2025 Cervical Screening update: What you need to know about the latest clinical guidelines

Webinar hosted by Doctor Lara Roeske and Professor Deborah Bateson with support from Jovi Stuart

Good evening. Good evening, everyone, and welcome to tonight's webinar, National Cervical Screening Guidelines, a 2025 Update. We are joined tonight by speakers Doctor Lara Roeske and Professor Deborah Bateson.

My name is Jovi and I'm the Education and Events Officer for the specific interest faculty at the RACGP.

Just a few housekeeping notes to go over.

If you cannot see a panel like the image above, please place a cursor over the shared presentation screen and this panel will appear.

This panel provides you with your audio options and most importantly, your Q&A box.

We have placed everyone on mute to ensure learning will not be disrupted by background noise, please chat to us using the Q&A box as a chat function has been disabled.

We will do our best to address all your questions.

However, in the interest of time, if you have any unanswered questions relating to tonight's session, I will share the email address at the end of the webinar.

Just a couple more things.

Tonight's webinar will be repeated on the 13th of March 2025.

A recording will be made available after this date on the RACGP website web page within the next week.

And your CPD 1.5 hour of education activity will be uploaded within the next 7 days and as well as automatically generated closed captions are available.

Just note that Zoom may get a couple of words occasionally incorrect.

And lastly, that's it.

I'd like to now formally introduce to IGP facilitator and speaker for this webinar.

Doctor Lara Roeske is AGP and previous practice owner Provost for the RACGP Specific Interest and has held many senior positions at the RACGP including Chair of the RACGP Board, chair of the RACGP Interest Specific Interest, deputy Chair of the Victoria Council, inaugural chair of the RACGP Specific Interest Sexual Health Medicine Group.

Lara is a past member of the Australian Commission on Safety and Quality in Healthcare Cervical Screening, Redrafting Working Group and Ministerial Advisory Committee on Bloodborne Viruses and Sexually Transmissible Infections, and past member of the Commonwealth Self-collection, Advisory and Implementation Committees and National Guidelines Working Party.

Lara's worked in Advisory roles to key stakeholders on steering committees representing the RACGP across a range of domains relating relevant to the sexual and reproductive health, cervical cancer prevention and translation of evidence into practice at state and national levels.

With that, I'd like to now hand over to Lara.

Thank you, Lara, Thank you.

Thanks very much Jovi.

I'm really delighted to welcome many of our members this evening and colleagues.

And of course, a warm welcome to non-members who have joined us this evening.

Thank you for your time and attention.

It's now my pleasure to introduce my co-host, Professor Deborah Bateson.

Deb is Professor of Practice in the Faculty of Medicine and Health at the University of Sydney. She's worked as a clinician, research educator, and advocate in sexual and reproductive health for over 20 years, with a focus on equitable access to sexual and reproductive healthcare, including cervical screening.

Deb is currently leading an NHMRC study to increase cervical screening participation of people with intellectual disability.

She's acting chair of the National Cervical Screening Program Clinical Advisory Group, former chair of the Self-collection Implementation Committee and was a member of the Cervical Screening Guidelines Update Working Party.

We're really fortunate to have you here with us Deb, and to share your expertise.

And for me, it's an absolute pleasure as always to work with you.

We go back a long way.

We're still here, which is great.

Thank you, That's lovely.

Most importantly, I would like to extend our acknowledgement the traditional custodians of the land and the sea on which we work and live.

I'd like to extend a very well welcome and respect to our Aboriginal and Torres Strait Islander colleagues who have joined us this evening. And of course, pay our respects to Elders past, present and emerging.

Without further ado, the learning outcomes for tonight's educational webinar are we will discuss and you'll be able to discuss the 2025 updates to the National Cervical Screening Guidelines in relation to general practice and specifically your practices.

We will be and we hope that you will as a result of attending tonight understand, outline and be able to implement changes to the guidelines across a number of important management protocols and pathways.

Notably for test of cure following treatment of high grade squamous intraepithelial lesion as part of surveillance follow up post treatment adenocarcinoma in situ (AIS).

And also we'll understand the categories and expansion and clarification of immune deficiency for the various patients that present to us.

We'll also use the updated guidelines, and we'll use case illustration to do this work.

And Deb will be doing that for us this evening to really simplify management without of course compromising safety or quality for screening after total hysterectomy.

And also for repeat HPV at nine months or more in our patients who have a non-HPV 16/18 HPV detected on self-collection.

However, do not turn up for follow up LBC in a timely manner.

And let's face it, that is a is an occurrence for us in practice and we will come hearing more about those changes.

But I'm now going to hand over to you Deb and you're going to tell us me, me important information about the aims and the strategies of cervical cancer control in Australia.

Over to you.

Thanks much Lara, and a pleasure to be collaborating with you as well.

Good evening, everyone. Pleasure to be here.

It is exciting news indeed that we can say Australia is predicted to eliminate cervical cancer by 2035.

It may even be a bit earlier.

In fact, we're the first country we're going to be the first country in the world to do so.

The key thing though, of course is we have to achieve this equitably.

But how have we got to this enviable position?

It's through our HPV vaccination program.

As you all know, it's a single dose now and gender neutral, vaccinating girls and boys aged 12 and 13.

Obviously, the other key thing was the change of the National Cervical Screening Program in 2017 at the end of that year from 2 yearly Pap smears to HPV screening every five years.

And then of course the landmark change of policy to universal access to self-collection.

Everyone has that choice from 2022, supported of course by the National Cancer Screening Register, gives you that provider portal, which is wonderful.

And this enabled the Assistant Minister for Health Minister Ged Kearney to actually launch the National Strategy for the Elimination of Cervical Cancer in Australia.

It was launched in November of 2023 and we're monitoring the progress against the targets that have been set.

What are our targets that we've set?

The WHO has set global targets by 20-30 and we call them the 907090 targets.

90% vaccination, 70% around screening and 90% around treatment.

We've got some stretch goals, I'd suppose you'd say. Just to remind us all that elimination is not eradication.

Elimination, that threshold's been sent set at few of them for new cases per 100,000 women.

Our targets are 90% of all eligible people.

That's that includes boys as well as girls to be vaccinated, 70% of people screened every five years who are eligible and 95% of people eligible people will receive optimal treatment.

And how are we going with these with reaching this elimination threshold?

Well, at the moment we're at 6.4 per 100,000.

Overall that's good, but we do know there’s inequities within populations.

For instance, Aboriginal and Torres Strait Islander women are three times higher rate of being diagnosed with cervical cancer, and have twice as high mortality.

We've really got to close these gaps, and we know that the priority populations are populations where there is under screening Aboriginal and Torres Strait Islander people.

I've mentioned before culturally, linguistically diverse people, LG, the LGBTQ community, people with disability and those living in rural and remote areas as well as those low socio-economic background because what we know.

We've really got to focus our efforts here because over 70% of invasive cancers are diagnosed in under and never screened people.

But I want to tell you good news as well.

This is looking at self-collection, it's looking at the count and the percentage of all HPV tests reported as self-collection.

That's in yellow.

The blue is the dark blue is clinician collected.

And you can see.

If you look at the very start of the graph, it starts at the end of 2017 when the program switched to HPV testing.

We didn't introduce self-collection in fact until early in 2018. But it was very restricted if you remember to start with.

It was only offered to under screened people who people who were 30 and above - very small numbers.

But that all changed when we introduced universal, universal choice and you can see the numbers have been steadily going up since July of 2022.

And now in fact I've just heard that it's actually up to 40% of all screening tests are now self-collected.

