Australia has been a world leader in research and surveillance documenting the impact of control programs for cervical cancer. C4 Partners include many investigators who have been collecting, analysing, and reporting key epidemiological information about the occurrence of cervical cancer and its precursors. The resources of C4 and its partner organisations have been used in consultation with key stakeholders to deliver this comprehensive report. This inaugural report is planned to be the first in a regular series on Australia’s progress towards the elimination of cervical cancer as a public health problem. The report is based on 11 key indicators grouped into 4 components framed by the WHO ‘90/70/90’ 2030 scale up targets for elimination, derived from the most recently available data.
Twin goals of the report are to monitor progress towards achievement of targets and to provide recommendations for improving the quality, availability and timeliness of indicator data.
- The first four indicators cover disease outcomes including the target for elimination (incidence below 4 per 100,000 women). Indicator 1 Cervical cancer incidence and Indicator 2 Cervical cancer mortality are low by global standards (6.3 per 100,000 in 2011–2015 and 1.4 per 100,000 in 2014–2018) but substantial inequities remain, with the incidence rate in non-Indigenous women just below the threshold defining a rare cancer (at 5.7 per 100,000 in 2011–2015), whereas the incidence rate for Indigenous women was more than twice as high (at 12.1 per 100,000). Mortality rates were over three times higher in Indigenous women. In the final year of the cytology-based screening program (2017), the rate of Indicator 3 Detection of high-grade cervical disease (the precursor of cervical cancer detected through screening) was 7.1 per 1,000 women screened. This rate has been falling due to the downward trend in disease rates in young women following the HPV vaccination program. Indicator 4 Prevalence of HPV infection also documents the success of the HPV vaccination program, with HPV16 or 18 (the most serious cancer-causing types of HPV and prevented by vaccination) detected in only 2.0% of screened women across age groups, socioeconomic groups, remoteness areas and jurisdictions. Other cancer-causing types were detected in 6.5% of screened women.
- The next two indicators monitor delivery of the HPV vaccine at a benchmark age by which adolescents have had the opportunity to be vaccinated. Indicator 5 HPV vaccine completion by age 15 found that 78.2% of 15 year olds in 2019 had completed the course (79.6% of females and 76.8% of males), with Indigenous adolescents having a lower completion rate of 68.5% (female 71.6%, male 65.4%). In contrast, Indicator 6 HPV vaccine initiation by age 15 found equal coverage by Indigenous status (84.0% in Indigenous, 84.6% in non-Indigenous adolescents), with Indigenous females in NSW, the NT and Victoria the only groups with over 90% dose 1 coverage. HPV vaccination appears to be more equitably delivered than cervical screening and is at close to the rate predicted to be required for eventual elimination of vaccine preventable HPV types in a both-sex vaccination program (80%), although below the 90% WHO target for girls.
- Two indicators monitor screening participation, with Indicator 7 Screening participation by age 35 and 45 years enabling assessment directly against the WHO scale up target for 2030 of 70% for the globally recommended minimum target of two screens with a high precision test (HPV test or better) in a lifetime. By age 35 in 2019, 54.9% of women had had an HPV test, with the same percentage having had an HPV test by age 45 and a previous cytology screen in the preceding 10 years. Women in the NT and very remote areas had lower participation. Indicator 8 Screening participation, Australian program monitors participation against the national program recommendations, with 52.4% of Australian women up to date with recommended screening by the end of 2019, two years into the renewed screening program, but inequities in participation were apparent by socioeconomic status and area of residence.
- The final three indicators relate to the third pillar of the elimination strategy which is treatment. Indicator 9 Colposcopy attendance suggested, within the limitations of likely under reporting, that most women do eventually have a colposcopy when indicated on the basis of their screening result (87.8% by 15 months for women referred in 2018) but that some women experienced suboptimal timeliness, with 60.8% of women having a colposcopy within three months, with variation by geography and socioeconomic status. Data for Indicator 10 High-grade cervical disease treatment rates, which will measure directly against the WHO 2030 scale up target of 90%+ of women receiving treatment, could not be reported due to a lack of available data at this time (this indicator requires comprehensive histopathology and treatment data from colposcopy reports). Similarly, limited data was available for Indicator 11 Cervical cancer treatment rates, with no national data available to assess against the WHO 2030 scale up target of 90%+ treatment. Queensland data from 2011–2014 indicated a treatment rate of 94% in metropolitan and regional areas and 92% in rural and remote areas. Two small studies suggested some potential underuse of chemotherapy and radiotherapy historically at one centre and that Indigenous women may be more likely to receive suboptimal treatment.