2 Section of the Handbook
CD.
The National Screening Program produces two
booklets for women:
Larly uclccllon ls lhc 8csl Prolccllon
An Abnormal Pa Smcar Pcsull
These can be viewed or downloaded from the
website www.cancerscreening.gov.au
If quantities are required they can be ordered from
the Queensland Cervical Screening program website:
www.health.qld.gov.au/cancerscreening
Brochure Brochure
Clinical Skills
4.4 The Management of Screen Detected Abnormalities
Key concepts
the difference between
recommendations for asymptomatic
women and symptomatic women
overview of the NHMRC Guidelines
Screening to Prevent Cervical Cancer:
Guidelines for the Management of
Asymptomatic Women with Screen
Detected Abnormalities.
Learning outcomes
will be able to:
differentiate between and explain
the signicance of asymptomatic and
symptomatic women
know where to source guidelines
relating to the management of
asymptomatic women with screen
detected abnormalities.
The management and treatment of screen-detected abnormalities involves low grade squamous
abnormalities, high-grade squamous abnormalities and cervical glandular abnormalities.
SUMMARY INFORMATION
Clinical Skills
4.4 The Management of Screen Detected Abnormalities
The National Health and Medical Research
Council (NHMRC) Guidelines Screening to
Screen Detected Abnormalities, are for the
management of asymptomatic women with
screen detected abnormalities. Therefore women
who are symptomatic need to be managed in
accordance with their presenting history and
symptoms. Symptoms that may require specic
management outside the NHMRC guidelines
include women who present with symptoms such
as:
intermenstrual bleeding
post-coital bleeding
post-menopausal bleeding.
Women with any of the above signs or
symptoms or any other signs or symptoms of
concern should be referred for further tests
to a specialist gynaecologist so that their
condition can be assessed and appropriate
management plan formulated. Women
with intermenstrual bleeding or post-coital
bleeding should be managed in accordance
with the Royal Australian and New Zealand
College of Obstetricians and Gynaecologists
(RANZCOG) Guidelines for the management of
intermenstrual and postmenopausal bleeding.
These guidelines recommend appropriate
management of women presenting with
intermenstrual bleeding or post-coital bleeding
and referral indications.
2
Screening to Prevent Cervical Cancer:
Guidelines for the Management of
Asymptomatic Women with Screen
Detected Abnormalities
About two million Australian women have a
Pap smear each year.
1
The clinical management
of women that present with an abnormal Pap
smear involves health professionals that work
across many sectors and disciplines. In July
2006, the NHMRC released guidelines Screening
to Prevent Cervical Cancer: Guidelines for the
Screen Detected Abnormalities. These guidelines
are a population health package encompassing:
new terminology for the reporting of Pap
smears (The Modied Bethesda System 2004)
information about the natural history of
cervical cancer and HPV infection
the management of squamous and glandular
abnormalities
management for special clinical
circumstances which include:
- pregnancy
- immunosuppressed women
- women following hysterectomy
- postmenopausal women with normal
endometrial cells
- women exposed to diethylstilboestrol
(DES) in utero
monitoring and implementation.
The NHMRC guidelines are integral to the
Australian National Cervical Screening Program
with a short two-year screening interval.
It is important to remember that these
guidelines are not prescriptive, except to
laboratories, and clinicians and women can
still customise management to suite individual
circumstances.
References and Additional Reading
Screen Detected Abnormalities. This document
can be sited or downloaded from NHMRC
website: http://www.nhmrc.gov.au/publications/
synopses/wh39syn.htm
2. The Royal Australian College and New Zealand
College of Obstetricians and Gynaecologists,
College Statement July 2004.
PowerPoint Presentation 4.4: Management of
Screen Detected Abnormalities. Part 2 Section of the
Handbook CD.
Extensive information relating to the new NHMRC
guidelines has been prepared to assist general
practitioners and women by the National Cervical
Screening Program. www.cervicalscreening.gov.au
Key concepts
follow-up and duty of care
follow-up protocols and processes.
Learning outcomes
will be able to:
explain the importance of follow up
procedures for abnormal Pap smear
results
discuss the importance of follow-up
protocols and processes.
It is essential that Pap smear providers understand Pap smear results and have an effective system for
communicating results to women. This is particularly crucial where the result is abnormal. Medico-
legal cases have resulted from women not being informed of an abnormal Pap smear result and
consequently not receiving appropriate management. To ensure appropriate follow-up occurs, medical
practitioners should establish systems and standards for the review and processing of all Pap smear
reports.
An appropriate explanation of the Pap smear result and any subsequent follow-up should be given
to women in lay terms. It is recommended that abnormal Pap smear results, options for further
investigations / treatment, referral and other relevant issues be discussed directly with the woman.
SUMMARY INFORMATION
Clinical Skills
4.5 Follow Up and Referral
Clinical Skills
4.5 Follow Up and Referral
Laboratories are responsible for communicating
Pap smear results, in writing, directly to the Pap
smear provider. Laboratories can also supply
copies of reports to other medical practitioners
when requested by the Pap smear provider or
by the woman who has had a Pap smear. It is
not the responsibility of the laboratory to notify
women directly, or to provide them with a copy
of their report.