And the really great news is that the greatest uptake is in amongst those who need it most.

It's in under and never screen people.

It's also in older age groups, which is interesting, very remote areas, in low socio economic groups, and amongst Aboriginal and Torres Strait Islander women.

This is good news indeed.

I'm going to hand on to the next slide and over to you Lara.

Thanks very much Deb.

And before we actually go into and delve into the detail of the evidence-based changes and the new recommendations, and I think that we did have really important little Red Star at the start to tell us this is all coming in April of this year.

Those of you that are here tonight, it's a really good use of your time because you'll be making these changes in a couple of months’ time.

It's a nice opportunity, however, to just pause and introduce our audience to the Magic App platform.

Some of you will be familiar with it with it and some of you won't.

I'll just pause and briefly tell you what it's all about.

The link to the Magic App platform.

So, what is it?

It's an easy access digital platform that houses living evidence.

It actually houses a very large number of evidence-based guidelines that are both national and international.

And importantly, cervical screening national guidelines are now found here and are housed here.

If you're looking for the guidelines, you can certainly find them via the Magic app platform and we'll provide the link on the next slide or via the Cancer Council Australia website, which me of you will be very familiar with. And has been the usual way.

You'll also find a range of very useful resources for our GPS and practice nurses and these are really designed to support and provide guidance to your clinical practice around cervical screening.

That links at the bottom of the slide and, Jovi, maybe even pop it in the Q&A if that's possible because people can have a quick look and familiarise themselves or keep it for reference.

Our next slide is also an important piece of support that I think is really welcome for GPS again and practice nurses in the clinical setting.

I think it's fantastic when those putting together guidelines really put something together specifically to provide us with guidance and advice and support in our clinical practice.

And of course, that's where the known unknowns and the unknown unknowns and a variety of often a whole range of situations can challenge us.

And what I found really useful, and I do recommend this chapter to you audience and I do suggest if you're going to read anything, this is the one you take to bed and read at night diligently.

We've got me very helpful sections here on explaining HPV to patients.

The role of the National Cancer Screening Register supporting informed choice is an example, but you'll see as you work through the chapter that the guidance is categorised to around a range of scenarios, presentations and issues, really helping with actions that are either strong recommendations for, but really great to see strong recommendations against.

Also, good practice statements and guidance and consensus recommendations.

And I think that provides a lot of comfort to clinicians who, again, often in day-to-day clinical practice, have to deal with a whole range of issues that sometimes we feel perhaps guidelines don't sufficiently address or support us around.

A great chapter.

Deb, it's over to you.

Thanks much, Lara.

 This is just a summary of the changes and I do just want to reiterate what Lara said that the guidelines are just much easier to use now you can find the flow charts immediately that are at the front of every chapter before I do agree they were very difficult to find.

The guidelines have shifted to this magic app platform.

It's incredibly easy to use and to navigate, and this new chapter cervical screening in in clinical practice, as Lara says, because it's a one stop shop, it's really your go to and good bedtime reading.

As you mentioned, the big changes we're going to cover today are the changes to the test of cure.

And this is for people who've been successfully treated for a high-grade change and for adenocarcinoma in situ (AIS) and we'll go over exactly what those changes are.

The other key thing which Lara mentioned before, which is actually really fantastic when it comes to clinical practices, a repeat HPV at nine months.

If, if someone hasn't returned for their follow up LBC, in other words, they have a self-collected HPV test, it comes back, not 16/18.

You know that you need to get them back.

You advise them that ideally, they come back within six weeks for that LBC.

But you know, life happens, and people don't always come back.

 if they arrive back at nine months or later, maybe 12 months, for instance, then we know that it's what we're doing then is just testing to see whether the HPV has disappeared or not.

If it hasn't, if it's persistent, then you've got to obviously follow up on that with a cytology test.

But if it's disappeared, they can go back to routine screening made just immune deficiency.

It's much clearer.

We'll go through that.

And also, Hooray, screening after total hysterectomy has been simplified as well.

We move on now.

I know that obviously all of you are experienced and you all see all of these people in your clinic at me point or another.

But it's just a reminder to us all really about just not missing these particular groups of people because they're groups that may be under screens, they may be missed sometimes.

The people we should be encouraging it's encouraging all people, of course, but it's encouraging people regardless of whether they're gay or lesbian, transgender or straight, whether they've had the HPV vaccination or not.

We do know this is a common misconception that you don't need screening.

And I will say that the group we're a little bit more concerned about at the moment because they're not coming for screening at rates that really we should be doing, which is the group who are aged 25 to 29.

I think that's just something to remember for us all people who are no longer sexually active, very common to think I don't need screening anymore.

They might not have been sexually active for years and think surely that's not needed.

You need to be able to correct misinformation, people who've been through menopause, people who've only had one sexual partner again, maybe a long time ago, but still you know that screening is needed because of that HPV transmissibility.

People who've experienced traditional cutting or circumcision have had a baby and are pregnant.

All the people that we see all the time.

I think this is a useful slide because obviously we're talking about the guidelines and you know, at the centre of that is the routine screening pathway.

But there are just me groups where we just need to know they've got specific management advice.

And again, I was delighted to see when I just checked again today in the Magic app platform that it's really clear to be able to find these other groups.

You don't have to go hunting around for information.

It's all there.

We've just highlighted in orange here the ones that we're going to cover tonight because that's what's changed in guidelines.

We've got you know, clarified around the management about well, the classification who of who's included in in the immune deficiency.

I'll talk to the management, simplified management after a total hysterectomy.

We'll follow up.

We'll get more information of course about the tests of cure both for a high-grade squamous lesion and after treatment for AIS.

But just a quick reminder for us all.

Someone's put in the chat and that's it's an important thing actually.

I think partly they're talking about the equivalence in accuracy between self-collection and clinician collection.

And we know that we've got that strong data there.

The key thing here though is people thinking about people with symptoms suggestive of cervical cancer.

We've always got to take that history.

There is we do know it is easy sometimes to hand out a self-collected swab and perhaps forget to take that history.

And you absolutely can't do that because of course if you're offering self-collection, you're not going to do an examination.

And you do need to find out whether someone's got a history of post coital bleeding, for instance, because if someone does have symptoms suggestive of cervical cancer, then you're not doing a screening test, you're doing a Co test.

That's HPV and LBC on the same sample.

It has to be clinician collected and we do a Co test because it gives a lower threshold for referring to colposcopy.

Always, always ask about symptoms, people who are pregnant. We know pregnancy is an optimal time actually to offer cervical screening.

It's often the time when people who haven't been in touch with a health service throughout the ages and possibly never at all that they're, they're coming in to see you for antenatal care, maybe to in a hospital.

 we do want to be able to offer screening.

It can be self-collected. It's very safe.

If someone has changes that require colposcopy, we don't delay sending people to colposcopy.

If they do it's really to exclude serious disease.

And usually, of course, treatment will be deferred till after the delivery.

People who are aged 70 to 74.

I've known for myself, actually, I think I was a bit confused about this as well.

And now I've been on the working group, I'm no longer confused.

But the key thing about people who are 70 to 74 who come along for screening.

Basically, the guidance here is that if they have any type of HPV detected oncogenic HPV, either 16/18 but also non 16/18, then they're referred directly for colposcopy.

If it’s self-collected, they don't need to come back for that LBC test.

And then if it's normal, then they actually that's their last test.

If they're aged 75 or above, it's the same sort of system.

But basically, we're just offering this to people who haven't had a screening test in the last five years.

If they request that those exposed to DES diethylstilboestro, they're getting fewer and fewer.

