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Cervical Cancer Screening in New South Wales

ANNUAL STATISTICAL REPORT 2005

Noore Alam, Clare Banks, Wendy Chen, Deborah Baker, Grace Kwaan, James Bishop

CERVICALSCREENING

NSW

PROGRAM

Cancer Institute NSW catalogue number:

SR-2008-01

National Library of Australia Cataloguing–in–Publication data:

Cervical Cancer in New South Wales: Annual Statistical

Report 2005

State Health Publication number: (CI) 080005

ISBN: 978-1-74187-190-6

Key words: Cervical Cancer, Cancer Incidence, Cancer

Mortality, Trends, Screening, Pap Test, Pap Test Register, New

South Wales, Australia.

Suggested citation:

Alam N, Banks C, Chen W, Baker D, Kwaan G, Bishop J.

Cervical Cancer Screening in New South Wales: Annual

Statistical Report 2005. Sydney:Cancer Institute NSW,

January 2008.

Published by the Cancer Institute NSW, February 2008.

Cancer Institute NSW

Level 1, Biomedical Building

Australian Technology Park

EVELEIGH NSW 2015

PO Box 41

Alexandria NSW 1435

Telephone (02) 8374 5600

Facsimile (02) 8374 5700

E–mail [email protected]

Homepage www.cancerinstitute.org.au

Copyright © Cancer Institute NSW February 2008.

This work is copyright. It may be reproduced in whole or

part for study or training purposes subject to the inclusion of

acknowledgement of the source. It may not be reproduced

for commercial usage or sale. Reproduction for purposes

other than those indicated above requires written permission

from the Cancer Institute NSW.

NSW Cervical Screening Program Staff

Manager Dr Robyn Godding

Project Offi cers Elvessa Marshall

NSW Pap Test Register Staff

Manager Dr Robyn Godding

Project Coordinator Lianne Fletcher

Data Manager Grace Kwaan

Assistant Data Manager Flora Ding

Data Offi cers Melanie Caballes

Jayne Court

Kathy Holm

Follow-up Coordinator Liping Qian

Ass’t Follow-up Coordinator Suzanne Voysey

Infoline Dianne Gallagher

Infoline / Follow-up Felicity Malouf

Administration / Infoline Maureen Allemann

Monitoring, Evaluation and Research Unit

Manager Deborah Baker

Senior Biostatistician Heather McElroy

Epidemiologists Dr Stephen Morrell

Noore Alam

Research Offi cer Clare Banks

Biostatisticians Wendy Chen

Former staff 2005

Dr Yeqin Zuo Manager, NSW Pap Test Register

Jayne Ross Manager, NSW Cervical Screening Program

Jane Macqueen Acting Manager – NSW CSP

Julianne O’Flynn Project Offi cer, NSW Pap Test Register

Nadine Ben-Mayor Data Offi cer, NSW PTR

1

Contents

List of tables and fi gures 2

Foreword from the Minister 5

Chief Cancer Offi cer’s report 6

Acknowledgements 7

Executive Summary 8

1. Introduction 11

2. Methods 13

3. Participation 15

3.1 Biennial participation rate 16

3.1.1 Biennial participation rate by Area Health Service 17

3.1.2 Trends in participation 19

3.1.3 Biennial participation rate by location 20

3.1.4 Biennial participation rate by NSW Local Government Area 21

3.1.5 Biennial participation rate by socioeconomic status (SES) 21

3.2 Triennial participation rate 23

3.2.1 Triennial participation rate by Area Health Service 23

4. Screening interval 24

5. Early re-screening 25

5.1 Early re-screening by Area Health Service 27

6. Screening results 28

6.1 Technically unsatisfactory Pap smear 28

6.1.1 Technically unsatisfactory Pap tests by Area Health Service 29

6.2 Endocervial component 30

6.3 Cytology results 32

6.3.1 Squamous cell codes 32

6.3.2 Human papilloma virus (HPV) 33

6.3.3 Endocervical cell 33

6.3.4 Other (non-cervical) cell 34

6.4 Histology results 34

6.4.1 Correlation between cytology and histology results 38

6.4.2 Histologically validated cytology results of CIN 2 or worse 36

6.4.3 Histologically validated CIN of any degree or worse 40

6.5 Low-grade and high-grade intraepithelial abnormalities reported by histology 42

6.5.1 Low-grade intraepithelial abnormalities 42

6.5.2 High-grade intraepithelial abnormalities 43

6.5.3 Ratio of low to high-grade intraepithelial abnormalities 43

6.6 Interval cancer 44

7. Screening recommendation 45

7.1 Reporting of recommendation codes 45

7.1.1 No management recommendation 45

7.1.2 Recommendation for colposcopy or specialist opinion 47

8. Incidence and mortality 49

8.1 Incidence 49

8.1.1 Age-specifi c incidence: 2003–2005 49

8.1.2 Secular trends in incidence 50

8.1.3 Incidence of micro-invasive and invasive cervical cancer 51

8.1.4 Age-specifi c incidence rates of cervical cancer by histological type 52

8.2 Mortality 54

8.2.1 Age-specifi c mortality from cervical cancer: 2003–2005 54

8.2.2 Secular trend in mortality 55

Appendixes 56

2

Cervical Cancer Screening in New South Wales: Annual Statistical Report 2005

List of tables and fi gures

Tables

Table 3.1

Participation in cervical screening, NSW, 2005 15

Table 3.2

Biennial cervical screening rates by fi ve-year age

group, NSW, 2004–2005 16

Table 3.3

Biennial cervical screening rates by NSW

Area Health Service and age, 2004–2005 18

Table 3.4

Biennial participation by areas of residence and

age, NSW, 2004–2005 20

Table 4.1

Participation of women in target age group

by screening interval, NSW 24

Table 5.1

Number and proportion of women with repeat

Pap tests within a two-year period, NSW, 2005 25

Table 5.2

Number and proportion (%) of women who had a

further Pap test in less than two years by age,

NSW, 2005 26

Table 6.1

Technically unsatisfactory Pap tests by Area

Health Service and age, NSW, 2005 29

Table 6.2

Number and proportion of technically satisfactory

smears containing an endocervical component by

age, NSW, 2005 30

Table 6.3

Technically satisfactory smears with an endocervical

component present by Area Health Service and age,

NSW, 2005 31

Table 6.4

Squamous cell codes, NSW, 2005 32

Table 6.5

Human papilloma virus tests, NSW, 2005 33

Table 6.6

Endocervical cell results, NSW, 2005 33

Table 6.7

Other (non-cervical) cell codes, NSW, 2005 34

Table 6.8

Cervical histology results, NSW, 2005 34

Table 6.9

Correlation between cytology and histology

results, NSW, 2005 35

Table 6.10

Histological confi rmation within six months of cytology

reports of CIN 2 or worse by age, NSW, 2005 37

Table 6.11


reports of CIN 2 or worse by Area Health Service,

NSW, 2005 38

Table 6.12


reports of CIN 2 or worse by laboratory location,

NSW, 2005 39

Table 6.13


reports of CIN of any degree or worse by age,

NSW, 2005 40

Table 6.14


reports of CIN of any degree or worse by Area Health

Service, NSW, 2005 41

Table 6.15

Histologically reported low-grade intraepithelial

abnormalities per 1,000 screened women by age,

NSW, 2005 42

Table 6.16

Histologically reported high-grade intraepithelial

abnormalities per 1,000 screened women by age,

NSW, 2005 43

Table 6.17

Ratio of histologically reported low-grade to high-grade

intraepithelial abnormalities by age, NSW, 2005 44

Table 7.1

Reporting of recommendation codes for NSW

women, 2005 45

Table 7.2

Number and proportion (%) of screened women whose

fi rst cytology reports contained no management

recommendation by age, NSW, 2005 46

Table 7.3

Number and proportion of women with no management

recommendation by laboratory location, 2005 46

Table 7.4

Recommendation for colposcopy or specialist opinion

by age, NSW, 2005 47

Table 7.5

Cytology reports with a recommendation for

colposcopy or specialist opinion by NSW Area

Health Service and age, 2005 48

Table 8.1

Number and mean age-specifi c incidence rates

of cervical cancer, NSW, 2003–2005 50

3

Table 8.2

Micro–invasive and invasive cervical cancer by

age, NSW, 2003–2005 51

Table 8.3

Number of new cases and mean age-specifi c

incidence rates of squamous cell carcinoma and

non-squamous cancer cases, NSW, 2003–2005 52

Table 8.4

Number of cervical cancer deaths and mean age-specifi c

mortality rates of cervical cancer, NSW, 2003–2005 55

Table A1

Number of women at risk of cervical cancer by age and

year, NSW, 2001–2005 62

Table A2

Proportion of women with an intact cervix,

NSW, 2005 62

Table A3

Target female population in NSW by remoteness

classifi cation and age 64

Table A4

Number and proportion (%) of women aged 20–69

years with initially negative test result who had a

repeat Pap test within two years by Area Health

Service, 2005 66

Table A5

Biennial screening rate by metropolitan Divisions

of General Practice and age, NSW 67

Table A6

Biennial screening rate by rural Divisions of

General Practice and age, NSW 68

Table A7

Biennial cervical screening by Area Health

Service and fi ve-year age group, NSW 69

Table A8

Biennial cervical screening rates (%) by age groups

(20–49, 50–69, 20–69), Area Health Service and Local

Government Area, NSW, 2004–2005 70

Table A9

Age-standardised incidence of cervical cancer,

NSW, 1972–2005 75

Table A10

Age-standardised mortality from cervical cancer,

NSW, 1972–2005 76

Table A11

Age-specifi c population estimates for NSW against

2001 standard Australian population 77

Table A12

Number and proportion of women of all ages screened

with age unknown, Area Health Service unknown and

opt-off rate, NSW, 2004–2005 78

Figures

Figure 3.1

Biennial (2004–2005) and triennial (2003–2005)

screening rates by age, NSW 17

Figure 3.2

Trends in biennial participation rates (%) by reporting

quarter, NSW, June 1998 December 2005 19

Figure 3.3

Biennial participation rates by area of residence,

NSW, 2004–2005 20

Figure 3.4

Biennial screening rates by quintile of socioeconomic

status (SES), NSW, 2004–2005 22

Figure 3.5

Biennial screening rates by quintile of socioeconomic

status (SES) in rural and urban NSW, 2004–2005 22

Figure 3.6

Triennial participation rates (%) by NSW Area Health

Services, 2003–2005 23

Figure 4.1

Participation rates by screening interval, NSW,

2001–2005 24

Figure 5.1

Proportion (%) of women who had early re-screens,

by Area Health Service and fi ve-year age group,

NSW, 2005 27

Figure 6.1

Proportion of technically unsatisfactory Pap smears

by age, NSW, 2005 28

Figure 8.1

Age-specifi c incidence of cervical cancer,

NSW, 2003–2005 49

Figure 8.2

Age standardised incidence of cervical cancer, NSW,

1972–2005 50

Figure 8.3

Mean age-specifi c incidence rates of micro-invasive

and invasive cervical cancer, NSW, 2003–2005 52

Figure 8.4

Age-standardised incidence of squamous and

non-squamous cervical cancer, NSW, 1972–2005 53

Figure 8.5

Mean age-specifi c mortality rates per 100,000 women,

NSW, 2003–2005 54

Figure 8.6

Age-standardised mortality rates per 100,000

population, NSW, 1972–2005 55

4


Abbreviations used in this report

ABS Australian Bureau of Statistics

ACT Australian Capital Territory

AHS Area Health Service

ARIA Accessibility/Remoteness Index of Australia

ASGC Australian Standard Geographic Classifi cation

CCR Central Cancer Registry, NSW

CI Confi dence interval

CIN Cervical Intra-epithelial Neoplasia

CME Continuous Medical Education

CSP Cervical Screening Program, NSW

DGP Division of General Practice

ERP Estimated Resident Population

GIN Glandular Intra-epithelial Neoplasia

GP General Practitioner

HPV Human papillomavirus

IUCD Intra-uterine Contraceptive Device

LGA Local Government Area

NATA National Association of Testing Authorities

NHMRC National Health and Medical Research Council

NOS Not Otherwise Specifi ed

NPAAC National Pathology Accreditation Advisory Council

NSW New South Wales

PTR NSW Pap Test Register

SCC Squamous Cell Carcinoma

SES Socioeconomic status

SNOMED Systematized Nomenclature of Medicine

VCCR Victorian Cervical Cytology Registry

WSAHS Western Sydney Area Health Service

For interpretation of the common terminology used in this report, refer to the Glossary in Appendix 1.

5

Foreword from the Minister

The NSW Government has made tackling cancer a top priority. NSW was the fi rst State to develop and implement a Cancer Plan and the fi rst State to create a dedicated, expert policy body to examine and refi ne our response

to the disease.

The Government is now delivering on its second Cancer Plan, with primary focus on prevention, ongoing training for health professionals, more effective treatments, cutting-edge research and the dissemination of vital information to the NSW community about cancer trends and priorities.

A vital part of the work the Government has requested from the Cancer Institute NSW is leadership of the State’s early detection programs, including central management of the NSW Cervical Screen Program and the Pap Test Register.

Cervical cancer is the leading cause of cancer death in women living in developing countries, however in NSW it ranks 15th. Early detection through regular Pap testing has saved the lives of thousands of Australian women, and continues to do so.

This report details the activity of the NSW Cervical Screening Program. The success of cervical screening in NSW is due to the dedicated efforts of Government, general practitioners, medical research and women, in united determination to wipe out cervical cancer altogether.

I commend this report to you.

The Hon. Verity Firth MP

Minister for WomenMinister for Science and Medical ResearchMinister Assisting the Minister Health (Cancer)Minister Assisting the Minister for Climate Change,Environment and Water (Environment)

6


Chief Cancer Offi cer’s report

Cervical cancer was the 15th most common cause of cancer mortality in NSW women in 2005, accounting for 75 deaths compared with 100 in 1991. Cervical screening, as a means of early detection of cervical cancer, has been a

very successful public health achievement in the modern era. It is estimated to be over 90% effective in preventing cases of cervical cancer in women.

In 1991, the Commonwealth Government, in conjunction with the States and Territories, established the Organised Approach to the Prevention of Cancer of the Cervix, later renamed as the National Cervical Screening Program in 1995. Nationally, since the inception of the organised approach to cervical screening in 1991, deaths from cervical cancer have fallen by approximately 61% in the target group of women aged 20–69 years.

Cervical Cancer Screening in New South Wales: Annual Statistical Report 2005 is a detailed report of cervical cancer in NSW. This report provides information on the number and rates of cervical screening in NSW, the new cases of cervical cancer and the deaths from cervical cancer.

This report demonstrates that there has been a continued progressive decline in the incidence and mortality of cervical cancer in women in NSW. The incidence and mortality reduction has been most pronounced in the past 10 years (1996–2005). During this period, age-standardised incidence of cervical cancer has fallen by 42% and mortality by 47%, coinciding with the establishment of the NSW Cervical Screening Program.

This report is a valuable source of information on cervical cancer screening for researchers, planners, academics, students and for the general public.

Professor James F Bishop MD MMED MBBS FRACP FRCPA

Chief Cancer Offi cer CEO, Cancer Institute NSW

7

Acknowledgements

This report was made possible through the collaboration of a number of individuals and institutions. They include: clinicians, general practitioners, hospital and clinic staff and pathologists. We would particularly like to thank the pathological laboratories in NSW, Victoria, ACT and Queensland for their collaboration with the NSW Cervical Screening Program and the NSW Pap Test Register in the reporting of pathological tests without which this report would not have been possible. Cervical screening data are supplied by the NSW Pap Test Register and the cervical cancer incidence and mortality data were obtained from the NSW Central Cancer Registry – both cancer registries are managed by the Cancer Institute NSW. All population data used in this report are from the Australian Bureau of Statistics via the Health Outcomes Information Statistical Toolkit (HOIST) operated by the NSW Department of Health. Hysterectomy data was obtained from the NSW Health Survey Program conducted by the NSW Department of Health.