It is a requirement of National Pathology
Accreditation Advisory Council (NPAAC) that
laboratories process 90% of smears within ve
working days. The turnaround time for Pap
smear results may vary from ve days to 14 days
depending on the location of the Pap smear
provider and laboratory workload. This allows for
the prompt follow-up of abnormalities.
Where a Pap smear provider is not the womans
usual GP, he /she should ask the laboratory
to forward a copy to the womans nominated
GP (if the woman consents to this) to ensure
continuity of care.
It is the responsibility of the Pap smear provider
to establish with a woman a mutually acceptable
method of obtaining the results of her Pap
smear. It is a womans responsibility to follow
this advice and ensure the Pap smear provider
has her current details such as her current
address, telephone number etc. It is appropriate
for a woman, if she requests, to be given a copy
of her Pap smear result.
All Pap smear reports should be reviewed
by the Pap smear provider. Whilst reports
include a recommendation based on the
NHMRC Guidelines, it is important that this
recommendation is considered in view of
the womans history and presentation, as the
laboratory does not necessarily have access to
this information. The Pap smear provider on
review of the results and recommendations
needs to establish a process for the
communication of results to women and decide
which results need further discussion/action.
An explanation of the results should be given
to a woman in the language that she can
understand. The date for the next Pap smear
should also be advised at that time.
Fail safe procedures must exist to ensure
that every woman with an abnormal result
is informed of this result with sensitivity and
once a choice of referral is made, that her
prompt attendance for assessment is monitored.
If the woman with an abnormal Pap smear
has not made contact as arranged, the Pap
smear provider, should make every attempt
to notify her by telephone or mail and should
keep a record of such attempts. The most
frequent legal claims initiated against doctors
concerning Pap smears arise from the failure to
communicate test ndings to the client.
1
In one
study it was found that 93% of women with an
abnormal Pap smear result reported having been
notied of their result while 11% of women
whose result was abnormal were unaware that
an abnormality had been detected.
2
References
1. Towler B, Irwing L and Shelley J (1993) The
Adequacy of management of women with
CIN2/3 Pap Smear Abnormalities. Medical
Journal of Australia 159: 523-28
2. Schiels MJ, Sanson-Fisher R, Haplin Sand
Redman S (1994) Notication and Follow-up of
Pap Test Results: Current Practices and Womens
Preferences. Preventive Medicine 23: 276-83
Canberra.
Considerations should always be given to
maintaining womans condentiality when
providing results. For example a woman may
wish to have her results sent to an address other
than her residential address. Those details should
be established at the time of providing a Pap
smear.
Recall Systems
As mentioned above, laboratories are responsible
for communicating Pap smear results to a Pap
smear provider who in turn is a responsible
for communicating Pap smear results to
women. It is the responsibility of the Pap smear
provider to establish with a woman a mutually
acceptable method for obtaining the results of
her Pap smear. This highlights the importance
of ensuring the Pap smear provider has the
womans current contact details such as address,
telephone number etc.
3
If a woman with an abnormal Pap smear has
not made contact as arranged, the medical
practitioner has a duty of care to ensure she is
notied of this and should attempt to notify
her by telephone or mail and keep a record
of such attempts. A protocol for notifying
women of abnormal results and a documented
recall system is an important risk management
strategy that can assist in ensuring women with
abnormalities are appropriately followed up. In
many practices, the Practice Nurse coordinates
this recall system.
Clinical Skills
PowerPoint Presentation 4.6 Follow up and Referral
A client booklet: An Abnormal Pap Smear, what
it means for you (Commonwealth of Australia
2006) has been developed for women who have
an abnormal Pap smear result. This publication is
available from the Queensland Cervical Screening
Program website www.health.qld.gov.au/
cervicalscreening and from the National Cervical
Screening Program www.cervicalscreening.gov.au
Shorter version of this information is available from
the Queensland Cervical Screening Program . It can
be viewed or ordered from the website
Additional Readings
Report of the Steering Group of Quality Assurance in
Commonwealth Department of Human Services and
Health, Canberra.
Britten N (1988) Personal View. British Medical
Journal 296: 1191.
Grimes D (1988) Value of negative Smear. British
Medical Journal 296: 1363.
National Cervical Screening Program (2006)
Pap smear results: A Guide For Women With An
Abnormal Pap Smear.
Straton JAY (1994) Recruitment for Cervical
Screening. A Review of Literature. National Cervical
Screening Program. Australian Government
Publishing Service. Canberra. (Pages 17-29).
Clinical Skills
Since 1991 the National Screening Program has promoted two-yearly screening of eligible women
using the Papanicolaou (Pap) smear. This strategy has been very successful in decreasing the incidence
and mortality from cervical cancer.
The limitations of the Pap smear have generated the development of devices to improve the sensitivity
and specicity of the Pap smear and also address workforce shortages of cytologists. These include the
automated thin layer slide preparation system (ThinPrep) and image analysis devices to screen slides.
A number of these technologies are actively promoted to health professionals and consumers. Many
laboratories in Australia offer one or more of these tests on request, for an additional fee which is not
refunded through Medicare Australia or private health funds.
SUMMARY INFORMATION
Key concepts
liquid based cytology
automated and semi automated cervical
screening devices.
