Cervical Cancer Screening
By Dr Michael Gannon
It is time to sink some of the myths around changes to National Cervical Screening Program (NCSP). The well-intentioned change.org petition, which is hurtling past 50,000 signatures, is nonetheless woefully misinformed and misguided. The new guidelines are evidence-based, and a fabulous good news story for girls and women across Australia.
The new guidelines have been developed over many years by an eminent panel of Gynaecologists, Pathologists, Clinicians, and Scientists. They have been meticulously reviewed through the Medical Services Advisory Council (MSAC) process, and represent a further improvement to the Cervix Cancer screening program, which was already the world’s best.
The new NCSP reflects an increased understanding of the biology of Cervix Cancer. It reflects the changes in epidemiology that will accrue from having a population of young adults (boys and girls) who should nearly all be vaccinated against cancer producing HPV (wart virus) infection.
These changes will mean that millions of women can perfectly safely reduce the number of times they face the nuisance, expense, and discomfort of having Pap smears. Perhaps the only down side of the change is the health promotion opportunities that have accrued from women visiting their GP on a two-yearly basis.
Nonetheless, it will lead to thousands of women avoiding the anxiety of an abnormal Pap smear and an appointment for follow-up testing. In time, this will result in thousands of women avoiding the need for referral to a Gynaecologist for examination and Colposcopy.
Most importantly, it will mean that thousands of women will avoid surgery historically performed (in good faith) to reduce the risk of progression to severe pre-cancerous changes or Cervix Cancer.
The natural history of HPV infection is that, in many cases, especially in healthy, young non-smokers, the immune system will eliminate the virus without treatment. These women need not have surgery.
The old system was never particularly good in detecting Cervix Cancer in women under the age of 25. The progression from pre-cancerous change to invasive Cancer typically takes many years. The change from cytology (examining the cells under a microscope) to HPV testing is appropriate, with more than 99 per cent of cases of Cervix Cancer being caused by HPV infection.
The most important reason to reduce the number of women having this kind of surgery is to reduce short and medium term risks such as infection, haemorrhage, and cervical stenosis.
Most importantly, at a population level it will reduce the incidence of Cervical Incompetence and preterm birth.
Prematurity is the number one cause of death and disability in children less than five years old in the developed world.
In many women, preterm birth occurs secondary to a deficiency in the defence mechanism that a length of closed cervix provides. A reduction in the number of women having surgery on the uterine cervix will be expected to reduce the incidence of prematurity.
Prematurity is associated with increased risks of Cerebral Palsy, chronic lung disease, intellectual impairment, hearing impairment, blindness, learning difficulties, and behavioural problems.
The NCSP changes will thus save taxpayers millions of dollars, but they are not merely a cost-saving measure. This is a well thought out, evidence-based change to Gynaecological practice, which will be a bonanza for improvements in child health.
The existing Cervix Cancer screening program was never perfect in detecting non-HPV-related cancers. It is absolutely essential that, with the new NCSP guidelines, we remind women of the importance of presenting for asymptomatic screening.
It is also absolutely essential that all women are encouraged to report abnormal bleeding to their GP. Whether this bleeding occurs throughout the cycle or after intercourse, it must (as always) be interrogated. It will remain the case that women under the age of 25 with abnormal bleeding will merit Gynaecological investigation and care.
This is a good news story for not only the health of Australian women and girls, but that of their future children. The fact that it is likely to be cost-effective is an added bonus for the taxpayers who fund the success story that is Australia’s NCSP.
Dr Michael Gannon is AMA President and Head of Department, Obstetrics & Gynaecology, St John of God Subiaco Hospital in Perth.
Published: 23 Feb 2017