Medical Services Advisory Committee recommendations for HPV testing

GUIDELINE UPDATES - This guideline was last updated 01/07/2022

In 2014 the Medical Services Advisory Committee (MSAC) recommended that the National Cervical Screening Program (NCSP) adopt human papillomavirus (HPV) testing for cervical screening at 5-yearly intervals.^[1]

After considering the strength of the available evidence in relation to the safety, clinical and cost-effectiveness of a cervical screening pathway for the NCSP, MSAC supported public funding for the following:^[1]

five-yearly cervical screening using a primary HPV test with partial HPV genotyping and reflex liquid-based cytology (LBC) triage, for HPV vaccinated and unvaccinated women aged 25–69 years, with exit testing of women up to age 74 years
self-collection of an HPV sample for an under-screened or never-screened woman, facilitated by a medical practitioner, nurse practitioner or other healthcare professional on behalf of a medical practitioner who also offers mainstream cervical screening
a system of invitations and reminders to be sent to women aged 25–69 years, and exit communications to be sent to women aged 70–74 years of age, to ensure the effectiveness of the program
de-listing of the existing cervical screening test MBS items over a 6- to 12-month transition period.

See MSAC outcomes. Application No. 1276 – Renewal of the National Cervical Screening Program.

The renewed NCSP applies to both HPV-vaccinated and unvaccinated women. It involves a primary screening test for HPV with partial genotyping (to distinguish HPV types 16 and 18 from other oncogenic types) and reflex LBC testing for all women with a positive oncogenic HPV test result:

Women who have a positive oncogenic HPV (16/18) test result are referred immediately to colposcopy, with reflex LBC results available to inform the colposcopy examination.
For women with a positive oncogenic HPV (not 16/18) test result, LBC is used as a triage to determine whether they are referred for colposcopy, or for repeat HPV testing in 12 months.

MSAC advised that this screening strategy was safer, more effective and more cost-effective than the pre-renewal NCSP,^[1] which is based on 2-yearly screening using conventional cytology (the Pap test) in sexually active women between the ages of 18–20 and 69 years.

The MSAC recommendation was based on systematic review of evidence and a comprehensive modelled evaluation.^[2][3][1] The modelling for HPV primary screening with partial genotyping for HPV 16/18 indicated an expected reduction in cancer incidence and mortality of over 20% (if women were screened until age 70 years).^[3] Subsequent modelling, taking into account post-colposcopy management as recommended in these guidelines, has predicted that a 31–36% reduction in incidence and mortality may be achievable in unvaccinated cohorts and a 24–29% reduction may be achievable in cohorts offered vaccination (see Appendix A. Modelled evaluation of the predicted benefits, harms and cost-effectiveness of the renewed National Cervical Screening Program (NCSP) in conjunction with these guideline recommendations).

These recommendations were accepted by the Australian Government in May 2015. A revised NCSP policy has been developed based on these recommendations and has been endorsed by the Standing Committee on Screening.

NCSP policy summary
Five-yearly cervical screening using a primary HPV test:

partial HPV genotyping and LBC triage
in HPV-vaccinated and unvaccinated women aged 25–69 years
exit testing of women up to age 74 years.

Source: National Cervical Screening Policy (2016)

2021 MSAC review

In 2021, the Medical Services Advisory Committee (MSAC) reviewed an application from the National Cervical Screening Program requesting expansion of the eligibility to participate in cervical screening using self-collection.¹ The Self-Collection Expert Advisory Group was convened to guide this review, and to provide advice on policy, implementation and consultation.

MSAC noted the large body of evidence showing no material difference in the diagnostic accuracy of HPV testing between using self-collected and clinician-collected samples (relative sensitivity = 0.98; 95% CI: 0.96 to 1.01; relative specificity = 0.99; 95% CI: 0.98 to 1.01).¹

MSAC concluded that HPV testing using self-collected samples is just as accurate as using clinician-collected samples. MSAC supported expanding access to self-collection to include everyone eligible for cervical screening, giving all eligible people a choice in how their screening sample is collected. MSAC considered self-collection to be safe and effective, and that it would likely increase participation in cervical screening.

MSAC advised that expanding self-collection is an important option to increase access to screening, particularly for people who may feel uncomfortable with a clinician collecting their sample. People who choose to use self-collection would still access cervical screening through their healthcare provider, to allow for education and engagement.

Flowchart 6.1 Cervical screening pathway for primary oncogenic HPV screening (HPV tests on clinician-collected or self-collected samples)

routine-cervical-screening-flowchart-6-1

MSAC evidence-based recommendation

REC6.1: Eligibility for screening on a self-collected sample to include all people eligible for cervical screening

Anyone who is eligible for cervical screening (people with a cervix aged 25-74 years who have ever been sexually active) should be offered the choice of HPV testing on a self-collected vaginal sample or on a clinician-collected sample.

Practice Point

REC12.5: Data collection and recording Aboriginal and Torres Strait Islander status
Healthcare professionals should ask all patients whether they identify as Aboriginal or Torres Strait Islander, and a person’s Aboriginal and Torres Strait Islander status should be recorded on relevant clinical records, including pathology request form in accordance with the Australian Bureau of Statistics classification and standards. Aboriginal and Torres Strait Islander status influences clinical management of tests in some cases.

Practice Point

REC6.2 Clinician-collected cervical samples

A short course of topical oestrogen therapy could be considered in post-menopausal women, people experiencing vaginal dryness, or trans men, prior to collecting the sample, for example daily for a period of at least 2 weeks, ceasing 1-2 days prior to the appointment. The reason for this should be explained (to reduce discomfort from the speculum and to improve the diagnostic accuracy of any associated LBC).

References

Medical Services Advisory Committee. MSAC Outcomes. Application No. 1276 – Renewal of the National Cervical Screening Program. [homepage on the internet] Canberra: Australian Government Department of Health; 2014 [updated 2015 Apr]. Available from: http://www.msac.gov.au/internet/msac/publishing.nsf/Content/FD36D6990FFAA639CA25799200058940/$File/1276%20-%20Final%20MSAC%20PSD%20-%20NCSP%20Renewal.pdf.
Medical Services Advisory Committee. National Cervical Screening Program renewal: executive summary. Report November 2013.MSAC application no. 1276. Assessment report. Canberra: Australian Government Department of Health; 2014 Available from: http://www.cancerscreening.gov.au/internet/screening/publishing.nsf/Content/E6A211A6FFC29E2CCA257CED007FB678/$File/Executive%20Summary%20notated%2013.6.14.pdf.
Medical Services Advisory Committee. National Cervical Screening Program renewal: effectiveness modelling and economic evaluation in the Australian setting. Report November 2013. MSAC application 1276. Canberra: Australian Government Department of Health; 2014 Available from: http://www.cancerscreening.gov.au/internet/screening/publishing.nsf/Content/E6A211A6FFC29E2CCA257CED007FB678/$File/Renewal%20Economic%20Evaluation.pdf.

WEBSITE UPDATES - This website was last updated 01/07/2022