Lucan · Conditions

Cervical cancer screening

Australian guidance: RANZCOG C-Gyn 19 Cervical Cancer Screening (2024) + National Cervical Screening Program

1. Definition and epidemiology

Cervical cancer is a malignancy arising from the epithelium of the uterine cervix, overwhelmingly driven by persistent infection with oncogenic human papillomavirus (HPV). In Australia, approximately 900 women are diagnosed each year and roughly 250 die from the disease annually, placing it among the more preventable cancers given effective vaccination and screening programs. The National Cervical Screening Program (NCSP), which transitioned to five-yearly HPV primary screening in December 2017, replaced the previous two-yearly Pap smear approach and has substantially reduced cervical cancer incidence and mortality.

2. Pathophysiology

Cervical carcinogenesis is almost entirely attributable to persistent infection with oncogenic HPV strains, most critically HPV 16 and HPV 18, which together account for approximately 70% of invasive cervical cancers. HPV infects the basal cells of the squamocolumnar transformation zone, the region where columnar endocervical epithelium meets squamous ectocervical epithelium. The viral oncoproteins E6 and E7 disable the tumour suppressor proteins p53 and retinoblastoma protein (Rb) respectively, disrupting cell cycle regulation and permitting uncontrolled proliferation. Most HPV infections are cleared by host immunity within one to two years. When clearance fails, low-grade squamous intraepithelial lesions (LSIL) may progress over years to high-grade squamous intraepithelial lesions (HSIL) and eventually to invasive squamous cell carcinoma or, less commonly, adenocarcinoma of the endocervix. Adenocarcinomas, arising from glandular cells, account for around 15 to 20% of cervical cancers and are less reliably detected by cytology, which is one reason primary HPV testing has become preferred. (Robbins Ch 22)

3. Clinical presentation and diagnostic criteria

Early cervical cancer is frequently asymptomatic, which is the central rationale for population-based screening. When symptoms do occur they typically include postcoital bleeding, intermenstrual bleeding, or postmenopausal bleeding. Unusual or blood-stained vaginal discharge is another common feature. Advanced disease may present with pelvic pain, dyspareunia, urinary symptoms such as haematuria or frequency, and lower limb oedema from lymphatic obstruction. A negative screening test should never be used to dismiss symptoms: any woman with symptoms suggestive of cervical cancer warrants investigation regardless of her screening history or vaccination status. On speculum examination the cervix may appear grossly normal in early disease, or may reveal an obvious exophytic, ulcerated, or friable lesion in more advanced cases.

4. Investigations and AU-specific cutoffs

The NCSP uses a five-yearly oncogenic HPV test collected by a clinician or, since 2022, by self-collection, from women aged 25 to 74 years. The test simultaneously performs reflex liquid-based cytology (LBC) on the same sample. Interpretation follows this pathway:

Negative HPV result: routine five-yearly recall.

Positive HPV 16 or 18 result: refer directly for colposcopy regardless of reflex LBC result, within eight weeks. If the reflex LBC reports invasive carcinoma, refer to a gynaecological oncologist within two weeks of the suspected diagnosis.

Positive oncogenic HPV (not 16/18) with reflex LBC showing possible high-grade squamous intraepithelial lesion (pHSIL), HSIL, or glandular abnormality: colposcopy within eight weeks.

Positive oncogenic HPV (not 16/18) with reflex LBC showing low-grade squamous intraepithelial lesion (LSIL) or less: repeat HPV test in 12 months. If HPV persists at 12 months, colposcopy is indicated.

For women with a suspected or confirmed diagnosis at colposcopy, the diagnostic work-up includes gynaecological examination, colposcopic assessment, cervical biopsy for histological confirmation, cone biopsy or type 3 large loop excision of the transformation zone (LLETZ) as needed, full blood count, liver and renal function tests, and pelvic ultrasound. Staging is clinical but aided by chest x-ray, CT, MRI, or PET as appropriate.

Special populations: Aboriginal and Torres Strait Islander women commence screening at 25 and continue to 74 with same intervals. Immunocompromised women (including those living with HIV) require more frequent screening per NCSP guidelines. Women who have had a total hysterectomy for benign disease and have no history of HSIL do not require vault screening. Women who have received HPV vaccination still require routine screening as the vaccine does not cover all oncogenic HPV types.

