Download - VCCR Statistical Report - 2012
STATISTICAL REPORT 2012
2
Editorial Committee:Associate Professor Dorota Gertig, VCCR Medical DirectorAssociate Professor Marion Saville, VCS Executive DirectorDr Julia Brotherton, Epidemiologist
Genevieve Chappell, VCCR ManagerBianca Barbaro,Senior Research Offi cerLesley Rowlands, Follow-up Manager Produced by: Tanya O’Farrell, Health Information Manager (Registry Operations)
Victorian Cervical Cytology RegistryPO Box 161, Carlton South, Victoria 3053 Telephone: (03) 8417 6816 Email: [email protected]: www.vccr.org
STATISTICAL REPORT 2012
The Victorian Cervical Cytology Registry
acknowledges the support of the Victorian Government
4
CONTENTS
EXECUTIVE SUMMARY 6
1. INTRODUCTION 7 1.1 Background 71.2 Functions of the VCCR 71.3 National Policy: the NHMRC Guidelines for the Management of Asymptomatic Women with Screen Detected Abnormalities and Renewal of the Cervical Screening Program 71.4 The National HPV Vaccination Program 71.5 Data included in this report 8
2. PARTICIPATION IN SCREENING 92.1 Number of Pap tests and women screened 9 Table 2.1:NumberofPaptestsregisteredandnumberofwomenscreenedinVictoria,1990–2012. 92.2 Participation by Age Group 9 Table 2.2:Estimatedcervicalscreeningratesbyagegroupoveroneyear,twoyear, threeyearandfiveyearperiods. 10 Figure 2.2.1:Estimatedtwoyearcervicalscreeningratesbyagegroup,2000-01to2011-12. 11 Table 2.2.1: Estimatedtwoyearcervicalscreeningratesbyagegroup,2000-01to2011-12. 112.3 Participation by Area 12 2.3.1 Participation by Medicare Locals 13 Table 2.3.1: EstimatedtwoyearcervicalscreeningratesbyMedicareLocal,2010-2011
and2011-2012. 13Figure 2.3.1: EstimatedtwoyearcervicalscreeningratesbyMedicareLocal,2011-2012. 14
2.3.2 Participation by Department of Health Region 15 Table 2.3.2: EstimatedtwoyearcervicalscreeningratesbyDepartmentofHealthregion,
2010–2011and2011–2012. 15 Figure 2.3.2: EstimatedtwoyearcervicalscreeningratesbyDepartmentofHealthregion,2011–2012. 15 2.3.3 Participation by Local Government Area 16 Table 2.3.3: EstimatedtwoyearcervicalscreeningratesbyLocalGovernmentArea,
2010–2011and2011–2012. 16 Figure 2.3.3:EstimatedtwoyearcervicalscreeningratesbyLocalGovernmentArea,2011–2012. 182.4 Pap tests collected by Nurses 19 Table 2.4: ProportionofPaptestscollectedbynurses,2003–2012. 19 2.4.1 Proportion of Pap Tests Collected by Nurses by Department of Health Region 20 Table 2.4.1: Paptestsforwomenwithacervixcollectedbynurses,byDepartmentof Healthregion,2012. 20 Figure 2.4.1: ProportionofPaptestscollectedbynurses,byDepartmentofHealthregion,2012. 212.5 Closing the Data Gaps:Identifying Aboriginal and Torres Strait Islander People, and collecting country of birth and language spoken at home 22 Table 2.5 (a): ProportionofWomenScreenedbyAboriginalandTorresStraitIslanderOrigin. 22
Table 2.5 (b): ProportionofPapTestsbyPractitionerTypewithAboriginalandTorresStrait IslanderOriginInformationrecorded. 222.6 Frequency of Early Re-Screening 23
Table 2.6: SubsequentPaptestsovera21monthperiodforwomenwithanegativereportinFebruaryof2011. 23
Figure 2.6: Earlyre-screeningafteranegativePaptestreportinFebruary2011byagegroup. 23
VictorianCervicalCytologyRegistryStatistical Report 2012 5
3. CYTOLOGY REPORTS 243.1 Unsatisfactory Pap tests 243.2 Negative Pap tests 243.3 Pap tests without an endocervical component 24 Figure 3.3: PercentageofPaptestswithoutanendocervicalcomponent. 243.4 Pap tests with a squamous abnormality 25 Table 3.4: NumberandpercentofPaptestscollectedin2012withasquamousabnormality. 253.5 Pap tests with an endocervical abnormality 25 Table 3.5:NumberandpercentofPaptestscollectedin2012withanendocervicalabnormality. 253.6 Type of tests 25
4. HISTOLOGY REPORTS 26 Table 4: HistologyfindingsreportedtotheVCCRin2012. 26
5. HIGH-GRADE ABNORMALITY DETECTION RATES 27 Figure 5.1: Detectionrateofhigh-gradeintraepithelialabnormalities(histologically-confirmed)from
2009-2012per1,000screenedwomen. 27Figure 5.2: Trendsinhigh-gradecervicalabnormalities(histologically-confirmed)byage,2000–2012,VCCR. 27
6. CORRELATION BETWEEN CYTOLOGY AND HISTOLOGY REPORTS 28 Table 6.1: Correlationofsquamouscytologytothemostserioussquamoushistologywithin6months, womenaged20to69years,cytologytestsperformedin2011. 29 Table 6.2:Correlationofendocervicalcytologytothemostseriousendocervicalhistologywithin6months, womenaged20to69years,cytologytestsperformedin2011. 30
7. FOLLOW-UP AND REMINDER PROGRAM 31 Table 7: NumberoffirstandsecondreminderletterssenttowomenbytheVCCRin2012. 31
8. CERVICAL CANCER INCIDENCE AND MORTALITY IN VICTORIA 32 Figure 8.1: Age-standardisedincidenceandmortalityratesforalltypesofcervicalcancerinVictoria,1982–2012. 32 Figure 8.2: Age-standardisedincidencerates(ASR)forcervicalcancerbyhistologicalsubtypeinVictoria,1982–2012. 33 Figure 8.3: Age-specificincidenceratesofcervicalcancerbyhistologicalsubtypeinVictoria,2010–2012. 33
9. SCREENING HISTORY OF WOMEN DIAGNOSED WITH CERVICAL CANCER IN 2010 AND 2011 34 Table 9 (a): ScreeninghistoryofVictorianwomendiagnosedwithcervicalcancerfortheperiod 1January2010to31December2010. 34 Table 9 (b): ScreeninghistoryofVictorianwomendiagnosedwithcervicalcancerfortheperiod 1January2011to31December2011. 35
ACKNOWLEDGEMENTS 36LISTOFABBREVIATIONS 36GLOSSARYREFERENCES 37
APPENDIX1. CYTOLOGYCODINGSCHEDULE 38APPENDIX2.REMINDERANDFOLLOW-UPPROTOCOLUSEDDURING2012 39APPENDIX3.MAPOFMEDICARELOCALS 40APPENDIX3.MAPOFLOCALGOVERNMENTAREAS-MELBOURNE 41APPENDIX3.MAPOFLOCALGOVERNMENTAREAS-VICTORIA 42
6
EXECUTIVE SUMMARY
1 BrothertonJ,FridmanM,MayC,ChappellG,SavilleM,GertigD.Early effect of the HPV vaccination programme on cervical abnormalities in Victoria, Australia: an ecological study.2011.Lancet.377:2085-20922 GertigDM,BrothertonJML,BuddAC,DrennanK,ChappellG,SavilleAM.Impact of a population-based HPV vaccination program on cervical abnormalities: a data linkage study.BMC Medicine 2013,11:227.
Aspartofthecervicalscreeningprogram,theVictorianCervicalCytologyRegistry(VCCR)playsanimportantroleinimprovingthescreeningparticipationofVictorianwomenbysendingreminderlettersandconductingresearchintounder-screening.In2012theVCCRintroducedasecondPaptestreminderletterforVictorianwomen,fundedbytheVictorianGovernment.OurevaluationshowedthatthisletterincreasedparticipationamongwomenoverdueforaPaptestby8.1%comparedtotheprevioustimeperiodbeforetheletterwasintroduced.Datainthisreportshowthatforthefirsttimeinoveradecadetherehasbeenasmallincreaseinscreeningparticipationacrossallagegroupswithanestimated60%twoyearparticipationfor2011-2012forwomeninthetargetagerangeof20to69yearscomparedwith59.2%inthepreviousperiodof2010-2011.ThecorrespondingsustainedincreaseinthenumberofwomenacrossallagegroupshavingPaptests,suggeststhatthisislikelyduetothesecondreminderletterinitiative.
However,substantialvariationexistsinscreeningratesbetweendifferentareasofVictoria,asrepresentedbyMedicareLocals,withthelowesttwoyearscreeningratefor2011–2012at53.2%andthehighestat67.6%.ThescreeningrateforVictorianDepartmentofHealthregionsrangedfrom56.6%to63.1%,whiletheestimatedtwoyearparticipationratebyLocalGovernmentArearangedfrom45.7%to75.5%.
Aspartofthefollow-upandreminderprogram,theVCCRregisteredatotalof602,367Paptestsin2012,representing574,123womenandsentover410,000follow-upandreminderletterstowomenandpractitioners.Morethan6,000abnormalPaptestswerefollowed-upbytheVCCRin2012.Almost120,000secondreminderlettersweresenttowomenandofthosesentafteranegativePaptest,24%hadasubsequentPaptestwithin3monthsofthereminder.
OfPaptestsrecordedbytheVCCRduringtheperiodofthisreport,adefinitehigh-gradesquamouscellabnormalitywaspresentin0.8%oftestsandanendocervicalabnormalitywasidentifiedinfewerthan0.1%oftests.Forthe3,653high-gradecytologytestsreported,2,911weresubsequentlyconfirmedwithhigh-gradehistologyonbiopsywithinasixmonthperiod.Thisrepresentsapositivepredictivevalueof79.7%andreflectsthehighqualityoflaboratoryreportinginVictoria.
OverthelastdecadetherehasbeenagradualincreaseintheproportionofPaptestscollectedbynurses.In2012thenumberofPaptestscollectedbynursesrepresented5.6%ofallPaptestscollectedinVictoriaandhighlightstheimportantrolenurseshaveintheCervicalScreeningProgram.
VCCRcontinuestoworkcloselywithProgramPartnerstoidentifygroupsinourcommunitythatarelesslikelytoscreen.CollectinginformationfromwomenattendingscreeningabouttheiridentificationasanAboriginalandTorresStraitIslander,theirCountryofBirthandtheLanguageSpokenatHomeiscriticalforunderstandingwhoparticipatesincervicalscreening.Theoverallpercentageofwomenscreenedin2012whohadtheirAboriginalandTorresStraitIslanderstatusrecordedbytheVCCRwas19.4%,forcountryofbirth14.5%andlanguagespokenathome15.2%.
Accordingtothemostrecentdata(2012)fromtheVictorianCancerRegistry,mortalityfromcervicalcancerinVictoriais1.1per100,000women.Thisisatremendousachievementandreflectsthesuccessoftheorganisedcervicalscreeningprogram,whichisunderpinnedbythePaptestregistries.Despitethissuccess,furthereffortsarenecessarytoimproveparticipationamongstunder-screenedwomenas77%ofVictorianwomenwhowerediagnosedwithinvasivecervicalcancerin2011hadneverhadaPaptest,orwerelapsedscreeners,priortotheircancerdiagnosis.
TheVCCRisleadingandcollaboratingonanumberofresearchactivitiesthatwilllikelyinfluencepolicyinitiativesincervicalscreening.CervicalabnormalityratesinthecohortofyoungwomenwhocommencedscreeningfollowingtheintroductionoftheNationalHPVVaccinationProgramin2007continuetobemonitoredinthisreport.FollowingthepublicationofVCCRdataintheLancetin2011,whichdocumentedthefirstdeclineinhigh-gradeabnormalitiesseeninavaccinatedpopulationinternationally1,histologically-confirmedhigh-gradeabnormalitieshavecontinuedtodeclineforwomenagedlessthan20yearsandinwomenaged20to24years.ThisyeartheVictorianCytologyService(VCS)andtheAustralianInstituteofHealthandWelfare(AIHW)havepublishedmoreworldfirstfindings,whichhavemeasuredHPVvaccineeffectivenessagainstcervicalabnormalitiesusingdataobtainedbylinkingtheVCCRwiththeNationalHPVVaccinationProgramRegister2.Thestudyfoundthatwomenvaccinatedintheschoolcohortsofthecatch-upprogram(aged12to17yearsin2007)attendingscreeninghavea48%lowerrateofhigh-gradeabnormalitiesthanunvaccinatedwomen.Aswomenvaccinatedatearlierages(theroutinevaccinationprogramisat12to13yearsofage)commencescreening,theimpactofthevaccineisexpectedtoincreasefurther.
Victorian Cervical Cytology Registry Statistical Report 2012 7
1. INTRODUCTION
3 NHMRC Screening to prevent cervical cancer: guidelines for the management of asymptomatic women with screen-detected abnormalities,2005. http://www.nhmrc.gov.au/publications/synopses/wh39syn.htm4 TabriziSN,BrothertonJML,KaldorJM,SkinnerSR,CumminsE,LiuB,BatesonD,McNameeK,GarefalakisM,GarlandSM.Fall in Human Papillomavirus Prevalence Following a National Vaccination Program.JInfectDis.2012;206(11):164551. Availableathttp://jid.oxfordjournals.org/content/early/2012/10/17/infdis.jis590.full.pdf+html
1.1 BACKGROUNDTheVictorianCervicalCytologyRegistry(VCCR)isoneofeightsuchregistriesoperatingthroughoutAustralia.EachStateandTerritoryoperatesitsownregister.VictoriawasthefirstStatetoestablishsucharegisterandcommencedoperationinlate1989afteramendmentstotheCancerAct1958.
ThePaptestRegistries,astheyarecommonlyknown,wereintroducedprogressivelyacrossAustraliathroughoutthe1990s.TheRegistriesareanessentialcomponentoftheNationalCervicalScreeningProgramandprovidetheinfrastructurefororganisedcervicalscreeningineachStateandTerritory.
TheVCCRisavoluntary“opt-off”confidentialdatabaseorregisterofVictorianwomen’sPaptestresults.LaboratoriesprovidetheVCCRwithdataonallPapteststakeninVictoria,unlessawomanchoosesnottoparticipate.
TheVCCRworkscloselywiththeVictorianDepartmentofHealthandotherProgramPartnersincludingPapScreenVictoriawhichisresponsibleforthecommunicationsandrecruitmentprogramaimedatmaintainingthehighratesofparticipationofVictorianwomenintheNationalCervicalScreeningProgram.
1.2 FUNCTIONS OF THE VCCRTheVCCRfacilitatesregularparticipationofwomenintheNationalCervicalScreeningProgrambysendingreminderletterstowomenforPaptestsandbyactingasasafetynetforthefollow-upofwomenwithabnormalPaptests.