They're probably lower 70s, I think now, but these women they, they did have that they do have that higher risk of various cancers, actually including cervical and vaginal cancer.

They do have an annual co-test and actually annual referral for a specialised colposcopy, not just of the cervix, but also of the vagina.

But their daughters, by the way, don't need any special testing – it’s just routine screening.

I think just be aware of who these specific groups are.

And it's over to you, Lara.

Thank you, Deb.

What I do without you?

We've got three excellent questions.

The middle one you'll be answering and in a really illustrative way around post hysterectomy screening.

But the first and the second I'll just address now, and I know Deb, you'll expand on those.

It is really important at the outset before we even go into the detail of guidelines changes that the audience is completely reassured and confident in the huge current evidence base at level of meta-analysis RCT International National that supports the effectiveness, accuracy and safety of self-collection.

You don't need to be concerned, and busyness has nothing to do with accuracy.

We are all busy.

We're not actually opting to self-collect because we're busy.

We're opting to self-collect because we are supported by the quality standards evidence base that's enshrined in our national screening guidelines and behind that, it's compelling evidence to support this as a safe, accurate option.

Why I'm harping on this is of course our patients at times need to be reassured about the option of self-collection and why it is just as accurate as and I use that wording with them and essentially just as good as if the doctor takes the test.

I think we'll ask them to expand on that in the Q&A, but it's really important to stay at the outset.

Julie, very quickly, our job in practice is to actually individualise guidelines and advice.

The NCSR performs a wonderful safety net function.

The definition of what sexual activity means and constitutes in terms of transmission of HPV is sometimes difficult for patients and clinicians to understand.

And Deb and I, you'll often hear us saying it involves all forms of sexual activity in terms of oral sex, anal sex, penetrative sex and close genital skin to skin contact.

And we start at 25 here.

Understandably patients and clients may be confused when they're invited, but it's not the NCR role to actually understand our patients in the way that we do.

And I think we provide a really good complementary function in terms of actually further individualising a protocol or a guideline-based approach.

Do you have any thoughts there?

Yeah, look, I think you've explained that perfectly.

I suppose the other thing that I would add on is just for us in clinical practice is we know we can't, we might ask people whether they're sexually active.

You know, people often don't know what they that means really.

But the key thing is that we do we can't make assumptions, and we do know that sometimes people will have experienced sexual assault or childhood sexual abuse and they don't disclose that.

And we want them to be able to, it may take a long time for them to disclose it.

We want them to have a very low threshold for offering cervical screening.

You know, it's a very simple test and you know, you just want people to have that choice.

We're not acting as sort of gatekeepers really.

But I do agree that it is, it is quite complex that description.

But I think hopefully we've answered your question over that now that thank you, Deb.

We've got a couple of other good ones.

A lot of them pertain to hysterectomy.

I know you'll be assessing those and making sure you incorporate the answers during the session.

And I think that last one we can talk to perhaps in the Q&A about how we actually do approach young people and what is a sensitive discussion around and just the history, just the person aged 75 for CST as I mentioned before, but perhaps too briefly, yes, if someone comes and they're 75 or over, if they haven't had a screening test in the past five years, it will be covered.

But ongoing screening wouldn't be covered, and it wouldn't be covered if they had had a more recent screening test.

That's just good information there.

But otherwise, they would have to pay for it.

And of course, that's the people's choice.

I'm going to be cheeky and say the average age of death of Australian women I think is upwards of 90.

Yeah, it's good point.

We all need to look at our superannuation and financial planning, I say.

But we might have to think about what does good healthcare screening and prevention look like across a whole lot of illness and Wellness.

That's a discussion for someone else.

But important point.

Now let's go to the test of cure and this slide is the status quo currently.

Just to refresh everyone's knowledge and update it all, people who've been treated for biopsy proven high grade squamous intraepithelial lesion are at an elevated risk of either disease recurrence or indeed progression, possible progression to invasive cancer.

And that elevated risk is mooted to exist for around 10 to 25 years.

Our job in in the screening follow up pathway is to have a protocol that's evidence based to return people to baseline safely that they can be returned to really the five yearly screening program.

Currently, our protocol involves 2 protests performed annually and consecutively a year apart.

And of course, if both those code tests are negative, those people can be safely returned to five-year screening and are deemed to be at baseline risk. The change which I think is welcome.

This slide is quite illustrative and easy to understand, and it tells us that really from April the protocol has been simplified without compromise to quality and safety.

And we can now offer and support 2 consecutive annual HPV tests which can be collected through the self-collection method.

 there is no need to insert a speculum necessarily and take a sample from the cervix for co-testing from April onwards provided HPV is not detected.

And I think our next slide illustrates that nicely.

We actually have the algorithm and if we follow the algorithm through, but I want you to cast your eyes on the caveat or the exception or the reason and the results that would underpin a referral for colposcopic evaluation in this pathway.

It's the bottom on my screen, right blue box.

If at any time during your follow up annual consecutive HPV test you return a 1618 result on your patient or you return a non 1618 or not 16/18 but the liquid based or not 16/18 but LBC is high grade or glandular or you return 3 consecutive HPV not 1618 results post treatment.

That would be in the sequence of three years annually consecutively.

Then you will need to organise a prompt referral for colposcopic evaluation and assessment.

I'm focusing on the result that we would most worry about or the outcomes we would most worry about.

And I generally say quite loosely, your ears need to prick up in clinical practice if you're seeing 16 or 18, if you're seeing high grade squamous epithelial lesion or findings or glandular findings on any liquid based cytology or if there is persistence over a period of time.

And that's exactly what that little rectangle box illustrates.

I think I'll just be talking through now, I don't know, adenocarcinoma in situ (AIS).

And again, right now we have a surveillance protocol for these patients which is very wielding.

It is a lifelong commitment to annual Co-tests or annual Co-tests indefinitely.

I must say in clinical practice, I'm not sure how well rigorously or consistently this plays out over time, but essentially adenocarcinoma is inside you.

Inside you is a precancerous HPV associated lesion of the glandular cells lining the end of cervical canal and it is a known precursor to endocervical adenocarcinoma.

These precursor lesions are actually identified usually at the time of excisional biopsy and this may or may not have completely sized a lesion.

Some attention particularly by the specialist gynaecologist or gynaecologist or colposcopist will be around the margins, but you should be interested in that as well and whether they're positive or negative.

There has been a welcome change, which actually on the next slide we will see takes away an indefinite or lifelong commitment to annual co-test provided the following circumstances occur.

We would start initially with annual co-testing for a period of five years and if all those co-tests are negative, the interval between the Co test can be expanded and extended to three years.

That protocol then remains in place 3 yearly co-tests and if they remain negative for a period of 25 years, which is still a long time, then a person at that stage, if they are 70 years and under can be returned to routine screening and would on be exiting screening in the next in that decade.

Or if in fact is older than 70 can exit from the national cervical screening program and can do safely.

I'd now like to talk to immune deficiency.

This has been a bit of a grey zone for us because a lot of the work that informs or the categorization or the inference around the frequency of screening in people who are immune deficient has really been drawn on work done with transplant recipients and people who have HIV.

It seems reasonable and has been acceptable for a long time now, that they should be screened more frequently, and that's because they're deemed to have a substantially higher risk of conversion to cervical precancer and cancer.

If at any point during three yearly screening results show up any HPV, the recommendation currently is referral to an experienced colposcopist or a tertiary centre for further evaluation.

If we look on the next slide, this quite nicely shows us an expansion, I guess of categories of people that we might see in our clinical practices where we can be confident to request or understand that three yearly screening will apply.