Learning outcomes
will be able to:
identify and critically evaluate new
technologies that are available for
cervical screening
discuss the advantages and
disadvantages of different technologies
and their use.
The National Cervical Screening Program
recommends Pap smears be used as the primary
method for screening until there is sufcient
evidence indicating the cost- effectiveness of
new cervical screening technologies.
1
New technologies have been explored to
automate cervical screening which has until
recently remained largely a manual procedure
in the Australian setting. Attempts to increase
the sensitivity and automate cervical screening
have led to the development of a number of
new technologies. These include liquid-based
cytology, such as ThinPrep and SurePath and
automated screening devices, for example the
Thin-Prep Imager and FocalPoint. Liquid-
based cytology is not publicly funded in
Australia at present as a review conducted by
the Medical Screening Advisory Committee
(MSAC) in 1998 determined there would be
limited benet and substantial cost involved in
publicly funding these technologies given the
effectiveness of the NCSP using the conventional
Pap smear (Australian Health Technology
Advisory Committee, 1998).
2
MSAC is presently
reviewing Automated Liquid Based Cytology in
Australia.
Liquid based cytology
Liquid-based cytology (LBC) whether ThinPrep
or SurePath thinlayer technology is the
production of a thin layer of cervical cells on
a microscope slide, suitable for diagnosis of
cytological abnormalities. These preparations can
be screened manually or by automated screening
which is supplemented by manual screening.
In the Private Sector, Liquid Based Cytology
(usually ThinPrep in Qld) has an additional
charge to the woman of approximately $30.
There is no Medicare rebate. In the public sector,
liquid based cytology is offered free of charge to
the woman if the criteria for an adjunctive test
is met as stated in the Queensland Health Policy
and Protocol for the use of ThinPrep
Automated Screening Technology
The Thin Prep Imaging System
The ThinPrep Imaging System is an automated
imaging and review system for use with
ThinPrep thin-layer slides. It combines imaging
technology to identify microscopic elds of
diagnostic interest with automated stage
movement of a microscope in order to locate
these elds. In routine use, the ThinPrep
Imaging system selects 22 elds of view for a
Cytotechnologist to review. Following review
of these elds, the Cytotechnologist will either
complete the diagnosis if no abnormalities
are identied or review the entire slide if any
abnormalities are identied (Cytec, 2002).
Clinical Skills
Diagram of ThinPrep vial and automated machine
FocalPoint Slide Proler
The FocalPoint Slide Proler prioritises the
slides based on the likelihood of abnormality to
help cytotechnologists reduce the incidence of
false negatives, by directing attention to slides
most likely to contain abnormality.
In the private sector, these methods of
computer-assisted screening have an additional
charge to the woman of approximately $30. This
technology is not available in private or public
labs in Queensland.
Optoelectronic Screening (TruScreen)
TruScreen is a relatively new Australian-
developed device that is used in conjunction
with the conventional Pap smear. The
TruScreen system consists of a portable console,
a handpiece and a single use sensor. TruScreen
uses a probe to emit electrical and light signals
onto the cervix. The sensor then measures the
reection and the computer analyses whether
the cells are normal or abnormal. The TruScreen
procedure takes an additional 1 2 minutes
after the conventional Pap smear collection
(Polartechnics).
TruScreen is slowly being released onto the
Australian market at an additional cost of
approximately $35 to the woman. There is no
Medicare rebate. The evidence in support of
Truscreen is somewhat variable. In the context
of the National Cervical Screening Program there
is no evidence to support TruScreen use nor is
there any obvious benet to women who are
having regular Pap smears.
8
The new technologies aim to improve the
quality of the cervical cell preparation, increase
human screener productivity, decrease the
unsatisfactory rate and increase the sensitivity of
the test.
NEW TESTS FOR CERVICAL CANCER SCREENING
Test Goals Advantages Disadvantages
Liquid-based/thin-
layer preparations
(e.g., ThinPrep,
AutoCyte Prep)
Improve the
quality of the Pap
smear
Decrease
unsatisfactory
Pap smears
Increase detection
of cancer precursors
High-quality smear
for review
Improved transfer
of cells from
collection device
Residual material
may be used for
HPV testing
Cost
Increased detection
of low-grade
lesions in initial
studies*
Retraining of
cytotechnologists
Computer-assisted
screening
(AutoCyte
Screen)
Improve Pap smear
interpretation
Increase laboratory
productivity
Increase detection
of cancer
precursors
Increase
cytotechnologist
productivity
May decrease
false-negative
reports
Cost
From studies on
PAPNET, increased
detection of low-
grade lesion*
*--There is controversy about whether this signicantly benets patients.
Advantages and Disadvantages of New Technologies
7
Clinical Skills
References
1. National Cervical Screening Program (2009) New
Technologies for Cervical Screening. Australian
Government Department of Health and Ageing.
1. Australian Health Technology Advisory
Committee (1998) Automated and semi-
automated cervical screening devices a
summary Australian Health Technology Advisory
Committee, Canberra.
2. The Medical Services Advisory Committee
Reference 12a Assessment Report (2002) Liquid
Based Cytology for Cervical Screening, Canberra.