TheprimaryfunctionsoftheVCCRasspecifiedintheCancerAct1958are:
a) tofollow-uppositiveresultsfromcancertests,
b) tosendremindernoticeswhenpersonswhosenamesappearintheregisteraredueforcancertests,
c) subjecttoandinaccordancewiththeregulations,togiveaccesstotheregistertopersonsstudyingcancer;and
d) tocompilestatisticsand,iftheorganisationconsidersitappropriate,topublishthosestatisticsthatdonotidentifythepersonstowhomtheyrelate.
SecondaryfunctionsoftheRegistrieshavedevelopedonamoreregionalbasis.InVictoria,theroleoftheVCCRincludes:
• theprovisionoftheknownscreeninghistoryofawomantothelaboratorythatisreportingthecurrentPaptest,
• theprovisionofquantitativedatatolaboratoriestoassistwiththeirqualityassuranceprograms;and
• theprovisionofaggregatedatatotheAIHWsothattheNationalCervicalScreeningProgramcanbejudgedagainstanagreedsetofperformanceindicators.
1.3 NATIONAL POLICY: THE NHMRC GUIDELINES FOR THE MANAGEMENT OF ASYMPTOMATIC WOMEN WITH SCREEN DETECTED ABNORMALITIES AND RENEWAL OF THE CERVICAL SCREENING PROGRAMOn1July2006,theNationalHealthandMedicalResearchCouncil(NHMRC)Guidelines for the Management of Asymptomatic Women with Screen Detected Abnormalities(2005)3wereimplementedaroundAustralia.Themainchangestotheexistingguidelineswere:
• thechangeofterminologyforcytologyreportstotheAustralianModifiedBethesdaSystem2004,
• repeatPaptestsformostwomenwithlow-gradesquamousabnormalities,
• nottotreatbiopsyprovenlow-gradeorHPVlesions,
• toreferallwomenwithatypicalglandularcellsforcolposcopy,
• toreferallwomenwithapossiblehigh-gradelesionforcolposcopy;and
• touseHPVtestsandcytologyasatestofcureforwomentreatedforCINIIandCINIII.
TheVCCRparticipatesintheNationalSafetyMonitoringoftheNHMRCguidelines.Thecervicalscreeningprogramispresentlyundergoingarenewal,whichaimstoidentifythebestscreeningprogramforAustralianwomengivenrecentchangestoavailabletechnologyandtheimplementationoftheNationalHPVVaccinationProgram.Furtherinformationcanbefoundathttp://www.cancerscreening.gov.au/internet/screening/publishing.nsf/Content/ncsp-renewal
1.4 THE NATIONAL HPV VACCINATION PROGRAMTheNationalHPVVaccinationProgramcommencedinApril2007andisalreadyhavingasubstantialimpactontheprevalenceofHPVinfectionandcervicallesionsinvaccinatedcohorts4.Between2007and2009,12to26yearoldfemaleswereofferedthequadrivalentHPVvaccination(Gardasil)inanationalcatch-upprogramprovidedthroughschools,generalpracticeandothercommunityproviders.Since2009theprogramhasofferedroutinevaccinationthroughschoolsfor12to13yearoldgirlsand,from2013,vaccinationtoboysat12to13years,withatwoyearcatch-upprogramfor14to15yearoldboys.
ThePaptestRegistriesaroundAustraliaplayanimportantroleinmonitoringtheimpactofthevaccinationprogramonparticipationratesincervicalscreeningandoncervicalabnormalitiesandcancerinthelongterm.TheimportanceofcontinuingregularPaptestsforvaccinatedwomenisemphasisedaspartoftheNationalHPVVaccinationProgram.
8
ofculturaldiversity,suchascountryofbirthandlanguagespokenathome.Informationontheproportionofwomenwhore-screenearlyisalsofeatured.
Cytology codingInformationprovidedonthecytologyreportofPaptestsispre-codedbythepathologylaboratorytotheCytologyCodingSchedule.Appendix1outlinestheAustralia-widecytologycodesthathavebeenusedsince1July2006tocorrespondwiththeimplementationoftheNHMRCguidelines.TheCytologyCodingScheduleallowsaPaptestreporttobesummarisedtoasixdigitnumericcodecoveringthetypeoftest,siteoftest,theresultforsquamouscells,theendocervicalcomponent,othernon-cervicalcells,andtherecommendationmadebythelaboratoryinregardtofurthertesting.DataarepresentedontheproportionofPaptestsclassifiedaccordingtotheirresultsasunsatisfactory,negative,squamousabnormalitypresentandendocervicalabnormalitypresent.ThepercentageofPaptestscollectedduring2012withoutanendocervicalcomponentisalsopresented.
Histology/colposcopy reportsThe2012histologyresultsinthisreportareasnotifiedby30June2013.Thevastmajorityofhistologyreportsarenotifiedbythistime.Whilereasonablycomprehensivenotificationoccursforhistologyreports,aproportionofcolposcopyonlyresultsarealsonotified,mosttypicallywhenahistologyreportisnotavailable.Dataincludedinthisreportexcludesresultsreportedfromacolposcopyreportalone(i.e.nolaboratoryreport).In2013,theVCCRimplementedroutinecollectionofdataoncolposcopiesperformedinVictoria.Thiswillassistwiththefollow-upofabnormalitiesandthemonitoringofcolposcopyquality.
Follow-up protocolTheVCCRReminderandFollow-upProtocolisbasedontheNHMRCGuidelines for the Management of Asymptomatic Women with Screen Detected Abnormalities.TheReminderandFollow-upProtocolusedbytheVCCRin2012isshowninAppendix2.ReminderlettersarenotsenttowomenwhoseVCCRrecordsindicateapasthistoryofhysterectomyorofcervicaloruterinemalignancy,ortowomenwhoareover70yearsofageandwhoselastPaptestwasnormal.
Cervical cancer incidence and mortality InformationoncervicalcancerincidenceandmortalityisprovidedinthisreportcourtesyoftheVictorianCancerRegistryattheVictorianCancerCouncil.AlsoincludedisasectionexaminingthescreeninghistoryofVictorianwomendiagnosedwithinvasiveandmicro-invasivecervicalcancerduring2010and2011.
5 TheNationalHPVVaccinationProgramRegisterwebsite.http://www.hpvregister.org.au6 GertigDM,BrothertonJML,BuddAC,DrennanK,ChappellG,SavilleAM.Impact of a population-based HPV vaccination program on cervical abnormalities: a data linkage study. BMC Medicine 2013,11:227.7 AustralianInstituteofHealthandWelfare2013.Cervical screening in Australia 2010-2011. CancerSeries76.Cat.no.CAN72.Canberra:AIHW
ANationalHPVVaccinationProgramRegister(theHPVRegister)5wasestablishedtosupport,monitorandevaluatetheNationalHPVVaccinationProgram.VCSInc,whichhasoperatedtheVictorianCervicalCytologyRegistryforover20years,wasengagedbytheDepartmentofHealthandAgeinginFebruaryof2008toestablishandmanagetheNationalHPVVaccinationProgramRegister.TheHPVRegisterreceivesdatafromallstatesandterritoriesandfromalltypesofvaccinationprovidersincludingLocalCouncils(whoinsomeStatesdelivertheschoolvaccinationprogram),GeneralPractitioners,nursesandotherimmunisationprovidersaroundAustralia.TheRegisterrecordsbasicdemographicinformationandinformationaboutdosesadministeredinAustralia.TheHPVRegistersupportstheprogrambysendingstatementsonvaccinationstatustoeligiblevaccinerecipientsandtheirproviders,andbyprovidingreportsandde-identifieddatatoapprovedprovidersandresearchers.LinkageofdataheldbytheHPVRegisterwithinformationheldbythePaptestandcancerregistrieswillbeacriticalcomponentofmonitoringandevaluatingtheimpactofvaccination.Thefirststudydemonstratingpopulation-basedeffectivenessoftheHPVvaccinationprogramwasrecentlypublishedbytheVCCR.Ade-identifieddatalinkagewasundertakenbetweentheNHVPRandtheVCCR,anddemonstrateda48%reductionontheratesofthemostseriouscervicalpre-cancersforwomenwhohadbeencompletelyvaccinatedintheschool-program,comparedwithunvaccinatedwomen6.
1.5 DATA INCLUDED IN THIS REPORT ThisstatisticalreportprovidestimelyinformationaboutcervicalscreeninginVictoriaduring2012.InmostcasesthemethodologyandterminologyusedinVCCRreportsisconsistentwiththatpublishedbytheAIHWaspartofreportingindicatorsfortheNationalCervicalScreeningProgram7.
Participation ratesThisreportincludesinformationonparticipationratesforwomenaged20to69yearsintenyearagegroupsandfiveyearagegroupsforthe20to29group.PopulationdatahasbeenadjustedtoexcludewomenwhohavehadahysterectomyusingmodelingcarriedoutbytheAIHWbasedontheNationalHospitalMorbidityDatabase.ThetwoyearparticipationratesarealsopresentedbyMedicareLocals,DepartmentofHealthregionandLocalGovernmentArea.ThenumberandproportionofPaptestscollectedbynursesispresentedinthisreport,byyearandDepartmentofHealthregion.FurtherinformationregardingPaptestscollectedbynursesisavailableinthereport‘Evaluation of Pap tests collected by Nurses in Victoria during 2012’,availableonourwebsiteathttp://www.vccr.org/stats.htmlTheParticipationinScreeningsectionalsoincludessomelimitedinformationontheidentificationofAboriginalandTorresStraitIslanderwomenandthecollectionofindicators
Victorian Cervical Cytology Registry Statistical Report 2012 9
2. PARTICIPATION IN SCREENING
Table 2.1:NumberofPaptestsregisteredandnumberofwomenscreenedinVictoria,1990–2012.1
Year
Number of Pap Tests registered
Number of women screened
2012 602,367 574,1232011 572,142 545,7952010 573,837 547,4402009 584,274 556,4982008 565,655 538,2292007 585,556 557,3712006 572,734 540,6812005 585,324 549,6422004 587,959 550,1482003 571,601 532,4182002 579,178 540,6532001 577,176 542,4022000 572,045 531,7871999 602,400 557,2571998 618,490 569,8581997 584,830 533,5251996 617,182 559,6251995 588,788 529,2701994 622,992 562,2431993 570,605 522,3221992 540,474 494,8751991 544,415 496,3011990 435,706 400,147
2.2 PARTICIPATION BY AGE GROUPMethod of calculating participation
TheparticipationofwomenestimatedtobepartoftheVictorianCervicalScreeningProgrambyagegroupisexpressedasapercentage.Thisisdeterminedbydividingthenumberofwomenscreenedbythenumberofwomeninthegeneralpopulationwhoareeligibleforscreening.
•Thenumberofwomenscreened(numerator)isdeterminedfromtheVCCRdatabase.ItisthenumberofwomenresidentinVictoriawhohadatleastonePaptestinthetimeperiodofinterestandhavenothadahysterectomyaccordingtoinformationheldbytheVCCR.
•Theeligiblepopulation(denominator)isthenumberofwomeninthegeneralpopulationaveragedforthetimeperiodofinterest,andadjustedtoincludeonlywomenwithanintactcervix.Todeterminethis,theVictorianEstimatedResidentPopulation(ERP)8collectedbytheAustralianBureauofStatistics(ABS)isaveragedandthenadjustedtoexcludetheproportionofwomenestimatedtohavehadahysterectomyusinghysterectomyfractions.WhilstVCCRparticipationstatisticsproducedpriortothe2011StatisticalReportusedhysterectomyfractionestimatesfromtheNationalHealthSurvey9,thesedataarenolongercollectedbytheABS.
2.1 NUMBER OF PAP TESTS AND WOMEN SCREENEDTable2.1showsdataonthenumberofPaptestsregisteredandthenumberofwomenscreenedforeachyearoftheVCCR’soperation.During2012atotalof602,367Paptestswereregisteredfrom574,123women.Fromthepreviousyear,thisisanincreaseof30,225Paptestsand28,328women.Since2003,95%ofwomenwithaPaptestrecordontheVCCRhaveaMedicarenumberavailable,andfrom1999theVCCRhasusedSSA-Name(matchingsoftware)inthelinkingofincomingteststopre-existingdataonthedatabase.Thishasresultedinmorecompleterecord-linkageofdifferentepisodesofcareforwomen.IninterpretingtheinformationinTable2.1,itisimportanttorealisethataproportionofwomeninVictoriaarescreenedonanannualbasis.TheVCCRisavoluntary“opt-off”registry;however,theproportionofwomenwhoarepartofthescreeningprogrambutdecidetoopt-offtheVCCRisestimatedtobefewerthan1%.CorrelatingVCSlaboratoryrecordswiththoseheldbytheVCCRshowsatenyear(2003-2012)opt-offrateof0.34%.WhereawomanobjectstoherPaptestbeingregistered,theVCCRholdsnoinformationaboutthattest.
8 AustralianBureauofStatistics.3101.0 –Australian Demographic Statistics, Dec 2012 (releasedate20/6/13)9 AustralianBureauofStatistics. 4364.0 – National Health Survey: Summary of Results, 2004-2005 (releasedate27/2/2006)10 AustralianInstituteofHealthandWelfare2013.Cervical screening in Australia 2010-2011.CancerSeries76.Cat.no.CAN72.Canberra:AIHW
Inthisandthepreviousreport,andconsistentwiththenationalapproach,thepopulationdataforthelatestscreeningperiodshavebeenadjustedwithhysterectomyestimatesfromanalysisconductedbytheAIHWusingdatafromtheNationalHospitalMorbidityDatabase(NHMD)10.Formoredetailsaboutthechangestomethodsrefertothe2011StatisticalReportathttp://www.vccr.org/stats.htmlItisimportanttoappreciatethatchangesinthemethodsusedtocalculateparticipationimpactupontheactualparticipationestimates.Hencecomparisonsinparticipationovertimeshouldbemadewithcaution.
Limitations of participation statisticsOnelimitationtotheseparticipationstatisticsistheimperfectrecord-linkagebetweenmultiplePaptestsfromthesamewomanthatcouldresultinanoverestimateofthenumberofwomenscreened.Inaddition,wheresiteofspecimeninformationisnotreportedtotheRegistrywhenaPaptestistakenfromawomanwithoutacervix,thewomanwillbeincorrectlyincludedinthenumerator.
1 ThenumberofPaptestsregisteredandwomenscreenedontheRegistryasat30September2013.
10
Participation in cervical screening by age group Table2.2showstheestimatedcervicalscreeningratesbyagegroupforone,two,threeandfiveyearperiods,withthepopulationdataadjustedwithestimatedhysterectomyratesfromtheNHMD11.Therewasaslightincreaseintheoneyearscreeningratefromthepreviousyearforwomenaged20to69years,at33.1%in2012,comparedwith31.8%for201112.Althoughtherewasanincreaseintheeligiblescreeningpopulationin2012,theincreaseinparticipationwasaresultofalargerincreaseinthenumberofwomenwhowerebeingscreened.Thetwoyearscreeningrate(forthecalendaryearsof2011–2012)forwomenaged20to69yearsisestimatedtobe60.0%,whichisaslightincreasefrom59.2%13forthepreviousreportingperiod(2010–2011).Asobservedwiththeoneyearparticipationdata,theslightincreaseisduetoagreaterincreaseinthenumberofwomenscreenedthanintheeligiblepopulation.Thistrendwasobservedamongallagegroups.The20to29yearoldcohortreportedthelowestparticipationat26.3%,comparedtothe40to49and50to59yearoldcohorts,eachwith36.9%.Theincreaseinoneyearparticipationandtoalesserextenttwoyearparticipation,acrossallagegroupscoincideswiththeimplementationofthesecondreminderletterbytheVCCRinJune2011.Theevaluationofthesecondreminderlettershowedanincreaseof8.1%(2,308women)whencomparingthesameperiodbefore(Jun-Dec2009)andaftertheimplementation(Jun-Dec2011)14.Agreaterimpactontwoyearparticipationisexpectednextyearasafulltwoyearsofthesecondreminderprojectwillbeincluded.
