Cervical screening and cervical cancer

Australian Cervical Screening Program & Gynaecological Malignancies

Gynaecological oncology encompasses the prevention, early detection, and multidisciplinary treatment of malignancies of the cervix, endometrium, and ovary. In Australia, population-based screening has transformed cervical cancer epidemiology, while transvaginal ultrasound triage protocols and biomarker stratification govern the management of postmenopausal bleeding and suspicious pelvic masses.

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The Australian National Cervical Screening Program (NCSP)

In December 2017, Australia transitioned from 2-yearly conventional Papanicolaou cytology to 5-yearly primary human papillomavirus (HPV) nucleic acid testing, a change that significantly improved sensitivity for detecting high-grade cervical intraepithelial neoplasia (CIN 2/3) and adenocarcinoma in situ (AIS).

Target Population & Collection Modalities

• Eligible Cohort: Asymptomatic individuals with a cervix aged 25 to 74 years (commencing at age 25, exit screening between ages 70 and 74 if prior tests were negative).
• Clinician-Collected Sample: Performed via speculum examination using a cervical broom or brush to sample the transformation zone (the squamocolumnar junction), rinsed into liquid-based cytology (LBC) transport medium (ThinPrep).
• Self-Collected Vaginal Swab: Available since July 2022 to all eligible screening participants as an empowered, universal choice. Performed using a dry flocked swab inserted into the mid-vagina. Polymerase chain reaction (PCR) assays demonstrate equivalent clinical sensitivity and specificity for oncogenic HPV detection compared to clinician collection. If oncogenic HPV (non-16/18) is detected on a self-collected sample, the patient must attend for a speculum examination to obtain cervical cells for reflex LBC before clinical management is determined.

Triage Algorithm and Referral Guidelines

1. Low Risk (Oncogenic HPV Not Detected):
   • Return to routine screening in 5 years.
2. High Risk (Oncogenic HPV Types 16 and/or 18 Detected):
   • HPV 16 and 18 are responsible for $> 70\%$ of cervical cancers and carry the highest immediate risk of high-grade disease.
   • Mandatory direct referral for colposcopy, regardless of the reflex LBC result (even if LBC is completely normal/negative).
3. Intermediate Risk (Oncogenic HPV Non-16/18 Detected):
   • Includes oncogenic types 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, and 68. The laboratory automatically performs reflex liquid-based cytology (LBC) on the collected sample:
   • LBC Negative or Low-Grade Squamous Intraepithelial Lesion (p-LSIL / LSIL): Advise the patient to have a repeat HPV test in 12 months in general practice.
     • Twelve-month follow-up: HPV negative generally returns to routine five-year screening. Persistent non-16/18 HPV with negative/low-grade LBC usually has another twelve-month follow-up; First Nations participants, those at least fifty and substantially underscreened patients can need colposcopy at this point. Persistent HPV at twenty-four months warrants colposcopy. Use the current history-specific NCSP pathway.
   • LBC High-Grade Squamous Intraepithelial Lesion (p-HSIL / HSIL), Atypical Squamous Cells Cannot Exclude HSIL (ASC-H), Atypical Glandular/Endocervical Cells, or Suspicion of Microinvasive/Invasive Carcinoma: Immediate referral for colposcopy.

Symptomatic Women Exempt from Screening Pathways

Symptoms require diagnostic assessment, including examination and an appropriate co-test rather than routine self-screening. Persistent/recurrent postcoital bleeding, a visible lesion or abnormal examination needs referral. A single episode with a normal cervix and negative co-test does not always require gynaecological referral. Persistent unexplained discharge or postmenopausal bleeding requires its own assessment regardless of a recent screening result.

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Cervical Carcinoma

Epidemiology & Histopathology

Persistent high-risk oncogenic HPV infection is the necessary cause of $> 99\%$ of cervical cancers. Viral oncoproteins E6 (which binds and accelerates the degradation of the tumour suppressor protein p53) and E7 (which binds and inactivates the retinoblastoma tumour suppressor protein pRb) drive unchecked cell cycle progression and genomic instability.

• Squamous Cell Carcinoma (SCC): Accounts for 70% to 80% of cases, arising at the transformation zone.
• Adenocarcinoma: Accounts for 20% to 25% of cases, arising from endocervical columnar epithelium (disproportionately associated with HPV 18). Its relative incidence has increased because cytology is less sensitive at sampling the endocervical canal.

Clinical Presentation

• Early-stage carcinoma is frequently asymptomatic, underscoring the role of the NCSP.
• The cardinal presenting symptom is postcoital bleeding (PCB), followed by intermenstrual bleeding, postmenopausal bleeding, and offensive serosanguinous vaginal discharge.
• Advanced lesions produce pelvic pain radiating to the sacrum, sciatic nerve pain, lower extremity oedema (from iliac venous compression or lymphatic obstruction), and oliguria/uraemia from bilateral ureteric obstruction.

FIGO Staging and Management

Staging is clinical and pathological, incorporating cross-sectional imaging (pelvic MRI and whole-body PET-CT):

• Stage I: Confined strictly to the cervix uteri (IA: microscopic depth $< 5\text{ mm}$; IB: depth $\ge 5\text{ mm}$ or clinically visible lesion confined to cervix).
• Stage II: Extends beyond the cervix but not to the pelvic sidewall or lower third of the vagina (IIA: upper two-thirds of vagina; IIB: parametrial infiltration).
• Stage III: Involves the lower third of the vagina (IIIA), extends to the pelvic sidewall or causes hydronephrosis (IIIB), or involves pelvic/para-aortic lymph nodes (IIIC).
• Stage IV: Infiltrates the mucosa of the bladder or rectum (IVA) or extends to distant metastatic organs (IVB).

Therapeutic Principles

• Early Stage (Stage IA1 without lymphovascular space invasion): Conservative fertility-sparing cervical conization or simple hysterectomy.
• Cervical treatment: Stage, size, nodes and fertility goals determine surgery versus chemoradiation. Selected early low-risk disease may have less radical surgery; do not apply radical hysterectomy to every early lesion.
• Locally Advanced Disease (Stage IB3 to IVA): Definitive concurrent chemoradiotherapy (external beam pelvic radiotherapy with concurrent weekly intravenous cisplatin, followed by high-dose-rate intracavitary brachytherapy). Primary surgical resection is strictly contraindicated in locally advanced disease due to excessive morbidity and inferior overall survival compared to chemoradiotherapy.

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Primary references (checked 7 October 2026): National cervical screening provider resources.