Volume 206 - Issue 6
The renewal of the National Cervical Screening Program
Authors: Jonathan Carter, Ian Hammond and Megan Smith
Med J Aust 2017; 206 (6): 274. || doi: 10.5694/mja16.01257
Published online: 3 April 2017
Published online: 3 April 2017
In reply
In reply:
The renewed National Cervical Screening Program (NCSP) will use 5-yearly oncogenic human papillomavirus (HPV) testing and partial genotyping with reflex liquid-based cytology. There is overwhelming evidence from prospective randomised trials that primary HPV screening is vastly superior to cytology testing alone.1,2 The renewal is based on recommendations of the Australian Medical Services Advisory Committee (MSAC) following a robust and transparent process involving a commissioned evidence review and health outcome and economic modelling.3
In his letter on The renewal of the National Cervical Screening Program article,4 Cox comments that the New South Wales group’s models used the same sensitivity for cervical intraepithelial neoplasia (CIN) grade 2 and CIN 3 in their evaluation,5 and that the overall renewal evaluation relies on “estimates with major regression and overdiagnosis bias”.
This is incorrect and the full modelled evaluation report considered by MSAC clarifies this matter. They did in fact use differential sensitivity for CIN 2 versus CIN 3, consistent with the findings of an international meta-analysis,6 and those states are assumed to have different potential for progression and regression as Cox comments. Therefore, the concerns raised by Cox are taken into account in their model.5
The MSAC report agreed with the estimate that the renewed NCSP will reduce cervical cancer incidence and mortality by at least a further 20% — updated modelling suggests up to 30% reduction — assuming that active invitations and recalls are effective in achieving high participation rates.3,5
Women and health care professionals should be reassured to know that there is an international trend toward primary HPV-based screening and triage with liquid-based cytology (in the Netherlands, the United Kingdom, New Zealand and a number of other countries) with an extended screening interval. Indeed, there are data to suggest that extending the screening interval beyond 5 years in women who are HPV-negative is safe.7
We should all be reassured that the changes to the NCSP are timely, evidence-based and considered by a team of experts to be both safe and efficacious.
Competing interests
No relevant disclosures.
References
- Ronco G, Dillner J, Elfström KM, et al. Efficacy of HPV-based screening for prevention of cervical cancer: follow-up of four European randomised controlled trials. Lancet 2014; 383: 524-532.
- Isdean SD, Mayrand MH, Ramanakumar AV, et al. Human papillomavirus testing versus cytology in primary cervical cancer screening: end-of-study and extended follow-up results from the Canadian cervical cancer screening trial. Int J Cancer 2016; 139: 2456-2466.
- Medical Services Advisory Committee. MSAC outcomes. Application no. 1276 — Renewal of the National Cervical Screening Program. Canberra: MSAC; 2014. http://www.msac.gov.au/internet/msac/publishing.nsf/Content/D924E2F768B13C4BCA25801000123B9E/$File/1276%20-%20Final%20MSAC%20PSD%20-%20NCSP%20Renewal.pdf (accessed Aug 2016).
- Carter J. The renewal of the National Cervical Screening Program. Med J Aust 2016; 205: 357-358.
- Lew JB, Simms K, Smith M, et al. National Cervical Screening Program renewal: effectiveness modelling and economic evaluation in the Australian setting (assessment report). MSAC application no. 1276. April 2014. Canberra: MSAC; 2014.
- Arbyn M, Verdoodt F, Snijders P, et al. Accuracy of human papillomavirus testing on self-collected versus clinician-collected samples: a meta-analysis. Lancet Oncol 2014; 15: 172-183.
- Dijkstra MG, van Zummeren M, Rozendaal L, et al. Safety of extending screening intervals beyond five years in cervical cancer screening programmes with testing for high risk human papillomavirus: 14 year follow-up of population based randomised cohort in the Netherlands. BMJ 2016; 355: i4924.