Overthethreeyearperiodfrom2010-2012,theparticipationrateofVictorianwomenaged20to69yearswasestimatedat72.4%,aslightincreasefromthepreviousperiodof2009-2011(72.0%).Table2.2alsohighlightsthefiveyearestimatedparticipationrateof83.9%for2008-2012,whichisaslightdecreasefromthepreviousperiod(84.1%)15.Threeandfiveyearparticipationratesforwomenaged20to39yearsdecreasedfromthepreviousperiod,whereasparticipationforwomenagedover40yearsincreased16.
Estimated two year participation over timeAsseeninfigure2.2.1,therewasasmalldeclineovertimeforeachagegroupbetween2000-2001and2010-2011;howeveranincreaseinthenumberofwomenbeingscreenedineachagegroupinthemostrecent2011-2012periodhasresultedinaslightincreaseinparticipationacrossallagegroups.ThedeclineinparticipationevidentinpreviousyearsisareflectionofthegrowingVictorianpopulation,refiningofthemethodtodeterminetheparticipationstatisticsincludingmoreprecisehysterectomyfractions;andinsomeinstancesactualdeclinesinthenumberofwomenscreened.Typicallywomenaged40to49yearsand50to59yearshavethehighesttwoyearscreeningratesandwomenaged20to29yearshavethelowestscreeningrate.Thistrendtowardsdecreasingparticipationinyoungwomenhasalsobeenseennationallyandinternationally17.
11 Ibid. 12 VictorianCervicalCytologyRegistry,Statistical Report 2011.Availableat:http://www.vccr.org/stats.html13 Ibid.14 Ibid.15 Ibid.16 Ibid.17 LancuckiL,FenderM,KoukariA,LyngeE,MaiVetal.A fall-off in cervical screening coverage of younger women in developed countries. 2010:JMed Screen.17:91-6
Age Group
% screened2012
(1 year)
% screened2011-2012(2 years)
% screened2010-2012(3 years)
% screened2008-2012(5 years)
20to29yrs 26.3% 47.1% 60.6% 80.1% - 20 to 24 yrs 23.2% 41.7% 54.7% 75.7% - 25 to 29 yrs 29.3% 52.2% 66.2% 84.4%30to39yrs 33.8% 61.3% 75.8% 90.9%40to49yrs 36.9% 66.9% 80.0% 89.0%
50to59yrs 36.9% 67.2% 77.8% 82.8%60to69yrs 33.3% 61.6% 68.8% 69.8%20 to 69 yrs 33.1% 60.0% 72.4% 83.9%
Table 2.2:Estimatedcervicalscreeningratesbyagegroupoveroneyear,twoyear,threeyearandfiveyearperiods.
Notes
1. Theeligiblefemalepopulationisadjustedfortheestimatedproportionofwomenwhohavehadahysterectomyusinghysterectomy fractionsderivedfromtheNationalHospitalMorbidityDatabase.2. Thetableprovidesthepercentageofwomenscreenedasaproportionoftheeligiblefemalepopulation(cruderate).Womenscreened onlyincludeswomenwhohavenothadahysterectomyaccordingtoinformationheldbytheVCCR.3. Periodscoveredapplytocalendaryears.
11Victorian Cervical Cytology Registry Statistical Report 2012
Participation %
20-69yrs 20-29yrs 30-39yrs 40-49yrs 50-59yrs 60-69yrs
2000-2001* 66.6% 56.0% 70.0% 74.0% 76.0% 58.0%
2001-2002* 64.4% 57.0% 67.0% 69.0% 70.0% 58.0%
2002-2003* 63.9% 55.0% 66.0% 69.0% 70.0% 58.0%
2003-2004* 64.4% 54.0% 67.0% 70.0% 72.0% 60.0%
2004-2005* 65.0% 54.4% 67.4% 70.5% 71.9% 60.9%
2005-2006 † 63.4% 53.2% 66.3% 66.7% 68.8% 63.6%
2006-2007 † 63.1% 52.7% 65.4% 66.5% 69.6% 64.4%
2007-2008 † 62.3% 51.2% 64.5% 65.9% 69.3% 64.1%
2008-2009 † 61.3% 48.5% 63.7% 65.5% 69.4% 64.6%
2009-2010 † 60.7% 47.1% 62.6% 65.5% 69.9% 65.3%
2010-2011 ‡ 59.2% 46.6% 61.1% 66.1% 66.1% 59.7%
2011-2012 ‡ 60.0% 47.1% 61.3% 66.9% 67.2% 61.6%
0
10
20
30
40
50
60
70
80
Par
ticip
atio
n ra
te (%
)
Time Period
20 - 29 yrs 30 - 39 yrs 40 - 49 yrs 50 - 59 yrs 60 - 69 yrs 20 - 69 yrs
‡ ‡
Figure 2.2.1: Estimated two year cervical screening rates by age group, 2000-01 to 2011-12.
Notes
1. The graph provides the percentage of women screened as a proportion of the eligible female population (crude rate). Women screened only includes women who have not had a hysterectomy according to information held by the VCCR. The eligible female population is adjusted for the estimated proportion of women who have had a hysterectomy using hysterectomy fractions as indicated by the symbols *, † and ‡; which are outlined in further detail below. 2. Periods covered apply to calendar years.
* 2000-2001 to 2004-2005 data has been adjusted using the 2001 National Health Survey hysterectomy fractions estimates.
† 2005-2006 to 2009-2010 data has been adjusted using the 2004-05 National Health Survey hysterectomy fractions estimates.
‡ 2010-2011 and 2011-2012 data has been adjusted using the National Hospital Morbidity Database (NHMD) hysterectomy fraction estimates (courtesy of the Australian Institute of Health and Welfare).
Table 2.2.1: Estimated two year cervical screening rates by age group, 2000-01 to 2011-12.
12
Otheradditional(butprobablylesser)sourcesofmeasurementerrorderivefrom:
•theproportionofVictorianPaptestsreportedbylaboratoriesoutsideofVictoriawhicharenotreportedtotheVCCR(thiswillmainlyaffectareaslocatedontheVictoria/NewSouthWalesandVictoria/SouthAustraliaborders);and,
•thedifferencesbetweentheAustraliaPostpostcodesusedtoreportscreeningnumbersaccordingtoaddressdatagivenbythewoman(usedasthenumeratorincalculatingparticipation)andtheABSPostalAreasforwhichpopulationstatisticsareavailable(usedasthedenominator).ItisimportanttonotethatalthoughtherearecommonalitiesbetweenpostcodesandPostalAreas,theyarenotexactmatchesandtheirboundariescandiffer.TheunderlyingreasonforthedifferencesintheseboundariesisthattheABSPostalAreaswerecreatedspecificallyforCensuspurposesanddisseminatingstatistics,whilepostcodesaredesignedtodistributemail.
Whencomparingparticipationrateestimatesbygeographicalarea,itshouldalsobenotedthatthesearecruderatesi.e.theyhavenotbeenage-adjusted.Thereforeareaswitholderpopulationswillhaveapparentlyhigherscreeningratesthanareaswithahighpopulationofyoungwomenbecauseofthestrongcorrelationbetweenageandscreeningrates.
18 ABS2012,customizedreport.Datausing2011postalboundaries:VictorianFemaleEstimatedResidentPopulationbyPostalAreaat30June2010and30June2011.19 AustralianInstituteofHealthandWelfare2013.Cervical screening in Australia 2010-2011.Cancerseries76.Cat.No.CAN72.Canberra:AIHW20 2012PostcodetoLGAconverteralgorithm(basedon2011MeshBlockboundaries)suppliedbyVictorianDepartmentofHealthandbasedonABSAustralianStatisticalGeographyStandard(ASGS)correspondence.21 AustralianBureauofStatistics,2011.AustralianStatisticalGeographyStandard(ASGS):Volume1–MainStructureandGreaterCapitalCityStatisticalAreas,July2011.Cat.No:1270.0.55.001.22AustralianGovernmentMedicareLocalBoundaryandConcordanceFileswebsite.
http://www.medicarelocals.gov.au/internet/medicarelocals/publishing.nsf/Content/digital-boundaries,cited4October2013.
2.3 PARTICIPATION BY AREAMethod of calculating participation
TheparticipationrateforageeligiblewomenincervicalscreeningforMedicareLocals(ML),DepartmentofHealth(DH)regionsandLocalGovernmentAreas(LGAs)isexpressedasapercentage.
•ThenumeratoristhenumberofwomenbypostcodewhohadatleastonePaptestinthetwoyeartimeperiodandwhohavenothadahysterectomyaccordingtotheinformationheldbytheVCCR.
•ThedenominatoristheestimatednumberofwomenineachPostalArea18adjustedtoexcludetheproportionofwomenestimatedtohavehadahysterectomy.The2011–2012dataareadjustedbythehysterectomyfractionsfromtheNationalHospitalMorbidityDatabase19.Theaveragefemalepopulationovereachtwoyearperiodisusedasthedenominator.
Tocalculatetheestimatedparticipationratesforareas,mappingofdatabyAustraliaPostpostcodesandPostalAreastoLGAsandMedicareLocalswasdoneusingconversionfilesprovidedbytheVictorianDepartmentofHealthandtheCommonwealthDepartmentofHealthandAgeingrespectively.
Themappingofthe2011–2012participationdataforLGAsisbasedonconcordances20consistentwiththenewABSAustralianStatisticalGeographyStandard(ASGS)21.ParticipationdatabyDHregionarecalculatedasanaggregateofLGAs,whileMedicareLocalswerecreatedbasedontheCommonwealthDepartmentofHealthPostcodetoMedicareLocalconcordancefile22.
Limitations
Small-areadata(eg.DHregions,LGAsandMedicareLocals)aresubjecttogreatermeasurementerrorthanthedatainsections2.1and2.2.ThemainsourceofinaccuracyinthefollowingtablesisderivedfromapplyingthenationalhysterectomyfractionstotherelativelysmallfemalepopulationresidentinthePostalAreas.
VictorianCervicalCytologyRegistryStatistical Report 2012 13
2.3.1 Participation by Medicare Locals
In2011theAustralianGovernmentestablishedthenewMedicareLocal23areanetworktoreplacethepreviousDivisionsofGeneralPractice,toplanandfundcommunity-basedprimarycareacrossAustralia.Participationratesfor2010-2011and2011-2012werecalculatedforthe17MedicareLocalsinVictoriawhicharepartiallyorentirelylocatedwithinVictoria.UsingmethodsdiscussedatthebeginningofSection2.3,theestimatedtwoyearparticipationrateshavebeencalculatedfortheseareas.
MedicareLocal
Number
Medicare Local Name
2010-20111 % screened (95% CI)
2011-20121 % screened (95% CI)
ML201 InnerNorthWestMelbourne 56.7%(56.4%-57.0%) 57.2%(57.0%-57.5%)ML202 Bayside 64.5%(64.3%-64.7%) 65.0%(64.8%-65.2%)ML203 SouthWesternMelbourne 52.4%(52.0%-52.8%) 53.2%(52.8%-53.5%)ML204 MacedonRangesandNorthWesternMelbourne 55.4%(55.1%-55.7%) 55.9%(55.6%-56.1%)ML205 NorthernMelbourne 58.1%(57.9%-58.3%) 59.0%(58.8%-59.2%)ML206 InnerEastMelbourne 62.1%(61.9%-62.3%) 62.8%(62.6%-63.0%)ML207 EasternMelbourne 61.8%(61.5%-62.0%) 62.4%(62.1%-62.6%)ML208 SouthEasternMelbourne 56.0%(55.7%-56.2%) 56.5%(56.2%-56.7%)ML209 Frankston-MorningtonPeninsula 58.9%(58.5%-59.2%) 59.2%(58.9%-59.6%)ML210 Barwon 62.2%(61.9%-62.5%) 63.3%(62.9%-63.6%)ML211 Grampians 55.5%(55.1%-55.9%) 56.8%(56.4%-57.2%)ML212 GreatSouthCoast 60.7%(60.2%-61.3%) 61.2%(60.6%-61.7%)ML213 LowerMurray 58.7%(57.9%-59.5%) 61.4%(60.6%-62.1%)ML214 Loddon-Mallee-Murray 60.7%(60.3%-61.1%) 62.8%(62.4%-63.3%)ML215 GoulburnValley 56.3%(55.8%-56.7%) 58.3%(57.8%-58.8%)ML216 Hume 65.5%(65.0%-66.0%) 67.6%(67.1%-68.1%)ML217 Gippsland 59.7%(59.4%-60.1%) 60.1%(59.8%-60.5%)
Table 2.3.1:EstimatedtwoyearcervicalscreeningratesbyMedicareLocal,2010-2011and2011-2012.
Notes
1. 2010-2011and2011-2012data:PostcodesmappedtoMedicareLocalsbasedontheCommonwealthDepartmentofHealthPostalAreatoMedicare Localconcordancefile.PopulationdataadjustedusingestimatedhysterectomyfractionsfromtheAIHWNationalHospitalMorbidityDatabase.
2. Thetableprovidesthepercentageofwomenscreenedasaproportionoftheeligiblefemalepopulation(cruderate).Womenscreenedonlyincludes womenwhohavenothadahysterectomyaccordingtoinformationheldbytheVCCR.
3. Periodscoveredapplytocalendaryears.
23 www.medicarelocals.gov.au
14
Figure 2.3.1:EstimatedtwoyearcervicalscreeningratesbyMedicareLocal,2011-2012.
Medicare Local boundaries have been truncated where they overlap the Victorian border. This includes the Lower Murray (ML 213), Loddon–Mallee-Murray (ML 214), and Hume (ML 216) Medicare Locals. Refer to Appendix 3 for a map of Medicare Locals which have not been truncated at the border.
VictorianCervicalCytologyRegistryStatistical Report 2012 15
Figure 2.3.2:EstimatedtwoyearcervicalscreeningratesbyDepartmentofHealthregion,2011-2012.
2.3.2 Participation by Department of Health Region
VictoriaisdividedintoeightDepartmentofHealth(DH)regions,withfiveinruralVictoriaandthreecoveringmetropolitanMelbourne.UsingmethodsdiscussedatthebeginningofSection2.3,thetwoyearparticipationrateshavebeencalculated.