Deb, can I check with you?

I mean, I do routinely write immune deficiency on my request form.

I tend to make notes.

I don't write why or what don't need to actually.

I think the key thing is, I mean, you can, but it's going to be easiest for the labs, I have to say, because they are going to just want to be able to follow the algorithm.

The main thing is you're the expert of your patient's immune deficiency.

You know, the key thing is that this keeps it does keep changing all the time.

I mean, this is an ever-expanding field, but I think just on the path form, just writing immune deficiency is, is sufficient, is sufficient.

Exactly.

Look, and when you're working with labs and you've got a good working relationship with them, if there's any question or concerns, they will contact you or equally you can contact them and speak to them.

Yeah, I think that brings me to the exciting post hysterectomy follow up section.

This is, I have to know, I've never seen many questions about hysterectomy and it's clearly the topic of the month.

It is actually very exciting because it is much more simple.

We have simplified, simplified it to easy to understand annual testing because basically it's either two, well, it's two consecutive tests, either co-tests following AIS adenocarcinoma in situ or HPV testing following squamous lesions treatment.

Sorry for following four squamous that I've probably got that mixed up, co-tests or HPV depending on the cervical pathology and history.

I'll leave it to that for now until there's two negative tests on two consecutive occasions.

Just on the left, this is what the flow chart used to look like. It was very difficult. I have to say.

I just mangled up talking about that then.

And I remember talking to Ransk people about that chart where they did very first come out and it was quite tricky.

Whereas we've made it.

What you can see here is we've made it really very straightforward, and I'll take you through it step by step.

The key thing just to remind us all is don't make assumptions.

If someone's had a hysterectomy, you do need to make sure that they've had it total hysterectomy.

Sometimes that means looking or feeling I've been called out a few times.

It happens rarely, but sometimes people maybe if they've come from overseas, but al down here may have had a partial hysterectomy, which means they stick, they've got a cervix, and they still need ongoing cervical screening.

A terrible, a terrible thing happened in Ireland last year, not to do with doctors or nurses, to do with the systems where the system to provide the advice about what to what to do next.

They made the system, made a mistake and in fact, they ended up not sending reminders to women who'd had a partial hysterectomy.

They were all grouped together as hysterectomy. And in fact, there were cervical cancers found. it's a big public inquiry. Just remember that. 

This is just again just looking at the new flow chart.

What you're going to be doing is all based on screening history and the pathology findings at hysterectomy, which may or may not be known, but this is what it's based on.

Understanding the screening history.

We'll just move on to the next slide and look at the different groups.

The by far the most common group of people that you're going to see after a hysterectomy are those whose screening history has shown no evidence of, of high-grade changes or adenocarcinoma in situ.

You know, they've got a benign history, benign reason for their screening for their hysterectomy rather or they've had high grade changes and test of cure has been treated, completed after treatment.

For this group, as long as they've had no cervical pathology found at hysterectomy, low grade changes, high grade or AIS, then they don't need any further follow up. This is going to be the majority of your patients.

You just need to get that history and then no further follow up needed for this group.

Now we'll move on to the next group. 

This is a group where they've either had high grade changes, they've had a test of cure, it's been completed and in fact they've got them at the pathology.

They either have HSiL or high-grade changes findings at hysterectomy.

That's just that group there. There's also the group if we go to that, they have annual HPV tests until HPV is not detected in two consecutive tests.

And just to remind you that when we're talking about HPV tests, it always means when we're talking about HPV test, it means they have the HPV done.

But of course, if it shows up any type of oncogenic HPV 16 or 18 or non-16/18, then you know, then you need that other action.

You need to get them back for cytology or they're referred directly back for colposcopy.

Just remember that that's the composite of the HPV test.

The next group, we'll just go over to the far right.

These are patients where they've had a history of high-grade change, but they've had the test of cure, but it's incomplete.

Regardless of any pathology findings at hysterectomy, they are al able to have annual HPV tests until HPV is not detected in two consecutive test results. That's important.

Then the other group, you may have quite a few of these patients, it's where they've never been screened, or they have an unknown screening history.

And for this group, again, regardless of pathology findings, hysterectomy, then they can have the animal HPV tests until they've had two consecutive negatives.

Sometimes you do need to rt of dwell on these to rt of get them into your brain.

But hopefully it's more straightforward than before.

We'll just come to the last section now. The next slide now, Jovi, thank you.

This is for people where they've had the hysterectomy and in their screening history, they have had a history of adenocarcinoma in situ.

Regardless of any pathology findings at hysterectomy, they do don't go with the HPV test pathway because they've got these this history of glandular AIS.

And they have annual co-tests and they've until they've had two consecutive negative co-tests.

And if you remember a co-test is where you the lab looks at HPV and the LBC at the same time.

And if there's any abnormality in either of those, then that's not a negative test and they have to continue.

That's just important to be aware of. 

I hope that's much simpler than it was before. I'm sure that might invoke a few questions.

Lara, is there anything you'd like to add on to that?

No, Deb, I'm just keeping your company here.

Oh, that's great. Thank you. Excellent.

Hopefully that's a lot easier.

Sometimes you do have to rt of get your head around it, but it's certainly much simpler than it was before.

And I think it's pretty easy to work out. that's great.

This is what I mentioned before. This is a new very practical recommendation.

It's the change in the guidelines and this is to make it easier for us all and including for our patients.

And this is for people who've opted to have self-collection of their screening test.

They've had that self-collected screening test.

It's come back with HPV, not 16/18 detected.

You advise them to come back within six weeks or as early as possible to have the LBC to inform the risk category.

But they don't come back. they don't come back. You don't see them for ages.

Maybe the next time they come in, they come in for something else and you realise it's nine months since they had the HPV.

And in this situation, you don't need to do an LBC too late for that.

Because in fact, if you remember rightly in the intermediate risk pathway, what we're doing is within following them up 12 months later to see if then that non not, not 16/18 HPV is persistent.

In this situ from anytime from 9 months, if they return, they haven't had the LBC, then you actually offer HPV and that of course can be self-collected HPV.

That's really handy.

And again, obviously if it's negative, that means they can be discharged from the screening program, they've cleared that virus. That's great news.

If the HPV not 16/18 is persisting, then they do need that LBC because you need to work out what the risk category is.

 I think you'll all, again just think about it in the in the context of your patients, but it certainly makes life easier for everyone, I think.

That's great. OK. we'll go to the next question.

No, no, we've got you, Lao.

You're going to talk about the really important things around unsatisfactory results.

Deb, did you want to talk to any of the questions post history now or should we get on?

I think we might stick to that. We might just stick because we might well finish.

Let's do that.

I think too.

We've got me helpful cases and then we'll try and address as many of those as we can in that allocated time.

Look, I like simplicity and when it comes to unsatisfactory results, I just remember the magic number six weeks.

And the reason why I remember that magic number is if you get an unsatisfactory result with an HPV test and these unsatisfactory results are really quite uncommon.

For those of you who are a little bit older, like Deb and I, you remember the days of the Pap smears program where we were actually getting quite a lot of unsatisfactory false negatives, etc.

We have a much more accurate test.

But we also have, and I think it's important that those of you that are working with our labs, our labs actually doing their best to ensure samples are appropriate and al that they're taking into account a number of things.

And I do want to highlight that there is a cellularity control particularly to ensure that cells are present and hence the potential to detect DNA is present.

There are and will be circumstances when a self-collect is not actually performed as you've carefully instructed or asked.

And in fact, there is no cellular material present and that's a pickup that the lab is able to do.