3. Davey E, Barratt A, Inwig L, Chan SF, Macaskill
P, Mannes P and Vaville M (2006) Effect of
Study Design and Quality on Unsatisfactory
Rates, Cytology Classications, and Accuracy in
Liquid-Based Versus Conventional Cytology : A
Systematic Review Lancet 367:122-132.
5. Arbyn M,Bergeron CH, Klinkhamer P, Martin-
Hirsch P,Siebers G and Bulten J (2008) Liquid
Compared with Conventional Cervical Cytology.
A Systematic Review and Meta-analysis.
Obstetrics and Gynaecology 111: 1; 167-177.
4. Cytec Corporation (2002) Thin Prep Imaging
System. Cytec United Kingdom.
Queensland Health Policy and Protocol for the
use of Thin Prep. Queensland Health, Brisbane.
8. Singer A, Coppleson M Canfell K, Skladnev
V, Mackellar G and Pisal N (2003) A real
time optoelectronic device as an adjunct
to the Pap smear for cervical screening: A
multicentre evaluation. International Journal of
Gynaecological Cancer, 13: 804-811.
PowerPoint Presentation 4.6 New Technologies Part 2
Section of the Handbook CD.
Queensland Health Policy and Protocol for the Use of
Liquid Based Cytology (LBC), Information Sheet see
website www.health.qld.gov.au/cervicalscreening
Clinical Skills
Infection with Human papillomavirus (HPV) is a major risk factor for cervical cancer. There are over
a 200 strains of genotypes of HPV however infection with HPV 16 is responsible for 50% of cervical
cancers and HPV 18 is responsible for an additional 20% of cancers.
1
Vaccines have been developed for preventing infection with high risk HPV 16 and 18.
HPV DNA testing is available to identify if a woman has HPV and whether it is a high risk type HPV or a
low risk HPV. This test is has been approved for use as a test of cure for women following treatment
of a high-grade cervical abnormality.
Key concepts
HPV vaccination
HPV DNA testing.
Learning outcomes
will be able to:
explain the concept and purpose of HPV
vaccine
describe the National HPV Vaccination
Program
explain the HPV test of cure for
women treated for high-grade cervical
abnormalities.
SUMMARY INFORMATION
Persistent infection with high risk HPV types
can cause cell changes that may lead to cervical
cancer over a period of about 10 years. High risk
HPV types 16 and 18 are linked to 70-80% of
cervical cancers and about 50% of high grade
cervical pre-cancerous lesions in Australia. HPV
types 16 and 18 also account for about 25% of
low grade cervical abnormalities.. Low risk HPV
types include type 6 and 11 which are linked to
approximately 90% of genital warts cases and
around 10% of low grade cervical abnormalities.
1
Two vaccines for prevention of infection with
high risk HPV have been developed and are
currently available in Australia; a quadrivalent
vaccine against types 6/11/16 and 18 called
Gardasil and a bivalent vaccine against 16 and
18 called Cervarix. Gardasil is licensed for use
in Australia for females aged 9 to 26 years and
males aged 9 to 15 years. Cervarix is licensed
for use in Australia for women aged 10 to 45
years. Both vaccines are comprised of three doses
to ensure optimal protection.
2
These vaccines
are most effective when given before exposure
to HPV (that is, before any sexual activity takes
place) to produce immunity to HPV. The vaccines
assist the womans immune system to destroy
the virus before an infection becomes fully
established.
The HPV vaccine should not be seen as a
replacement for Pap smears. Being vaccinated
lowers the chances of becoming infected with
the high risk HPV types contained in the vaccine.
Women who have ever had sex need to continue
with two-yearly Pap smears so that any changes
to the cells of the cervix can be detected and
if necessary, treated in accordance with the
NHMRC Guidelines for Asymptomatic Women
with Screen Detected Abnormalities.
www.nhmrc.gov.au/publications
The duration of immunity from vaccination
with Gardasil is not yet known, but research
has shown that Gardasil confers protective
immunity and efcacy for at least ve years and
there is no indication currently that boosters
will be needed. In addition, there is evidence
of immune memory response, so long term
protection is likely. Clinical trials are continuing
and the results will be monitored to determine
whether booster doses will be needed in the
future.
3

To date Gardasil is the only vaccine to be
included on the Australian National HPV
Vaccination program. It is estimated that the
vaccination program will reduce the lifetime
risk of cervical cancer by 48%, compared to
the current screening system. This estimate
is based on data from the National Cervical
Screening Program in Australia, 100% vaccine
effectiveness, lifetime duration of efcacy
and 80% coverage. The vaccine should also
substantially reduce the incidence of cervical
precursor lesions and related interventions.
4
Clinical Skills
As HPV vaccines do not protect against
all cancer-causing HPV types, vaccinated
women still need to have regular Pap smears
through the National Cervical Screening
Program to ensure early detection and
treatment of cervical lesions.
As Australia is the rst country in the world
to commence a national vaccination program
against HPV, Australian women will be the rst
cohort of young women in the world where
further reductions in cervical cancer mortality
and morbidity are likely to be observed.
4
The National HPV Vaccination Program
Implementation of a vaccination program for 12
to 26 year old women has been shown to be cost
effective in Australia.