We acknowledge the contributions of the staff members of the NSW Pap Test Register and the NSW Central Cancer Registry for supplying data for this report and assisting with comments on the draft report.

8


Biennial participation rates

In 2005, there were a total of 681,306 Pap tests registered with the NSW Pap Test Register (PTR). Of these, 641,932 Pap tests were in women aged 20–69 years. The overall biennial cervical screening rate for 2004–05 was 58.1% for the 20–69 year age group. This includes the recorded cervical screening rates for the 20–69 year age groups (57.1%), the opt-off rate (0.93%), and screens involving women of unknown age (0.08%). The highest screening rate (62.4%) was in the 45–49 year age group and the lowest (44.3%) in the 20–24 year age group (Table 3.2).

Spatial distribution

Biennial screening rates for the target age group were the highest (66.0%) in North Coast Area Health Service (AHS) and the lowest (53.1%) in Western Sydney AHS (Table 3.3). Of the six regional classifi cations, based on the population density and remoteness of locations, the highest biennial screening rate (59.6%) was observed in women living in the ‘inner regional’ areas and the lowest (41.9%) in ‘very remote’ areas (Figure 3.3, Table 3.4). Screening rates were generally higher in Northern NSW local government areas (LGA) and lower in Southern and Western LGAs with highest (75.3%) reported in Mosman LGA (Northern Sydney and Central Coast AHS) and lowest (15.2) in Conargo LGA (Greater Southern AHS).

Socioeconomic status (SES)

In New South Wales in 2005, the highest participation rate was observed in the highest socioeconomic quintile (62.8%) and the lowest screening rates reported in the most disadvantaged group (52.4%) (Figures 3.4 and 3.5). The trend of screening rates across the SES quintiles were not statistically signifi cantly different between NSW overall and Urban NSW (p>0.05). However, in all SES categories, there was a statistically signifi cant difference observed between NSW overall and rural NSW (p for trend p<0.05). Between rural and urban NSW, there was a statistically signifi cant difference observed in all SES categories (p=0.01).

Screening interval

In the fi ve-year period from 1 January 2001 to 31 December 2005, 1,578,662 women aged 20–69 years were screened at least once. This constitutes 84.5% of the total women in the target age group (average population in the fi ve-year period). Counting backward from 31 December 2005, the two-, three-, four- and fi ve-year screening rates were 57.1%, 70.0%, 77.6% and 84.5% respectively (Table 4.1, Figure 4.1).

Re-screening

The recommended screening interval is two years but some women received Pap tests earlier than this because of past history, or on advice from their doctor. In February 2005 (index month), there were 17,824 women (32.7%) aged 20–69 years who had one or more repeat tests after having a negative Pap test result in the preceding two-year period (Tables 5.1, 5.2).

Executive Summary

Participation rate

9

Unsatisfactory smears

During the 12-month reporting period of January–December 2005, the number of Pap tests reported as technically unsatisfactory was 14,367 (2.2%), well below the highest acceptable national standard (5%) (Figure 6.1 and Table 6.1).

Tests containing endocervical cells

In 2005, 84.2% of technically satisfactory Pap tests involving women aged 20–69 years contained an endocervical component. The proportion of technically satisfactory smears decreased with increasing age (Table 6.2).

Cytology and histology results

In 2005, there were a total of 618,763 (90.8%) Pap tests that reported no abnormal squamous cells present. Of the results that were reported as abnormal, 34,661 (5.1%) tests were reported as a squamous low-grade epithelial abnormality (CIN 1) in that period. The number of tests reported as squamous high-grade epithelial abnormality (CIN 2/3) was 5,297 (0.8%), and 3,305 (0.5%) tests were reported as inconclusive (Table 6.4). A total of 15,217 tests (2.2%) were reported as showing human papilloma virus (HPV) induced changes (Table 6.5).

In 2005, 25.7% of tests reporting a cytologically confi rmed low-grade result (CIN 1) with histology performed within six months had a high-grade epithelial abnormality (CIN 2 or CIN 3) on histology (Table 6.9). Of the 3,692 cytology reports of CIN 2 or worse in 2005, 74.7% were histologically confi rmed as a high-grade epithelial abnormality (>CIN2), with a positive predictive value (PPV) of 75.5% for the 20–49 year age group and 63.8% for the 50–69 year age group. Of them, 2.2% and 15.0% were cervical cancer detected by histology for 20–49 and 50–69 year age group respectively (Table 6.10).

Interval Cancer

Between 1 January 2003 and 31 December 2003, 578,146 women were screened with negative cytology. Of these, 38 were listed with the NSW CCR as having interval cervical cancer in 2005. The rate is 6.57 cases per 100,000 screen-negative women (section 6.6 Interval cancer).

Screening recommendation

The overall rate of screened women aged 20–69 year whose fi rst cytology report did not contain a management recommendation was 24.4, with the highest proportion in the 65–69 year age group (29.4%) (Table 7.2).

About 3% of screened women in the target age group had a fi rst cytology report containing a management recommendation for colposcopy or specialist opinion (Table 7.4).

Screening results

10


Incidence

There were a total of 715 new cases of cervical cancer reported in the three-year period 2003–2005, including 571 new cases in the target age group. In 2005, 208 new cases of cervical cancer were registered with the NSW CCR. Between 1972 and 2005, the age-standardised incidence rate of cervical cancer have fallen by 59.0%, from 16.6 new cases per 100,000 in 1972 to 5.8 per 100,000 in 2005. In the 10-year period 1996–2005, the age-standardised incidence rates fell by 41.6% (Figure 8.2).

Mortality

During the period 2003–2005, there were 230 deaths associated with cervical cancer in women of all ages recorded with the NSW CCR (Table 8.4). Between 1972 and 2005, age-standardised cervical cancer mortality rates have fallen by 69.6%; from 6.4 deaths per 100,000 in 1972 to 2.0 in 2005. During the period 1996–2005, the age-standardised mortality rates have dropped by 46.7% (Figure 8.6).

Incidence and mortality

11

The Program is committed to:

encouraging women aged 20–69 year to have biennial Pap tests ■

improving the reliability and accessibility of services for taking Pap tests ■

optimising the management of women with screen-detected abnormalities ■

improving monitoring and evaluation. ■

1. Introduction

1.1 NSW Cervical Screening Program

The NSW Cervical Screening Program (the ‘Program’) is a jointly funded Commonwealth/State and Territory initiative under the Public Health Outcomes Funding Agreement to implement the National Cervical Screening Policy in New South Wales (NSW). The Program is part of the National Cervical Screening Program. As such, it operates in NSW within the national cervical screening policies and guidelines. Until 2005, the Program was operating under the then Western Sydney Area Health Service. Since 1 July 2005, the Program has been managed by the Cancer Institute NSW, with an aim to implement an organised approach to cervical screening in NSW.

The goal of the Program is to reduce the incidence and mortality from cervical cancer at an acceptable cost to the community. The Program is committed to achieving a range of outcomes across the cervical screening pathway in NSW. The Program’s Strategic Plan 2000–20041 identifi ed fi ve key areas of activity as follows:

develop and implement strategies to recruit all women in the target age group of 20–69 year to undergo regular two- ▪yearly Pap tests, including provision of appropriate information and ensuring access to appropriate services

support General Practice (GP) structures and activities to facilitate the primary role of GPs in delivering acceptable Pap ▪test services to women

work with laboratories to optimise their role in cervical screening ▪

promote best clinical practice in cervical screening ▪

undertake ongoing operations-oriented research, monitoring and evaluation to support and guide the direction of the ▪Program.

In keeping with its commitment to ongoing monitoring and provision of accurate data to all relevant stakeholders along the screening pathway, the Program reports on key performance outcome measures in collaboration with the NSW Pap Test Register.

The Program is managed by the Cancer Institute NSW with an aim to implement an organised approach to cervical screening.

12


Key monitoring indicators: ■

1. Participation in screening.2. Screening interval.3. Re-screening.4. Screening results.5. Interval cancer.6. Screening recommendation.7. Incidence. 8. Mortality.

1.2 NSW Pap Test Register

The NSW Pap Test Register (‘PTR’ or the ‘Register’) was established in 1996. It is a central and confi dential database of NSW women’s Pap tests and cervical biopsy test results. It provides a follow-up and reminder service to women to encourage them to have regular Pap tests every two years, or as recommended by their doctors or nurses. PTR processes Pap tests and cervical histology tests results undertaken by pathological laboratories in NSW and some interstate laboratories located in areas bordering NSW. The PTR operates a free ‘Information Line’ (131 556), which provides information to the general public, women who have had Pap tests and health practitioners. Information provided includes Pap test and cervical biopsy history to assist in clinical management and answers to queries regarding the role of the PTR. Women also contact the ‘Information Line’ to provide details of change of name and/or address. The PTR is based in and managed by the Cancer Institute NSW.

1.3 Objectives

The purpose of this report is to illustrate the achievements made against the agreed performance measures derived from the operation of the Program during the year 2005. These measures are of interest to the managers of the Programs at the Cancer Institute NSW, State and Australian Government Health Departments, NSW Area Health Services (AHS), non-government organisations, universities and other research and teaching institutes, as well as health care professionals, community groups and women.

1.4 Monitoring indicators

This report presents information according to the eight indicators which measure the Program’s activities, performances and outcomes achieved during the reporting year (2005). These indicators were developed following development of the national cervical screening performance indicators and the national laboratory performance indicators (standards) with the aim to gauge changes in cervical cancer screening, incidence and mortality rates and, most importantly, the effects of cervical screening on the prevention or reduction of deaths attributed to cervical cancer.

13

2.1 Data sources

The primary sources of data for this report were NSW Pap Test Register (for screening data) and NSW Central Cancer Registry (for cancer incidence and mortality data). The proportion of women estimated to have undergone a full hysterectomy was derived from the 2004 NSW Population Health Survey conducted by the NSW Department of Health. Australian Bureau of Statistics (ABS) Estimated Resident Population (ERP) at 30 June 2005 was used as the denominator population.

2.2 Data analysis

For the calculation of rates, screening data with the corresponding population data were stratifi ed by age, Area Health Service, local government area and the areas under the Divisions of General Practice. NSW Area Health Service populations were derived by aggregating statistical local areas (ERP), using Area Health Service boundaries as at 1 January 2005. Screening rates were presented in percentage (%) and the cervical cancer incidence and mortality rates were presented in rates (crude and age-standardised) per 100,000 population with corresponding 95% confi dence interval (CI).

SAS for WindowsTM Version 9.12 and Epi InfoTM Version 3.4.13 was used for all data analysis and Microsoft Offi ce ExcelTM 20034 for the production of data tables and charts.

2.3 Reporting data

The target age group used in this report is women between the ages of 20 and 69 years. Populations in this age group were adjusted for the hysterectomy fraction by removing the women who have had a hysterectomy. The target population is presented in Table A1 and the proportion of women with an intact cervix in Table A2 in Appendix 3.

2.4 Reporting period

The reporting periods for the triennial and biennial participation rate are from 1 January 2003 to 31 December 2005, and from 1 January 2004 to 31 December 2005 respectively. For all other measures, the reporting period is from 1 January 2005 to 31 December 2005. For cervical cancer incidence and mortality data, the reporting period is 2003–2005 for cross-sectional data; and 1972–2005 and 1996–2005 for trend data.

In this report, February is used as the index month for measurement of re-screening rates. This is because February is considered as the most stable month in terms of the number of women screened. Also, this is the month with no public holidays gazetted in NSW.

2. Methods

The target age group is women between the ages of 20 and 69 years.

14


This report used the ‘Socioeconomic Index For Areas’ (SEIFA) developed by the ABS. The SEIFA consists of four indexes, one of which is the Index of Relative Socioeconomic Disadvantage that includes attributes such as low-income, low-educational attainment, high unemployment and people with low-skilled occupations. These attributes together refl ect or measure relative disadvantage of an area in NSW. Five categories of socioeconomic disadvantaged have been created to demonstrate cervical screening rates with ‘SES quintile 1’ being the least disadvantaged and ‘SES quintile 5’ is the most disadvantaged (Appendix 5).

A number of geographical classifi cations have been used in this report. These include Area Health Service (AHS), local government area (LGA) and remoteness classifi cation based on the Accessibility/Remoteness Index of Australia (ARIA), developed in 2001 by the National Key Centre for Social Applications of Geographical Information Systems (GISCA) at the University of Adelaide and is sponsored by the Commonwealth Department of Health and Ageing. Within each AHS, LGAs have been assigned to one of the fi ve area classifi cations (Appendix 5).

The boundaries for AHSs are derived from the local government area (LGA) boundaries produced by the Australian Bureau of Statistics and detailed in the 2005 Edition of the Australian Standard Geographical Classifi cation (ASGC). The screening rates were created by mapping LGAs into GP division boundaries (Appendix 7).

A number of Pap tests are conducted on women who do not consent to disclose personal details to the PTR. In other words, they chose to opt off the PTR. In 2005, the opt-off rate involving women age 20–69 was 0.93% (1.03% in all ages; Table A12). The calculation was based on pro-rating the number of tests on the PTR to the number of women on the PTR, and applying this ratio to the number of tests recorded without identifying information. Unless otherwise specifi ed, all analyses of screening data were based on the number of women on the PTR. Although small in numbers, the impact of ignoring the opt-off rate is to underestimate the true rate of women of all ages screened in NSW.

The method of calculating 95% confi dence intervals is described in Appendix 12. The main purpose of calculating confi dence intervals is to indicate the precision of screening rate estimates to aid interpretation of differences and trends. Non-overlapping confi dence intervals indicate signifi cant statistical differences, but overlapping confi dence intervals do not necessarily mean statistical non-signifi cance.

2.5 Socioeconomic status (SES)

2.6 Geographical classifi cation

2.7 Opt-off rate

2.8 95% Confi dence intervals

15

The most useful indicator to show the Program’s reach and effectiveness is the participation rate as it looks at women’s compliance with the Program’s policy. The National Cervical Screening Policy5 recommends that routine screening with Pap smears should be carried out every two years for women who have no symptoms or history suggestive of cervical abnormalities. Participation rates for different periods are reported for the following reasons:

Two-year: ▪ the recommended screening interval is two years, the key performance measure. A routine reminder is usually sent by the general practitioner at 24 months when a woman is due for their next Pap smear. A 27-month reminder letter is sent by the PTR and serves as a ‘safety net’ reminder for women who may not have received the general practitioner’s routine reminder or had forgotten about having their Pap test.

Three-year: ▪ three-year screening rates indicate whether these reminders are effective or not.

Four-year: ▪ to encourage women who have not had a Pap test for four years or longer the Federal Government introduced a Practice Incentive Payment (PIP) program paid to general practitioners. Four-yearly screening rates help gauge the effectiveness of the PIP.

Five-year: ▪ this tells about the participation of women prior to the possible development of cancer (usually 10 years).

The cytology test results (Pap tests) of all women in NSW are recorded on the NSW PTR database. The inclusion on the NSW PTR is voluntary. Those women who choose to opt-off the PTR remain on the PTR with identifying details excluded. In 2005, the opt-off rate for women within the target 20–69 year age group was 0.93%.

Table 3.1 Participation in cervical screening, NSW, 2005

*Women who opted-off the PTR were excluded.