The other is al the presence of contaminants and suddenly there are controls in place to rule out or rule in or understand if there are in fact any of the contaminants listed present.

Again, if a HPV test is unsatisfactory then it is absolutely fine to repeat that test as on as practical and ideally within six weeks.

On the other side, for liquid based cytology, what is required and preferred is that you wait six weeks and that's because you've actually sampled directly from the cervix and we need to allow me time for regeneration of cells.

This is important as well.

We have people here who are practising across the country in various settings and each of you will have your own relationship with laboratories and they will support you in a variety of ways.

There are really two options for the type of sample that you will be returning on behalf of your patient.

When it comes to self-collection, one is a 1-step process and the other is a 2-step process.

Many of you will now be familiar with the red top flocked swab and that swab is validated for accuracy or precision and should be the only swab that you're using when you're supporting patients to take their own sample.

And that swab can be directly returned to the laboratory.

However, me laboratories have systems in place that require you to return a liquid based sample.

And what that actually means is that you, not the patient, will need to re suspend the sample from the red top flop swab into the thin prep vial.

That's a 2-step protocol and I would encourage you to know and understand which one you're supported to do.

And if you have a preference, I certainly do for a one step, I'd suggest you advocate strongly to be supported to provide that that service in that way.

Now what's really important is the lab has no way of telling when you send a thin prep vial in whether that was clinician-collected, or self-collected.

And that can actually have a ramification on reporting and the incidence of false negatives.

Again, one thing I would ask you to do when you're doing the two-step process and sending in the vial that has the re suspended self-collection sample in it that you note on the lab form SC or self-collected Deb, anything else you want to add there?

No, I think you've covered that very thorough.

We'll move to the most exciting part of the talk there, I think, which is now the interactive cases.

And I'm going to hand over to you for those.

And I just want to thank you all for your fantastic questions, by the way, and engagement.

It's really great to get all these.

We'll see, make sure we can cover as many as we can, but let's just come to these cases.

We're going to meet two people and we've got a series of questions which we're going to do me of those lovely polls for.

First of all, we're going to meet Amal. She's 30.

She presents for contraception and we check if she's up to date with cervical screening through the provider portal of the NCSR.

And you found that her first screening test was actually 12 months ago.

And you have a chat with Amal and she's she doesn't didn't think she needed to have it because she's had HPV screening.

It wasn't until she talked to her friend that she realised she needed screening.

But she had you find out too, that her tests showed HPV, not 16/18 detected on a self-collected sample.

And your records show that she did not return for her LBC.

You do ask her whether she's got any symptoms suggestive of cervical cancer, which she hasn't.

What do you advise?

This is our polling question 1.

Just a reminder, she had her first screening test 12 months ago, not 16/18 HPV detected.

She didn't return at that point for the LBC.

It's now obviously 12 months on.

What do you advise?

We'll let you have a look at that.

Is it an OBC only test to determine her risk category A co-test, that's HPV and LBC test and HPV test which could be self-collected, check if the virus is cleared or none of the above.

We're going to give you time to complete that poll polling capacity on to be able to do that.

That's great.

OK, fantastic.

We've got the results.

And look, yes, almost 75% of you, 3/4 have got that correct answer.

Just to go through it.

Well, we just really talked about it, haven't we?

She was late coming back for that LBC and she's reached that nine month threshold where we say, look, you can have a repeat HPV test, it could be self-collected, it could be clinician collected.

But the main thing is that we just wanted to check if that virus is cleared.

Thank you, that was great.

And now we're just going to show you the correct answer.

And let's have a think about what happens next with Amal.

Yep, Amal test comes back as HPV, not 16 detected.

And what do you advise now?

This is polling question 2.

What's your advice in this situation?

Again, she's got HPV not 16/18 twelve months after the first one.

Do you advise her to return in another 12 months or a second follow up HPV test to see if the virus is cleared?

Do you advise her to return for an LBC test within six weeks to determine her risk category?

Do you refer her for colposcopy?

She was more than two years overdue for her initial screening test or none of the above?

I'll just give you a bit of time with that.

Yeah.

Now I do know that this is a tricky question.

That's what I'm going to say.

Because in fact the right answer here, and it is tricky because we all need to remember the intermediate risk pathway.

The correct answer is going to show up in red here, and it is that she is referred to colposcopy as she was more than two years overdue for her initial screening tests.

I'm just going to go to the next slide to explain this in full.

And it relates to someone's question that I've seen in the chat as well.

This is just a reminder.

This is nothing new by the way, this is already in the guidelines.

This has been in the guidelines since for the last few years. You're all familiar with this.

But we do know that the intermediate pathway can so sometimes be a bit complex.

The key thing is that if someone has a not 1618 result and they have low grade or possible low grade or negative cytology, that means they're intermediate risk.

And for everyone in that situation, we follow them up in 12 months’ time and do a repeat HPV test.

Now for most people, the majority and I think of the question in in the chat was that what about for a young healthy person no, no issues.

She you know, she has persistent HPV 2 for two consecutive years.

You know, do we wait for her to have a third consecutive HPV non-16/18 before referring her to colposcopy?

And the answer is yes.

For the majority of the population, the majority of people coming into the screening program, if they have persistent HPV, not 16/18 again at that second follow up test, we know it's very safe for them to have surveillance for another year and then they come back for that second follow up test.

And if that's still persistent non 16/18 HPV, they get referred for colposcopy regardless of cytology.

But there are a small group of people and they're important people where it's deemed that their risk, they are at higher risk of harbouring a high-grade abnormality even if they have negative cytology but they still have persistent HPV, not 16/18 at that first follow up test.

In other words 12 months after the index case.

And who are these groups?

Well, it does include them all because in fact, if you remember, her first screening test was actually, she was late.

You know, it was, it was only 12 months ago.

She's aged 30 now. She is under screened.

She falls into that category of being overdue for screening by at least two years for her first screening test.

And in fact, she is directly referred to colposcopy as are people who are aged 50A years and above and Aboriginal and Torres Strait Islander background people.

It's just remembering most people we can surveil them up to three years, but for this small group we can't.

We have to just make sure that you know that that if they have a repeat follow up tests that have not 16/18, they need referral.

Let’s move on then.

Let's carry on with Amal. She is referred for colposcopy and the LBC is taken during this visit.

You don't need to get her to come back to you.

If she had a self-collected test, the colposcopies and biopsies confirm high grade lesions with SIM 2 and she has a loop excision procedure and she's referred back to you for tests of cure 12 months after treatment.

Which test do you advise Amal in terms of test of cure? 

There's the polling test here. We'll get that poll going.

What's a test of cure test following treatment for HSiL 2?

Is it annual co-testing HPV and LBC on the same test at two consecutive negative tests?

Is it an HPV test with a reflex liquid-based cytology clinician collected from the cervix annually?

It can be clinician collected from the cervix annually until 2 consecutive negative tests.

Is an HPV test self-collected from the vagina annually until there's two consecutive negative tests or is it an LBC annually until there are two consecutive negative tests?

Now I will say it's a bit of a trick question.

I'm going to give you tell you that in advance because there may be more than one correct answer here.

You've done very well.

Actually, it isn't though.

It isn't co-testing because we've changed now from co-test to HPV test.

The test of cure now after a high-grade lesion, the squamous lesion syn 2 or syn 3 is actually 2 consecutive HPV tests.

Now those HPV tests could actually be either self-collected or clinician collected.

I think you know, you've done well with that.

It's not just an LBC test, it's the HPV test.

All right?

Obviously if it's clinician collected, then there will be reflex liquid based cytology done on that test.