Region Name 2010-20111
% screened (95% CI)2011-20121
% screened (95% CI)
BarwonSouthWestern 61.8%(61.5%-62.1%) 62.6%(62.3%-62.9%)
EasternMetropolitan 62.0%(61.8%-62.1%) 62.6%(62.5%-62.8%)
Gippsland 59.7%(59.4%-60.1%) 60.1%(59.7%-60.5%)
Grampians 56.3%(55.9%-56.7%) 57.6%(57.2%-58.0%)
Hume 60.6%(60.2%-61.0%) 62.6%(62.2%-62.9%)
LoddonMallee 61.0%(60.7%-61.3%) 63.1%(62.8%-63.4%)
NorthernWestMetropolitan 56.0%(55.8%-56.1%) 56.6%(56.5%-56.8%)
SouthernMetropolitan 60.5%(60.3%-60.6%) 60.9%(60.8%-61.1%)
Table 2.3.2:EstimatedtwoyearcervicalscreeningratesbyDepartmentofHealthregion,2010–2011and2011–2012.
Notes
1. 2010–2011and2011-2012data:ParticipationdatabyDHregioniscalculatedasanaggregateofLGAs.Postcode/PostalAreasmappedtoLGAusing aconverteralgorithmsuppliedbytheVictorianDepartmentofHealthandbasedonABSAustralianStatisticalGeographyStandard(ASGS)2011correspondencedata.PopulationdataadjustedusingestimatedhysterectomyfractionsfromtheAIHWNationalHospitalMorbidityDatabase.
2. Thetableprovidesthepercentageofwomenscreenedasaproportionoftheeligiblefemalepopulation(cruderate).Womenscreenedonlyincludes womenwhohavenothadahysterectomyaccordingtoinformationheldbytheVCCR.
3. Periodscoveredapplytocalendaryears.
Unincorporated Victoria refers to the areas within Victoria which are not administered by incorporated local government bodies.
16
DH region LGA Code1 LGA 2010–20112 % screened (95% CI)
2011–20122 % screened (95% CI)
Barwon South West
21750 Colac-Otway 66.4%(65.1%-67.6%) 62.9%(61.6%-64.2%)
21830 Corangamite 57.8%(56.3%-59.3%) 61.6%(60.1%-63.1%)
22410 Glenelg 57.1%(55.7%-58.4%) 56.7%(55.3%-58.0%)
22750 GreaterGeelong 61.1%(60.7%-61.5%) 62.5%(62.1%-62.9%)
25490 Moyne 61.1%(59.6%-62.6%) 62.2%(60.8%-63.7%)
26080 Queenscliffe 69.5%(66.2%-72.8%) 73.6%(70.4%-76.7%)
26260 SouthernGrampians 61.9%(60.4%-63.3%) 61.9%(60.4%-63.3%)
26490 SurfCoast 67.4%(66.4%-68.5%) 67.7%(66.6%-68.7%)
26730 Warrnambool 63.6%(62.6%-64.6%) 63.0%(62.0%-64.0%)
Eastern Metropolitan
21110 Boroondara 67.0%(66.6%-67.4%) 67.4%(67.0%-67.8%)23670 Knox 62.4%(61.9%-62.8%) 62.7%(62.3%-63.2%)24210 Manningham 65.1%(64.6%-65.7%) 66.0%(65.5%-66.5%)24410 Maroondah 60.9%(60.4%-61.5%) 60.6%(60.0%-61.1%)24970 Monash 57.2%(56.8%-57.7%) 57.9%(57.5%-58.3%)26980 Whitehorse 60.1%(59.6%-60.5%) 61.0%(60.6%-61.5%)27450 YarraRanges 61.8%(61.4%-62.3%) 63.4%(62.9%-63.8%)
Gippsland 20740 BassCoast 60.0%(58.9%-61.1%) 59.0%(57.9%-60.0%)20830 BawBaw 61.4%(60.5%-62.3%) 63.4%(62.5%-64.2%)22110 EastGippsland 61.9%(61.1%-62.8%) 62.2%(61.3%-63.0%)23810 Latrobe 56.4%(55.8%-57.1%) 57.5%(56.8%-58.1%)26170 SouthGippsland 62.8%(61.6%-63.9%) 63.6%(62.5%-64.7%)26810 Wellington 59.6%(58.7%-60.5%) 58.0%(57.1%-58.9%)
Grampians 20260 Ararat 50.4%(48.6%-52.2%) 57.2%(55.3%-59.0%)20570 Ballarat 56.1%(55.5%-56.7%) 56.7%(56.2%-57.3%)22490 GoldenPlains 61.5%(60.1%-62.8%) 62.1%(60.7%-63.4%)22910 Hepburn 65.3%(63.8%-66.8%) 62.7%(61.2%-64.2%)22980 Hindmarsh 52.4%(49.8%-54.9%) 57.3%(54.7%-59.9%)23190 Horsham 58.0%(56.6%-59.3%) 60.4%(59.1%-61.7%)25150 Moorabool 54.9%(53.9%-56.1%) 58.1%(57.0%-59.1%)25810 NorthernGrampians 53.4%(51.6%-55.2%) 51.6%(49.8%-53.3%)25990 Pyrenees 52.6%(50.3%-55.0%) 55.8%(53.5%-58.1%)26890 WestWimmera 44.9%(41.8%-48.0%) 47.7%(44.5%-50.9%)27630 Yarriambiack 54.5%(52.1%-56.9%) 53.4%(51.0%-55.8%)
Hume 20110 Alpine 68.8%(67.2%-70.4%) 67.2%(65.6%-68.9%)21010 Benalla 67.6%(66.1%-69.1%) 70.3%(68.8%-71.8%)22830 GreaterShepparton 57.0%(56.2%-57.7%) 59.6%(58.8%-60.3%)23350 Indigo 66.0%(64.6%-67.5%) 67.8%(66.3%-69.2%)24250 Mansfield 65.8%(63.8%-67.8%) 67.0%(65.0%-69.0%)24850 Mitchell 54.0%(53.0%-55.0%) 55.3%(54.3%-56.3%)24900 Moira 54.2%(53.1%-55.4%) 56.7%(55.5%-57.8%)25620 Murrindindi 57.2%(55.6%-58.8%) 59.6%(58.0%-61.2%)26430 Strathbogie 63.9%(62.0%-65.8%) 64.3%(62.4%-66.2%)26670 Towong 63.9%(61.5%-66.4%) 67.2%(64.8%-69.6%)26700 Wangaratta 67.3%(66.2%-68.4%) 70.3%(69.2%-71.3%)27170 Wodonga 64.3%(63.3%-65.2%) 66.0%(65.0%-66.9%)
2.3.3 Participation by Local Government Area
WithinVictoriathereare79LocalGovernmentAreas(LGAs).UsingmethodsdiscussedatthebeginningofSection2.3,
theestimatedtwoyearparticipationrateshavebeencalculated.
Table 2.3.3: EstimatedtwoyearcervicalscreeningratesbyLocalGovernmentArea,2010–2011and2011–2012.
VictorianCervicalCytologyRegistryStatistical Report 2012 17
DH region LGA Code1 LGA 2010–20112 % screened (95% CI)
2011–20122 % screened (95% CI)
Loddon Mal ee
21270 Buloke 62.7%(60.3%-65.2%) 62.9%(60.5%-65.4%)
21370 Campaspe 58.7%(57.7%-59.6%) 63.2%(62.2%-64.2%)
21670 CentralGoldfields 49.2%(47.5%-51.0%) 53.1%(51.4%-54.9%)
22250 Gannawarra 57.0%(55.1%-58.9%) 59.4%(57.5%-61.3%)
22620 GreaterBendigo 61.0%(60.4%-61.6%) 62.2%(61.6%-62.8%)
23940 Loddon 53.5%(51.2%-55.7%) 52.9%(50.7%-55.1%)
24130 MacedonRanges 68.4%(67.6%-69.2%) 69.0%(68.2%-69.9%)
24780 Mildura 58.8%(57.9%-59.6%) 61.2%(60.4%-62.0%)
25430 MountAlexander 72.9%(71.6%-74.2%) 75.5%(74.2%-76.7%)
Northern & Western Metropolitan
26610 SwanHill 55.6%(54.3%-56.9%) 59.9%(58.5%-61.2%)20660 Banyule 64.2%(63.7%-64.7%) 65.1%(64.6%-65.6%)21180 Brimbank 54.5%(54.1%-54.9%) 54.6%(54.2%-55.0%)21890 Darebin 57.7%(57.2%-58.1%) 59.0%(58.5%-59.4%)23110 HobsonsBay 58.0%(57.4%-58.6%) 60.4%(59.8%-61.0%)23270 Hume 52.3%(51.9%-52.8%) 53.6%(53.2%-54.0%)24330 Maribyrnong 54.9%(54.4%-55.6%) 56.7%(56.0%-57.3%)24600 Melbourne 45.6%(45.1%-46.1%) 45.7%(45.2%-46.2%)24650 Melton 51.6%(51.0%-52.1%) 51.7%(51.1%-52.2%)25060 MooneeValley 60.8%(60.3%-61.3%) 61.1%(60.6%-61.7%)25250 Moreland 57.2%(56.8%-57.7%) 58.5%(58.1%-59.0%)25710 Nillumbik 71.3%(70.6%-71.9%) 71.5%(70.8%-72.1%)27070 Whittlesea 54.8%(54.3%-55.2%) 55.3%(54.8%-55.7%)
Southern Metropolitan
27260 Wyndham 49.3%(48.8%-49.7%) 49.6%(49.2%-50.1%)27350 Yarra 65.4%(64.9%-66.0%) 66.2%(65.6%-66.7%)20910 Bayside 72.6%(72.1%-73.1%) 73.9%(73.4%-74.4%)21450 Cardinia 56.4%(55.8%-57.1%) 57.2%(56.6%-57.9%)21610 Casey 56.8%(56.4%-57.1%) 57.3%(56.9%-57.6%)22170 Frankston 55.4%(54.9%-55.9%) 55.2%(54.7%-55.7%)22310 GlenEira 63.1%(62.6%-63.6%) 64.2%(63.7%-64.6%)22670 GreaterDandenong 54.3%(53.8%-54.8%) 54.6%(54.2%-55.1%)23430 Kingston 61.5%(61.0%-61.9%) 61.3%(60.9%-61.8%)25340 MorningtonPeninsula 62.1%(61.6%-62.6%) 63.0%(62.6%-63.5%)25900 PortPhillip 63.4%(62.9%-63.9%) 62.9%(62.4%-63.4%)26350 Stonnington 65.5%(65.0%-66.0%) 66.6%(66.1%-67.1%)
Notes
1. RefertoAppendix3formapsshowingLocalGovernmentAreacodes.
2. 2010–2011and2011-2012data:Postcode/PostalAreasmappedtoLGAusingaconverteralgorithmsuppliedbytheVictorianDepartmentofHealthand basedonABSAustralianStatisticalGeographyStandard(ASGS)2011correspondencedata.Populationdataadjustedusingestimatedhysterectomy fractionsfromtheAIHWNationalHospitalMorbidityDatabase.
3. Thetableprovidesthepercentageofwomenscreenedasaproportionoftheeligiblefemalepopulation(cruderate).Womenscreenedonlyincludes womenwhohavenothadahysterectomyaccordingtoinformationheldbytheVCCR.
4. Periodscoveredapplytocalendaryears.
l
18
% PARTICIPATIONLess than 50%
50% - 55%
55% - 60%
60% - 65%
65% - 70%
Greater than 70%
Unincorporated Victoria
INSET: Melbourne and surrounds
Figure 2.3.3: EstimatedtwoyearcervicalscreeningratesbyLocalGovernmentArea*,2011–2012.
Unincorporated Victoria refers to the areas within Victoria which are not administered by incorporated local government bodies.
*NotethatmapsshowingVictorianLGAcodesareprovidedinAppendix3.
VictorianCervicalCytologyRegistryStatistical Report 2012 19
Table 2.4: Proportion of Pap tests collected by nurses, 2003–2012.
2.4 PAP TESTS COLLECTED BY NURSES ThecredentiallingofnurseseverythreeyearstoperformPaptestsrecognisesnurses’expertiseanddedicationtotheVictorianCervicalScreeningProgram.Thisprocesshasbeensetinplacetoallownursestobeaccountabletothepublicandresponsiblefortheirindividualpracticewhileatthesametimemaintainingastandardofexcellence.ThecredentiallingprogramiscoordinatedbyPapScreenVictoria.
During2012,atotalof33,875PaptestswerecollectedandreportedtotheRegistryby416credentiallednurses.Thisnumberrepresents5.6%ofallPaptestscollectedinVictoriaduring2012.Thisfigurereflectsthesignificantgrowthintheroleofnursesincervicalscreening,withtheproportionofPaptestsperformedbynurseshavingsteadilyincreasedovertheyearsfromaninitialreportedfigureof0.8%(5,170tests)in1996.Table2.4showsthenumberandproportionofPaptestscollectedbynursessince2003.
NursePaptestdatahighlighttheincreasinglyimportantrolethatnurseshaveinthedeliveryoftheVictorianCervicalScreeningProgram,particularlyinrelationtotheincreasingnumberofPaptestscollectedbytheminrecentyearsandthehighqualityoftheirtests.Asobservedinrecentyears,Paptestscollectedbynursesaremorelikelytohaveanendocervicalcomponent,whichisconsideredtobeareflectionoftestquality.GeneralPracticeandCommunityHealthsettingsremainthemaintypesofpracticeswherenursescollectPaptests(85.5%ofpracticetypesin2012).
During2012,39.2%ofthePaptestscollectedbynurseswerefromwomenover50yearsofagecomparedwith30.1%collectedbyotherprovidertypesinVictoriaduringthisperiod24.
Year Number of Pap tests collected
by nurses
% of all Victorian Pap tests
2012 33,875 5.6%
2011 31,613 5.5%
2010 28,546 5.0%
2009 25,594 4.4%
2008 21,668 3.8%
2007 18,651 3.2%
2006 16,035 2.8%
2005 14,375 2.5%
2004 13,100 2.2%
2003 11,494 2.0%
24 VCCR Evaluation of Pap tests collected by Nurses in Victoria during 2012report.Refertowww.vccr.org/stats.html
20
Table 2.4.1:Paptestsforwomenwithacervixcollectedbynurses,byDepartmentofHealthregion,2012.
2.4.1 Proportion of Pap tests collected by nurses by Department of Health RegionDataonPaptestscollectedbynurseswereanalysedbyDepartmentofHealth(DH)region.ThefollowingtableandfigureshowthattheruralDHregionshadahigherproportionoftestscollectedbynurses,forwomenwithacervix,thanthosewithinmetropolitanMelbourne.TheproportionofPaptestscollectedbynursesincreasedacrossBarwonSouthWest,EasternMetropolitan,LoddonMalleeandtheNorthernandWesternMetropolitanregions.ThelargestincreasesintheproportionofPaptestscollectedbynurseswereseenintheLoddonMallee(3.4%)andBarwonSouthWestregions(0.9%)25.
Region name Number of Pap tests collected
by nurses1
Number of nurses in each
region2
% Pap tests in region collected
by nurses
BarwonSouthWest 3,915 55 10.7%
EasternMetropolitan 2,324 32 2.1%
Gippsland 2,365 31 9.9%
Grampians 4,046 29 19.7%
Hume 3,878 54 14.8%
LoddonMallee 7,046 70 23.2%
Northern&WesternMetropolitan 7,168 101 4.1%
SouthernMetropolitan 2,738 37 2.0%
25 Ibid.
1 Excludes345post-hysterectomyPaptestsand50womenwhosepostcodewasmissingornotabletobematched.2 Excludessevennurseswhosepostcodecouldnotbematched.