3. Participation

In 2005, there were a total of 681,306 Pap tests on 650,756 women. Of these, 641,932 (94.2%) tests ■were in the target age group of 20–69 years. The overall biennial participation rate was 58.1%.

5,126 (0.8%) women were histologically detected with high-grade abnormalities, 208 new cases of ■cervical cancer were recorded compared with 329 in 1996 and there were 75 deaths in 2005 compared with 100 deaths in 1996.

Number of Pap tests Number of women

Total no.

of tests

Identifi ed

tests

(all ages)

De-identifi ed

tests (all ages)

Tests in

women aged

20–69 years

Women (all ages)

registered* with the

NSW PTR

Women aged 20–69

years registered with

the NSW PTR

681,306 675,032 6,274 641,932 650,756 614,304

The most useful indicator to show the Program’s reach and effectiveness is the participation rate.

16


3.1 Biennial participation rate

The overall biennial screening rate for 2004–2005 was 58.1% for the target (20–69 year) age group. This screening rate includes the recorded biennial screening rates for the 20–69 year age groups (57.1%), the opt-off rate (0.93%), and screens involving women of unknown age (0.08%).

Biennial cervical screening rates show the 20–49 year age group had higher screening rates than the 50–69 year age group, although this difference was not statistically signifi cant (p>0.05). The overall screening trend is similar for biennial and triennial screening intervals (Figure 3.1).

Age–group

(year)

No. of women

screened

Biennial cervical screening rate

Proportion (%) 95% CI

20–24 99,164 44.3 (44.1–44.5)

25–29 125,235 55.8 (55.6–56.0)

30–34 154,851 60.2 (60.0–60.4)

35–39 143,854 61.2 (61.0–61.4)

40–44 145,393 61.1 (60.9–61.3)

45–49 126,332 62.4 (62.2–62.6)

50–54 104,000 57.5 (57.3–57.8)

55–59 84,233 57.9 (57.7–58.2)

60–64 57,298 55.3 (55.0–55.6)

65–69 39,676 48.5 (48.2–48.9)

20–49 794,829 57.5 (57.5–57.6)

50–69 285,207 55.8 (55.6–55.9)

20–69 1,080,036 57.1 (57.0–57.1)

Notes:

The data exclude women who opted off the NSW Pap Test Register (0.93%) and those with unknown age (0.08%).1.

Women who had an address outside NSW were excluded.2.

Participation rates have been adjusted for the estimated proportion of NSW women who have had a hysterectomy.3.

Biennial screening rates:

57.1% for the target 20–69 year age group ■

highest (62.4%) in ages 45–49 ■

lowest (44.3%) in ages 20–24. ■

Table 3.2 Biennial cervical screening rates by fi ve-year age group, NSW, 2004–2005

17

Figure 3.1 Biennial (2004–2005) and triennial (2003–2005) screening rates by age, NSW

Notes:

1. The data exclude women who opted off the NSW Pap Test Register (0.93%) and those with unknown age (0.08%).

2. Women who had an address outside NSW were excluded.

3. Participation rates have been adjusted for the estimated proportion of NSW women who have had a hysterectomy.

0

20

40

60

80

100

20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69

Age-group (year)

Scre

enin

g ra

te (

%)

Biennial Triennial

3.1.1 Biennial participation rate by Area Health Service

Biennial cervical screening rates in the target age group by the Area Health Services (AHS) across NSW ranged from 66.0% (North Coast AHS) to 53.1 (Sydney West AHS). Screening rates were highest in North Coast AHS for both 20–49 and 50–69 year age groups (66.8% and 64.3% respectively), followed by Hunter and New England AHS for 20–49 year age group (61.5%). For the 50–69 year age group, Northern Sydney and Central Coast AHS had the second highest biennial screening rates (60.1%) after North Coast AHS. Screening rates were lowest in Sydney West AHS for the 20–49 year olds (52.1%) and Sydney South West AHS for the 50–69 year olds (51.2%).

Higher screening rates were observed along the eastern seaboard and greater southern hinterland. The rates tended to decrease with distance from the coast. It is not clear whether the accessibility to the services, knowledge of the Program, or other barriers are operating to create this pattern.

Comparison of biennial screening rates by AHS is important as this helps identify locations where screening activity may not be at target levels and therefore may require intervention such as promotional activities.

18


Tabl

e 3.

3 B

ienn

ial c

ervi

cal s

cree

ning

rat

es b

y N

SW A

rea

Hea

lth

Serv

ice* a

nd a

ge, 2

004–

2005

Note

s:

1. T

he

dat

a excl

ude

wo

men w

ho o

pte

d o

ff t

he

NSW

Pap

Test

Regi

ster

(0.9

3%

) an

d t

hose

with u

nkn

ow

n a

ge (

0.0

8%

).

2. P

artici

pat

ion r

ates

hav

e been a

dju

sted fo

r th

e est

imat

ed p

ropo

rtio

n o

f N

SW

wo

men w

ho h

ave

had

a h

yste

rect

om

y.

3. W

om

en w

hose

AH

S w

ere

not

avai

lable

may

incl

ude

inte

rsta

te w

om

en.

*N

SW

Are

a H

eal

th S

erv

ices

bo

undar

y as

of 1 Jan

uar

y 2005.

Are

a H

ealt

h S

erv

ice

20–49 y

ears

50–69 y

ears

20–69 y

ears

Wo

men

Scre

en

ed

Bie

nn

ial ra

te (

%)

(95%

CI)

Wo

men

Scre

en

ed

Bie

nn

ial ra

te (

%)

(95%

CI)

Wo

men

Scre

en

ed

Bie

nn

ial ra

te (

%)

(95%

CI)

Gre

ater

South

ern

49,7

02

60.0

(59.6

–60.3

)20,8

65

55.3

(54.8

–55.8

)70,5

67

58.5

(58.2

–58.8

)

Gre

ater

Wes

tern

29,5

41

53.4

(52.9

–53.8

)11,9

15

51.3

(54.2

–53.5

)41,4

56

53.6

(53.2

–53.9

)

Hunte

r &

New

Engl

and

91,3

96

61.5

(61.3

–61.8

)35,9

92

55.2

(54.8

–55.6

)127,3

88

59.6

(59.4

–59.8

)

Nort

h C

oas

t51,4

23

66.8

(66.4

–67.1

)23,5

94

64.3

(63.8

–64.8

)75,0

17

66.0

(65.7

–66.3

)

Nort

her

n S

ydney

&

Cen

tral

Coas

t142,1

14

60.3

(60.1

–60.5

)54,9

10

60.1

(59.8

–60.4

)197,0

24

60.2

(60.1

–60.4

)

South

Eas

tern

Syd

ney

& Illa

war

ra

145,8

03

58.0

(57.8

–58.2

)49,7

60

53.4

(53.1

–53.7

)195,5

63

56.8

(56.6

–57.0

)

Sydney

South

Wes

t161,7

84

54.5

(54.3

–54.6

)48,3

46

51.2

(50.9

–51.5

)210,1

30

53.7

(53.5

–53.8

)

Sydney

Wes

t121,5

12

52.1

(51.8

–52.3

)39,3

00

56.4

(56.0

–56.8

)160,8

12

53.1

(52.9

–53.2

)

AH

S not

avai

lable

9,5

26

3,3

52

12,8

78

NS

W802,8

01

58.1

(58.1

–58.2

)288,0

34

56.4

(56.3

–56.6

)1,0

90,8

35

57.7

(57.6

–57.7

)

19

45

47

49

51

53

55

57

59

61

63

65

Jun-

98

Oct

-98

Feb-

99

Jun-

99

Oct

-99

Feb-

00

Jun-

00

Oct

-00

Feb-

01

Jun-

01

Oct

-01

Feb-

02

Jun-

02

Oct

-02

Feb-

03

Jun-

03

Oct

-03

Feb-

04

Jun-

04

Oct

-04

Feb-

05

Jun-

05

Oct

-05

Reporting quarter

Scre

enin

g R

ate

(%)

20-49 50-69 20-69

Biennial screening rates, by rolling quarters, increased by 2.5%. ■

Screening trends vary by age. ■

3.1.2 Trends in participation

The overall biennial screening rates for the 20–69 year age group, based on rolling quarters, increased by 2.5% from 56.3% in June 1998 to 57.7% in December 2005. However, there was an opposite trend in screening rates observed between the 20–49 and 50–69 year age groups, with the 20–49 year group showing a decrease in rates while the 50–69 years group showing an increase in rates. For the target age group, biennial screening rates over the rolling quarters reached a peak of 59.8% in October 1999.

Figure 3.2 Trends in biennial participation rates (%) by reporting quarter, NSW, June 1998–December 2005

20


3.1.3 Biennial participation rate by location

Six regional classifi cations were made based on the population density and remoteness of locations (for further description see Appendix 5, Table A3, and for breakdown by NSW LGA see Appendix 7). These classifi cations are: ‘major city’, ‘inner regional’, ‘outer regional’, ‘remote’, ‘very remote’ and ‘not known’. For the target age group, the ‘inner regional’ had the highest screening rates (59.6%) of all other areas and NSW overall (57.6%). ‘Inner regional’ had the highest screening rates in all age groups in contrast with the ‘very remote’ being the lowest screening rates in all age groups (Figure 3.3 and Table 3.4).

Women aged 20–69 years living in the inner regional centres had the highest screening rates (59.6%) ■compared with those living in the very remote region (41.9%).

Figure 3.3 Biennial participation rates by area of residence, NSW, 2004–2005

Table 3.4 Biennial participation by areas of residence and age, NSW, 2004–2005

*Due to the changes in regional classifi cations from the ‘Rural/Remoteness Classifi cations’ used in the previous (2004) reports to ‘ARIA’, there were 12,878 (1.2%) women who could not be allocated to a region because, ‘ARIA’ was based on 2001 LGAs, whereas, the PTR screening data were based on 2005 LGAs.

0 10 20 30 40 50 60 70

Very Remote

Remote

Major City

Outer Regional

Not Known

Inner Regional

Screening rate (%)

Region

20–49 years 50–69 years 20–69 years

Women

screened

Biennial rate

(%)

(95% CI)

Women

screened

Biennial rate

(%)

(95% CI)

Women

screened

Biennial rate

(%)

(95% CI)

Major City 456,786 55.7 (55.6–55.9) 144,451 54.9 (54.7–55.1) 601,237 55.5 (55.5–55.6)

Inner Regional 260,636 60.6 (60.5–60.8) 104,908 57.1 (56.9–57.3) 365,544 59.6 (59.4–59.7)

Outer Regional 52,555 58.2 (57.9–58.5) 25,199 54.9 (54.4–55.4) 77,754 57.1 (56.8–57.3)

Remote 6,007 50.0 (49.1–50.9) 2,421 51.0 (49.6–52.4) 8,428 50.3 (49.6–51.1)

Very Remote 1,169 41.0 (39.2–42.8) 396 45.0 (41.7–48.2) 1,565 41.9 (40.3–43.5)

Not Known 16,122 60.2 (50.6–60.8) 7,307 56.3 (55.4–57.1) 23,429 58.9 (58.4–59.4)*Region could not

be allocated9,526 3,352 12,878

NSW 802,801 58.1 (58.0–58.2) 288,034 56.4 (56.2–56.5) 1,090,83557.7

(57.6–57.7)

21

3.1.4 Biennial participation rate by NSW local government area

Biennial cervical screening rates by NSW LGA can be used as an aid to focus future localised promotional activities within each Area Health Service as well as a useful comparison between Area Health Services.

LGAs with screening rates below 50% were: Gland, Conargo, Jerilderie, Junee, Wakool and Snowy River (Greater Southern AHS), Bogan, Bourke, Brewarrina, Central Darling, Cobar, Gilgandra, Lachlan, Walgett, Warren and Wentworth (Greater Western AHS), Moree Plains and Tenterfi eld (Hunter & New England AHS), Campbelltown and Liverpool (Sydney South West AHS) and Blacktown and Parramatta (Sydney West AHS).

LGAs that had screening rates exceeding 70% were Deniliquin & Urana (Greater Southern AHS), Walcha and Glen Innes (Hunter & New England AHS), Byron (North Coast AHS), Mosman (Northern Sydney & Central Coast AHS), Woolahra (South Eastern Sydney & Illawarra AHS). For further details of biennial cervical screening rates for all local government areas of NSW, refer to Appendix 7 (Table A8).

3.1.5 Biennial participation rate by socioeconomic status (SES)

In urban NSW, screening rates ranged from 62.8% for SES quintile 1 to 50.6% in SES quintile 5. In rural NSW, the screening rates were mixed with highest being in SES quintile 1 (62.5%) and the lowest being in SES quintile 3 (53.4%) (Figures 3.4 and 3.5). The trend of screening rates across the SES quintiles were very similar for NSW overall and Urban NSW and were not statistically signifi cantly different (p>0.05). However, in all SES categories, there was a statistically signifi cant difference observed between NSW overall and rural NSW (p for trend p<0.05). Between rural and urban NSW, there was a statistically signifi cant difference observed in all SES categories (p=0.01).

Biennial screening rates:

highest (75.3%) in Mosman (Northern Sydney & Central Coast AHS) ■

lowest (15.2%) in Conargo (Greater Southern AHS) ■

seven LGAs had screening rates >70% ■

23 LGAs had screening rates <50% ■

screening rates were generally higher in Northern NSW LGAs and lower in Greater Southern and ■Greatern Western LGAs

screening rates varied by SES ■

highest screening rate in the least disadvantaged (62.8%) ■

lowest screening rate in the most disadvantaged group (52.4%). ■

22


Figure 3.4 Biennial screening rates by quintile of socioeconomic status (SES), NSW, 2004–2005

Figure 3.5 Biennial screening rates by quintile of socioeconomic status (SES) in rural and urban NSW, 2004–2005

0 20 40 60 80 100

5

4

3

2

1

SES

quin

tile

Screening rate (%)

Most disadvantaged

Least disadvantaged

0 20 40 60 80 100

5

4

3

2

1

SES

quin

tile

Screening rate (%)

Rural Urban

Least disadvantaged

Most disadvantaged

It is worth noting that women living in rural areas and who are in the most disadvantaged quintile had screening rates very similar to women living in the least disadvantaged rural and urban areas. Similarly, the screening rates in the second most and most disadvantaged groups are higher in rural than urban groups and also higher than the second and third least disadvantaged. This may suggest that SES status is less important for accessing screening services in rural areas.

23

Triennial participation rate was 70.0% (95% CI: 70.0–70.1) for the 20–69 year age group. The highest triennial screening rate for the reporting period of 2003–2005 was observed in the 30–34 year age group (75.8%), and the lowest in the 65–69 year age group (55.2%). The rates were slightly higher but not statistically signifi cantly different for the 20–49 year age group (72.3%) compared to the 50–69 year age group (71.0%).

3.2.1 Triennial participation rate by Area Health Service

North Coast AHS had the highest screening rate (76.7%, 95% CI: 76.4%–76.9%) in the target age group. There was no statistically signifi cant linear trend observed in the screening rates across the geographical differences of the AHSs compared to the overall NSW screening rate (χ23.65, p for trend: 0.06).

Figure 3.6 Triennial participation rates (%) by NSW Area Health Services, 2003–2005

58.0 60.0 62.0 64.0 66.0 68.0 70.0 72.0 74.0 76.0 78.0

Sydney West

Sydney South West

SE Sydney & Illawarra

NSW

N Sydney & C Coast

North Coast

Hunter & New England

Greater Western

Greater Southern

NSW

Are

a H

ealt

h Se

rvic

es

Screening rate (%)

3.2 Triennial participation rate

24


Table 4.1 Participation of women in target age group by screening interval, NSW

Figure 4.1 Participation rates by screening interval, NSW, 2001–2005

†Average population in the fi ve-year period.