4
The National HPV Program
is funded by the Australian Government. The
school based program commenced in April 2007
and the community based program in July that
year. Under the program, the HPV quadrivalent
vaccine Gardasil is provided free to girls and
women aged 12 to 26 years. There are three
aspects to the program:
an ongoing vaccination program for all 12
year olds girls
a two year catch-up program for school girls
aged 13-18 and
a general practitioner based program for
women aged 19 to 26 years.
The catch-up and general practitioner based
programs ended in June 2009.
The National HPV Vaccination program
represents an additional prevention strategy
against cervical cancer and other HPV related
diseases and will complement the National
Cervical Screening Program.
A National HPV Vaccination Program Register
Legislation was passed by the Australian
Government in 2007 to establish a HPV Program
Register which would receive data from all
states and territories. Personal details are kept
condential and only used to evaluate the
impact of the HPV Vaccination program on
cervical cancer rates, to issue reminders if the
course is incomplete, to issue conrmation
the course is complete and to contact vaccine
recipients should booster doses be required.
3

For more information see website:
www.hpvregister.org.au
HPV DNA Testing
As mentioned earlier there is a well established
link between cervical cancer and infection with
HPV. A number of types of HPV (commonly
referred to a high risk or oncogenic HPV) are
associated with cervical cancer (primarily,
HPV16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58,
59 and 68). A test is available to detect HPV,
called an HPV DNA test. This test identies if a
woman has HPV and whether it is a high risk
type of HPV or a low risk HPV. The test is usually
collected at the same time as a Pap smear using
the same or similar collection devices. This test
is available in Australia but is quite expensive
(approximately $80.00) and is only subsidised by
the government as a test of cure.
References
1. Clifford GM, Franceschi S, Diaz M et al. (2006)
HPV type-distribution in women with and
without neoplastic diseases. Vaccine 24
Supplement
3: s26-34
2. Australian Government, Department of Health
and Ageing (2009) National Cervical Screening
Program. www.cancerscreening.gov.au
3. Wain G 2008 HPV Vaccines and the Australian
Human Papillomavirus (HPV) Vaccination
program. Cancer Forum, 32;2: 96-98
4. Kulasingam S, Connelly L, Conway E et al .2007
A cost-effectiveness analysis of adding human
papilloma virus vaccine to the Australian
National Cervical Screening Program. Sexual
Health, 4 165-17.
5. MSAC Reference 12a Assessment report (2002)
Liquid based cytology for cervical screening.
Commonwealth of Australia, Canberra.
6. Davy M (2006) The Queensland Cervical
Screening Program Update. Queensland Health,
Brisbane.
7. Mc Crory DC, Matchar DB et al (1999) Evaluation
of cervical cytology. Agency for Health Care
Policy and Research, Publication No. 990E010,
Rockville, MD.
8. Garland S M (2006) Human Papillomavirus
Vaccines: Challenges to Implementation. CSIRO
Publishing and MINNIS Communications Sexual
Health, 3: 63-65.
HPV DNA testing in Australia is recommended
under the National Health and Medical Council
(NHMRC) Guidelines for the Management of
Abnormalities who have had treatment for HSIL
in order to identify those women who are at risk
of further high-grade disease.
www.nhmrc.gov.au/publications
HPV DNA Test of Cure is only covered by
Medicare for women with a biopsy-proven
HSIL following treatment. For these women it
is recommended that HPV DNA testing should
be performed in addition to a Pap smear 12
months after treatment and then again annually
with a conventional Pap smear until both tests
appear normal on two consecutive occasions.
1,6

Queensland Health has developed a Policy and
Procedure for HPV DNA Test of Cure.
Additional applications of HPV DNA testing are
to be explored further in the Australian setting
in view of the implementation of the National
HPV Vaccination Program.
Clinical Skills
PowerPoint Presentation 4.7 HPV Vaccine and HPV
Testing Presentations: Part 2 Section of Handbook
CD.
Information Sheet: Queensland Health Policy and
Procedure for HPV DNA Test of Cure
Quality
Assurance
Activities
SECTION 5
Key concepts
medico-legal aspects of cervical
screening
risk management strategies
indemnity procedure guidelines
quality assurance check list.
Learning outcomes
will be able to:
describe the key components of a high
quality system for cervical screening
within medical practice
discuss the medico-legal aspects and
risk management strategies for cervical
screening
explain how they would seek advice on
both individual and practice indemnity
situations.
The provision of high quality cervical screening is essential in achieving positive outcomes for eligible
women. A number of medico-legal issues have been associated with cervical screening which Pap
smear providers need to be aware of. Claims have been made against Pap smear providers and
laboratories.
A number of key principles need to be taken into consideration as part of risk management to ensure
that service providers are meeting their legal responsibilities for cervical screening.
SUMMARY INFORMATION
5.1 Risk Management
Quality Assurance Activities SECTION 5
5.1 Risk Management
Delay in diagnosis or failure to diagnose cancer
are the main causes of medically related
litigation.
1
Claims against Pap smear providers can
allege:
failure to offer cervical screening
failure to investigate vaginal bleeding,
particularly post coital bleeding
failure to collect appropriate cells during the
procedure
failure to arrange specialist care when there
is vaginal bleeding or any other concerning
symptom/s
failure to inform a woman of an abnormal
Pap smear result and to arrange for
appropriate care.