VictorianCervicalCytologyRegistryStatistical Report 2012 21
Unincorporated Victoria refers to the areas within Victoria which are not administered by incorporated local government bodies.
Figure 2.4.1:ProportionofPaptestscollectedbynurses,byDepartmentofHealthregion,2012.
22
VCCRisworkingcloselywithProgramPartnersincludingtheDepartmentofHealth,PapScreenVictoriaandVCSPathologytoimprovetheidentificationofAboriginalandTorresStraitIslanderwomenandtheongoingcollectionofCALDdatatotheRegistry.
VCSPathologycontinuestoworkwithnurseswhocollectPaptests,tosupportandencouragetheidentificationofAboriginalandTorresStraitIslanderwomenandtherecordingofthisinformationontheVCSPathologyRequestForms.NursePractitionershavethehighestproportionofanypractitionertype,94.1%,ofPaptestswherethisinformationwasreported.Table2.5(b)showstheproportionofPaptestsbypractitionertypewhereAboriginalandTorresStraitIslanderinformationwasrecordedinthewoman’srecord.
2.5 CLOSING THE DATA GAPS: IDENTIFYING ABORIGINAL AND TORRES STRAIT ISLANDER PEOPLE, AND COLLECTING COUNTRY OF BIRTH AND LANGUAGE SPOKEN AT HOME
DatafromtheAIHW26hasshownthatAboriginalandTorresStraitIslanderwomenarefivetimesmorelikelytodieofcervicalcancerthannon-AboriginalandTorresStraitIslanderwomen.Thenational“ClosingtheGap”strategyisacommitmentbyallAustralianGovernmentstoovercomedisadvantageandimprovethelivesandhealthoutcomesofAboriginalandTorresStraitIslanderpeople27.
WomenfromCulturallyandLinguisticallyDiverse(CALD)backgroundshavealsobeenidentifiedasanunder-screenedgroup28.StrategiesforengagingwithAboriginalandTorresStraitIslanderandCALDwomen,andincreasingparticipation,areapriorityfortheVictorianDepartmentofHealthasoutlinedintheVictorianPublicHealthandWellBeingPlan2011-2015andthepreviousgovernments’VictorianCancerActionPlan(2008-2011).
Whereprovidedbypractitioners,laboratories,anddirectlybywomenthroughupdatesofpersonalinformation,theVCCRwillrecordifawomanhasidentifiedasanAboriginalandTorresStraitIslanderpersonaswellashercountryofbirthandlanguagespokenathomeasindicatorsofculturaldiversity.
Aboriginal and Torres Strait Islander Women
In2012theoverallpercentageofwomenscreenedwhohadtheirAboriginalandTorresStraitIslanderoriginrecordedbytheVCCRwas19.4%.Table2.5(a)showsthenumberandproportionofwomenbytheiridentificationasanAboriginalandTorresStraitIslanderperson.
Status No. %Aboriginal 1052 0.2%
TorresStraitIslander 41 0.0%
Aboriginal&TorresStraitIslander
172 0.0%
NotAboriginal&TorresStraitIslander
110,336 19.2%
NotCollected 462,508 80.6%
DeclinedtoAnswer 14 0.0%
TOTAL 574123 100.0%
Practitioner Type No. %GeneralPractitioner 67259 14.0%
Hospital 1122 15.1%
NursePractitioner 31865 94.1%
Obstetrician&Gynaecologist 14473 18.4%
Other 359 15.4%
Table 2.5 (a): ProportionofWomenscreenedbyAboriginalandTorresStraitIslanderOrigin.
Table 2.5 (b): ProportionofPapTestsbyPractitionerTypewithAboriginalandTorresStraitIslanderOriginInformationrecorded.
26 AustralianInstituteofHealthandWelfareOctober31st2011http://www.aihw.gov.au/media-release-detail/?id=1073742043427 AustralianGovernment,DepartmentofSocialServices,http://www.dss.gov.au/our-responsibilities/indigenous-australians/programs-services/closing-the-gap28 MullinsRAntiCancerCouncilVictoria,2006EvaluationoftheimpactofPapScreen’sCampaignonCulturallyandLinguisticallyDiverse(CALD)Women http://www.cancervic.org.au/downloads/cbrc_research_papers/Cervical_cancer_research/06rep_rm_eval_PapScreen_campaign_CALD_women.pdf29UnitedKingdom(includesChannelIslandsandIsleofMan)isassignedwhentheCountryofBirthisnotfurtherspecified.
Culturally and Linguistically Diverse Women
In2012theoverallpercentageofwomenscreenedwhohadaCountryofBirthrecordedbytheVCCRwas14.5%.ThemostcommoncountriesofbirthoutsideofAustraliawereVietnam,England,NewZealand,UnitedKingdom(includesChannelIslandsandIsleofMan)29,China(excludesSARSandTaiwan),India,Italy,Philippines,GreeceandMalaysia.
TheoverallpercentageofwomenscreenedwhohadLanguageSpokenatHomerecordedwas15.2%.Themostcommonlanguagesreported,otherthanEnglish,wereVietnamese,Italian,Greek,Mandarin,Chinese(notelsewhereclassified),Arabic,Spanish,Cantonese,TurkishandMaltese.
VictorianCervicalCytologyRegistryStatistical Report 2012 23
2.6 FREqUENCY OF EARLY RE-SCREENINGWhiletheAustralianscreeningpolicyrecommendsscreeningeverytwoyearsafteranegativePaptestreport,aproportionofwomenarescreenedmorefrequently.Asmalllevelofearlyre-screeningcanbejustifiedonthebasisofapasthistoryofabnormality.
Inlate2000,theNationalCervicalScreeningProgramadoptedthefollowingdefinitionofearlyre-screening:
Early re-screening is the repeating of a Pap test within 21 months of a negative Pap test report, except for women who are being followed up in accordance with the NHMRC guidelines for the management of cervical abnormalities.
Thisdefinitionrecognisesthatsomere-screeningmayoccuropportunisticallybetween21and24monthsafteranegativePaptestreportandthismaybecost-effective.
Todeterminehowmanywomenaretrulyscreenedearly,womenwithapriorcytologicalorhistologicalabnormalityrecordedbytheVCCRwithin36monthsoftheindexPaptestwereexcluded.ThisisinlinewiththenationalreportingofindicatorsbytheAIHWforthesameperiodandisalsoconsistentwiththeNHMRCGuidelines.
Table2.6showsthenumberoffurtherPaptestsovera21monthperiodforwomenwhoreceivedanegativePaptestreportintheFebruaryof2011.Thedatashowthat86.4%ofwomenaged20to69yearswhohadanegativePaptestinFebruary2011hadnofurthertestswithinthenext21months.
Thisdataiscomparablewiththatprovidedinthe2009,2010and2011StatisticalReports,howevernotwithpriorreports,asthemethodofdeterminingthepercentagenowexcludeswomenwhohaveanabnormalitywithin36monthsoftheirnegativeindexPaptest.
AsseeninFigure2.6,somevariationinearlyre-screeningoccursbyagegroup.Thegraphshowstheproportionofwomen,byagegroup,whohadearlyre-screeningafteranegativePaptestreportinFebruary2011.
Figure 2.6 :Earlyre-screeningafteranegativePaptestreportinFebruary2011byagegroup.
0
2
4
6
8
10
12
14
16
Per
cent
age
of e
arly
re-
scre
enin
g
20-29 yrs 30-39 yrs 40-49 yrs 50-59 yrs 60-69 yrs
Table 2.6:SubsequentPaptestsovera21monthperiodforwomenwithanegativereportinFebruaryof2011.
Number of subsequent Pap tests since February 2011 Percent
Nofurthertests 86.4%
1 13.0%
2 0.5%
3 < 0.1%
4 < 0.01%
5ormore < 0.01%
24
3. CYTOLOGY REPORTS
Cytology reports received by the VCCR are coded according to the 2006 Cytology Coding Schedule (refer to Appendix 1). From this coding, Pap test results are categorised into the broader groups of unsatisfactory, negative, having no endocervical component, and having a squamous abnormality or endocervical abnormality. These groupings are consistent with the cytology result types requested by the AIHW for the reporting of national indicators for the same period.
For this analysis, the results of 593,119 Pap tests from any provider type were considered. These include Pap tests which were collected during 2012, from women of any age, but not post-hysterectomy smears (also referred to as vault smears).
3.1 UNSATISFACTORY PAP TESTSAnunsatisfactoryPaptestresultisdefinedashaving:
• unsatisfactorysquamouscells(SU)andunsatisfactoryendocervicalcells(EU);or
• unsatisfactorysquamouscells(SU)andnoendocervicalcells(E0)ornoendocervicalabnormality(E1).
OfPaptestresultsreceivedduring2012bytheVCCR,14,700wererecordedashavinganunsatisfactoryresult.Thisequatesto2.5%ofPaptests.TheNationalPathologyAccreditationAdvisoryCouncil(NPAAC)Performance measures for Australian laboratoriesreporting cervical cytology(NPAAC2006)includesarecommendedstandardfortheproportionofspecimensreportedasunsatisfactoryasbetween0.5%and5.0%ofallspecimensreported30.
3.2 NEGATIVE PAP TESTSAnegativePaptestresultisdefinedashavingsquamouscellswithnoabnormality(S1)andnoendocervicalcells(E0)ornoendocervicalabnormality(E1).
OfthePaptestresultsreceivedduring2012bytheVCCR,538,455wererecordedashavinganegativeresult.Thisequatesto90.8%ofPaptests.
3.3 PAP TESTS WITHOUT AN ENDOCERVICAL COMPONENTThepresenceofendocervicalcellswithinaPaptestspecimenisconsideredtobeareflectionoftestquality.PaptestsidentifiedasnotcontaininganendocervicalcomponentarecodedashavingaresultofE0fortheendocervicalcellresult.
OfthePaptestresultsreceivedduring2012bytheVCCR,153,123wererecordedasnothavinganendocervicalcomponentpresentinthespecimen.Thisequatesto25.8%ofPaptests.
AsillustratedinFigure3.3,theproportionofPaptestswithoutanendocervicalcomponenthasgraduallyincreasedfrom19.7%in2004to25.8%in2012(p<0.001).Thisincreasehasalsobeenseenatanationallevel.ThereasonforthedeclineinPaptestswithanendocervicalcomponentisunclear.Itislikelytobemulti-factorial,andamoredetailedanalysisofthesetrendsisbeingcompletedbytheVCCR.
30 AustralianInstituteofHealthandWelfare2013.Cervical screening in Australia 2010-2011.Cancerseries76.Cat.no.CAN72.Canberra:AIHW.
Figure 3.3: PercentageofPaptestswithoutanendocervicalcomponent.
0
5
10
15
20
25
30
Per
cent
age
2004 2005 2006 2007 2008 2009 2010 2011 2012
Year
3.4 PAP TESTS WITH A SqUAMOUS ABNORMALITYTable3.4showsthattheproportionofPaptestswithasquamouscellabnormality(withanabnormalityofpossiblelow-gradelesionorworse)in2012was39,621whichequatesto6.7%ofallPaptestsfortheyear.
Adefinitehigh-gradeabnormality(i.e.high-gradelesionwithorwithoutpossiblemicro-invasionorinvasion,invasivesquamouscellcarcinoma)wasreportedin0.8%ofallPaptestsfor2012.
3.5 PAP TESTS WITH AN ENDOCERVICAL ABNORMALITYThepresenceofendocervicalcellswithinaPaptestspecimenisnecessaryforthedetectionandreportingofglandularabnormalitiesincludingatypicalcells,possiblehigh-gradelesions,endocervicaladenocarcinomainsituandadenocarcinoma.
ThefollowingtableshowstheproportionofPaptestsfor2012whereanendocervicalabnormalitywasdetected.Paptestswhichareknowntohavebeencollectedpost-hysterectomyareexcluded.
For2012,thetotalnumberofPaptestswithanendocervicalabnormality(atypicalendocervicalcellsofuncertainsignificanceorworse)was505,whichequatestofewerthan0.1%ofallPaptestsfortheyear.
VictorianCervicalCytologyRegistryStatistical Report 2012 25
Table 3.5:NumberandpercentofPaptestscollectedin2012withanendocervicalabnormality.
Endocervical Component Code Number of Pap tests
% of Pap tests
Atypicalendocervicalcellsofuncertainsignificance(E2)
239 0.1%
Possiblehigh-gradeendocervicalglandularlesion(E3)
166 0.1%
Adenocarcinomainsitu(E4) 77 0.1%
Adenocarcinomainsituwithpossiblemicro-invasion/invasion(E5)
10 0.01%
Adenocarcinoma(E6) 13 0.01%
Table 3.4:NumberandpercentofPaptestscollectedin2012withasquamousabnormality.
Squamous Cell Code Number of Pap tests
% of Pap tests
Possiblelow-gradesquamousintraepitheliallesion(LSIL)(S2)
19,091 3.2%
Low-gradesquamousintraepitheliallesion(LSIL)(S3)
11,371 1.9%
Possiblehigh-gradesquamousintraepitheliallesion(HSIL)(S4)
4,496 0.8%
High-gradesquamousintraepitheliallesion(HSIL)(S5)
4,521 0.8%
High-gradesquamousintraepitheliallesion(HSIL)withpossiblemicro-invasion/invasion(S6)
88 0.1%
Squamouscarcinoma(S7) 54 0.01%
3.6 TYPE OF TESTSInJuly2006,theVCCRbeganrecordingthetypeofPaptesttaken;thatis,conventionalcytology,liquid-basedspecimenorcombination.During2012theproportionofliquid-basedtestswas4.0%ofalltestsreportedtotheRegistry.Nearlyallofthesetestswere“splitsamples”wheretheconventionalPapsmearisaccompaniedbytheliquid-basedspecimen.Verysmallnumberswereliquid-basedspecimensonly(0.2%).
4. HISTOLOGY REPORTS
ThissectiondescribesthehistologyreportsthatwerenotifiedtotheVCCRduring20121.Althoughthereportingofhistologyresultsisnotmandatory,themajorityofallrelevantcervicalbiopsiesarereportedtotheVCCR.AllcancersarenotifiedtotheVictorianCancerRegistrybylaboratories,hospitalsandtheVCCR.
In2012,therewere20,630histologyreportsrelatingtothecervixreceivedbytheVCCR.Thefollowingtableshowsthedistributionofhistologyfindingsfor2012.
NotethatthedatapresentedinTable4includesallhistologyreportsreceivedbytheVCCR,andisnotrestrictedtothemostseverereportforawoman.
Table 4: HistologyfindingsreportedtotheVCCRin2012.