4. Screening interval

IntervalNo. of women screened at least

once during screening interval

Proportion (%) of

eligible women screened

Five-year (1 January 2001–31 December 2005) 1,578,662 84.5

Four-year (1 January 2002–31 December 2005) 1,456,641 77.6

Three-year (1 January 2003–31 December 2005) 1,310,381 69.2

Two-year (1 January 2004–31 December 2005) 1,080,036 57.1

0

20

40

60

80

100

20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69

Age group (year)

Scre

enin

g ra

te (

%)

Biennial Triennial Four yearly Five yearly

In NSW, in the fi ve-year period from 1 January 2001 to 31 December 2005, 1,578,662 women aged 20–69 years were screened at least once. This constitutes 84.5% of the total women† in the target age group. The longer interval screening rates indicate that a high proportion of women are being screened (Table 4.1, Figure 4.1). However, this should be interpreted with caution, as the number of women screened in a given interval (one–fi ve years) may overestimate the true number due to double counting. This can occur when women change their names and addresses between one test and the next despite rigorous quality assurance to remove duplicate records. The proportion of duplicate records is unknown; however, the longer the interval, the higher the degree of over-estimation.

From 1 January 2001 to 31 December 2005, 1,578,662 women aged 20–69 years were screened at least once.

25

The Australian National Cervical Screening Program policy recommends biennial cervical screening. However, many women screen more frequently than this with the main reason being a prior abnormal Pap test. Under the PTR follow-up protocols for the reporting period (before the NHMRC Guidelines 2005 were implemented in NSW), once a woman has had an abnormal result of CIN 1 or higher, she would stay on yearly screens until she turns 70, even though she had two or more normal Pap smears after the CIN 1 or higher results.‡ Also, if a woman has a histologically proven high-grade abnormality, then annual screening is recommended for her.

Another possible reason for women having a second Pap test in less than a two-year period may be that some women attend their doctor a little earlier for their repeat two-yearly tests because the date is more suitable for them. Also, early re-screening is often prompted by the perception of some medical practitioners who consider a smear sample without an endocervical component as an unsatisfactory smear and therefore recommend a repeat test earlier than the normal two-year interval.6

In February 2005, there were 17,824 women aged 20–69 years who had one or more repeat tests after having a negative Pap test result within the preceding two-year period.

Table 5.1 Number and proportion of women with repeat Pap tests* within a two-year period, NSW, 2005

*Women with a negative test in the index period (1 February 2005–28 February 2005).

5. Early re-screening

In 2005, the rates of re-screening earlier than the two-year period were slightly higher in the younger ■women aged <50 years compared to the older women aged 50> years (33.4% compared to 31.5%).

Number of further tests Number of women screened Proportion (%) of women screened

0 36,666 67.3

1 15,164 27.8

2 2,284 4.2

3 295 0.5

4 72 0.1

>5 9 <0.01

Total 54,490 100

Early re-screening refl ects both legitimate screening and some unnecessary screening.‡This information is correct according to the PTR protocols for the reporting

period. However, under the NHMRC guidelines (2005), effective from 1 July 2006, women with low–grade or possible low-grade Pap smear should have two negative Pap smears 12 months apart following their abnormal Pap smears, upon which they will be on normal biennial screening.

26


Table 5.2 Number and proportion (%) of women* who had a further Pap test in less than two years by age, NSW, 2005

*Women screened initially in February 2005 with a negative cytology result were included. Women with a negative cytology result with a recorded history of CIN were excluded.

Age group

(year)

No. of women with

initial negative test

results

No further tests One further test >1 further test

Number of women

(%)

Number of women

(%)

Number of women

(%)

20–24 4,263 3,026 (71.0) 1,014 (23.8) 223 (5.2)

25–29 6,050 4,085 (67.5) 1,611 (26.6) 354 (5.9)

30–34 7,744 5,092 (65.8) 2,240 (28.9) 412 (5.3)

35–39 7,409 4,799 (64.8) 2,235 (30.2) 375 (5.1)

40–44 7,554 5,002 (66.2) 2,194 (29.0) 358 (4.7)

45–49 6,406 4,233 (66.1) 1,839 (28.7) 334 (5.2)

50–54 5,252 3,437 (65.4) 1,590 (30.3) 225 (4.3)

55–59 4,113 2,785 (67.7) 1,147 (27.9) 181 (4.4)

60–64 2,810 1,979 (70.4) 728 (25.9) 103 (3.7)

65–69 1,982 1,500 (75.7) 425 (21.4) 57 (2.9)

20–49 39,426 26,237(66.5) 11,133 (28.2) 2,056 (5.2)

50–69 14,157 9,701 (68.5) 3,890 (27.5) 566 (4.0)

20–69 53,583 35,938 (67.1) 15,023 (28.0) 2,622 (4.9)

Younger women, aged 25–29 years, are identifi ed as having the most (5.9%) short-interval re-screening (more than one further test within a two-year period) followed by those in the 30–34 year age group (5.3%). The rate was lowest in the 65–69 year age group (2.9%).

The proportion of women who initially screened negative who had one or more further tests within two years was highest in women aged 35–39 years (35.3%), and lowest in women aged 65–69 years (24.3%).

One explanation for more re-screening in younger women may be due to the perception held by some GPs that younger women have higher rates of abnormality.7 Also, some women are advised by their GPs to re-screen within three months of a negative result because the initial smear sample lacked an endocervical component.6

27

5.1 Early re-screening by Area Health Service

Early re-screening rates were generally higher in Sydney metropolitan areas. The highest rates were observed in Northern Sydney & Central Coast AHS and South Eastern Sydney & Illawarra AHS followed by Sydney South West AHS, and the lowest rate was in Greater Western AHS. In the 20–49 year age group the early re–screening rate was highest in Northern Sydney & Central Coast AHS (Figure 5.1, Table A8 in Appendix 7). Variation across Area Health Services may be infl uenced by a number of factors, including those which have previously been discussed. There is evidence that variation may arise largely from service providers. Reasons include continued annual screening by some service providers, or as a result of timing in the distribution of reminder letters.6

Figure 5.1 Proportion (%) of women* who had early re–screens#, by Area Health Service and fi ve-year age group, NSW, 2005

*Women screen initially in February 2005 with a negative cytology result.

#Excluding women with negative cytology result with recommendation to screen in less than two years or with a history of CIN.

0 5 10 15 20 25 30 35 40

Sydney West

Sydney South West

South Eastern Sydney & Illawarra

Northern Sydney & Central Coast

North Coast

Hunter & New England

Greater Western

Greater Southern

Are

a H

ealth

Serv

ice

Early re-screening rate (%)

20-4950-6920-69

28


6. Screening results

Conventional cervical cytology is the most widely used cervical screening test to detect abnormal cervical cells. Accurate diagnosis of cervical lesions requires concordance of all three elements of the assessment process, namely cytology from the Pap smear, visualisation of the cervix by colposcopy, and histology from a cervical biopsy.

6.1 Technically unsatisfactory Pap smear

Although the simple and inexpensive cervical cytology test method has played a central role in the dramatic decline in cervical cancer incidence, the technique is not always performed to a satisfactory standard. This may be due to physical diffi culties relating to the patient, the inability of the clinician to perform the test, or the patient’s young age. During 2005 there were 641,932 Pap tests involving women aged 20–69 years recorded on the NSW PTR. Of these, 14,367 (2.2%) were reported as being technically unsatisfactory for cytological diagnosis. This rate is below the recommended benchmark set by the National Association of Testing Authorities (NATA) of up to 5% of all cervical cytology tests reported as technically unsatisfactory by any one laboratory.8 On detection of a technically unsatisfactory smear, the pathology laboratory concerned usually advises the clinician to re-perform the test.

In 2005, the proportion of Pap tests reported as technically unsatisfactory was highest for women aged 20–24 years (2.5%) and lowest for women aged 40–49 years (1.96%) (Figure 6.1). Technically unsatisfactory smears are important factors to monitor because they demonstrate whether there is a need for better training of clinicians to ensure that adequate samples are taken and the techniques used in smear taking are appropriate, in order to reduce the need for re-screening.

Figure 6.1 Proportion of technically unsatisfactory Pap smears by age, NSW, 2005

1.9

2.0

2.1

2.2

2.3

2.4

2.5

2.6

20 - 24 25 - 29 30 - 34 35 - 39 40 - 44 45 - 49 50 - 54 55 - 59 60 - 64 65 - 69

Age group (year)

Prop

ortio

n (%

) of s

mea

rs

In 2005, NSW had a signifi cantly lower rate of technically unsatisfactory Pap smears (2.2%) ■compared with the maximum allowable level (up to 5%).

A range of factors is involved in obtaining cervical screening results, including technical accuracy and a variety of pathology testing.

29

Area

Health Service

Age 20–49 years Age 50–69 years Age 20–69 years

No. of

smears

No. of

technically

unsatisfactory

Pap tests (%)

No. of

smears

No. of

technically

unsatisfactory

smear (%)

No. of

smears

No. of

technically

unsatisfactory

smear (%)

Greater Southern 28,519 633 (2.2) 11,723 281 (2.4) 40,242 914 (2.3)

Greater Western 17,076 567 (3.3) 6,827 222 (3.3) 23,903 789 (3.3)

Hunter & New England 53,704 1,295 (2.4) 20,494 522 (2.5) 74,198 1,817 (2.4)

North Coast 29,682 560 (1.9) 13,522 303 (2.2) 43,204 863 (2.0)

Northern Sydney &

Central Coast 85,071 1,458 (1.7) 32,651 633 (1.9) 117,722 2,091 (1.8)

South Eastern Sydney

& Illawarra87,885 1,509 (1.7) 29,182 495 (1.7) 117,067 2,004 (1.7)

Sydney South West 97,864 2,588 (2.6) 29,119 762 (2.6) 126,983 3,350 (2.6)

Sydney West 71,361 1,837 (2.6) 22,907 481 (2.1) 94,268 2,318 (2.5)

AHS Not Available 5,064 76 (1.5) 1,529 26 (1.7) 6,593 102 (1.5)

Non-identifi ed tests 4,518 93 (2.1) 814 26 (3.2) 5,332 119 (2.2)

TOTAL 480,744 10,616 (2.2) 169,012 3,751 (2.2) 649,756 14,367 (2.2)

6.1.1 Technically unsatisfactory Pap tests by Area Health Service

There was some variation observed in the rates of technically unsatisfactory Pap tests across the Area Health Services. In the 20–69 year age group, the proportion of Pap tests reported as technically unsatisfactory was highest in the Greater Western Area Health Service (3.3%), and lowest in the South Eastern Sydney & Illawarra Area Health Service (1.7%) (Table 6.1). The variation across the Area Health Services may be due to the presence of one or more of the factors associated with ‘technically unsatisfactory’ tests (staff skills, techniques used in smear taking, women’s age). The Program monitors those factors and undertakes appropriate actions which include GP training in order to reduce the rate of technically unsatisfactory smears.

Table 6.1 Technically unsatisfactory Pap tests by Area Health Service and age, NSW, 2005

30


6.2 Endocervial component

The success of the cervical screening program depends on high-quality smears. The presence of endocervical cells collected in the smear samples is regarded as an indicator of the quality of smear taking, although the lack of an endocervical component does not necessarily indicate inappropriate sampling.8,9 It is often diffi cult to obtain an endocervical component in older women because of the diffi culty in reaching and thus sampling the transformation zone cells. Generally, 80–85% of Pap smears are expected to contain endocervical cells.

The trend of decreasing proportion of technically satisfactory smears containing an endocervical component with increasing age was statistically signifi cant (p<0.0001). Although the absence of endocervical cells does not constitute suffi cient grounds to report a specimen as unsatisfactory for reporting, the situation often prompts pathologists to suggest repeat Pap smears involving additional cost to the health care system.8 The performance of both clinicians and pathologists is therefore important in Pap test screening practice. The Program strives to increase the performance of clinicians and pathologists in quality smear taking and reading through training and provision of information.

In 2005, the proportion of technically satisfactory smears containing an endocervical component was highest in the Sydney West AHS (86.1%) and lowest in the Greater Southern AHS (81.9%). The proportion of technically satisfactory smears containing an endocervical component across all Area Health Services was signifi cantly heterogeneous (p<0.001).

Table 6.2 Number and proportion of technically satisfactory smears containing an endocervical component by age, NSW, 2005

Age group (year) No. of technically satisfactory smears Smears with an endocervical component (%)

20–24 59,510 51,632 (86.8)

25–29 74,553 65,038 (87.2)

30–34 92,229 80,652 (87.4)

35–39 84,933 74,057 (87.2)

40–44 84,754 72,839 (85.9)

45–49 74,149 62,094 (83.7)

50–54 60,724 49,194 (81.0)

55–59 48,937 38,105 (77.9)

60–64 33,129 24,858 (75.0)

65–69 22,470 16,362 (72.8)

20–49 470,128 406,312 (86.4)

50–69 165,260 128,519 (77.8)

20–69 635,388 534,831 (84.2)

In 2005, 84.2% of technically satisfactory Pap smears involving women aged 20–69 year ■contained an endocervical component.

31

Tabl

e 6.

3 Te

chni

cally

sat

isfa

ctor

y sm

ears

wit

h an

end

ocer

vica

l com

pone

nt p

rese

nt b

y A

rea

Hea

lth

Serv

ice

and

age,

NSW

, 200

5

A

ge 2

0–49 y

ears

Age 5

0–69 y

ears

Age 2

0–69 y

ears

Are

a H

ealt

h S

erv

ice

No

. of

tech

nic

ally

sati

sfacto

ry s

mears

No

. of

smears

wit

h

en

do

cerv

ical

co

mp

on

en

t

pre

sen

t (%

)

No

. of

tech

nic

ally

sati

sfacto

ry s

mears

No

. of

smears

wit

h

en

do

cerv

ical

co

mp

on

en

t

pre

sen

t (%

)

No

. of

tech

nic

ally

sati

sfacto

ry

smears

No

. of

smears

wit

h

en

do

cerv

ical

co

mp

on

en

t p

rese

nt

(%)

Gre

ater

South

ern

27,8

86

23,5

15 (

84.3

)11,4

42

8,6

76 (

75.8

)39,3

28

32,1

91 (

81.9

)

Gre

ater

Wes

tern

16,5

09

14,0

20 (

84.9

)6,6

05

5,2

45 (

79.4

)23,1

14

19,2

65 (

83.3

)

Hunte

r &

New

Engl

and

52,4

10

44,2

56 (

84.4

)19,9

72

15,4

98 (

77.6

)72,3

82

59,7

54 (

82.6

)

Nort

h C

oas

t29,1

22

24,8

07 (

85.2

)13,2

19

10,0

67 (

76.2

)42,3

41

34,8

74 (

82.4

)

Nort

her

n S

ydney

& C

entr

al

Coas

t83,6

12

72,7

23 (

87.0

)32,0

17

25,1

48 (

78.5

)115,6

29

97,1

58 (

84.6

)

South

Eas

tern

Syd

ney

&

Illa w

arra

86,2

98

74,9

04 (

86.8

)28,7

17

22,2

54 (

77.5

)115,0

15

97,1

58 (

84.5

)

Sydney

South

Wes

t95,3

55

82,6

81 (

86.7

)28,3

27

21,7

22 (

76.7

)123,6

82

104,4

03 (

84.4

)

Sydney

Wes

t69,5

23

61,2

23 (

88.1

)22,4

26

17,9

44 (

80.0

)91,9

49

79,1

67 (

86.1

)

AH

S N

ot A

vaila

ble

4,9

88

4,2

78 (

85.8

)1,7

47

1,3

82 (

79.1

)6,7

35

5,6

60 (

84.0

)

Non–id

entifi e

d t

ests

4,4

25

3,9

05 (

88.2

)788

583 (

74.0

)5,2

13

4,4

88 (

86.1

)

To

tal

470,1

28

406,3

12 (

86.4

)165,2

60

128,5

19 (

77.8

)635,3

88

534,8

31 (

84.2

)

32


6.3 Cytology results

All Pap test results are coded by the laboratories completing the tests following the PTR’s Cytology Codifi cation Scheme derived from the NHMRC Guidelines 1994. Cytology reports are coded into the following fi ve categories:

squamous cell code ▪

human papilloma virus (HPV) code ▪

endocervical cell code ▪

other (non-cervical) cell code ▪

recommendation code (for the management of women with abnormal results). ▪

6.3.1 Squamous cell codes

Under the NHMRC Guidelines 1994, cytology reports are coded with one of the 11 possible squamous cell codes. In 2005, there were 15,221 smears (2.2%) reported as ‘unsatisfactory’. About 5% was reported as ‘low-grade squamous epithelial abnormality’ (less than CIN 2), and 0.8% as ‘high-grade squamous epithelial abnormality’ (CIN 2 or higher) (Table 6.4).