2

Claims against laboratories can allege:
failure to detect and report abnormal cells on
a Pap smear
failure to report a specimen as unsatisfactory
For the claim of negligence to succeed,
the plaintiff must prove that:
a duty of care was owed and what the
standard of that duty was
the care offered was less than a reasonable
standard for the duty of care
the illness experienced was a direct
consequence of that failure of the duty of
care.
2

Within the cervical screening program, the area
of contention relates to the reasonable standard
for the duty of care for both the medical
practitioner and the laboratory. To date, little
progress has been made in dening objective
standards of care. Several reasonably high-
prole cases have proceeded to trial, most have
found in favour of the plaintiff. Other cases
have been settled out of court. This means that
each case of alleged negligence still has to be
defended on an individual basis.
2
In the present highly litigious world all those
involved in cervical screening have their own
professional indemnity insurance to ensure that
their personal nancial interests are adequately
protected. It is vital that medical Pap smear
providers have proper protection against the
costs associated with defending a legal action.
Whether the action has any basis in truth or not,
it will still be an expensive exercise to prove their
innocence.
3
There are various medical indemnity insurers that
can be accessed. The Royal Australian College of
General Practitioners provides advice on medical
insurers.
3
Managing risk in General Practice
appropriate training is vital
ensuring women are aware the Pap smear is
not perfect but regular screening offers the
best protection against cervical cancer
good Pap smear technique
It is important to review these reports and
identify any areas where the indicators differ
from the average results provided. For example,
a high number of Pap smears without an
endocervical component could indicate that
the transformation zone is not being sampled
adequately and may indicate the need for
further training in Pap smear technique.
Participating in Quality Assurance Activities
Pap smear providers should be encouraged to
participate in quality assurance activities, e.g.
Pap smear audits or specic training programs.
Credits often apply for participation in these
activities which contribute to continued
vocational registration for medical practitioners
or continued fellowship of the Royal Australian
College of General Practitioners (RACGP) and
Royal Australian and New Zealand College of
Obstetricians and Gynaecologists ( RANZCOG).
4
Laboratory Quality Assurance
Pathology laboratories must be registered with
the National Association of Testing Authorities
(NATA). A list of registered pathology
laboratories is available from NATA, RACGP
and RANZCOG. NATA requires all cytology
laboratories to have internal quality assurance
mechanisms and to be actively involved in The
Royal College of Pathologists of Australia (RCPA)
external quality assurance program.
5,6,7
following the recommendations for the
treatment and management of asymptomatic
women with screen-detected abnormalities
investigation of women with symptoms or
signs even if the Pap smear is reported as
negative
referral for a specialist assessment when
indicated
establishing practice standards for:
- the return of results
- the notication of results
- follow-up processes for abnormal results
- recall and reminder systems
advising women of the Pap Smear Register
(PSR) and promoting the benets of the PSR
as a back-up reminder system and safety
net.
4
Quality assurance mechanisms
Obtaining a Quality Pap Smear
It has been demonstrated that feedback
improves the performance of Pap smear
providers.
4
Laboratories provide regular feedback
to Pap smear providers about the following:
the proportion of unsatisfactory smears
the proportion of smears that lack an
endocervical component
the proportion of Pap smears showing
abnormalities.
References
1. Curtis P, Varenholt JJ Skinner B Addison L,
Resnick J and Kebede M (1993) Development of
Pap Smear Quality Assurance System in Family
Practice. Clinical Research and Methods.
25:135-39.
2. Kearney MA (1996) Is There a Medical Litigation
Crisis. Medical Journal of Australia 164: 178-182.
3. Australian Doctor (1998) Litigation is becoming
an issue. An article. March 1998.
4. www.racgp.org.au
5. www.ranzcog.edu.au
6. www.rcpaqap.com.au
Canberra.
Additional Readings
Report of the Steering Group of Quality Assurance
in Screening for the Prevention of Cancer of the
Cervix. Commonwealth Department of Human
Services and Health, Canberra. (Chapter 2)
PowerPoint Presentation 5.1: Risk Management
Presentations: Part 2 Section of the Handbook CD.
General practitioners play a central role in cervical screening and are in an ideal position to encourage
women to participate in cervical screening. A clinical audit gives general practitioners an opportunity
to enhance their awareness of cervical screening rates, the cytological quality of Pap smears performed
and management of women with screen detected abnormalities in their practice. More importantly
clinical audits allow general practitioners to compare their practice with an accepted standard and
develop strategies to modify practice if necessary. It has been demonstrated that such activities
improve performance and maintain it at a high level.
1
In addition to this, Pap smear providers should
be encouraged to participate in update training programs related to Pap smear audits.
SUMMARY INFORMATION
Key concepts
rationale and process for clinical audits
in medical practice
information about Continued
Professional Development (CPD)
activities relating to clinical audits and
how to participate.
Learning outcomes
Participants of the cervical screening course
will be able to:
explain how they will utilise reports
from cytology providers to improve their
own practise
describe how they will undertake
regular audits within their own practice
describe how they will identify under-
screened women in their own practice as
a result of the audit
participate effectively in Continued
Professional Development (CPD)
activities relating to clinical audits.
