Screening pathways and primary CVD prevention

1. National Bowel Cancer Screening Program (NBCSP)

• NBCSP entry: People aged 45–49 request their first kit; people aged 50–74 are routinely mailed biennial kits. A completed program round supports future two-year invitations. Assess symptoms diagnostically rather than relying on screening.
• Modality: Immunochemical Faecal Occult Blood Test (iFOBT). The iFOBT detects the globin portion of human hemoglobin. Because globin is rapidly degraded by upper gastrointestinal enzymes, the test is highly specific for lower gastrointestinal bleeding. Unlike older guaiac-based tests, iFOBT requires no dietary restrictions (such as avoiding red meat or vitamin C).
• Management of a Positive iFOBT:
  • Golden Rule: Never repeat the iFOBT to confirm a positive result.
• Positive iFOBT: Refer promptly for appropriate colonoscopy. Do not repeat iFOBT to “clear” a positive result; there is no universal national mandatory 30-day colonoscopy deadline.
  • Approximately 1 in 30 people with a positive iFOBT will be diagnosed with colorectal cancer, and 1 in 2 will have an advanced adenoma or polyp.
• Symptomatic Patients: The NBCSP is strictly for asymptomatic population screening. Patients presenting with rectal bleeding, unexplained persistent altered bowel habit, iron-deficiency anaemia, or palpable abdominal masses must be investigated with direct colonoscopy, never sent an iFOBT.

2. BreastScreen Australia

• Target Cohort: Asymptomatic women aged 50 to 74 years receive biennial invitation letters. Women aged 40 to 49 years and women aged $\ge 75\text{ years}$ are also eligible for free screening upon request, but do not receive automated invitations.
• Modality: Bilateral two-view screening mammography (craniocaudal and mediolateral oblique views), independently read by two screening radiologists. If findings disagree, an independent third radiologist reviews the images.
• Asymptomatic vs Symptomatic Presentation:
  • BreastScreen is exclusively designed for asymptomatic women.
  • Any woman presenting with a focal breast lump, localized persistent breast pain, nipple inversion, blood-stained nipple discharge, or skin changes (peau d'orange) must be investigated using the Triple Test in diagnostic clinical practice:
    1. Clinical breast examination.
    2. Diagnostic breast imaging (mammography $\pm$ ultrasound).
    3. Pathological assessment (core biopsy or fine-needle aspiration cytology).

3. National Cervical Screening Program (NCSP)

• Eligibility & Interval: Women and people with a cervix aged 25 to 74 years, screened every 5 years.
• Modality: Primary nucleic acid testing for oncogenic Human Papillomavirus (HPV) genotypes. This replaced 2-yearly Papanicolaou (Pap) smear cytology, providing superior sensitivity for high-grade cervical dysplasia.
• Universal Self-Collection Option: All eligible screening participants have the choice to collect their own sample using a simple vaginal swab, or to have a clinician perform a speculum examination and cervical sample collection. High-level evidence confirms that self-collected vaginal swabs have equivalent sensitivity to clinician-collected cervical samples for detecting high-risk HPV.
• NCSP Management Algorithm:
  • HPV Not Detected: Patient is reassured and returns to routine 5-yearly recall.
  • HPV Detected (Types 16 and/or 18): Highest oncogenic risk (types 16 and 18 cause $> 70\%$ of cervical cancers). Requires direct referral for colposcopy, regardless of liquid-based cytology findings.
  • HPV Detected (Non-16/18 High-Risk Types): Reflex liquid-based cytology (LBC) is performed on the specimen:
    • If cytology is negative (normal) or low-grade (pLSIL): Repeat HPV test in 12 months.
    • If cytology is high-grade (HSIL, ASC-H) or glandular abnormality: Immediate referral for colposcopy.

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Absolute Cardiovascular Disease Risk Assessment: The 2023 Australian Guideline

The 2023 Australian Guideline for assessing and managing cardiovascular disease risk replaced the older 2012 Framingham-based risk charts with the PREDICT-based Australian CVD Risk Calculator.

Eligibility for Risk Assessment

• Asymptomatic adults aged 45 to 79 years without known atherosclerotic cardiovascular disease.
• Aboriginal and Torres Strait Islander adults aged 30 to 79 years.
• Adults with diabetes aged 35 to 79 years.

Risk Factors Integrated into the PREDICT Equation

Age, sex, smoking status, systolic blood pressure, use of blood pressure-lowering medication, total cholesterol, HDL-cholesterol, diabetes status, HbA1c, eGFR, urine albumin-to-creatinine ratio (ACR), and socioeconomic disadvantage index (SEIFA).

Clinically Determined High Risk (No Calculation Required)

Patients with any of the following clinical conditions are automatically classified as high risk ($\ge 10\%$ 5-year risk) and must not be run through the calculator:

• Moderate to severe chronic kidney disease (eGFR $< 45\text{ mL/min/1.73m}^2$ or persistent urine ACR $> 25\text{ mg/mmol}$ in men, $> 35\text{ mg/mmol}$ in women).
• Current automatic high-risk conditions: Confirmed familial hypercholesterolaemia and moderate-to-severe CKD establish high risk without calculation. Old automatic categories based on diabetes after 60, severe BP or a lipid cut-off must not be carried into the 2023 calculator pathway.

5-Year CVD Risk Stratification & Management

Therapeutic Targets in High-Risk Patients

• Treatment goals: Individualise BP and lipid targets using the relevant disease guidance, tolerability and patient priorities. Primary-prevention risk categories alone do not impose the same LDL target as established ASCVD. Offer indicated blood-pressure and lipid-lowering treatment with lifestyle support and monitor effectiveness/adverse effects.

National Lung Cancer Screening Program

The program began in July 2025. Eligible asymptomatic people are aged 50–70, have at least 30 pack-years of smoking and currently smoke or quit within the past ten years. Screening uses low-dose CT, generally every two years, with nodule follow-up governed by the program pathway. Symptoms such as haemoptysis or unexplained weight loss need diagnostic assessment rather than a screening appointment. Discuss radiation, incidental findings and follow-up, and offer smoking-cessation support without stigma. Eligibility and the cessation interval must be assessed accurately; one pack per day for 30 years is 30 pack-years, as is two packs for 15 years.

Self-collected HPV results

A self-collected vaginal swab tests HPV but does not supply cervical cells for reflex liquid-based cytology. Non-16/18 HPV detected on a self-collected sample generally requires a clinician-collected cervical specimen for LBC. HPV16/18 leads to colposcopy regardless, with further sampling arranged through that pathway. Screening is for asymptomatic people; persistent bleeding or a visible cervical lesion requires the symptom/diagnostic pathway.

Primary references (checked 7 October 2026): Current Immunisation Handbook; 2026 adult pneumococcal update; National lung screening.