If it's positive for oncogenic HPV, if it's a self-collected test, then that person needs to come back for the cytology to inform next step.

That's good.

Amal completes the test of cure, and she's discharged.

It's all negative and she's negative for HPV on those two consecutive occasions and she's discharged to routine screening.

Now let's move on and meet Freda.

This is Freda. She presents with her daughter for cervical screening. She's aged 72. Her last screen was 10 years ago.

She assumed she didn't need any more screening if she's not been sexually active since her husband died 8 years ago.

She al remembers a very bad experience with her last pap smear.

She's very agreeable to the idea of self-collection. But the test comes back as unsatisfactory.

And what you find, what the lab has said, is that there are absent cells.

It does suggest – I don't like this term… actually, I must say that me of our lab friends used to be socially unsatisfactory – in other words, it looks like Freda was still nervous around cervical screening.

She took the swab behind the curtain or perhaps took it to the bathroom, but she didn't, she actually didn't insert it into the vagina for a variety of reasons.

We sometimes can't guess what those are. But basically, that's the result. It's come back as unsatisfactory.

We do organise an appointment within six weeks.

There's no need to wait, of course, to sensitively discuss the result with Freda.

And you can advise her that if she, if she's wants to, if she prefers, could actually assist her with taking a self-collected vaginal sample.

In fact, she's very agreeable to that because she does remember that it was a bad experience last time.

But she's just hesitant about doing this herself.

She's not sure she's going to get it right.

 and don't underestimate assisted self-collection.

We know that it can be really useful for helping people who are hesitant to take their own self-collected sample.

But they really don't want they've made a choice.

They don't want a speculum exam.

The test comes back with HPV type 16/18 detected.

What do we advise next? Let's have a look at the options.

Do we ask Freda to return for a follow up HPV test in 12 months’ time?

Do we ask her to return for an LBC test, a cytology test within six weeks to determine the risk category?

Do we ask, do we advise that referral to colposcopy is recommended or is it none of the above?

And we'll give you just me time to answer these.

Excellent, excellent.

Well, we did mention this before.

The key thing here, of course is Freda's age that we mentioned and it's this concept of exit testing that I mentioned before.

And you know the majority of you are correct with this, that referral to colposcopy is recommended.

Freda is referred for colposcopy.

Just a bit of a summary. Patients can be discharged from the program if they're 70 to 75 and have had a screening test at which HPV is not detected.

But if any type of HPV is found non 16/18 then people are referred to colposcopy.

If the self sample was self-collected, there's no need to return for that LBC because it's going to be collected at that time.

We do advise Freda, we've talked to her about the referral to colposcopy.

She had that very uncomfortable pap smear.

She's postmenopausal and we do advise that she has a two-week course of vaginal oestrogen prior to the colposcopy.

Generally, you exclude the two nights immediately before the cream doesn't get in the way and the colposcopy shows and the carcinoma in situ, it's confirmed with a diagnostic comb biopsy.

She has complete excision with clear margins, and she returns to you for ongoing surveillance.

Which tests do you offer Freda for surveillance following treatment of AIS adenocarcinoma in situ?

We'll start the poll.

Do you offer an HPV test with reflex liquid-based cytology clinician collected from the cervix annually until she's had two consecutive negative tests?

Do you offer an HPV test self-collected from the vagina annually until there's two consecutive negative tests?

Do you offer an LBC annually until 2 consecutive negative tests?

Or do you offer annual co-testing the HPV and LBC?

This one again, it's a tricky question, the correct answer. Most of you have got that correct answer, right.

I mean, these, these are brand new changes of course.

It is actually after any after AIS then always if you remember back to the slide that Lara showed its annual co-testing. That's HPV and LBC.

Now we have changed as a little bit used to be for life.

I mean Frieda is already 72.

We know that they can stop cut this annual co-testing after 25 years of co-tests.

We know that they can change from annual to just go down in frequency of the co-testing after five years.

But basically it is co-testing. That's just important to remember.

That's a good reminder.

And I'm going to hand over to now, who am I handing this to?

Is this to you Lara or Jovi?

It's to Lara.

Oh, yeah.

Excellent.

Just before I go to this step, I've worked out there about 5 or 6 questions which I can knock off really quickly.

And they, they all pertain to sampling and timing and samples.

Mr or Miss Anonymous, the red top flock swab should be discarded after it's been agitated and releases the sample material into the liquid based bile.

You're absolutely right there.

Thank you for that comment, Megan.

That's right.

me labs will forward on the flop swab to a laboratory such as VCs here in Melbourne when they themselves are not able to support that collection method.

And there are me really helpful arrangements in place around the country.

 again, your practice manager or practice nurse could look into how your practice can be supported in terms of what the clinicians and doctors there would like Assisted in inverted commas.

Self-collection.

 when might this occur?

And it's actually always been something which has been supported by the program.

Range of scenarios.

People with low vision, poor vision, significant parkinsonian tremor, very tight hips due to an arthritic process, lack of confidence, preference.

In those situations, if the patient has been given their options, prefers self-collection, but asks for the clinician to actually do the self-collection, that's absolutely fine.

Deb, I think you're nodding and absolutely fine.

Absolutely fine. You don't need to write anything on the form like assisted or I helped or doctor assisted.

It's self-collection.

Thanks for that question.

There is absolutely no need to wait before referring to colposcopy.

Often we're waiting too long to get people into colposcopy in a timely way.

Now when your test returns a 1618 on a self-collected sample on a patient, you don't take the LBC, you actually organise a direct referral to colposcopy and at that time a liquid based cytology test will be taken.

That addresses I think Kim White's question.

We often would be asked about tests of cure and this half back to the Pap smear days as well.

Can we, will we accept the test of cure that's done before 9 months?

Now I know that patients have travel plans and they're busy and all sorts of things happen and they may not be able to come in annually exactly at the 12 months.

But you are doing them a disservice if you're not allowing them sufficient time for clearance of infection and for changes in the cervix to resolve.

We would strongly support where possible you encourage your patients to come as close to that 12 mark and nine months or before is too early.

I hope I've answered me questions.

And I need to clarify a couple of points because I probably was a bit misleading in this case.

And then we'll go to you Dev and then we're getting close to resources and Q&A.

Look, we want to commend this to you.

This is the self-collection for cervical screening mini audit.

It was the brainchild of two specific interest groups, notably our environmental medicine, environmental health specific interest group, who really put me thought into really the green aspect of saving plastic specular across this nation.

And it's a very simple, straightforward order.

It's not hard to do.

It's not an onerous, but it punches a nice five measuring outcomes and one reviewing performance and it's been really endorsed by our membership with 1254 completing at last year in the CBD cycle.

 we really encourage you to consider doing a self-collection mini audit as an audit activity for this year's CPD.

Deb, I think I'm over to you now for recent and you might want to make me commentary as you said regarding yeah.

 I'll just pick up a couple of questions and we'll move on to the next slide.

 I can see someone's asked about, yes, the register sentence reminders three months before someone's due for their cervical screening test. And that's you can, they can get the rebate on that.

And that al happens in the three months before someone turns 25.

I think that answers that question.

If someone turns up three months shy of their 25th birthday, then they can have that screening test in the Frida test.

Someone saying can you, Julie, thank you.

Does she continue to have screening for the rest of her life?

Yes.

I have to say with AIS at the moment, we just don't have enough data to say that it's safe to stop those annual co-tests.

They can go down in frequency.

But for someone who hasn't had a hysterectomy, she's had the cone box, the excisional treatment with an excisional cone biopsy, then no, she does need the annual screening.