Result category – squamous cell codes No. of tests Percentage (%)

Unsatisfactory 15,221 2.2

No abnormal squamous cells 618,763 90.8*

Minor reactive and infl ammatory changes 3,814 0.6

Low–grade squamous epithelial abnormality

Mild atypia 27,867 4.1

Mild Dysplasia (CIN 1) 6,794 1.0

High–grade squamous epithelial abnormality

Moderate Dysplasia (CIN 2) 2,432 0.4

Severe Dysplasia (CIN 3) 2,865 0.4

Suspicious malignancy or micro–invasion 122 <0.01

Squamous cell carcinoma 66 <0.01

Inconclusive 3,305 0.5

Code not applicable 59 <0.01

Total 681,308 100

*Of satisfactory tests.

Only 2.2% of all the Pap tests performed were reported unsatisfactory. ■

95.3% reported ‘HPV cell changes absent’ while 2.2% reported the presence of HPV cell changes. ■

82.4% contained normal endocervical cells and 15.7% smears were reported as containing no ■endocervical components.

Table 6.4 Squamous cell codes, NSW, 2005

33

Table 6.5 Human papilloma virus tests, NSW, 2005

*These include tests reported as unsatisfactory and no assessment could be made.

Result category – HPV No. of tests Percentage (%)

HPV cell changes absent 649,409 95.3

HPV cell changes possible 4,096 0.6

HPV cell changes present 15,217 2.2

HPV code not applicable* 12,586 1.8

Total 681,308 100

Result category – endocervical cell No. of tests Percentage (%)

Normal endocervical component present 561,428 82.4

No endocervical component present 107,038 15.7

Minor reactive & infl ammatory changes 548 0.1

Low-grade endocervical abnormality 457 0.1

Inconclusive 152 <0.1

High-grade endocervical abnormality 57 <0.1

Suspicious invasion 39 <0.1

Invasive 33 <0.1

Code not applicable1 11,556 1.7

Total 681,308 100

1Include tests reported as unsatisfactory and no assessment could be made.

The reader should note that the cervical intraepithelial neoplasia or CIN terminology used in this report has changed under the new NHMRC guidelines (2005) effective from 1 July 2006. Accordingly, this will refl ect in the next 2006 report.

6.3.2 Human papilloma virus (HPV)

In NSW, cytology reports are coded with one of four possible human papilloma virus codes. In 2005, over 95% of the Pap tests reported ‘HPV cell changes absent’ and only 2.2% of all test results reported the presence of HPV cell changes (Table 6.5).

6.3.3 Endocervical cell

In NSW, cytology reports are coded with one of nine possible endocervical cell codes (Table 6.6). Categories of high- and low-grade endocervical intraepithelial abnormality are consistent with dysplasia or glandular intraepithelial neoplasia (GIN). In 2005, 82.4% of all Pap smears contained normal endocervical cells and 15.7% smears were reported as containing no endocervical component. A total of 666 smears (0.1%) were reported as either a low-grade intraepithelial endocervical abnormality, inconclusive, or high-grade intraepithelial endocervical abnormality.

Table 6.6 Endocervical cell results, NSW, 2005

34


Histology results* No. of tests Percentage (%)

Negative, benign 10,934 39.7

Atypical / abnormal not otherwise specifi ed 1,550 5.6

Low–grade intraepithelial abnormality

HPV effect alone 2,841 10.3

CIN 1 +/– HPV 3,642 13.2

CIN/Dysplasia not graded 186 0.7

High–grade intraepithelial abnormality

CIN 2, CIN 3, +HPV 7,396 26.9

Micro–invasive cancer 20 0.1

Cervical cancer 455 1.7

Diagnosis not applicable# 501 1.8

Total 27,525 100

*Include both squamous and glandular abnormalities

#Diagnosis not related to cervical screening

Table 6.8 Cervical histology results, NSW, 2005

Table 6.7 Other (non–cervical) cell codes, NSW, 2005

*Include intra–uterine contraceptive device (IUCD) cells and endometrial hyperplasia #Includes metastatic malignancy †Include tests reported as unsatisfactory and no assessment could be made.

Result category – non-cervical cells No. of tests Percentage (%)

No other abnormal cells 668,407 98.1

Abnormal cells present* 305 0.04

Malignant cells present – uterine body 59 0.01

Malignant cells present – ovary 0 0

Malignant cells present – vagina 0 0

Malignant cells present – other# 16 <0.00

Code not applicable† 12,526 1.8

Total 681,308 100

6.3.4 Other (non-cervical) cell

In NSW, cytology reports outside the squamous cell, HPV and endocervical cell categories are coded with one of seven possible codes for non-cervical entities. In 2005, there were 75 cases of non-cervical malignancies reported. Of these, 59 reported malignant cells of uterine origin and 16 from other origins (Table 6.7).

6.4 Histology results

The PTR collects and stores the results of cervical histology tests and codes according to the SNOMED International III Codes. In 2005, the PTR received a total of 27,525 cervical histology results (Table 6.8). Histological confi rmation of high-grade abnormalities is generally reported with treatment recommendations. However, SNOMED International does not distinguish between CIN 2 and CIN 3 but reports these lesions together as a high-grade intraepithelial abnormality. As a result, in the correlation tables (Tables 6.9 to 6.14) where histology is compared with cytology, the cytology results of CIN 2 and CIN 3 have also been combined into a single category of high-grade intraepithelial abnormality. When considering these tables, the reader should note that the result groupings incorporate both squamous and glandular abnormality.

35

Table 6.9 Correlation between cytology and histology results*, NSW, 2005

*Tests are included in this table when histology is performed within six months of the Pap test date.#Tests in this category include HPV alone, without the evidence of CIN. †Diagnosis not related to cervical screening.

Histology results

Cytology results

Low–grade

Inconclusive

No. (%)

High–grade

Mild Atypia

No. (%)

HPV#

No. (%)

CIN 1

No. (%)

CIN 2, CIN 3

& cancer

No. (%)

Negative, benign 779 (30.3) 318 (23.5) 585 (18.8) 445 (24.5) 275 (7.4)

Atypical/Abnormal not otherwise specifi ed 268 (10.4) 112 (8.3) 227 (7.3) 122 (6.7) 89 (2.4)

Low-grade intraepithelial abnormality

HPV effect alone 465 (18.1) 297 (22.0) 476 (15.3) 199 (11.0) 178 (4.8)

CIN 1 + HPV 517 (20.1) 310 (22.9) 965 (31.0) 248 (13.6) 368 (10.0)

CIN / Dysplasia not graded 10 (0.4) 13 (1.0) 12 (0.4) 15 (0.8) 24 (0.7)

High-grade intraepithelial abnormality

CIN 2, CIN 3 +HPV 481 (18.7) 281 (20.8) 800 (25.7) 749 (41.2) 2,595 (70.3)

Micro–invasive cancer 0 (0.0) 0 (0.0) 0 (0.0) 1 (0.1) 10 (0.3)

Cervical cancer 11 (0.0) 5 (0.4) 13 (0.4) 20 (1.1) 134 (3.6)

Diagnosis not applicable† 39 (1.5) 16 (1.2) 33 (1.1) 18 (1.0) 19 (0.5)

Total 2,570 1,352 3,111 1,817 3,692

6.4.1 Correlation between cytology and histology results

This measure estimates the positive predictive value of a cytology test by examining the correlation between cytology fi nding and the histology, where histology is performed within six months of the cytology report.

In 2005, 25.7% of tests reporting a cytologically confi rmed low-grade result (CIN 1) with histology performed within six months had a high-grade epithelial abnormality (CIN 2 or CIN 3) on histology. About 19% of women had a negative or benign histological result where the preceding Pap test was a low-grade result (CIN 1 or less). Of the 3,692 women with a high-grade epithelial abnormality or cervical cancer reported by their Pap tests, 74.2% were subsequently diagnosed with high-grade epithelial abnormality or cervical cancer on histology (Table 6.9). It is worth noting that only a small proportion of cytology-detected low-grade abnormality (atypia, HPV and CIN 1) is further investigated by histology and an even smaller proportion of negative cytology is followed by colposcopy.

36


6.4.2 Histologically validated cytology results of CIN 2 or worse

High-grade detection rates are often considered as an indicator of laboratory performance. While a laboratory may have acceptable high-grade detection rates by cytology, these may not be the true high-grade results on histological review. For confi rmation of cervical cancer, the ‘gold standard’ method is histology.10-12

Of the 4,029 cytology results of CIN 2 or higher in 2005, 3,012 were histologically confi rmed as high-grade epithelial abnormality (Table 6.10). The positive predictive value is 74.7%. Histological confi rmation was more likely for women in the 20–49 year age group (75.5%) than for women in the 50–69 year age group (63.8%). There was a statistically signifi cant trend of a decreasing proportion of women with histologically-confi rmed high-grade epithelial abnormality with increasing age (p<0.0001). The trend in negative histology has also increased signifi cantly with age (p<0.0001).

Women aged 50–69 years with cytologically-confi rmed high-grade epithelial abnormality were signifi cantly more likely to have a negative histological diagnosis than women in the 20–49 year age group [17.1% compared to 6.8%, (p<0.0001) (Table 6.10, column 3)]. This is consistent with results found by Massad et al (2003)13 that demonstrate that older women are more likely to have false positive cytology due to atrophy.

There was some geographical variation observed in the rates of histologically-confi rmed cytology reports of CIN 2 or higher. In metropolitan NSW, Sydney West AHS had the highest high-grade confi rmation rate (78.6%), and Sydney South West AHS the lowest (72.8%). In rural NSW, North Coast AHS had the highest high-grade confi rmation rate (77.9%), and Greater Western AHS the lowest (72.6%) (Table 6.11). Negative histology rates were highest in South Eastern Sydney AHS (8.3%) and lowest in Sydney West AHS (4.5%). In rural NSW, the highest high-grade abnormality was reported in North Coast AHS (77.9%) and lowest in Hunter–New England AHS (72.0%). Negative histology rates were highest in Greater Southern AHS (12.4%) and lowest in Greater Western AHS (3.0%).

For women in the target age group of 20–69 years, there was a statistically signifi cant heterogeneity observed across Area Health Services for histologically confi rmed high-grade epithelial abnormality (p<0.001), and for negative histology results (p<0.001).

It is important however to note that the Area Health Service results were derived from laboratories, some of which are located outside the geographical boundary of the Area Health Service.

Cytology appears to be a better predictor for detection of cervical abnormalities in younger women, ■but not in older women aged 50 years and over.

37

Tabl

e 6.

10 H

isto

logi

cal c

onfi r

mat

ion

wit

hin

6 m

onth

s of

cyt

olog

y re

port

s* of

CIN

2 o

r w

orse

by

age,

NSW

, 200

5

*Elig

ible

cyto

logy

repo

rts

for

this t

able

incl

ude

both

squam

ous

and e

ndo

cerv

ical

evi

dence

of C

IN 2

or

wo

rse.

Cyto

logy

cas

es

repo

rted a

s in

concl

usi

ve h

ave

been e

xcl

uded. B

oth

squam

ous

and

endo

cerv

ical

fi n

din

gs o

n h

isto

logy

hav

e been t

aken into

acc

ount.

#T

he

lesi

ons

incl

uded in t

his c

atego

ry c

onta

in m

orp

ho

logi

c ab

no

rmal

itie

s an

d c

ellu

lar

atyp

ia n

ot

consi

stent

with a

dys

pla

sia.

Age

gro

up

(Year)

No

. of

CIN

2 o

r

wo

rse

case

s

Negati

ve

Oth

er

no

n–sp

ecifi

c

his

tolo

gic

ab

no

rmaliti

es#

Lo

w–gra

de

Un

gra

ded

dysp

lasi

a

Hig

h–gra

de

HP

V a

lon

eC

IN 1

+H

PV

CIN

2, C

IN 3

,

HP

V

Mic

roin

vasi

ve

can

cer

Cerv

ical

can

cer

No

. of

wo

men

(%)

No

. of

wo

men

(%)

No

. of

wo

men

(%)

No

. of

wo

men

(%)

No

. of

wo

men

(%)

No

. of

wo

men

(%)

No

. of

wo

men

(%)

No

. of

wo

men

(%)

20–24

841

51 (

6.1

)21 (

2.5

)45 (

5.4

)99 (

11.8

)3 (

0.4

)621 (

73.8

)1 (

0.1

)0 (

0.0

)

25–29

995

50 (

5.0

)18 (

1.8

)41 (

4.1

)108 (

10.9

)7 (

0.7

)759 (

76.3

)4 (

0.4

)8 (

0.8

)

30–34

884

57 (

6.4

)25 (

2.8

)32 (

3.6

)75 (

8.5

)1 (

0.1

)675 (

76.4

)1 (

0.1

)18 (

2.9

)

35–39

494

47 (

9.5

)15 (

3.0

)27 (

5.5

)30 (

6.1

)5 (

1.0

)350 (

70.9

)2 (

0.4

)18 (

3.6

)

40–44

350

32 (

9.1

)9 (

2.6

)16 (

4.6

)47 (

13.4

)2 (

0.6

)222 (

63.4

)1 (

0.3

)21 (

6.0

)

45–49

219

20 (

9.1

)5 (

2.3

)13 (

5.9

)26 (

11.9

)1 (

0.5

)134 (

61.2

)1 (

0.5

)19 (

8.7

)

50–54

111

20 (

18.0

)6

(5.4

)3 (

2.7

)13 (

11.7

)0 (

0.0

)54 (

48.6

)2 (

1.8

)13 (

11.7

)

55–59

61

10 (

16.4

)3 (

4.9

)5 (

8.2

)3 (

4.9

)2 (

3.3

)30 (

49.2

)0 (

0.0

)8 (

13.1

)

60–64

49

8 (

16.3

)1 (

2.0

)2 (

4.1

)5 (

10.2

)1 (

2.0

)24 (

49.0

)0 (

0.0

)8 (

16.3

)

65–69

25

4 (

16.0

)0 (

0.0

)1 (

4.0

)2 (

8.0

)0 (

0.0

)9 (

36.0

)1 (

4.0

)8 (

32.0

)

20–49

3,7

83

257 (

6.8

)93 (

2.5

)174 (

4.6

)385 (

10.2

)19 (

0.5

)2,7

61 (

73.0

)10 (

0.3

)84 (

2.2

)

50–69

246

42 (

17.1

)10 (

4.1

)11 (

4.5

)23 (

9.3

)3 (

1.2

)117 (

47.6

)3 (

1.2

)37 (

15.0

)

20–69

4,0

29

299 (

7.4

)103 (

2.6

)185 (

4.6

)408 (

10.1

)22 (

0.5

)2,8

78 (

71.4

)13 (

0.3

)121 (

3.0

)

38


Tabl

e 6.