5.2 Clinical Audits
A clinical audit is a planned medical education
activity designed to help general practitioners
review aspects of their own clinical performance
in practice with the aim of improving patient
care.
1
A clinical audit has two main components:
an evaluation of the care that the individual
general practitioner provides
a quality improvement process.
A clinical audit compares actual clinical practice
against established standards of practice. A
clinical audit is not the same as research.
2
The
following information provides an example of
Step 1
Needs assessment
Step 2
Identify standards
Step 5
Monitor progress
analysis
Step 3
Data collection
Step 4
Identifying and
implementing change
5.2 Clinical Audits
a clinical audit and has been obtained from
RACGP. RACGP has kindly given Queensland
Cervical Screening Program permission to
reproduce this information.
Why do a clinical audit?
Research into evidence-based medicine shows
that a clinical audit is more likely to result in
changes in general practitioners behaviour
and improvement in practice than traditional
didactic medical education methods. As a quality
improvement tool, a clinical audit is accepted
internationally and supported by research.
Clinical audit activities are based on the following cycle:
Who participates in the clinical audit?
Clinical audits are designed to seek the
participation of a group of general practitioners.
Small group audits may be designed by the
group itself or may be externally designed by an
education provider. (A small group consists of
4-10 participants of which 50% of those must
be general practitioners). Individual general
practitioners may design their own audits which
may be specic to their own practice.
Who organises the clinical audit?
An education provider develops the audit tools,
and advertises and recruits individual GPs. Many
ready made clinical audits are provided by
various groups, eg. divisions of General Practice,
universities, RACGP and other organisations.
Practice-based groups are encouraged to develop
clinical audits to investigate issues of relevance
to their practice. A small group clinical audit
template is available on the RACGP website to
assist with this development.
Mode of delivery
Data may be collected and collated on-line or
be paper-based. Feedback mechanisms vary and
may be face-to-face, on-line or via paper based
materials.
Program duration
Clinical audits can either be of xed time
duration, or by certain number of patients,
depending on the prevalence of the condition or
the issues for audit, eg. if presentation is quite
rare, the audit may continue for more than 1
year. Other audits are structured around patient
numbers, which may include large numbers
collected over a short period of time, eg a
practice that performs a large number of Pap
smears over 3 to 6 months.
Points allocation
Points are allocated according to the relevant
organisations standards. Information is usually
readily available on-line, for example RACGP
allocates 30 points to Steps 1-5 of the audit
described in the Clincal Audit activities diagram
on page 101.
References
1. Williams PA, Williams M (1988) Barriers and
Incentives for Primary Care Physicians. In Cancer
Prevention and Detection. Cancer 61: 2382-90.
2. The Royal Australian College of General
Practitioners 2007 QA and CPD Quality Assurance
and Continuing Professional Development
Program handbook 2008-2010 Triennium. The
Royal Australian College of General Practitioners,
Melbourne. http://www.racgp.org.au The Royal
Australian College of General Practitioners has
kindly given Queensland Cervical Screening
Program permission to reproduce the section on
Clinical Audits.
Additional Readings
Health (1994) Making the Pap Smear Better. Report
of the Steering Group on Quality Assurance in
Health. Canberra.
NSW Cervical Screening Program (2002)
Opportunistic Cervical Screening in General Practice
NSW Cervical Screening Program.
Westmead Hospital, Sydney.
www.csp.nsw.gov.au
Supporting Material
PowerPoint Presentation 5.3 Clinical Audits
Presentations: Part 2 Section of the Handbook CD.
Key concepts
information about the Queensland
Health Pap Smear Register (PSR), its
function and role
Pap smear providers legal obligations
with respect to the PSR.
Learning outcomes
will be able to:
explain the role and benets of
the PSR
encourage women to participate in
the PSR
explain the opt-off process to prevent
the transfer of data to the PSR
know how to access PSR and complete
necessary documentation
explain their legal obligations in relation
to the PSR
Cytology registers have an important role both in quality assurance and in the recruitment of women
into the cervical screening program. An accurate register that identies all eligible women who are
having Pap smears and how often they are having them, is essential to achieve rates of participation
in a successful screening program. Registers also enable the identication of eligible women who are
not having Pap smears, using population registers, such as the electoral roll, and provide a basis for
targeted recruitment programs.
SUMMARY INFORMATION
The Queensland Health Pap Smear Register (PSR)
commenced operations on 8 February 1999
under Amendments to the Health Act 1937.
Provisions were then updated and transferred
into the Public Health Act 2005. The current
provisions commenced on 1 December 2005.
The Legislation requires:
1) Pathology laboratories to provide
information to the PSR
2) Protect the privacy and condentiality of
womens data and support the opt-off
principle
3) Pap smear providers to inform women about
the PSR.
Under this legislation, Pap smear providers,
pathology laboratories and the PSR have
legislative obligations to ensure women are
correctly placed on the register.
The legislation also ensures that womans
information is strictly condential and access to
womens information is restricted to her health
care provider, and pathology laboratories.
The information included on the PSR is
obtained by electronic transfer from pathology
laboratories which interpret Pap smears and
related cervical tests. For this reason it is
essential that the personal information provided
about the woman is accurate to ensure her
results can be matched to any previous results
on the PSR.