There was another one I was going to do quickly.

I know someone said around a hysterectomy if the register keeps saying you know, this person needs screening, she had a hysterectomy many years ago.

But we don't know what the results of the hysterectomy pathology were.

Look, one thing you could do is, is just follow that pathway where you could have the advice for, if you didn't know someone's screening history, just have the two consecutive HPV tests.

And if they're both negative, then that person doesn't need to go back to for any further screening.

But let's go on to the next slide.

Now, I'm sure we're going to mop up all of these questions.

I just want to, I won't dwell on these, I want to do all the questions, but this is just to highlight these really fabulous resources.

These are all the links to them. They're all gathered together on them, on the same website.

They're easily accessed through the, the guidelines as well.

You've got those, the overall practice guidelines.

I'd urge you all to have a look.

What we're talking about here is they're available at the moment on the website.

I just looked them up this afternoon again, but they're not coming into effect until the 14th of April.

And what that means is the laboratories I'm still following the current advice.

I suppose we call this you know, but from the 14th of April 2025, not too long from now, then the laboratories will change all their recommendations in line with these new guidelines.

You can just get this is for you to get used to these now, but from the from that time these this is this is the recommendations.

We've got this healthcare provider toolkit.

I don't think many people know about it.

It's really great.

It's around just again, particularly around bringing in under screen pro people.

Really great information, for instance, on providing screening for the LGBTQ community or people with disability, but all just handy tips as well.

There's just a lot of good information for you.

There's a summary guide for health providers Lara talked about and there's a quick two-page reference guide as well, which potentially you could print off and laminate.

There's, if you remember, there was previously training modules when the program first came out and there's updated training modules now.

They're all accredited for CPD points, of course, and they're available through the ACPCC website. There's quite a few modules there.

I would just urge you all to just have a look at that, that web link and see how you can upskill yourself and really become experts in this.

I'd just like to finish by acknowledging just the support of the National Cervical Screening Program at the Department of Health and Age Care, particularly the Director, Dejan and Kelly.

But also thank Marion Savile at the Australian Centre for the Prevention of Cervical Cancer and her team for the basis of many of these slides.

Thank you to all.

And Jovi, I think it's over to the Q&A now. We've got lots of questions.

You've got a lot of Deb, I'll give you an opportunity to just have a scan through.

I'll pick up another four or five quickly and then I'll hand over to you.

Look, really good questions here.

The audit, Fatima, the mini audit is quite self-explanatory.

What you'll actually do is you'll be given a table to fill out that as you're actually offering the choice of self-collection and should it be taken up, there'll be a key of key prompts there of what you need to fill out as part of that consultation and what you might consider.

It's really easy to do it.

I think it's 5 patients.

It's not onerous.

Hopefully that helps with that.

Yes, there are absolutely lab standards, very rigorous standards around reporting and language and alignment to recommendations.

If you feel that your lab has provided a recommendation that doesn't seem to either align to the guidelines, but to your clinical understanding and interpretation of those, I would really encourage you to pick up the phone and have a conversation with the lab.

I think that's a really good place to start.

Screening in other countries.

Look, our country here in Australia is one of the most diverse.

It's very important that we understand that screening here and in other places is not necessarily an equal match.

We do know Australia has an exceptional screening program.

Where possible, I do encourage patients to get involved in obtaining relevant past screening history information.

Often they're best to contact previous doctors or specialists from where they came from.

If I can't make sense of it, I actually then defer to, well, what would I do for someone with these individual characteristics clinically, age and stage in their life?

How do they slot into our program here?

And I would take it from there.

It's not an absolute answer, nothing's perfect, but I think that's a reasonable approach.

People often ask what is the difference between a co-test and a HPV test and reflex liquid based cytology.

It's an excellent question.

It was one we hoped we addressed well when we brought in HPV 5 yearly screening.

I'll explain it right now.

A Co test usually occurs not as a routine asymptomatic screening test.

A Co test happens usually when there's a clinical indicator and you're in a follow up arm when we first offer screening as in the CST or cervical screening.

And indeed, it if it is clinician collected, it should be to those individuals who are eligible who are at baseline risk.

We're talking asymptomatic routine.

In that circumstance, if the patient says Yep, I'm happy to have a clinician collected sample, the sample will be sent to the lab in a liquid based vial.

The first thing the lab will do is an HPV test.

Based on that result, the lab will then run reflex liquid-based cytology.

It's sequential and two step a Co test means that the HPV test and the liquid-based psychology will be run at the same time.

The liquid-based cytology will not be based on the results of the HPV older women very quickly.

Deb, and then over to you, all women presenting with HPV 18 who had no HPV detected five years ago.

You did qualify and you comment that there's been no, no new sexual partner or sexual activity.

Look, the HPV test is pretty accurate.

We do have a fairly ageist country.

Increasingly now, women and men in particular living longer and are sexually active and are changing partners more into those older years.

I don't know if that's particularly helpful, but I would maintain an open mind.

However, as our clinicians, it's not our role, I guess, to infer or draw conclusions beyond what we can with the facts before us.

And I know sometimes our patients are seeking more information and guidance.

It's a tricky area.

And I think the thing we need to focus on is HPV 18 is a signal for colposcopic evaluation and timely at that.

Thanks Deb, over to you.

Thank you.

Yes, that's an interesting question, Karen.

I mean, often just give the possibilities that just with age, we know that decline and immunity, it can mean that HPV that's been around for a very long time then becomes detectable.

But it's giving those options and not making assumptions and let people working it work it out.

And I have to say, I was busy writing down questions, I hope I'm not going to repeat ones You've talked to Lara.

Just tell me if I have someone has talked about the person with persistent 16/18, HPV 16/18 where there's normal colposcopy.

I did just want to say with this that that we've got me new data out of a country where they weren't really following these people up.

And what we do know is that HPV 16 in particular more than 18 is a unique, very powerful carcinogen.

Even where people have negative colposcopies, we still have to be alert to these six teams.

And really it is from our perspective in primary care unfortunately we do have to keep referring these people to their gynaecologists and we do.

We're opening up new guidance around what we call endocervical curettage for instance, where we're looking up in the canal just to make sure there's not something going on there.

We just can't leave these group alone, say oh they've got normal colposcopies, nothing's going on, let's see them again in 10 years’ time.

We really do have to just ensure that we are following these people up and that they are seeing the gynaecologist for thorough review.

Someone talked about international comparison.

What if someone's had screening overseas and they come and they start screening here and we don't have any history on them.

I think the key thing is, I mean it's very hard.

There's lots of different screening programs in different countries.

We can't keep on top of them all.

Basically, someone who's newly arrived in the country would be provided with they've got a Medicaid card, they'll be provided with a screening test because they'll be perceived as being a new screener.

Obviously, it's up to you then to be able to get as much of a history as you can to help inform what's happening.

But yes, we don't have those, those sort of comparisons, I suppose, but it's just you doing your best to get the best history you can.

Say someone comes in and they they've just started their menstrual period.

Is it best to offer self-collection or to, to get them to come back?

That'll entirely depend on your judgement.

The just to say that the rate of, of unsatisfactory tests due to you know, contamination with blood is actually quite low.

You have to have a lot of bleeding.

But sometimes they are that they do come back as unsatisfactory as Lara has talked about.

But I think it's you weighing up whether you think if you know someone well that they're going to they're going to come back, then that's fine.

But generally you'd be inclined they've come all the way that come to see you.

I'd be inclined generally to offer that offer the self-collection that may well come back completely fine, of course.