Histology findings Number (%)
Endocervicalabnormality
Carcinomaofthecervix–other2 15 ( 0.1%)
Adenosquamouscarcinoma 4 ( 0.1%)
Endocervicaladenocarcinoma,invasive 51 (0.2%)
Endocervicaladenocarcinoma,micro-invasive 4 ( 0.1%)
High-gradecarcinomainsitu/adenocarcinomainsitu 68 (0.3%)
High-gradeendocervicalabnormality,adenocarcinomainsitu 114 (0.6%)
High-gradeendocervicalabnormality,endocervicaldysplasia 11 ( 0.1%)
Endocervicalatypia 0 (0.0%)
Squamousabnormality
Squamouscellcarcinoma,invasive 106 (0.5%)
Squamouscellcarcinoma,micro-invasive 25 (0.1%)
High-gradesquamousabnormality,CINIII 2,922 (14.2%)
High-gradesquamousabnormality,CINII 2,136 (10.4%)
High-gradesquamousabnormality,CINnototherwisespecified 241 (1.2%)
Low-gradesquamousabnormality 3,373 (16.3%)
Benignchanges/normal 11,302 (54.8%)
Unsatisfactory 258 (1.3%)
TOTAL 20,630 (100%)
26
1 ThenumberofHistologyReportsnotifiedtotheVCCRasat30June2013.2 Carcinomaofthecervix–other:includessmallcellcarcinomaandothermalignantlesions
(mayincludetumoursofnon-epithelialorigin).
VictorianCervicalCytologyRegistryStatistical Report 2012 27
5. HIGH-GRADE ABNORMALITY DETECTION RATES
Figure5.2showstherateofhistologically-confirmedhigh-gradecervicalabnormalitiesbyyearsince2000,foryoungwomen(<20,20-24,25-29)andthose30+yearsofage.32Thepreviouslynoteddecline,followingtheNationalHPVVaccinationProgram,inwomenunder20yearsofageiscontinuing,withanearhalvingoftherateof11casesper1,000womenscreenedin2006downto6casesper1,000in2012(p<0.001).Ratesinwomen20to24yearshavebeendecliningsince2010;howevertherehasbeenasteadyriseindetectionratesfor25to29yearoldwomenoverthelast10years.
TheVCSandtheAIHWhaveundertakenananalysisofde-identifiedlinkeddatafromtheVCCRandtheNHVPRtodeterminewhetherthedeclinesobservedinhigh-gradeabnormalityratesamongstyoungwomen(aged12to17yearsin2007)sincethevaccinationprogramareduetovaccination.Theanalysisconfirmedthatvaccinatedwomenattendingscreeninghavea48%lowerrateofhigh-gradeabnormalitiesthanunvaccinatedwomen,afteradjustingforage,socioeconomicstatusandareaofresidence(HazardRatio0.72(95%CI0.58-0.91)forreceiptofanynumberofdosesofHPVvaccine).ThisisthefirstinternationalevidenceoftheeffectivenessofHPVvaccinationinpreventinghigh-gradecervicalabnormalitiesinapopulation.33
In2012theoverallrateofhistologically-confirmedhigh-gradeabnormalitiesdetectedinVictoriaforwomenaged20to69yearswas7.65per1,000womenscreened.31Figure5.1illustratesthedetectionrateofhistologically-confirmedhigh-gradeintraepithelialabnormalitiesper1,000screenedwomenfortheyears2009-2012byfiveyearagegroup.Thegraphclearlyillustratesthatyoungerwomenhaveamuchhigherrateofhigh-gradeabnormalities,resultingfromhighratesofincidentHPVinfectionfollowingtheonsetofsexualactivity,thanolderwomen.Notablehoweveraretheyearonyeardeclinesintherateintheyoungestwomen(aged20to24years),correspondingtotheimplementationoftheHPVvaccinationprogrambetween2007-2009.Historicallythisagegrouphashadthehighestratesofabnormalitiesbutfrom2009theratehasbeenhigheramongst25to29yearolds.Since2008theratein20to24yearoldshasfallenfrom21.1(notshowninfigure)to15.3per1,000in2012(p<0.001)(2009=18.7;2010=17.9;2011=15.8).Theyoungestvaccinatedwomen,whoarelesslikelytohavebeenpreviouslyexposedtohigh-riskHPVtypesthroughsexualactivity,arenowcommencingcervicalscreening.AccordingtotheNationalHPVVaccinationProgramRegister,Victorianwomenaged15to19yearsin2012haveanotifiedthree-dosevaccinecoverageof72.6%andthoseaged20to24yearshaveanotifiedcoverageof52.9%(NHVPR,unpublisheddata).
Figure 5.2:Trendsinhigh-gradecervicalabnormalities(histologically-confirmed)byage,2000-2012,VCCR.
20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69yrs yrs yrs yrs yrs yrs yrs yrs yrs yrs
Age group
Rat
e pe
r 1,
000
scre
ened
wom
en
0
2
4
6
8
10
12
14
16
18
20
20112012
20102009
Rat
e pe
r 1,
000
scre
ened
wom
en
Year
0
5
10
15
20
25
30
<20 yrs 20-24 yrs 25-29 yrs 30+ yrs
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012
Figure 5.1:Detectionrateofhigh-gradeintraepithelialabnormalities(histologically-confirmed)from2009-2012per1,000screenedwomen.
Histology findings Number (%)
Endocervicalabnormality
Carcinomaofthecervix–other2 15 ( 0.1%)
Adenosquamouscarcinoma 4 ( 0.1%)
Endocervicaladenocarcinoma,invasive 51 (0.2%)
Endocervicaladenocarcinoma,micro-invasive 4 ( 0.1%)
High-gradecarcinomainsitu/adenocarcinomainsitu 68 (0.3%)
High-gradeendocervicalabnormality,adenocarcinomainsitu 114 (0.6%)
High-gradeendocervicalabnormality,endocervicaldysplasia 11 ( 0.1%)
Endocervicalatypia 0 (0.0%)
Squamousabnormality
Squamouscellcarcinoma,invasive 106 (0.5%)
Squamouscellcarcinoma,micro-invasive 25 (0.1%)
High-gradesquamousabnormality,CINIII 2,922 (14.2%)
High-gradesquamousabnormality,CINII 2,136 (10.4%)
High-gradesquamousabnormality,CINnototherwisespecified 241 (1.2%)
Low-gradesquamousabnormality 3,373 (16.3%)
Benignchanges/normal 11,302 (54.8%)
Unsatisfactory 258 (1.3%)
TOTAL 20,630 (100%)
31 NotethatthemethodusedtocalculatetherateofhighgradeabnormalitieshasbeenupdatedtobeconsistentwiththeAIHWindicator4.2(AustralianInstituteofHealthandWelfare2013.Cervical screening in Australia 2010-2011.Cancerseries76.Cat.no.CAN72.Canberra:AIHW).Thereforeratesareslightlydifferenttothosepresentedinpreviousreports.
32 Ibid.33 GertigDM,BrothertonJML,BuddAC,DrennanK,ChappellG,SavilleAM.Impact of a population-based HPV vaccination program on cervical abnormalities: a data linkage study. BMC Medicine 2013,11:227.
28
6. CORRELATION BETWEEN CYTOLOGY & HISTOLOGY REPORTS
Tables6.1and6.2showthecorrelationbetweencytologyresultsandhistologyfindings.Thecorrelationisrestrictedtocytologyperformedin2011whereasubsequenthistologytestwasreportedwithinsixmonths.Ifmultiplehistologyresultswerereportedthemostsevereresultisused.Colposcopyreports,withouthistologicalconfirmation,havebeenexcludedfromthisanalysis.
Ininterpretingthisinformation,itisimportanttorememberthatonlyaminorityoflow-gradecytology(atypiaandCINI)isfurtherinvestigatedbycolposcopyorbiopsy,andanevensmallerpercentageofnegativecytologyreportsarefollowedbycolposcopyorbiopsy.Womenwhohaveabiopsyarelikelytobeanatypicalsubsetofthewholegroupofwomenwithnegativeorlow-gradecytologyreports.
ThecorrelationdatapresentedusestheCytologyCodingScheduleimplementedinJuly2006whichisbasedontheAustralianModifiedBethesdaSystemof2004(refertoAppendix1).EachPaptestisassignedasummarycode(negative,low-grade,glandular,possiblehigh-gradeandhigh-grade)basedonspecificcriteriaofthesquamous,endocervicalandother/non-cervicalcodes.Thecorrelationusesthisclassificationforcytology.
ThehistologyclassificationandmethodofcorrelationpresentedisconsistentwiththeAIHWnationalreportingindicators.Itisbasedonthetest,notthewoman,andthedataincludeswomenaged20to69years.ItalsoincludestherecordsofwomenwhoresideoutsideofVictoriabuthavedatarecordedontheVCCR.
Whereadefinitehigh-gradesquamouscytologyresultwasreported,79.7%(2911/3653)ofwomenweresubsequentlydiagnosedwithhigh-gradehistologyatbiopsy(includinghigh-gradeCINnototherwisespecified,CINII,CINIIIandmicro-invasiveandinvasivesquamouscarcinoma).Thisfigurerepresentsthepositivepredictivevalueofahigh-gradecytologyreportforhigh-gradehistology.TheNationalPathologyAccreditationAdvisoryCouncil(NPAAC)performancestandardsrequirethatnotlessthan65%ofcytologyspecimenswithadefinitehigh-gradeepithelialabnormalityisconfirmedonhistologywithinsixmonthsashavingahigh-gradeabnormalityorcancer34.
WomenwithaPaptestreportof‘atypicalendocervicalorglandularcellsofuncertainsignificance’haveglandular(orendocervical)cellsontheirsmearwhich,intheopinionofthereportingpathologist,appearunusualbutarenotsufficientlyabnormaltojustifyamoresignificantdiagnosis.Unfortunatelythereisoverlapinthecellularfeaturescausedbybenign,inflammatorychanges(byfarthemostcommoncause)andmoresignificantprocessessuchaspre-cancer(occasionally)andcancer(rarely).TheNHMRCGuidelines35
recommendcolposcopyasaninitialevaluationbecauseoftheriskofinvasivecancer36.Ofthe26cytologyreportsof‘atypicalendocervicalorglandularcellsofundeterminedsignificance’,2weresubsequentlydiagnosedwithinvasiveormicro-invasivecancer(wherehistologywasavailablewithinsixmonthsafterthecytologyresult).
Therewerenocasesofcervicalcancerreportedonhistologywithin6monthsofalow-gradesquamouscytologyin2011(Table6.1).
34 NationalPathologyAccreditationAdvisoryCouncil(NPAAC)2006.Performance Measures for Australian Laboratories Reporting Cervical Cytology,Canberra:DepartmentofHealthandAgeing.
35 NHMRC Screening to prevent cervical cancer: guidelines for the management of asymptomatic women with screen-detected abnormalities,2005 http://www.nhmrc.gov.au/publications/synopses/wh39syn.htm36 Appendix 8. Outcome after a cytological prediction of glandular abnormality in 1999.AuthorDrHeatherMitchell.ScreeningtopreventCervicalCancer Guidelinesforthemanagementofasymptomaticwomenwithscreendetectedabnormalities.
AvailablefromtheNHMRCwebsitewww.nhmrc.gov.au/_files_nhmrc/publications/attachments/wh39.pdf
VictorianCervicalCytologyRegistryStatistical Report 2012 29
Table 6.1: Correlation1ofsquamouscytologytothemostserioussquamoushistologywithin6months,womenaged20to69years,cytologytestsperformedin2011.
1 Thecorrelationexcludesdiagnosisbasedoncolposcopicimpressionalone2 Negativecytology:noabnormalsquamouscellsoronlyreactivechanges3 Possiblehigh-gradecytology:includespossiblehigh-gradesquamousintraepitheliallesion4 High-gradecytology:includeshigh-gradesquamousintraepitheliallesion5 HGPlus:includeshigh-gradesquamousintraepitheliallesionwithpossiblemicro-invasion/invasion
Cytology Prediction
Histology fi nding
HG: High-Grade LG: Low-Grade SQ: Squamous
Negative2 Possible Low-Grade
Low-Grade Possible High-Grade3
High-Grade4 High-Grade Plus5
SCC
S1 S2 S3 S4 S5 S6 S7
Squ
amou
sA
bnor
mal
ity
NegativeHS01
3,236 76.3% 1406 51.6% 670 31.4% 996 31.6% 354 9.7% 3 5.4% 1 3.0%
LGSQabnormalityHS02
776 18.3% 936 34.3% 1042 48.9% 672 21.3% 388 10.6% 2 3.6% 0 0.0%
HGSQabnormalityCINNOSHS03.1
16 0.4% 25 0.9% 26 1.2% 65 2.1% 55 1.5% 0 0.0% 3 9.1%
HGSQabnormalityCINIIHS03.2
126 3.0% 224 8.2% 270 12.7% 629 19.9% 865 23.7% 9 16.1% 0 0.0%
HGSQabnormalityCINIIIHS03.3
85 2.0% 134 4.9% 124 5.8% 780 24.7% 1944 53.2% 26 46.4% 10 30.3%
SQCellCarcinoma–micro-invasiveHS04.1
1 <0.1% 0 0.0% 0 0.0% 6 0.2% 24 0.7% 4 7.1% 1 3.0%
SQCellCarcinoma–invasiveHS04.2
2 <0.1% 0 0.0% 0 0.0% 5 0.2% 23 0.6% 12 21.4% 18 54.5%
Totals 4242 100% 2725 100% 2132 100% 3153 100% 3653 100% 56 100% 33 100%
30
Table 6.2: Correlation1ofendocervicalcytologytothemostseriousendocervicalhistologywithin6months,womenaged20–69years,cytologytestsperformedin2011.
1 Thecorrelationexcludesdiagnosisbasedoncolposcopicimpressionalone2 Endocervicaladenocarcinoma–invasive:includesadenocarcinomaandembryonal/clearcellcarcinoma3 Carcinomaofthecervix–other:includessmallcellcarcinomaandothermalignantlesions(mayincludetumoursofnon-epithelialorigin)4 Glandularcytology:includesatypicalglandularcellsofuncertainsignificance(E2)5 Possiblehigh-gradecytology:includespossiblehigh-gradeendocervicalglandularlesion
Cytology Prediction
Histology fi nding
HG: High-Grade
Negative Atypical Endocervical
cells of uncertain signifi cance4
Possible High-Grade5
Adenocarcinoma in situ (AIS)
AIS with possible
micro-invasion /invasion
Adenocarcinoma
E1 E2 E3 E4 E5 E6
End
ocer
vica
lAbn
orm
alit
y
NegativeHE01
1736 95.5% 8 30.8% 3 6.5% 0 0.0% 0 0.0% 0 0.0%
EndocervicalAtypiaHE02
0 0.0% 0 0.0% 0 0.0% 0 0.0% 0 0.0% 0 0.0%
HGEndocervicalAbnormality,EndocervicalDysplasiaHE03.1
4 0.2% 1 3.8% 1 2.2% 0 0.0% 0 0.0% 0 0.0%
HGEndocervicalAbnormality,AdenocarcinomainsituHE03.2
24 1.3% 13 50.0% 26 56.5% 28 50.9% 3 42.9% 1 12.5%
HGCarcinomainsitu/AdenocarcinomainsituHE03.3
36 2.0% 2 7.7% 9 19.6% 14 25.5% 0 0.0% 0 0.0%
EndocervicalAdenocarcinoma–micro-invasiveHE04.1
0 0.0% 0 0.0% 1 2.2% 1 1.8% 0 0.0% 0 0.0%
EndocervicalAdenocarcinoma–invasive2
HE04.2
11 0.6% 1 3.8% 6 13.0% 12 21.8% 4 57.1% 7 87.5%
AdenosquamousCarcinomaHE04.3
5 0.3% 1 3.8% 0 0.0% 0 0.0% 0 0.0% 0 0.0%
Carcinomaofthecervix–Other3HE04.4
2 0.1% 0 0.0% 0 0.0% 0 0.0% 0 0.0% 0 0.0%
Totals 1818 100% 26 100% 46 100% 55 100% 7 100% 8 100%
VictorianCervicalCytologyRegistryStatistical Report 2012 31
7. FOLLOW UP & REMINDER PROGRAM
The VCCR Reminder and Follow-up Protocol (refer to Appendix 2) adheres to the 2006 NHMRC Guidelines. As part of the follow-up service provided by VCCR, a total of 410,680 follow-up and reminder letters were mailed to women and practitioners in 2012.