11 H

isto

logi

cal c

onfi r

mat

ion

wit

hin

6 m

onth

s of

cyt

olog

y re

port

s* of C

IN 2

or

wor

se b

y A

rea

Hea

lth

Serv

ice,

NSW

, 200

5

*Elig

ible

cyto

logy

repo

rts

incl

ude

both

squam

ous

& e

ndo

cerv

ical

evi

dence

of C

IN 2

or

wo

rse.

Cyto

logy

cas

es

repo

rted a

s in

concl

usi

ve h

ave

been e

xcl

uded.

Both

squam

ous

and e

ndo

cerv

ical

fi ndin

gs o

n h

isto

logy

tak

en into

acc

ount.

#T

he

lesi

ons

incl

uded in t

his c

atego

ry c

onta

in m

orp

ho

logi

c ab

no

rmal

itie

s an

d c

ellu

lar

atyp

ia n

ot

consi

stent

with a

dys

pla

sia.

Are

a H

ealt

h S

erv

ice

No

. of

CIN

2 o

r

wo

rse

case

s

Negati

ve

No

. (%

)

Oth

er

no

n–sp

ecifi

c

his

tolo

gic

ab

no

rmaliti

es#

No

. (%

)

Lo

w–gra

de

Un

gra

ded

dysp

lasi

a

No

. (%

)

Hig

h–gra

de

HP

V a

lon

e

No

. (%

)

CIN

1 +

HP

V

No

. (%

)

CIN

2, C

IN 3

,

HP

V

No

. (%

)

Mic

roin

vasi

ve

can

cer

No

. (%

)

Cerv

ical

can

cer

No

. (%

)

Nort

her

n S

ydney

& C

entr

al

Coas

t 693

48 (

6.9

)20 (

2.9

)25 (

3.6

)66 (

9.5

)5 (

0.7

)503 (

72.6

)0 (

0.0

)26 (

3.8

)

South

Eas

tern

Syd

ney

&

Illaw

arra

876

73 (

8.3

)26 (

3.0

)36 (

4.2

)84 (

9.6

)7 (

0.8

)619 (

70.7

)2 (

0.2

)28 (

3.2

)

Sydney

South

Wes

t717

58 (

8.2

)23 (

3.1

)35 (

4.8

)76 (

10.6

)3 (

0.5

)497 (

69.3

)2 (

0.2

)24 (

3.3

)

Sydney

Wes

t580

26 (

4.5

)8 (

1.4

)28 (

4.8

)60 (

10.3

)2 (

0.3

)440 (

75.9

)3 (

0.5

)13 (

2.2

)

Metr

op

olita

n2,8

66

205 (

7.2

)77 (

2.7

)124 (

4.3

)286 (

10.0

)17 (

0.6

)2,0

59 (

71.8

)7 (

0.2

)91 (

3.2

)

Gre

ater

South

ern

249

31 (

12.4

)6 (

2.4

)7 (

2.8

)17 (

6.8

)4 (

1.6

)178 (

71.5

)2 (

0.8

)4 (

1.6

)

Gre

ater

Wes

tern

164

5 (

3.0

)2 (

1.2

)23 (

14.0

)15 (

9.1

)0 (

0.0

)109 (

66.5

)2 (

1.2

)8 (

4.9

)

Hunte

r &

New

Engl

and

515

40 (

7.8

)13 (

2.5

)24 (

4.7

)67 (

13.0

)0 (

0.0

)361 (

70.1

)1 (

0.2

)9 (

1.7

)

Nort

h C

oas

t 221

17 (

7.7

)3 (

1.4

)6 (

2.7

)22 (

10.0

)1 (

0.5

)163 (

73.8

)1 (

0.5

)8 (

3.6

)

Rura

l1,1

49

93 (

8.1

)24 (

2.1

)60 (

5.2

)121 (

10.5

)5 (

0.4

)811 (

70.6

)6 (

0.5

)29 (

2.5

)

No A

HS

14

1 (

7.1

)2 (

14.3

)1 (

7.1

)1 (

7.1

)0 (

0.0

)8 (

57.4

)0 (

0.0

)1 (

7.1

)

NS

W4,0

29

299 (

7.4

)103 (

2.6

)185 (

4.6

)408 (

10.1

)22 (

0.5

)2,8

78 (

71.4

)13 (

0.3

)121 (

3.0

)

39

Table 6.12 Histological confi rmation within 6 months of cytology reports* of CIN 2 or worse by laboratory location, NSW, 2005

*Eligible cytology reports include both squamous and endocervical evidence of CIN 2 or worse. Cytology cases reported as inconclusive have been excluded. Both squamous and endocervical fi ndings on histology have been taken into account.#The lesions included in this category contain morphologic abnormalities and cellular atypia not consistent with a dysplasia.

Laboratory

location Total Negative

Other non–

specifi c

histologic

abnormalities#

Low–grade Ungraded

dysplasia

High–grade

No. (%)

No. (%)

HPV

alone

No.

(%)

CIN

1±

HPV

No.

(%)

No. (%) CIN 2,3 ±

HPV

No. (%)

Micro–

invasive

No. (%)

Cervical

cancer

No. (%)

Within

Sydney3,256 233 (7.2) 86 (2.6)

143

(4.4)

328

(10.1)13 (0.4)

2,339

(71.8)11 (0.3) 103 (3.2)

Outside

Sydney448 40 (8.9) 11 (2.5)

30

(6.7)

45

(10.0)4 (0.9) 308 (68.8) 0 (0.0) 10 (2.2)

Total NSW 3,704 273 (7.4) 97 (2.6)173

(4.7)

373

(10.1)17 (0.5)

2,647

(71.5)11 (0.3) 113 (3.1)

Outside

NSW345 26 (7.5) 6 (1.7)

13

(3.8)

38

(11.0)8 (2.3) 243 (70.4) 2 (0.6) 9 (2.6)

NSW and

Interstate4,049 299 (7.4) 103 (2.5)

186

(4.6)

411

(10.2)25 (0.6)

2890

(71.4)13 (0.3) 122 (3.0)

6.4.2.1 Histologically validated CIN 2 or worse by laboratory location

Although this measure is primarily a laboratory performance indicator, rates of confi rmed high-grade abnormalities by geographical location may refl ect the differences in underlying risk factors for cervical cancer.

Laboratories within Sydney had slightly higher histological confi rmation rates (76.3%) of high-grade results within six-months of cytology reports of CIN 2 or worse compared to the laboratories located outside Sydney (71.0%) (Table 6.12). These differences however were not statistically signifi cant (p>0.05).

40


Table 6.13 Histological confi rmation within six months of cytology reports of CIN of any degree or worse by age, NSW, 2005

*Eligible cytology and histology cases include both squamous and endocervical evidence of CIN. #Cytology cases reported as inconclusive were excluded.

Age group (year)

No. of women with cytology

report* of CIN of any degree

or worse#

No. of women with histologically*

confi rmed CIN of any degree or worse

Number Number Proportion (%)

20–24 1,653 1,220 73.8

25–29 1,627 1,256 77.2

30–34 1,339 1007 75.2

35–39 769 517 67.2

40–44 595 386 64.9

45–49 384 233 60.7

50–54 196 95 48.5

55–59 104 52 50.0

60–64 71 34 47.9

65–69 27 10 37.0

20–49 6,367 4,619 72.5

50–69 398 191 48.0

20–69 6,765 4,810 71.1

6.4.3 Histologically validated CIN of any degree or worse

This measure reports the number and proportion of women with cytology reports of CIN of any degree where histology performed within six months confi rms the abnormality as being CIN of any degree or worse. During 2005 a total of 6,765 women in the 20–69 years age group had a cytology report of CIN of any degree with histology performed within six months (Table 6.13). Of these, 4,810 women (71.1%) had an abnormality confi rmed through histology as being CIN of any degree.

The proportion of women with histologically confi rmed CIN or worse was signifi cantly higher in the 20–49 year age group (72.5%) compared to the 50–69 year age group (48.0%) (p<0.0001). There was a signifi cant trend of decreasing proportion of women with histologically confi rmed CIN of any degree or worse with increasing age (p for trend <0.0001). However, this should be interpreted with caution because not all women with CIN 1 necessarily have histology performed as a follow up. The current PTR screening follow-up recommendations allows for either histologic or colposcopic follow-up or re-screening in 12-month period.

In the 20–69 year age group, the proportion of women with histologically confi rmed CIN of any degree or worse was highest in the North Coast AHS (73.7%) and lowest in the Greater Western AHS (59.5%) (Table 6.14). It should be noted that the Area Health Service results were derived from multiple laboratories, some of which are located outside the geographical boundary of the Area Health Service.

41

Tabl

e 6.

14 H

isto

logi

cal c

onfi r

mat

ion

wit

hin

six

mon

ths

of c

ytol

ogy

repo

rts

of C

IN o

f any

deg

ree

or w

orse

by

Are

a H

ealt

h Se

rvic

e, N

SW, 2

005

Note

: Elig

ible

cyto

logy

and h

isto

logy

cas

es

for

this t

able

incl

ude

both

squam

ous

and e

ndo

cerv

ical

evi

dence

of C

IN. C

yto

logy

cas

es

repo

rted a

s in

concl

usi

ve a

re e

xcl

uded.

Are

a H

ealt

h S

erv

ice

A

ge 2

0 –

49 y

ears

Age 5

0 –

69 y

ears

Age 2

0 –

69 y

ears

No

. of

cyto

log

y r

ep

ort

No

. an

d p

rop

ort

ion

(%

) o

f

his

tolo

gic

al co

nfi

rmati

on

No

. of

cyto

log

y r

ep

ort

No

. an

d p

rop

ort

ion

(%)

of

his

tolo

gic

al

co

nfi

rmati

on

No

. of

cyto

log

y r

ep

ort

No

. an

d p

rop

ort

ion

(%

) o

f

his

tolo

gic

al co

nfi

rmati

on

Nort

her

n S

ydney

& C

entr

al

Coas

t 1,1

38

745 (

65.5

)86

33 (

38.4

)1,2

24

778 (

63.6

)

South

Eas

tern

Syd

ney

&

Illa w

arra

1,4

62

945 (

64.6

)73

37 (

51.5

)1,5

35

982 (

64.0

)

Sydney

South

Wes

t1,2

54

774 (

61.8

)71

33 (

45.7

)1,3

25

807 (

60.9

)

Sydney

Wes

t847

557 (

65.8

)59

29 (

49.2

)906

586 (

64.7

)

Metr

op

olita

n4,7

01

3,0

21 (

64.3

)289

132 (

45.7

)4,9

90

3,1

53 (

63.2

)

Gre

ater

South

ern

365

234 (

64.1

)17

9 (

52.9

)382

243 (

63.6

)

Gre

ater

Wes

tern

247

149 (

60.3

)12

5 (

41.7

)259

154 (

59.5

)

Hunte

r &

New

Engl

and

742

466 (

62.8

)52

27 (

51.9

)794

493 (

62.1

)

Nort

h C

oas

t 289

215 (

74.4

)26

17 (

65.4

)315

232 (

73.7

)

Rura

l1,6

43

1,0

64 (

64.8

)107

58 (

54.2

)1,7

50

1,1

22 (

64.1

)

AH

S not

avai

lable

23

17 (

73.9

)2

1 (

50.0

)25

18 (

72.0

)

NS

W6,3

67

4,1

02 (

64.4

)398

191 (

48.0

)6,7

65

4,2

93 (

63.5

)

42


This measure indicates the histologically detected low-grade and high-grade intraepithelial abnormalities per 1,000 women screened in a 12-month period by fi ve-year age group. This indicator provides a broad indication of the sensitivity of screening for low-grade and high-grade intraepithelial abnormalities.

6.5.1 Low-grade intraepithelial abnormalities

In 2005, the detection rate for low-grade intraepithelial abnormalities was 9.6 per 1,000 screened women for the target age group 20–69 years. There was a statistically signifi cant trend observed in decreasing rates per 1,000 screened women with increasing age (p<0.001) (Table 6.15). It should be noted however that not all low-grade cytology is confi rmed by histology. Therefore, there may be an underestimate of the overall impact.

Table 6.15 Histologically reported low-grade intraepithelial abnormalities per 1,000 screened women by age, NSW, 2005

*Defi ned as a lesion that is warty atypia (HPV effect), atypia, equivocal CIN, possible CIN, CIN 1, or endocervical dysplasia NOS.

Age group (year)

No. of women with

histologically reported

low–grade intraepithelial

abnormality*

No. of women screened

Women screened per 1,000

20–24 1,412 55,548 25.4

25–29 1,313 70,615 18.6

30–34 959 88,711 10.8

35–39 706 82,413 8.6

40–44 595 82,371 7.2

45–49 433 72,314 6.0

50–54 237 59,438 4.0

55–59 140 48,215 2.9

60–64 56 32,629 1.7

65–69 43 22,050 2.0

20–69 5,894 614,304 9.6

6.5 Low-grade and high-grade intraepithelial abnormalities reported by histology

43

*Defi ned as a lesion that is CIN 1/2, CIN 2, CIN 3, or adenocarcinoma in situ.

6.5.3 Ratio of low- to high-grade intraepithelial abnormalities

This measure provides a broad indication of the specifi city of screening for high-grade lesions. The ratio of histologically reported low-grade to high-grade intraepithelial abnormalities is calculated using the number of women with a histologically reported low-grade intraepithelial abnormality in a 12-month period as a ratio to the number of women with a histologically reported high-grade intraepithelial abnormality in the same period. The higher the ratio, the lower the specifi city of the histopathology tests.

In 2005, the ratio of low-grade to high-grade abnormality detection was 1:1 for the target age group of 20–69 years. The ratio ranged from 0.9 to 2.5 across the fi ve-year age groups, with higher values concentrated in the 45–69 year age range

Age group (year)

No. of women with

histologically reported

high–grade intraepithelial

abnormality*

No. of women screened Women screened per 1,000

20–24 1,277 55,548 23.0

25–29 1,338 70,615 18.9

30–34 1,106 88,711 12.5

35–39 603 82,413 7.3

40–44 366 82,371 4.4

45–49 215 72,314 3.0

50–54 96 59,438 1.6

55–59 65 48,215 1.3

60–64 43 32,629 1.3

65–69 17 22,050 0.8

20–69 5,126 614,304 8.3

6.5.2 High-grade intraepithelial abnormalities

In 2005, the histological detection rate for high-grade intraepithelial abnormalities was 8.3 per 1,000 screened women for the target age group 20–69 years (Table 6.16). The observed screening rates ranged from as low as 0.8 to as high as 23.0 per 1,000 women with a statistically signifi cant trend of decreasing rates of detection with increasing age (p<0.001).

Table 6.16 Histologically reported high-grade intraepithelial abnormalities per 1,000 screened women by age, NSW, 2005

44


suggesting low specifi city of the histopathology tests performed in women in older age groups (Table 6.17).

Table 6.17 Ratio of histologically reported low-grade to high-grade intraepithelial abnormalities by age, NSW, 2005*Defi ned as a lesion that is warty atypia (HPV effect), atypia, equivocal CIN, possible CIN, CIN 1, or endocervical dysplasia NOS.#Defi ned as a lesion that is CIN 1/2, CIN 2, CIN 3, or adenocarcinoma in situ.