5. Management

Management is governed by the NCSP pathway and the Cancer Council Australia cervical cancer guidelines, with the Cancer Council Optimal Care Pathway providing the overarching framework for diagnosed disease.

Precancerous lesions: LSIL confirmed on histology is generally managed conservatively with surveillance colposcopy at 12 months given high rates of spontaneous regression. HSIL confirmed on histology requires excisional treatment, typically LLETZ, which achieves both diagnosis and treatment. Glandular abnormalities require cone biopsy to exclude adenocarcinoma in situ or invasive disease.

Early invasive cervical cancer (FIGO Stage IA1 to IIA): surgery is the preferred modality for small tumours confined to the cervix. Radical hysterectomy with pelvic lymph node dissection is standard. Fertility-sparing radical trachelectomy may be considered in carefully selected women with early-stage disease who desire future pregnancy. Adjuvant radiotherapy plus or minus chemotherapy is recommended post-operatively when high-risk pathological features are present (positive margins, positive lymph nodes, parametrial involvement).

Locally advanced cervical cancer (FIGO Stage IIB and beyond): concurrent chemoradiation, combining external beam radiotherapy with brachytherapy and weekly cisplatin-based chemotherapy, is the standard of care. Treatment should begin within four weeks of the decision to treat.

All newly diagnosed women should be discussed at a multidisciplinary team meeting before treatment commences. Fertility, early menopause, and sexual function must be addressed at the treatment planning stage.

6. Pharmacology and AU PBS notes

Cisplatin (concurrent with radiation): given weekly at 40 mg/m2 during external beam radiotherapy for locally advanced disease. This is the standard sensitising agent and is not PBS-listed as a standalone cervical cancer indication but is funded through public hospital chemotherapy programs.

Pembrolizumab (anti-PD-1): approved by the Therapeutic Goods Administration (TGA) for persistent, recurrent, or metastatic cervical cancer with PD-L1 combined positive score 1 or higher. PBS-listed under Section 85 for this indication in combination with chemotherapy (paclitaxel plus cisplatin or carboplatin), with or without bevacizumab, for women with disease not amenable to curative treatment. PBS streamlined authority code applies; confirm current PBS schedule for exact code.

Bevacizumab (anti-VEGF): used in combination with chemotherapy for recurrent or metastatic disease. PBS-listed for this indication.

HPV vaccination: Gardasil 9 (9-valent HPV vaccine) is funded on the National Immunisation Program for males and females at age 12 to 13 years, with a catch-up schedule to age 26. Vaccination does not replace screening. AU brand name is Gardasil 9 (Merck Sharp and Dohme).

7. Complications and monitoring

Treatment complications:

Surgery: lymphoedema of the lower limbs, bladder dysfunction (urinary retention, urgency), ureteric injury, sexual dysfunction from shortened or scarred vagina, premature menopause if ovaries are removed.

Chemoradiation: acute effects include radiation proctitis, cystitis, fatigue, and myelosuppression from cisplatin. Late effects include bowel and bladder fibrosis, fistula formation (vesicovaginal or rectovaginal), lymphoedema, and vaginal stenosis requiring regular dilator use.

Post-treatment surveillance: there is no universal AU consensus on a single surveillance schedule, but the following is standard practice: clinical review (including examination) every three to four months for the first two years, every six months for years three to five, then annually thereafter. Vault smear or HPV testing is not routinely recommended post-hysterectomy unless the original indication was HSIL or cancer. Cross-sectional imaging is reserved for symptomatic recurrence or clinical concern rather than scheduled routine imaging. Women should be counselled on symptoms of recurrence (pelvic pain, haematuria, vaginal bleeding, leg swelling) and advised to present promptly. Psychosocial support and referral to allied health services for lymphoedema management, pelvic floor physiotherapy, and sexual health are integral components of the follow-up care plan.

Written for Australian practice and grounded in the guidance named above. Study material only — not medical advice. Always check against current guidelines.