STEP 1: Prevention and early detection
A healthy diet, avoiding or limiting alcohol intake, taking regular exercise and maintaining a healthy body weight may help reduce cancer risk. This step outlines recommendations for the prevention and early detection of cervical cancer.
The number of new cases of cervical cancer is likely to be dramatically reduced as the benefits of human papillomavirus (HPV) vaccination are realised (Hall et al. 2018). It is likely that in the future, cervical cancer will largely (but not exclusively) be confined to women who have not been immunised, or for whom immunisation comes well after exposure to HPV.
Three HPV vaccines are registered for use in Australia – Gardasil, Gardasil 9 and Cervarix. All three vaccines protect against the two high risk HPV types (16 and 18) which are associated with around 70 per cent of cervical cancers in Australian women. Gardasil and Gardasil 9 also protect against two low risk HPV types (6 and 11), which cause 90% of genital warts (Cancer Council Australia, 2017). Gardasil 9 replaced Gardasil on the National Immunisation Program in January 2018, Gardasil 9 commenced use in the NHVP program for 12 and 13-year-old girls and boys. This is protecting against an additional five strains of HPV (31, 33, 45, 52 and 58), and predicted to further reduce the incidence of cervical cancer (Simms K T el al 2016). HPV vaccination is delivered via a school-based program to adolescent females and males in years 7 or 8 (i.e. aged 12 to 13 years) as part of the National Immunisation Program, with a catch up program available to individuals (females and males) up to the age of 19 years.
The National Cervical Screening Program aims to prevent cervical cancer by detecting early changes in the cervix. A five-yearly HPV test for women aged 25–74 years began on 1 December 2017 to replace the previous two-yearly Pap test for women aged 18–69 years. The cervical screening test checks for the presence of HPV, the causal agent for most cervical cancers (Australian Government Department of Health 2017).
Self-sampling is available to women at least 30 years of age and who are considered under- screened (four or more years since last Pap test), or who have never been screened and who decline a practitioner-collected specimen. Self-collection is a vaginal swab for HPV testing.
HPV-vaccinated women still require cervical screening tests because the HPV vaccine does not protect against all the types of HPV that cause cervical cancer.
Primary health practitioners, including general practitioners and nurses, play a crucial role in encouraging women to screen regularly.
For more information refer to the 2016 guidelines: The National Cervical Screening Program: guidelines for the management of screen-detected abnormalities, screening in specific populations and investigation of abnormal vaginal bleeding.
Long-term infection with certain types of HPV is known to be the cause of most cervical cancers. HPV is a common virus, with four out of five people having HPV at some time in their lives (Australian Government Department of Health 2017). In most cases, the infection is transient, but in rare cases, if the virus persists (usually over a 10-year period) and if left undetected, can lead to cervical cancer.
Currently the best protection against progressing to a cervical cancer is participating in regular cervical screening (Victorian Cervical Cytology Registry 2017).
Certain groups are less likely to access cervical screening and therefore are at higher risk. Vulnerable groups include Aboriginal and Torres Strait Islander people and culturally and linguistically diverse populations. For more information refer to the National Cervical Screening Program toolkit for engaging under-screened and never-screened women.
Other risk factors include:
- smoking
- previous abnormality or cancer of the cervix
- having many children
- exposure to diethylstilboestrol (DES) (Cancer Australia 2017)
- taking contraceptive pills for a long time
- being HIV positive
- being immunocompromised or taking immunosuppressive medication (Cancer Research UK 2014; Ngyuyen & Flowers 2013).
Cervical cancer is one of the most preventable cancers through HPV immunisation and regular cervical screening.
In Australia, women with disabilities are under-screened for cervical cancer compared with Australians without a disability (Department of Health and Human Services 2013). Barriers include physical limitations, competing health needs that require more urgent medical attention, the trauma of undergoing an invasive test, and lack of information. Assumptions that all women with disabilities are not sexually active also need to be addressed.
Rape victims and survivors of previous sexual abuse may also need additional support, including issues around disclosure of past history of sexual abuse or trauma.
The following approaches are recommended to promote participation and improve the experience of cervical screening:
- Consider reasonable adjustments, including alternative pathways, such as self-collection.
- Consider informed consent and the potential barriers associated with obtaining this, particularly if a power of attorney lies with a family member or carer.
- Encourage women to bring a support person with them to appointments.
- For women with disabilities, encourage use of the Australian Institute of Health and Welfare disability flag at the point of admittance, and note any disabilities in referral forms to diagnostic assessment.
- Ensure facilities actively address the access requirements of people with disabilities.
- Consider catch-up HPV vaccination if appropriate.