The Functions of the PSR
The PSR provides:
reminders to women who are overdue for
their next Pap smear as a back-up to existing
reminder systems
mechanisms to help ensure that women with
abnormal Pap smear results or technically
unsatisfactory Pap smears are advised to
receive appropriate follow-up (acts as a
safety net)
data to help monitor and evaluate the
effectiveness of the cervical screening
program
screening histories to assist pathology
laboratories to interpret a womans current
Pap smear and make clinical management
recommendations
screening histories for Pap smear providers to
assist in clinical management.
information to assist in the development of
recruitment strategies for unscreened and
under-screened women.
Pathology Laboratory Responsibilities
Pathology laboratories are required to provide
Pap smear and related histology results to the
PSR, no later than 4 weeks after the results of
the tests are given to the person who asked
for the test, unless there is a notation on the
pathology request form to indicate that the
womans information must not be given to the
PSR.
Pap smear provider responsibilities
It is the Pap smear providers responsibility under
the Public Health Act to inform each woman
having a Pap smear, HPV DNA test, cervical/
vaginal biopsy and other related procedures
about the PSR. This includes:
the existence and purposes of the PSR, and
the identifying and clinical information
about the woman that may be recorded in
the PSR, and
that the woman may elect for her
identifying and clinical information not to be
automatically included in the PSR.
GP information kits are available for Pap smear
providers to assist them in fullling their
responsibility in informing women about the
PSR. (Freecall 1800 777 790 or visit
www.health.qld.gov.au/cervicalscreening)
Unless the woman opts-off, her identifying
information and Pap smear, HPV DNA test or
histology results will automatically be provided
to the PSR by the pathology laboratory reading
the sample.
Pap smear providers who fail to inform women
about the PSR will incur no penalties.
The results extracted must be the nal results
that have been quality assured for women who
usually reside in Queensland.
Pathology laboratories have a responsibility to
ensure that if a woman has opted-off the PSR,
her identifying information and results will be
excluded from the pathology laboratory data
extraction for the register.
Pap Smear Register responsibilities
The PSR will ensure that information is provided
to Pap smear providers to assist them in fullling
their responsibility in informing women about
the register.
The PSR will ensure that information is provided
to the Laboratories to assist them in fullling
their responsibility in forwarding Pap smear
results to the register, for women who have not
chosen to opt-off.
After a womans identication is included on
the PSR, the Register will send the appropriate
Welcome letter to the woman stating her
information has been included in the Register.
Enrolment of Women on the Pap Smear Register
Women are registered on the PSR when they
have a Pap smear, HPV DNA Test or cervical/
vaginal histology performed. Inclusion is by an
opt-off system where women are automatically
included on the Register unless they specically
elect for their information not be provided to
the PSR.
1
Refusal to give consent (woman wishes to opt-
off)
If a woman indicates she chooses not to be
included on the Pap Smear Register, the Pap
smear provider should write or attach a sticker
-NOT FOR PAP SMEAR REGISTER on the
pathology request form.
The Pap smear provider will also make a notation
in the womans health record or ll out an
Exclusion from the Pap Smear Registry form
to record the womans decision to opt-off
and that the womans identifying and clinical
information must not be given to the PSR.
Women who have opted-off previously
For women who have opted off previously,
the Pap smear provider must ask the woman
whether she wants to reconsider her decision
each time she has a Pap smear or related test.
If the woman still does not want to be included
on the PSR, the Pap smear provider should
write or attach a sticker NOT FOR PAP SMEAR
REGISTER on the pathology request form.
If the woman reconsiders her decision and
tells the Pap smear provider she now wants
her identifying and clinical information to be
forwarded to the PSR, the provider must:
make a notation in the womans health
record or note on the existing (original)
Exclusion form the womans decision and
that the womans identifying and clinical
information must now be forwarded to the
PSR, and
send the sample and the pathology request
form to the pathology laboratory without a
NOT FOR PAP SMEAR REGISTER sticker.
Welcome letters
When the womans rst results (either Pap smear,
HPV DNA test, biopsy or hysterectomy) are
received and they are registered on the PSR, a
Welcome letter is automatically generated.
The Welcome letter states:
the information has been included in the PSR
the woman may have her screening history
removed from the PSR
the woman may have her identifying
information changed if she considers the
information is incorrect, and
the way the woman may have her registered
screening history removed or her identifying
information changed.
The Welcome letter also informs the woman:
what information is collected by the PSR
the benets of being on the PSR
how women can access their own records
from the PSR, and
who can access her information and what it
can be used for.
Welcome letters are sent to addresses provided
by the pathology laboratories.
Privacy concerns
For women concerned about receiving mail
from the PSR, the following processes have been
implemented:
all PSR mail addressed to women is in
a window face envelope with no items
identifying the PSR.
References
The Queensland Health Pap Smear Register.
Additional Readings
Health (1994) Making the Pap Smear Better. Report
of the Steering Group on Quality Assurance in
Screening for the Prevention of Cancer of the Cervix
Health, Canberra.
PowerPoint Presentations 5.4 Queensland Health Pap
Smear Register: Part 2 Section of the Handbook CD.

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