Age group (year)Low–grade intraepithelial

abnormality*

High–grade intraepithelial

abnormality#

Ratio

20–24 1,412 1,277 1.1

25–29 1,313 1,338 1.0

30–34 959 1,106 0.9

35–39 706 603 1.2

40–44 595 366 1.6

45–49 433 215 2.0

50–54 237 96 2.5

55–59 140 65 2.2

60–64 56 43 1.3

65–69 43 17 2.5

20–69 5,894 5,126 1.1

6.6 Interval cancer

An interval cancer case is defi ned as any woman who is listed with the Central Cancer Registry (CCR) as being a new case of cervical cancer (invasive or micro-invasive) in the reporting period within two years of any negative Pap test result. The number of cancers that are diagnosed in the interval between screening episodes is one of the fundamental indicators of the quality of Program performance. A low-interval cancer rate demonstrate the effectiveness of the screening program.

The rate of interval cancer in 2005 was 6.57 cases per 100,000 women. This rate was higher although not statistically signifi cantly different from the previous two year rates; 5.03 per 100,000 women in 2004 and 5.3 per 100,000 women in 2003.

From 1 January 2003 to 31 December 2003, 578,146 women were screened with negative cytology. Of ■these, 38 were listed with the NSW CCR as having interval cervical cancer in 2005, or 6.57 cases per 100,000 screen-negative women.

45

Screening recommendations made by the laboratory performing the Pap tests play a vital role in subsequent management of the patient. National Pathology Accreditation Advisory Council (NPAAC) requirements for gynaecological cytology state that the management recommendations on Pap test reports must be consistent with NHMRC management protocols for screen-detected abnormalities.14

7.1 Reporting of recommendation codes

In NSW, cytology reports are coded with one of the 10 possible recommendation codes (Table 7.1).

Table 7.1 Reporting of recommendation codes for NSW women, 2005

*Normal screening interval for negative Pap test result.

7.1.1 No management recommendation

During the reporting period, 24.4% of women aged 20–69 years had their fi rst cytology reports that contained no management recommendation (Table 7.2). The proportion of women whose fi rst cytology reports contained no management recommendation was highest among women in the 65–69 year age group (29.4%), and lowest for women aged 20–24 years (20.9%). A statistically signifi cant increasing trend in increasing age was observed in the proportion of screened women whose fi rst cytology report contained no management recommendation (p<0.001).

7. Screening recommendation

Age group (year) No. of tests Proportion (%)

No recommendation 161,896 23.8

Repeat smear – three years 13 0.0

Repeat smear – two years* 390,246 57.3

Repeat smear – one year 54,299 8.0

Repeat smear – six months 30,477 4.5

Repeat smear – three months 13,434 2.0

Repeat smear – four weeks or less 3,453 0.5

Referral for specialist opinion 9,847 1.4

Further investigation advised 9,331 1.4

Other 8,312 1.2

Total 681,308 100

Screening recommendations made by the laboratory performing the Pap tests must meet NHMRC management protocols.

46


Table 7.2 Number and proportion (%) of screened women whose fi rst cytology reports contained no management recommendation by age, NSW, 2005

Age group (year) No. of women screened

No. of reports with

no management

recommendation

Proportion (%)

20–24 55,365 11,566 20.9

25–29 70,501 15,081 21.4

30–34 88,495 20,661 23.3

35–39 82,252 19,661 23.9

40–44 82,223 20,119 24.5

45–49 72,137 18,229 25.3

50–54 59,313 15,609 26.3

55–59 48,065 13,007 27.1

60–64 32,586 8,975 27.5

65–69 21,995 6,471 29.4

20–49 450,973 105,317 23.4

50–69 161,959 44,062 27.2

20–69 612,932 149,379 24.4

Laboratory location No. of women screened

No. of reports with

no management

recommendation

Proportion (%)

Within Sydney 496,471 146,604 30.0

Outside Sydney 52,538 908 2.4

Total NSW 549,009 147,512 27.4

Outside NSW 63,923 1,867 3

All laboratories 612,932 149,379 24.8

The use of a ‘no management’ recommendation by the laboratories was mainly associated with a woman’s Pap test result being negative, with no past history of abnormality. In 2005, there were a total of 149,379 such reports which contained ‘no management’ recommendation.

Of the women who had Pap tests in 2005, 30.0% had ‘no management’ recommendation in their fi rst cytology report prepared by the laboratories within Sydney metropolitan area, compared to 2.4% of tests prepared by the laboratories outside Sydney (Table 7.3). This difference was statistically signifi cant (p<0.001). The rates are higher with the large laboratories within Sydney.

Table 7.3 Number and proportion of women with ‘no management’ recommendation by laboratory location, 2005

47

Table 7.4 Recommendation for colposcopy or specialist opinion by age, NSW, 2005

Age group (year)No. of women screened with

a recommendation

No. of reports with

recommendation for

colposcopy / specialist

opinion

Proportion (%)

20–24 42,896 3,155 7.4

25–29 54,396 2,887 5.3

30–34 66,648 2,569 3.9

35–39 61,531 1,780 2.9

40–44 61,208 1,419 2.3

45–49 53,134 1,081 2,0

50–54 43,046 742 1.7

55–59 34,452 492 1.4

60–64 23,200 325 1.4

65–69 15,287 227 1.5

20–49 339,813 12,891 3.8

50–69 115,985 1,786 1.5

20–69 455,798 14,677 3.2

7.1.2 Recommendation for colposcopy or specialist opinion

This measure reports the number and proportion of screened women who, on their fi rst Pap test report, received a recommendation for colposcopy or a referral to a gynaecologist for specialist opinion.

In 2005, there were 14,677 screened women aged 20–69 years whose fi rst cytology report contained a management recommendation for colposcopy or specialist opinion. This represented 3.2% of all women whose fi rst cytology report included any management recommendation (Table 7.4). A signifi cantly higher proportion of younger women aged 20–49 years (3.8%) with a recommendation for colposcopy or specialist opinion were included in the fi rst cytology report compared to the older women aged 50–69 years (1.5%) (p<0.001). The proportion of women who received a management recommendation for colposcopy or specialist opinion in their fi rst cytology report decreased with increasing age. This trend was statistically signifi cant (p<0.001).

In women from both the overall 20–69 year age group and the 20–49 and 50–69 year age groups, the proportion of reports containing a management recommendation for colposcopy or specialist opinion was higher in rural AHSs compared with Sydney metropolitan AHSs (Table 7.5). However, this should be interpreted with caution as women may live in a different area to the location where their tests were performed.

48


Tabl

e 7.

5 C

ytol

ogy

repo

rts

wit

h a

reco

mm

enda

tion

for

colp

osco

py o

r sp

ecia

list

opin

ion

by N

SW A

rea

Hea

lth

Serv

ice

and

age,

200

5

Are

a H

ealt

h S

erv

ice

Age 2

0 –

49 y

ears

Age 5

0 –

69 y

ears

Age 2

0 –

69 y

ears

No

. of

wo

men

scre

en

ed

wit

h a

reco

mm

en

dati

on

No

. of

reco

mm

en

dati

on

for

co

lpo

sco

py o

r

specia

list

op

inio

n

(%)

No

. of

wo

men

scre

en

ed

wit

h a

reco

mm

en

dati

on

No

. of

reco

mm

en

dati

on

for

co

lpo

sco

py o

r

specia

list

op

inio

n

(%)

No

. of

wo

men

scre

en

ed

wit

h a

reco

mm

en

dati

on

No

. of

reco

mm

en

dati

on

for

co

lpo

sco

py o

r

specia

list

op

inio

n (

%)

Nort

her

n S

ydney

& C

entr

al C

oas

t57,6

21

2,1

71 (

3.8

)20,7

48

256 (

1.2

)78,3

69

2,4

27 (

3.1

)

South

Eas

tern

Syd

ney

& Illa

war

ra64,1

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49

8.1 Incidence

Current NSW Central Cancer Registry (CCR) coding practices include micro-invasive carcinomas within the classifi cation of cancer of the cervix, but exclude cervical intraepithelial neoplasia or carcinoma-in-situ. Despite both micro-invasive and invasive cervical cancers being truly invasive, each category is presented separately in this report as well as in combination for better visibility of the incidences of each. When cervical cancer is mentioned uncategorised, it implies that both invasive and micro-invasive cervical cancers are included. For defi nitions of micro-invasive and invasive cervical cancers see Appendix 1. Cervical cancer incidence and mortality data presented in this report may vary from published NSW Cancer Registry data due to differences in time periods when reports are published.

8.1.1 Age-specifi c incidence: 2003–2005

Age-specifi c rates of the incidence of cervical cancer have been aggregated for three years (2003–2005), because annual data produce insuffi cient numbers for age-specifi c differences to be examined. The incidence of cervical cancer increased rapidly with age between 20 and 39 years, and more slowly thereafter (Figure 8.1). There is a general trend of higher incidence rates with the older age groups, although the number of cases was highest in the 45–49 year age group.

8. Incidence and mortality

During 2003–2005, 715 new cases of cervical cancer were reported among all women, with 571 in the ■target age group.

The age-standardised incidence rate for 2005 was 6 per 100,000 women. Incidence rates decreased ■by 59% between 1972 and 2005.

0 2 4 6 8 10 12 14 16 18

70+65–6960–6455–5950–5445–4940–4435–3930–3425–2920–24

Age

gro

up (y

ear)

Rate per 100,000

Figure 8.1 Age-specifi c incidence of cervical cancer, NSW, 2003–2005

Incidence rates decreased by 59% between 1972 and 2005, while mortality rates fell by 70%.

50


8.1.2 Secular trends in incidence

Between 1972 and 2005, the age-standardised incidence rates of cervical cancer in NSW decreased by 59.0%. In the 10-year period 1996–2005, the age-standardised incidence rates fell by 41.6% (Figure 8.2, Table A9). The steady decline observed during the past decade coincides with the introduction of organised screening in NSW in the early 1990s.15 The number of new cases in 2007 is projected to remain almost the same as 2005 level.16

Figure 8.2 Age-standardised* incidence of cervical cancer, NSW, 1972–2005

*Standard Australia population, 2001.

Table 8.1 Number and mean age-specifi c incidence rates of cervical cancer, NSW, 2003–2005

Age group (year) Number of new cases in 2003-2005Mean age-specifi c incidence

rates per 100,000 (95% CI)

20–24 7 1.0 (0.4–2.2)

25–29 32 4.7 (3.2–6.6)

30–34 65 8.4 (6.5–10.7)

35–39 84 11.4 (9.1–14.1)

40–44 74 9.6 (7.6–12.1)

45–49 98 13.7 (11.1–16.7)

50–54 70 10.7 (8.3–13.5)

55–59 56 9.4 (7.1–12.3)

60–64 40 8.8 (6.3–12.0)

65–69 45 11.6 (8.5–15.5)

70+ 144 12.9 (10.8–15.0)

20–49 360 8.3 (7.4–9.0)

50–69 211 10.1 (8.7–11.0)

20–69 571 8.9 (8.1–9.0)

0

5

10

15

20

25

1972 1974 1976 1978 1980 1982 1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004

Year

Rat

e pe

r 10

0,00

0

51

Table 8.2 Micro-invasive and invasive cervical cancer by age, NSW, 2003–2005

Age group (year)

Micro–invasive Invasive

New cases

(2003–2005)

Mean age–specifi c

incidence rate

per 100,000 (95% CI)

New cases

(2003–2005)

Mean age–specifi c

incidence rate

per 100,000 (95% CI)

20–24 3 0.4 (0.1–1.3) 4 0.6 (0.2–1.5)

25–29 9 1.3 (0.6–2.5) 23 3.4 (2.1–5.0)

30–34 19 2.5 (1.5–3.8) 46 5.9 (4.4–7.9)

35–39 8 1.1 (0.5–2.1) 76 10.3 (8.1–12.9)

40–44 7 0.9 (0.4–1.9) 67 8.7 (6.8–11.1)

45–49 4 0.6 (0.2–1.4) 94 13.1 (10.6–16.0)

50–54 4 0.6 (0.2–1.6) 66 10.1 (7.8–12.8)

55–59 2 0.3 (0.0–1.2) 54 9.1 (6.8–11.9)

60–64 1 0.2 (0.0–1.2) 39 8.6 (6.1–11.8)

65–69 3 0.8 (0.2–2.3) 42 10.8 (7.8–14.6)

70+ 2 0.2 (0.0–0.6) 142 12.7 (10.6–14.8)

20–49 50 1.1 (0.9–1.5) 310 7.1 (6.3–7.9)

50–69 10 0.5 (0.2–0.9) 201 9.6 (8.3–11.0)

20–69 60 0.9 (0.7–1.2) 511 7.9 (7.2–8.6)

8.1.3 Incidence of micro-invasive and invasive cervical cancer

During 2003–2005 there were 62 new cases of cervical cancer classifi ed as micro-invasive (squamous cell carcinomas) reported in all age groups to the NSW Central Cancer Registry (CCR). Of these, 60 (96.8%) were in the target age group of 20–69 years. The mean annual age-specifi c incidence rate for the 20–69 year age group was 0.9 (95% CI: 0.7–1.2). The incidence of micro-invasive cancer was highest in women aged 30–34 years.

Invasive cervical cancer includes all cervical cancers reported to CCR other than those classifi ed as micro-invasive. During 2003–2005, there were 653 new cases of invasive cervical cancer among all women in NSW (excludes 62 micro-invasive cervical cancers). Of these, 511 new cases of invasive cervical cancer were reported among women in the target age group of 20–69 years (Table 8.2).

The mean (2003–2005) age-specifi c incidence rates of invasive cervical cancer increased with increasing age. The trend is statistically signifi cant (p<0.0001). The higher invasive cervical cancer rate was observed in the 50–69 year age group compared to 20–49-year-olds (p<0.01). Incidence rates then decreased in the older age groups up to the 60–64 year age group. The rates then increased in subsequent age groups (Figure 8.3).

Apart from a peak in incidence in the 30–34 year age group, micro-invasive cervical cancer incidence varied minimally and rates were substantially lower compared to the rates of invasive cervical cancer (Figure 8.3).

52


Figure 8.3 Mean age-specifi c incidence rates of micro-invasive and invasive cervical cancer, NSW, 2003–2005

8.1.4 Age-specifi c incidence rates of cervical cancer by histological type

The morphology of incident cancers has been coded by NSW CCR according to SNOMED International. Data are available for incident cases of cervical cancer classifi ed as either squamous cell carcinoma (SCC) or non-squamous cell carcinoma for the period 1972–2005.

8.1.4.1 Squamous cell carcinoma

Of the 715 new cases of cervical cancer among all NSW women reported during 2003–2005, 486 (68%) were classifi ed as squamous cell carcinoma and 229 non-squamous cell carcinoma. Of the 486 cases of squamous cell carcinoma, 381 (78.4%) were reported in the target age group of 20–69 years. The rates of incidence generally increased with increasing age. Rates increased steeply from 20–49 years, before declining to age 50–69 years, and then increasing again in older women aged over 70 years (Table 8.3). The trend is consistent with the pattern of the current screening rates being lower in the 20–49 year age group and higher in the 50–69 year age group indicating a positive effect of screening.

8.1.4.2 Non-squamous cell carcinoma

Between 2003 and 2005, 229 new cases of cervical cancer classifi ed as non-squamous cell carcinoma were diagnosed in NSW women. Of these, 190 (83%) were reported in the target 20–69 year age group. Rates were lower in young women aged 20–29 years, but varied slightly across the remaining age groups.