That's just your judgement.

There is sexual abuse.

How do we tackle that with a young, shy woman?

You know, I think the key thing is that we're not we're not wanting to elicit disclosures necessarily.

I think the key thing would be to just talking in the third person around who we offer screening to, who needs screening?

It's anyone who's ever had any sort of sexual contact.

And that just saying that can sometimes be nonconsensual.

And we know we really do offer cervical screening to everyone.

It's a very simple test to do.

You're just putting that in that person's court really to decide whether they want to have that test.

And really most people will be very accepting, particularly now we've got that self-collection option.

I think another person asked about home testing.

Is it going to be like sending kids home a bit like for.

Colorectal cancers, I've got no name on that.

I think the key thing is absolutely we are looking now at new models.

The key thing now is to bring in under screen people into the program.

But our screening program is very much embedded within primary care and we know there's very good reasons for that because you've got that continuity of care.

If I'm giving someone a swab in the clinic to do self-collection and I get it back, I know I've got it back.

Whereas if it goes home, we know there's a, have a lower chance that it or a higher chance rather, it may not come back, but we are investigating lots of new models of care to ensure that we can bring people in.

But it's about having those safeguards in place.

And again, just having the GP, you play such an important role at the centre of those things.

But me, me of you of course, may be having me telehealth models where you've got that, you know that well established quality assurance in place to ensure that the key thing of course, is first of all to make sure the person has that test and you know, doesn't lose the, the swab, for instance.

But the other key thing of course is that it gets to the lab and then when the results come out there, there was a question around a list of biological actives and current.

I'm not aware of such a list.

And I think what we need to do as GPS is apply me und judgement around both the severity of any long standing chronic immune challenging disease process.

We were aware of our patients had and also understood both the frequency consistency with which they were receiving immune modulating treatment, whatever it would be.

And in the end, I'm sure that none of us are really going to be abusing the system and I would encourage you to be confident to put immune deficiency on the request form.

Deb, I'll answer two more and then I'm sorry about that.

That was a wonderful Sydney Uni Internet dropping off.

Not at all, not at all.

I guess just to support Deb's excellent advice around shy, the shy young 25 year old or young person.

And I think we've got a really good question about 25 and not sexually active.

I know that I do.

And you will have had many of these conversations.

I tend to start with a generic in Australia currently what we offer all sexually active Australians and particularly those with the cervix or women, the opportunity to start screening from the age of 25.

There it's important to understand that we're looking to screen to detect early infection with a virus known as HPV or human papilloma virus.

Many young Australians have been vaccinated, and you may have heard about this virus.

Well, it's it can be and is linked to serious change in the cervix down the track.

People ask how long can it be dormant?

It can be dormant or present for decades and usually takes many, many years to move from abnormal low grade change to significant change.

We often work in decades.

That's sorry, an aside and an answer to that question.

But back to the conversation with young people, I think it's important to explain that the HPV is transmitted through sexual activity.

And then you might say something along the lines.

I'd like to describe the sorts of HPV activity that we know can be linked to transmission because the people definition of being a virgin or not sexually active may mean oral sex is on and genital skin to skin contact is on.

But penetrative sex defines sexual activity.

And no, I'm not sexually active.

And it really helps both provide useful information in the consultation and clarification using very simple terms with the shy young 25 year old and a suspected or possible history of abuse.

I would be establishing rapport.

And it might not be the first or second consultation until I'm in a position where I think trust is established and the patient is feeling comfortable that I would explore this further.

And that's just to add on from the excellent advice Deb has given.

The PHN question is an excellent one, and we welcome that question.

And Deb, you may wish to speak to it too.

But look, there are me excellent resources and speakers available currently.

And I would just encourage any PHN to get on board, whether it be through ACPCC, through Deb, through the College here.

Obviously, these webinars are recorded and we're doing this again on the 13th of March, which is timely for an April start.

Which brings me to, well, what if someone's in a pathway and the recommendation changes.

And at the moment we're in a lovely hiatus.

Where you don't need to flip people across to a new recommendation.

You can just allow them to continue where they are.

Equally, if you wanted to start offering, I believe the HPV self-collection for the nine months and later it would be reasonable.

Deb, your thoughts around that?

No, I think that that would be reasonable.

The other case that may well come up is that you're halfway through a test of cure.

In other words, you've done a co-test and they're due for their next annual co-test, but now it's an HPV test after treatment for a high grade change, then you would just do the HPV test.

And if there's two obviously the first HPV would have been negative with low grade changes or negative changes, no cytology changes.

And if you've got a second consecutive negative HPV, then that would be a completed test of cure.

That's useful.

But yes, I mean, they, they do come into effect.

But I think if you're taking up me of these changes, certainly your patient shouldn't be disadvantaged by those.

Someone says I'm curious about HPV 16/18.

Any specific guidelines?

That's one of the non 16/18 types.

At the moment, as you know, and this will stay for me time, but I'll talk to you about what may happen in the future is that it's part of the, the, the whole group of those non 16/18 types.

There's no specific advice.

It just follows that advice for the intermediate risk pathway in the future we may.

What happens at the moment is that we test someone and they've got not 16/18 type HPV, so we test them again in a year.

They still have it.

It may be a different type of those, one of those different non 16/18 types.

We don't know that at the moment.

It may be that we're over following people up where they don't they've got a new infection which is transient.

It's not going to cause any challenges.

In the future we may move to something called extended genotype where genotyping where we can actually see whether it's the same type, but we're not doing that yet.

That's just one thing there.

Claire Oberton, that's nice.

You're asking me to talk about the work with screening with people with disabilities.

We know that this group's right under screened.

We had an excellent campaign last year called Screen Me to raise awareness of screening for people with disabilities.

We know there's lots of barriers, lots of unfortunately history of, of past sexual abuse and trauma, which can be real challenges.

I would say that the offer of assisted self-collection is really useful in this situation.

We're doing in our research to look at how, how useful it is.

We're going to, we've got lots of resources now.

There's me resources at the moment on the NCSP website under the Screen Me site.

I'd urge you all to look, look those up.

There's some research going on around community health nurses going to that's it.

Just to jump in there.

And I know Jovi want us to wrap up, but on that interesting question.

Last year we did run a series of optimising cervical screening and people living with disability webinars.

Both recordings are available and accessible.

And of course, that we had a fantastic advocate and woman who lives with disability, really giving us the perspective of the sorts of ways we could adapt, improve and change our practices and approach to be facilitative and supportive.

And I know that that was really well received.

And thank you to Amanda O’Donovan, who's put me really great examples of yes, fantastic, excellent.

Lara, did you cover that the case around the you could have an unidentified self-collected sample accidentally reflex and reported as a false negative.

Did you cover that one?

You probably did.

Yeah.

I think I mentioned that when I was going through.

Yeah.

There's a quality control in this.

That's actually right.

I think we might have to hand over to Jovi, but do what we usually do, which was try, try and find response, try and put together me responses to those.

We have an answer.

We will possibly Jovi have an opportunity in March to take up me of these as well.

Yes, correct.

The next repeat webinar is on the 13th of March.

 in the resource I'll be sending, I'll put the link to the next webinar.

Fantastic, thank you.

Thank you.

I'd like to extend my thanks to Lara and Deb and everyone that's joined us online tonight.

We hope you enjoyed the session.

Again, just a reminder copy of tonight's presentation along with resources and the length recording of the session will be sent to your registered email address within the next week.

And I guess that's all that we have time for this evening, and we'll see you again if you'd like to join us on the 13th of March.

Thank you and good night.

Thanks everyone.