Second reminder letters were implemented as part of the routine correspondence of the VCCR in June 2011 and are printed in-house on a weekly basis for mail-out. The implementation costs and outcomes of the first seven months of the second reminder initiative were evaluated and published in an interim report37. Based upon the positive outcomes of the interim evaluation, the Department of Health has extended the funding for the second reminder initiative until June 2014. The following is a summary of the VCCR follow-up activities during 2012.
First Reminders to Women
Between1January2012and31December2012,270,989firstreminderlettersweresenttowomeninthecategoriesshowninTable7.
Ofthe258,047reminderssentafteranegativePaptest,103,634(40%)womenhadasubsequentPaptestwithinthreemonthsofthedateofthereminder.
Second Reminders to Women
Between1January2012and31December2012;117,460secondreminderlettersweresenttowomen,inthecategoriesshowninTable7.
Ofthe112,469reminderssentafteranegativePaptest;26,974(24%)womenhadasubsequentPaptestwithinthreemonthsofthedateofthereminder.
Table 7: NumberoffirstandsecondreminderletterssenttowomenbytheVCCRin2012.
Follow-up
During2012,theVCCRsentout1,854questionnairestopractitionersseekingfurtherinformationafterahighgradeabnormalityonPaptestand4,493afteralow-gradeabnormality.Thesequestionnairesarepartofthefollow-upofabnormaltestsandseekinformationoncolposcopyorbiopsytoalterthefollow-upintervalaccordingly.TheVCCRalsosentout12,406reminderletterstopractitioners,followinglow-gradeorunsatisfactoryPaptests.
Duringtheyear,802womenwithahigh-gradeabnormalityrequiredfurtherfollow-upbytheVCCRasnofurtherinformationhadbeenreceivedby5.5monthsaftertheirPaptest.Forthesewomen,atleastonephonecalltothepractitionerwasmadetoascertainfollow-up,withmanyrequiringadditionalcalls.In345cases,theRegistrysentletterstothesewomen,mostlybyregisteredmailtoensurethattheywereawareoftheirabnormality.Forwomenwhohadlow-gradeabnormalitiesrequiringfurtherinvestigation,onwhomtheVCCRhadnotreceivedfollow-upinformation;2,178lettersweresenttothesewomenin2012.TheVCCRfollowedup151non-cervicalabnormalitieswithletterstothepractitionersseekinginformationaboutfurtherinvestigations.
Pap test report category First Reminders Second Reminders
High-gradewithsubsequentbiopsy 1,180 402
High-gradenosubsequentPaptestby12months 158 68
Low-grade-withsubsequentbiopsyorcolposcopy 1,674 612
Low-grade-previoustestabnormalorfluctuatingabnormality 800 329
Low-grade–over30withnonegativecytologyinprevious3years 504 227
Low-grade–allotherwomen 5,534 2,005
Negativewithpreviousabnormal 25,033 10,823
Negative 233,014 101,646
Unsatisfactorywithpreviousabnormal 120 40
Unsatisfactory 2,972 1,308
37 Interim evaluation report of Second Reminder, VCCR. PreparedbyLesleyRowlands,GenevieveChappellandDorotaGertig,April2012
8. CERVICAL CANCER INCIDENCE & MORTALITY IN VICTORIA
Thegreatestimpactofthecervicalscreeningprogramhasbeenonsquamouscellcarcinomaofthecervix,withage-standardisedincidenceratesdecliningfrom6.3per100,000womenin1989to2.7per100,000in2012.Thisisamarginalincreasefromanincidencerateof2.0in2010and2.2in2011per100,000women.Incidenceratesformicro-invasivecancerhaveincreasedslightlysince2000;andin2012were1.1per100,000womenscreened(2010:1.2and2011:1.1).Cervicalscreeningislesseffectiveforthedetectionofadenocarcinomas39,whichnowrepresentalargerproportionofallcancersduetothesuccessoftheprograminreducingtheincidenceofsquamouscancers.ItisanticipatedthatHPVvaccinationprogramswillreducethefutureincidenceofadenocarcinomas.
Figure8.3showstheage-specificincidenceratesofcervicalcancerbyhistologyandage,groupedoverthethreeyearperiodof2010to2012.Theage-specificincidenceofinvasivesquamouscervicalcancerincreasesinthe30to34yearoldagegrouptopeakatage45to49years,followedbyasubsequentpeakinwomenagedintheirearly70s.Micro-invasivecervicalcancerpeaksataround30yearsofageanddeclinessteadilythereafter.
38 FerlayJ,ShinHR,BrayF,FormanD,MathersCandParkinDM.GLOBOCAN2008v2.0,Cancer Incidence and Mortality Worldwide: IARC CancerBaseNo.10[Internet].Lyon,France:InternationalAgencyforResearchonCancer;2010.Availablefrom:http://globocan.iarc.fr39 NHMRC Screening to prevent Cervical Cancer: guidelines for the management of asymptomatic women with screen-detected abnormalities,2005 http://nhmrc.gov.au/publications/synopses/whj39syn.htm
Theaimofthecervicalcancerscreeningprogramistoreducetheincidenceofandmortalityfromcervicalcancer.DataoncancerincidenceandmortalityarecollectedbytheVictorianCancerRegistryandnotificationsarecompulsoryfromlaboratories,hospitalsandtheVCCR.
Figure8.1showstheincidenceandmortalityratesfromcervicalcancerinVictoriafrom1982to2012.Theincidenceofcervicalcancerhasdeclineddramaticallysincethe1980s,withaconsiderabledeclinefromthemid1990s.Therewasaplateauinincidencein2000andtheratehasremainedrelativelystablesincethattimeatbetween4and5per100,000women.Aslightincreasehasbeennotedin2012,astheincidencerateforcervicalcancerwas5.7per100,000women(2010:5.0and2011:4.9).
ThemortalityfromcervicalcancerinVictoriahasdeclinedgraduallyovertimeandsince2002hasbeenaround1.0per100,000women,whichisamongthelowestintheworld38.Themortalityrateforalltypesofcervicalcancerin2012was1.1per100,000Victorianwomen(2010:1.3and2011:1.1).
Figure8.2showstheage-standardisedincidenceratesforcervicalcancerbyhistologicalsubtypeovertime.
IncidenceMortality
Year
Rat
e pe
r 10
0,00
0 w
omen
(age
-sta
ndar
dise
d to
the
Wor
ld S
tand
ard
Pop
ulat
ion)
0
2
4
6
8
10
12
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
Source:ThursfieldV,FarrugiaH.CancerinVictoria:StatisticsandTrends2011.CancerCouncilVictoria,Melbourne2012.
32
Figure 8.1:Age-standardisedincidenceandmortalityratesforalltypesofcervicalcancerinVictoria,1982–2012.
VictorianCervicalCytologyRegistryStatistical Report 2012 33
Othercervicalcancersarecomprisedofallothertypes,includingadenocarcinomas.Source:Unpublisheddata,VictorianCancerRegistry,CancerCouncilVictoria.
Figure 8.2:Age-standardisedincidencerates(ASR)forcervicalcancerbyhistologicalsubtypeinVictoria,1982–2012.
Othercervicalcancersarecomprisedofallothertypes,includingadenocarcinomas.Source:Unpublisheddata,VictorianCancerRegistry,CancerCouncilVictoria.
Figure 8.3: Age-specificincidenceratesofcervicalcancerbyhistologicalsubtypeinVictoria,2010–2012.
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
19
9519
9619
9719
9819
9920
0020
0120
0220
0320
0420
0520
0620
0720
0820
0920
1020
1120
12
Year
0
1
2
3
4
5
6
7
8 Invasive squamous cell carcinomaMicro-invasive squamous cell carcinoma
Other invasive morphology
Rat
e pe
r 10
0,00
0 w
omen
(age
-sta
ndar
dise
d to
the
Wor
ld S
tand
ard
Pop
ulat
ion)
Age (Years)
0
2
4
6
8
10
12 Invasive squamous cell carcinomaMicro-invasive squamous cell carcinoma
Other invasive morphology
0-4
5-9
10-1
4
15-1
9
20-2
4
25-2
9
30-3
4
35-3
9
40-4
4
45-4
9
50-5
4
55-5
9
60-6
4
65-6
9
70-7
4
75-7
9
80-8
4
85+
Rat
e pe
r 10
0,00
0 w
omen
(age
-sta
ndar
dise
d to
the
Wor
ld S
tand
ard
Pop
ulat
ion)
3434
9. SCREENING HISTORY OF WOMEN DIAGNOSED WITH CERVICAL CANCER IN 2010 AND 2011
AccordingtotheVictorianCancerRegistry(VCR),183Victorianwomenwerediagnosedwithcervicalcancerin2010and185womenin2011(January1–December31).Thescreeninghistoriesofwomenwithhistologically-confirmedinvasiveandnon-invasivecervicalcancerrecordedontheVictorianCervicalCytologyRegistry(VCCR)isoutlinedbelow.
Cervical Cancer Diagnoses in 2010Ofthe183womendiagnosedwithcervicalcancerin2010,77werediagnosedwithinvasivesquamouscellcarcinoma,38withmicro-invasivesquamouscellcancerand68withothertypesofinvasivecervicalcancer(includingadenocarcinoma,smallcellcarcinoma,mixedadenosquamousadenocarcinomaandcarcinosarcomas/sarcomas)40.Ofthesewomendiagnosedwithcervicalcancer,137werealsorecordedontheVCCR,andthusascreeninghistorywasavailableforreview.
Cervical Cancer Diagnoses in 2011Ofthe185womendiagnosedin2011,83werediagnosedwithinvasivesquamouscellcarcinoma,36withmicro-invasivesquamouscellcancerand66withothertypesofinvasivecervicalcancer41.
Table 9 (a): ScreeninghistoryofVictorianwomendiagnosedwithcervicalcancerfortheperiod1January2010to31December2010.
Screening History
Invasive Squamous cell carcinoma
Number (%)
Other invasive cervical cancer
Number (%)Invasive
Sub-TotalMicro-invasive
Sub-Total
Invasive & Micro-invasive
Total
A.Neverscreened 38 49% 35 51% 73 50% 18 47% 91 50%
B.Lapsedscreeners(lastscreengreaterthan2.5years)
23 30% 18 26% 41 28% 11 29% 52 28%
C.Adequatelyscreened(lastscreenwithin2.5years)
10 13% 12 18% 22 15% 7 18% 29 16%
D.Delayeddiagnosis 6 8% 3 4% 9 6% 2 5% 11 6%
E.Noteligible1 0 0% 0 0% 0 0% 0 0% 0 0%
Total 77 100% 68 100% 145 100% 38 100% 183 100%
Ofthesewomendiagnosedwithcervicalcancer,113withaninvasivecancerdiagnosisand26withamicro-invasivediagnosiswerealsorecordedontheVCCRandthusascreeninghistorywasavailableforreview.
AnauditwasconductedonthescreeninghistoriesofwomenrecordedontheVCCRwithcervicalcancerbasedoncriteriausedinotherinternationalstudies42.Thefollowingcategorieswereused,andallscreeningtestswithin6monthsofdiagnosiswereexcluded(asitisassumedtheseledtothediagnosis):
A. Never screened (coverage failure),B. Lapsed screening: with more than two and a half years
between the cancer diagnosis and the ultimate Pap test,C. Adequately screened (screening failure): with less than
two and a half years between the cancer diagnosis and the ultimate Pap test,
D. Delayed diagnosis: eg. no colposcopy and/or biopsy recorded [biopsy, management or treatment failure],
E. Not eligible: Women over the age of 70 years and no longer eligible for the screening program1.
40 Unpublisheddata,VictorianCancerRegistry,CancerCouncilVictoria41 Ibid. 42 SasieniP,AdamsJ,CuzickJ.Benefi ts of cervical screening at different ages: evidence from the UK audit of screening histories.2003. BrJCancer.89(1):p.88-93.
VictorianCervicalCytologyRegistryStatistical Report 2012 35
1 Womenover70yearsandwithanegativescreeninghistoryareoutsidetheeligiblerangeforthescreeningprogram.RefertotheNationalCervical ScreeningProgramatwww.cancerscreening.gov.au
A. Women with no previous screening historyTheneverscreenedcategoryincludeswomenwhowereontheVCRandeithernotrecordedontheVCCR(37womenin2010and36womenin2011);andthusitisassumedtheywereneverscreened,orwererecordedontheVCCRbuttheirfirstPaptestwaswithin6monthsofdiagnosis(36womenin2010and37womenin2011).AproportionofthoseunknowntotheVCCRmayhavebeenscreenedinterstateoroverseas,orhaveopted-offtheRegistry.
B. Women with a lapsed screening history AccordingtotheVCCRrecords,therewere41women(28%)ineachof2010and2011thatwerecategorizedaslapsedscreeners.ThisisdefinedaswomenwithnorecordofaPaptestwithintwoandahalfyearsoftheircancerdiagnosis(butmorethansixmonthspriortodiagnosis)inaccordancewiththecurrentNationalscreeningpolicyrecommendationoftwoyearlyscreening.Theproportionofsquamousinvasivecancersforwhichtherewaseithernoscreeninghistoryoralapsedscreeninghistorywas79%in2010and81%in2011.Forglandularinvasivecancers,itwas77%in2010and71%in2011.
9. SCREENING HISTORY OF WOMEN DIAGNOSED WITH CERVICAL CANCER IN 2010 AND 2011
Table 9 (b): ScreeninghistoryofVictorianwomendiagnosedwithcervicalcancerfortheperiod1January2011to31December2011.
Screening History
Invasive Squamous cell carcinoma
Number (%)
Other invasive cervical cancer
Number (%)
Invasive
Sub-Total
Micro-invasive
Sub-Total
Invasive & Micro-invasive
Total
A.Neverscreened 43 52% 30 45% 73 49% 19 53% 92 50%
B.Lapsedscreeners(lastscreengreaterthan2.5years)
24 29% 17 26% 41 28% 11 31% 52 28%
C.Adequatelyscreened(lastscreenwithin2.5years)
11 13% 12 18% 23 15% 4 11% 27 15%
D.Delayeddiagnosis 4 5% 7 11% 11 7% 2 6% 13 7%
E.Noteligible1 1 1% 0 0% 1 1% 0 0% 1 1%
Total 83 100% 66 100% 149 100% 36 100% 185 100%
Invasive Cervical Cancers.
Tables 9(a) and 9(b) classify the screening history of women diagnosed with invasive cervical cancer into one of the following four groups:
C. Women with an adequate screening historyOfthewomendiagnosedwithcervicalcancer,22(15%)womenin2010and23(15%)womenin2011havebeenassessedashavinganadequatescreeninghistorywithatleastonePaptestbetweensixmonthsandtwoandahalfyearspriortotheircancerdiagnosis.Overhalfofthesewomeninboth2010and2011werediagnosedwithglandularcervicalcancers,whicharehardertodetectthroughcervicalscreening.
D. Women with a delayed diagnosisOfthewomendiagnosedwithfranklyinvasivesquamouscervicalcancer,9(6%)womenin2010and11(7%)womenin2011appeartohavehadadelayeddiagnosisormanagementfailureonthelimitedinformationavailabletotheVCCR.Paptestsarenotveryeffectiveatdetectionofadenocarcinoma,duetothedifficultyofsamplingtheendocervicalcanal,hencedelayeddiagnosismayplayaroleindetectionofthesecancers.
ACKNOWLEDGEMENTS
LIST OF ABBREVIATIONS
Theproductionofthisreportwouldnotbepossiblewithouttheco-operationofthestaffofthepathologylaboratoriesofVictoria,thestaffoftheVCCRandtheICTteam.Verysincerethanksareextendedtothemembersofallthesegroups.Inparticular,specialthanksgotothededicatedVCCRstafffortheircollectionofhigh-qualityinformationandtheprovisionofanexcellentserviceforwomenandhealthpractitioners.
ThefiguresonincidenceandmortalityfromcervicalcancerwerekindlyprovidedbytheVictorianCancerRegistryattheCancerCouncilVictoria.WewouldliketothankVickyThursfieldandHelenFarrugiafortheirassistanceinprovidingthesedata.
ABS: Australian Bureau of Statistics
AIHW: Australian Institute of Health and Welfare
ASR: Age-Standardised Rate (per 100,000 Victorian women standardised to World Standard Population)
CIN: Cervical Intraepithelial Neoplasia
ERP: Estimated Resident Population
HPV: Human Papillomavirus
HSIL: High-grade squamous intraepithelial lesion
ICT: Information and Communication Technology
LSIL: Low-grade squamous intraepithelial lesion
NHMRC: National Health and Medical Research Council
NHVPR: National HPV Vaccination Program Register
NPAAC: National Pathology Accreditation Advisory Council
PPV: Positive Predictive Value
SCC: Squamous Cell Carcinoma
VCCR: Victorian Cervical Cytology Registry
VCR: Victorian Cancer Registry
VCS: Victorian Cytology Service Inc.
36
VictorianCervicalCytologyRegistryStatistical Report 2012 37
GLOSSARY REFERENCES 43
Immunisation–Inducingimmunityagainstinfectionbytheuseofanantigentostimulatethebodytoproduceitsownantibodies(AIHW (2008) Australia’s Health 2008, Cat. No. AUS 99. AIHW, Canberra)
Incidence–Thenumberofnewcases(forexample,ofanillnessorevent)occurringduringagivenperiod
Intraepithelial lesion–Lesionconfinedtothesurfacelayerofthecervix
Invasive Cancer–Atumourwhosecellshavethepotentialtospreadtonearbyhealthyornormaltissueortomoredistantpartsofthebody
Lesion–Alterationofsurfacetissue,causedbyinjuryordisease
Malignant–Abnormalitiesincellsortissuesconsistentwithcancer
Micro–invasive squamous cell carcinoma (micro–invasive cancer)–Alesioninwhichthecancercellshaveinvadedjustbelowthesurfaceofthecervix,buthavenotdevelopedanypotentialtospreadtoothertissues
National Cervical Screening Program –Australia-widesystematicapproachtocervicalscreeningbasedonsoundinternationalscientificevidence,theaimofwhichistoreducetheincidenceandmortalityratesforcervicalcancer
Opportunistic screening–TakingPapsmearswhenawomanvisitsherGPforanotherreason
Pap Tests (or Smear)–Simpleprocedureinwhichanumberofcellsarecollectedfromthecervix,smearedontoamicroscopeslideandsenttoalaboratoryforcytologicalexaminationtolookforchangesthatmightleadtocervicalcancer.Upto90%accurateandthebestwaytopreventsquamouscervicalcancer.Namedafterthetest’sinventor,DrPapanicolaou
Pathology–Laboratory-basedstudyofdisease,asopposedtoclinicalexaminationofsystems
Screening –Testingofallpeopleatriskofdevelopingacertaindisease,eveniftheyhavenosymptoms.Screeningtestscanpredictthelikelihoodofsomeonehavingordevelopingaparticulardisease
Squamous cells –Thinandflatcells,shapedlikesoftfishscales.Theylinetheoutersurfaceofthecervix(ectocervix).Theymeetwithcolumnarcellsinthesquamo-columnarjunction.AbnormalitiesassociatedwithsquamouscellsarethemostlikelyabnormalitiestobepickedupbyPaptests
Squamous cell carcinoma–Acarcinomaarisingfromthesquamouscellsofthecervix
Adenocarcinoma–Ararecanceraffectingthecervix,butinvolvingthecolumnarcellsratherthanthesquamouscells.Thecolumnarcellsareinvolvedinglandularactivity.AdenocarcinomahasadifferenttypeandrateofprogressionandisnotsooftenpickedupinaPaptest
Atypia–Abnormalityinacell(toalowerdegreethandysplasia)
Biopsy of the Cervix–Removalofasmallpieceofthecervixforexaminationunderamicroscope
Carcinoma in Situ–Cancercellsthatarerestrictedtothesurfaceepithelium.Theabnormalcellsareevidentthroughouteachofthelayersoftheepitheliumbuttheyhavenotextendedintoother,deepertissueorsurroundingareas
Cervix–Theneckoftheuterus(womb),locatedatthetopofthevagina
Colposcopy–Adetailedexaminationofthelowergenitaltractwithamagnifyinginstrumentcalledacolposcope.Thismethodofnon-invasiveevaluationallowsthecliniciantomoreaccuratelyassessacytologicabnormalitybyfocusingontheareasofgreatestabnormalityandbysamplingthemwithabiopsytoobtainatissuediagnosis
Cytology–Themicroscopeevaluationofasampleofcellsobtainedfromatissue(orbodyfluid)duringproceduressuchasPaptests.Thesampledoesnotpermitevaluationoftheunderlyingstructureofthetissueoforigin (cf. histology)
Dysplasia-Abnormalappearance,developmentorgrowthpatternsofcells
Endocervix–Internalcanaloftheuterinecervixanditsepithelium,notusuallyvisibleoninspectionofthecervix
Glandular Lesion–Lesioninvolvingthecolumnarcellsofthecervix,whichproducemucusandhavebothadifferentappearanceandadifferentfunctionfromthesquamouscells
Histology–Themicroscopestudyoftheminuteanddetailedstructureandcompositionoftissues
Human Papillomavirus–Groupofvirusesthatcancauseinfectionintheskinsurfaceofdifferentareasofthebody,includingthegenitalarea.Theviruscancausevisiblegenitalwarts.SometypescancausetheabnormalcellchangeswhicharedetectedonaPaptestandwhichcansometimescausecancer.
Hysterectomy–Referstothesurgicalprocedurewherebyallorpartoftheuterusisremoved
Hysterectomy Fraction–Theproportionofwomenwhohavehadtheiruterusremovedbyhysterectomy
43 Unlessotherwiseindicated,alldefinitionshavebeensourcedfromthefollowingpublications:AustralianInstituteofHealthandWelfare2013.Cervical screening in Australia 2010-2011.Cancerseries76.Cat.no.CAN72.Canberra:AIHWNHMRC Screening to prevent cervical cancer: guidelines for the management of asymptomatic women with screen-detected abnormalities, 2005.http://www.nhmrc.gov.au/publications/synopses/wh39syn.htm
38
APPENDIX 1.CYTOLOGYCODINGSCHEDULE
S Squamous Cell E Endocervical O Other/Non-cervical
SU Unsatisfactoryforevaluatione.g.poorcellularity,poorpreservation,celldetailobscuredbyinflammation/blood/degeneratecells
EU Duetotheunsatisfactorynatureofthesmear,noassessmenthasbeenmade
OU Duetotheunsatisfactorynatureofthesmear,noassessmenthasbeenmade
S1 Cellnumbersandpreservationsatisfactory.Noabnormalityoronlyreactivechanges
E- Notapplicable:vaultsmear/previoushysterectomy
O1 Nootherabnormalcells
S2 Possiblelow-gradesquamousintraepitheliallesion(LSIL)
EØ Noendocervicalcomponent O2 Atypicalendometrialcellsofuncertainsignificance
S3 Low-gradeLSIL(HPVand/orCINI) E1 Endocervicalcomponentpresent.Noabnormalityoronlyreactivechanges
O3 Atypicalglandularcellsofuncertainsignificance-siteunknown
S4 Possiblehigh-gradesquamousintraepitheliallesion(HSIL)
E2 Atypicalendocervicalcellsofuncertainsignificance
O4 Possibleendometrialadenocarcinoma
S5 High-gradesquamousintraepitheliallesion(HSIL)(CINII/CINIII)
E3 Possiblehigh-gradeendocervicalglandularlesion
O5 Possiblehigh-gradelesion-non-cervical
S6 High-gradesquamousintraepitheliallesion(HSIL)withpossiblemicroinvasion/invasion
E4 Adenocarcinomainsitu O6 Malignantcells-uterinebody
S7 Squamouscarcinoma E5 Adenocarcinomainsituwithpossiblemicroinvasion/invasion
O7 Malignantcells-vagina
E6 Adenocarcinoma O8 Malignantcells-ovary
O9 Malignantcells–other
CYT
OLO
GY
Type AØNotstated A1Conventionalsmear A2Liquidbasedspecimen A3Conventionalandliquidbasedspecimen
Site BØNotstated B1Cervical B2Vaginal B3OthergynaecologicalsiteSPEC
IMEN
RØ Norecommendation R4 Repeatsmear6months R8 Referraltospecialist
R1 Repeatsmear3years R5 Repeatsmear6-12weeks R9 Othermanagementrecommended
R2 Repeatsmear2years R6 Colposcopy/biopsyrecommended
RS Symptomatic-clinicalmanagementrequired
R3 Repeatsmear12months R7 AlreadyundergynaecologicalmanagementR
ECO
MM
EN
DAT
ION
VictorianCervicalCytologyRegistryStatistical Report 2012 39
APPENDIX 2.REMINDERANDFOLLOW-UPPROTOCOLUSEDDURING2012
vic
tor
ian
cer
vic
al
cyt
olo
gy
reg
istr
y
sum
ma
ry
of
foll
ow
-up
an
d r
emin
der
pr
oto
co
l
Vic
tor
ian
ce
rVi
ca
l c
yto
log
y r
eg
istr
y p
o B
ox 1
61, c
arlt
on s
outh
, vic
tori
a 30
53 p
hone
(03)
925
0 03
99 f
ax: (
03) 9
349
1818
em
ail:
regi
stry
@vc
cr.o
rg w
ebsi
te: w
ww
.vcc
r.org
vict
oria
n c
ervi
cal c
ytol
ogy
reg
istr
y ac
know
ledg
es
the
supp
ort o
f the
vi
ctor
ian
gov
ernm
ent
cyt
olog
y r
epor
ts
ubse
quen
t B
iops
y or
col
posc
opy
oth
er c
ircu
mst
ance
sti
me
act
ion
by r
egis
try
Hig
h-gr
ade
squa
mou
s ab
norm
alit
y or
any
gla
ndul
ar
abno
rmal
ity
Yes
–12
mth
s1st
Rem
inde
r to
wom
an21
mth
s2nd
Rem
inde
r to
wom
anN
o–
4 m
ths
Que
stio
nnai
re to
pra
ctiti
oner
5.5
mth
sTe
leph
one
call
to p
ract
ition
er6
mth
sLe
tter
to w
oman
12 m
ths
1st R
emin
der
to w
oman
21 m
ths
2nd R
emin
der
to w
oman
Low
-gra
de s
quam
ous
abno
rmal
ity
Yes
–15
mth
s1st
Rem
inde
r to
wom
an24
mth
s2nd
Rem
inde
r to
wom
anN
oP
revi
ous
smea
r al
so a
bnor
mal
or
fluc
tuat
ing
lo
w-g
rade
abn
orm
alit
y4
mth
sQ
uest
ionn
aire
to p
ract
ition
er6
mth
sLe
tter
to w
oman
12 m
ths
1st R
emin
der
to w
oman
21 m
ths
2nd R
emin
der
to w
oman
Wom
an a
ged
30+
year
s an
d no
neg
ativ
e cy
tolo
gy
in p
rece
ding
36
mth
s7
mth
sQ
uest
ionn
aire
to p
ract
ition
er8.
5 m
ths
Lett
er to
wom
an15
mth
s1st
Rem
inde
r to
wom
an24
mth
s2nd
Rem
inde
r to
wom
anA
ll o
ther
wom
en13
.5 m
ths
Rem
inde
r to
pra
ctiti
oner
15 m
ths
1st R
emin
der
to w
oman
24 m
ths
2nd R
emin
der
to w
oman
Neg
ativ
e–
Pre
viou
s sm
ear
abno
rmal
or
past
his
tory
of b
iops
y pr
oven
CIN
2 o
r C
IN 3
wit
hout
HP
V ‘t
est
of c
ure’
15 m
ths
1st R
emin
der
to w
oman
24 m
ths
2nd R
emin
der
to w
oman
All
oth
er w
omen
27 m
ths
1st R
emin
der
to w
oman
36 m
ths
2nd R
emin
der
to w
oman
Uns
atis
fact
ory
Yes
–12
mth
s1st
Rem
inde
r to
wom
an21
mth
s2nd
Rem
inde
r to
wom
anN
o–
6 m
ths
Rem
inde
r to
pra
ctiti
oner
9 m
ths
1st R
emin
der
to w
oman
18 m
ths
2nd R
emin
der
to w
oman
this
pro
toco
l is
adju
sted
in s
ome
unus
ual c
linic
al c
ircu
mst
ance
s (e
.g. p
ost-
hyst
erec
tom
y, a
fter
a d
iagn
osis
of c
ervi
cal o
r en
dom
etri
al m
alig
nanc
y, w
omen
age
d 70
+ ye
ars)
.
May 2013 VCCR-Pub-19 V10
4040
APPENDIX 3.MAPOFMEDICARELOCALS
ML213
ML214
ML211
ML217
ML216
ML212
ML215
ML210
Medicare Locals
Victoria
ML217
ML215
ML204
ML207
ML210ML208
ML211ML205
ML203
ML209
ML216
ML206
ML202
ML201
SeeInset
INSET: Melbourne and surrounds
VictorianCervicalCytologyRegistryStatistical Report 2012 41
APPENDIX 3. MAPOFLOCALGOVERNMENTAREAS-MELBOURNE
42
APPENDIX 3.MAPOFLOCALGOVERNMENTAREAS–VICTORIA
APPENDIX 3. MAPOFLOCALGOVERNMENTAREAS–VICTORIA
44