0 2 4 6 8 10 12 14 16 18

70+65-6960-6455-5950-5445-4940-4435-3930-3425-2920-24

Age

gro

up (

year

)

Rate per 100,000

Invasive Micro-invasive

Most of the decline in the incidence of squamous and non-squamous cervical cancer is evident from the ■early 1990s coinciding with the establishment of the National Cervical Screening Program.

53

Table 8.3 Number of new cases and mean age-specifi c incidence rates of squamous cell carcinoma and non-squamous cancer cases, NSW, 2003–2005

8.1.4.3 Trends in squamous and non-squamous cell carcinoma of cervix

Between 1972 and 2005, the age-standardised incidence rates of squamous cell carcinoma of the cervix in NSW fell by 63%; from 13.2 per 100,000 women in 1972 to 4 per 100,000 women in 2005 (Figure 8.4). During 1996–2005, the incidence of squamous cell carcinoma of the cervix fell by 46.9%.

Between 1972 and 2005, the age-standardised incidence rates of non-squamous cell carcinoma fell by 27.2%; from 3.5 to 2.0 per 100,000 women. During the same period, the rates fl uctuated from as high as 4.0 to as low as 1.9 per 100,000 women.

Figure 8.4 Age-standardised* incidence of squamous and non-squamous cervical cancer, NSW, 1972–2005

*Standard population: Australia 2001.

Age group (year)

Squamous cell carcinoma Non-squamous cell carcinoma

No. of new casesMean age-specifi c

incidence rate

per 100,000 (95% CI)

No. of new casesMean age-specifi c

incidence rate

per 100,000 (95% CI)

20–24 6 0.9 (0.3–1.9) 1 0.1 (0.0–0.8)

25–29 20 2.9 (1.8–4.5) 12 1.9 (0.9–3.1)

30–34 45 5.8 (4.2–7.8) 20 2.6 (1.6–4.0)

35–39 51 6.9 (5.2–9.1) 33 4.5 (3.1–6.3)

40–44 50 6.5 (4.8–8.6) 24 3.1 (2.0–4.6)

45–49 71 9.9 (7.7–12.5) 27 3.8 (2.5–5.5)

50–54 48 7.3 (5.4–9.7) 22 3.4 (2.1–5.1)

55–59 35 5.9 (4.1–8.2) 21 3.5 (2.2–5.4)

60–64 25 5.5 (3.6–8.2) 15 3.3 (1.9–5.5)

65–69 30 7.7 (5.2–11.0) 15 3.9 (2.2–6.4)

70+ 105 9.4 (7.6–11.2) 39 3.5 (2.5–4.8)

20–49 243 5.6 (4.9–6.3) 117 2.7 (2.2–3.2)

50–69 138 6.6 (5.5–7.7) 73 3.5 (2.7–4.4)

20–69 381 5.9 (5.3–6.5) 190 3.0 (2.5–3.4)

0

2

4

6

8

10

12

14

16

18

1972 1974 1976 1978 1980 1982 1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004

Year

Rate

per

100

,000

Squamous Non-squamous

54


8.2 Mortality

Age-standardised mortality rates fell by: ■

70% during 1972–2005 ■

47% during 1996–2005. ■

8.2.1 Age-specifi c mortality from cervical cancer: 2003–2005

Age-specifi c mortality from cervical cancer is available from the NSW Central Cancer Registry from 1972 to 2005. There were 230 deaths from cancer of the cervix (ICD–10, C53) among women of all ages in NSW between 2003 and 2005. Of these, 135 (58.7%) deaths occurred in women in the target 20–69 year age group. In 2005, 75 cervical cancer-related deaths were recorded with the NSW CCR.

Figure 8.5 Mean age-specifi c mortality rates per 100,000 women, NSW, 2003–2005

0 2 4 6 8 10 12

70+

65-69

60-64

55-59

50-54

45-49

40-44

35-39

30-34

25-29

20-24

Age

grou

p (y

ear)

Rate per 100,000

55

8.2.2 Secular trend in mortality

Between 1972 and 2005, the age-standardised cervical cancer mortality rates decreased by 69.6%. Over the 10-year period: 1996–2005, age-standardised mortality rates fell by 46.7% (Figure 8.6, Table A10).

Figure 8.6 Age-standardised mortality rates per 100,000 population, NSW, 1972–2005

0

1

2

3

4

5

6

7

8

9

1972 1974 1976 1978 1980 1982 1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004

Year

Rate

per

100

,000

Age group (year) Number of deaths in 2003-2005Average age-specifi c mortality

rates per 100,000 (95% CI)

20–24 1 0.1 (0.0–0.8)

25–29 2 0.3 (0.0–1.1)

30–34 10 1.3 (0.6–2.4)

35–39 7 1.0 (0.4–2.0)

40–44 16 2.1 (1.2–3.4)

45–49 20 2.8 (1.7–4.3)

50–54 17 2.6 (1.5–4.2)

55–59 18 3.0 (1.8–4.8)

60–64 27 6.0 (3.9–8.7)

65–69 17 4.4 (2.6–7.0)

70+ 95 8.5 (6.9–10.4)

20–49 56 1.3 (1.0–1.7

50–69 79 3.8 (3.0–4.7)

20–69 135 2.1 (1.7–2.5)

Table 8.4 Number of cervical cancer deaths and mean age-specifi c mortality rates of cervical cancer, NSW, 2003–2005

56


Appendixes

Appendix 1: Glossary 56

Appendix 2: Number of women screened 60

Appendix 3: Target (denominator) population 61

Appendix 4: Proportion of screened women 62

Appendix 5: Sub-populations 63

Appendix 6: Re-screening 65

Appendix 7: Biennial (2004–2005) cervical screening rates 66

Appendix 8: Age-standardised incidence 74

Appendix 9: Age-standardised mortality 75

Appendix 10: Population estimates 76

Appendix 11: Explanatory notes on screening data 77

Appendix 12: Statistical Confi dence Intervals 78

Appendix 13: Related publications 79

Appendix 14: References 80

57

Abnormal

All technically satisfactory Pap test specimens not reported as positive.

Accessibility/Remoteness Index of Australia

The Accessibility/Remoteness Index of Australia (ARIA) datasets are indexes of remoteness derived from measures of road distance between populated localities and service centres. These road distance measures are used to generate a remoteness score for any location in Australia. Populated localities are given a score (from 0 to 12) based on the road distance to service towns of different sizes. Scores for regions are derived by averaging scores for localities. The index scores are classifi ed into the following 5 categories: (1) Highly accessible; (2) Accessible; (3) Moderately accessible; (4) Remote; (5) Very remote.

Area Health Service (AHS)

A geographical area that is usually defi ned by the boundaries of a number of local government areas. Area Health Services have responsibility for providing primary and secondary health care to the community within this area.

Cervical cancer

Cancer that occurs when cells in a woman’s cervix divide and grow out of control and take over healthy cells. Abnormal cells often form a tumour and spread from the surface of the cervix to tissue deeper in the cervix or to other parts of the body. The tumour may develop from the surface epithelium of the cervix (squamous carcinoma) or from the epithelial lining of the cervical canal (adenocarcinoma). In both cases, the tumour is invasive, spreading to involve surrounding tissue and subsequently to neighbouring lymph nodes and adjacent organs, such as the bladder and rectum (Martin 2002). Cervical cancer can be detected in an early stage of development through examining cervical cells via tests such as the Papanicolaou test, commonly known as the Pap test.

CIN

Cervical Intraepithelial Neoplasia, refers to the cellular changes or growth in the surface layers of the cervix preceding the invasive stages of cervical cancer. The CIN

Appendix 1: Glossary

classifi cation system distinguishes cervical abnormalities into three stages of severity, CIN 1 (mild dysplasia), CIN 2 (moderate dysplasia) and CIN 3 (severe dysplasia, carcinoma-in-situ).

CIN not graded

CIN that was detected on a histology specimen but where confi dent assessment of the severity of the abnormality was not possible.

Colposcopy

A method of examining and assessing the cervix and lower genital tract to help plan the sites for tissue removal and the appropriate treatment for an abnormality.

Cytology

The study of cells. A Pap test consists of cells scraped from the cervix that are screened for abnormal changes.

De-identifi ed tests

Pap tests performed on women who have opted off the NSW Pap Test Register.

Detection rate

The number of abnormalities detected per 1,000 women screened within the reporting period.

Division of General Practice (DGP)

These are local networks of general practitioners working within defi ned geographical areas. Divisions were established as part of Commonwealth initiatives aimed at enhancing general practice.

Dysplasia

This term describes abnormal changes in the cervix. It is also a classifi cation system that grades cervical abnormalities that have the potential to become cervical cancer. It classifi es abnormalities into three stages of severity, from mild dysplasia, through moderate dysplasia to severe dysplasia. This system is used interchangeably with the CIN nomenclature.

58


Endocervical cell

A type of cell found on the mucous membrane surface of the cervix. The presence of these cells on a Pap test shows that the sample comes from an area where the endocervical cells meet the squamous cells. This area is where cancer is more likely to develop. In this report, endocervical component is used interchangeably with endocervical cells.

Endocervical component

Refers to endocervical and/or metaplastic cells that are found on the surface of the cervix. The presence of these cells on a Pap test shows that the sample came from the area where the endocervical cells meet the squamous cells. This area is where cancer is more likely to develop. In this report endocervical component is used interchangeably with endocervical cells.

Glandular cell

Cells that secrete cellular products, for example mucous. Endocervical cells are glandular cells.

High-grade epithelial abnormality

Describes abnormalities of the cervix that are more severe than a low-grade epithelial abnormality. It includes abnormalities such as CIN 2, CIN 3, high grade endocervical lesions, adenocarcinoma in-situ, cancer (squamous and non–squamous) and lesions where cancer is suspected. Inconclusive reports and CIN not graded are not included in this category.

High-grade intraepithelial abnormality

Describes abnormalities of the cervix that are more severe in nature than a low-grade epithelial abnormality but less severe than cancer. It only includes abnormal change where the change is still confi ned to the surface of the cervix and invasion of the underlying tissue has not occurred. Abnormalities include CIN 2, CIN 3, high-grade intraepithelial endocervical lesions and adenocarcinoma in-situ. Inconclusive and CIN not graded are not included in this category.

Histology

The study of the structure of tissues. A small piece of tissue is removed from the cervix and is viewed for abnormal tissue structure and cellular change.

Histology confi rmation

Where an abnormality detected on a Pap test is confi rmed by a similar abnormality being detected on a subsequent histology specimen.

Human papilloma virus (HPV)

Group of viruses that can cause infection in the skin surface of different areas of the body including the genital area. The virus can cause visible warts of the skin or may only cause microscopic changes in the cells of the skin.

Inconclusive

A category of Pap test report where the Pap test contained abnormal cells that suggest the possibility of a high-grade abnormality but where a confi dent cytological diagnosis is not possible.

Invasive

A stage of cancer in which abnormal changes to the cells have progressed to an extent that the cells are invading surrounding tissue or other parts of the body.

Local government area (LGA)

Geographical areas of responsibility of an incorporated Local Government Council.

Low-grade abnormality

Describes abnormalities of the cervix that are less severe in nature than a high-grade epithelial abnormality. It includes abnormalities such as mild atypia, HPV effect, CIN 1 and low-grade glandular abnormalities.

Malignant

Describes abnormal changes consistent with cancer.

59

Micro-invasive cancer

Lesion in which the cancer cells have invaded just below the surface of the cervix, but have not developed any potential to spread to other tissues. For micro–invasive cancer, the degree of spread (invasion) of cancerous cells into normal tissue is minimal.

Mild atypia

Describes a low-grade epithelial abnormality of the cervix that is less severe than CIN 1. The changes maybe consistent with human papilloma virus.

Negative

Contains all specimens in which no abnormal material was detected plus specimens in which reactive and infl ammatory cellular change were reported. Reports of atypia and HPV effect are not considered to be in this category.

No abnormal squamous cells

The term describes Pap tests that are negative but have no infl ammatory or reactive squamous cell changes.

Opt-off

Refers to process whereby women who have Pap tests, can choose to decline to have their personal details placed onto the NSW Pap Test Register.

Non-squamous malignancy

Refers to cervical malignancy originating in cell types other than squamous cells. This covers malignancy originating from glandular cells, other cell types and malignancies where the cell type is not defi nable.

Pap test

A pathology test, named after Greek cytologist G. N. Papanicolaou (1883–1962), in which a specimen of cellular material scraped from the cervix that is stained and examined under a microscope in order to detect cell changes indicating the precursor of cancer. It is a screening test that

aims to fi nd signs that cervical cancer might appear in the future. The term Pap test is used interchangeably with the term Pap smear.

Pap smear

See Pap test.

Reactive and infl ammatory change

Refers to material that is negative but show signs of irritation which can be due to infection.

Recommendation

This is a part of a cytological report and advises about what management action should be taken in response to the Pap test result. The recommendations should be consistent with NH&MRC guidelines on the management of women with screen–detected abnormalities.

Re-screening

Refers to women who have another Pap test before the time set out by the Australian screening policy, which is every two years for well women in the target age range.

Screening test

A test done on all people at risk of developing a certain disease, even if there are no symptoms. Screening tests predict the likelihood of someone developing a particular disease.

Smear throughput

The number of Pap tests carried out in a given time by a laboratory.

60


SNOMED

Systematised Nomenclature of Medicine (Cote 1987), a classifi cation system created to index procedures and diagnoses. It allows integration of a medical report into a series of standardised codes.

Squamous cell carcinoma (SCC)

A cancer that develops from squamous cells found in the skin that covers the outside and lines the inside of the body.

Suspicious invasion

A situation where a high-grade intraepithelial abnormality exists and further abnormal material suggested the possibility of cervical cancer, but a confi dent diagnosis of cancer was not possible.

Technically satisfactory

A category of Pap tests that can be assessed for the presence of an abnormality.

Technically unsatisfactory

A category of Pap tests that cannot be assessed at all due to the paucity of the sample, a covering of blood or infl ammatory exudate and / or poor fi xation.

61

The number of women screened is the count of women who had a Pap test at least once during the reporting period, 1. and includes women whose fi rst test during the period was for follow-up or diagnostic purposes. The number may therefore lead to an over-estimation of the number of women who underwent a Pap test for the purposes of screening for cervical cancer. The Program aggregates the screening data into counts of women screened in each Area Health Service, by urban or rural regional classifi cation, by Division of General Practice and by socioeconomic status (SES).

The number of women screened may also be overestimated if the NSW Pap Test Register is unable to match the record 2. of a woman with her previous record. The extent of these matching failures is likely to be low and is currently unknown.

The number of women screened does not include any repeat Pap tests conducted on an individual woman during the 3. reporting period. A woman who received two or more Pap tests during a single reporting period is counted once only.

The number of women screened includes only women with an address reported by the NSW PTR as being located 4. in NSW. The count excludes women who were screened in NSW but whose nominated address is outside NSW or where postcode was not allocated to a NSW LGA. It does however include women normally resident in NSW (if a NSW address is given) but screened interstate and the screening tests are reported by a laboratory that has an information transfer agreement with the PTR.

Agreements between the NSW PTR and interstate laboratories that service border areas of NSW mean that, unless 5. otherwise stated, NSW women who are screened by interstate laboratories will be recorded by the NSW PTR if the women’s NSW address is provided. However, certain laboratories near NSW borders do not send information to the NSW PTR and therefore screening rates in certain LGAs near State borders may be underestimated.

Allocation of a woman to a specifi c LGA or AHS is made each time the data are extracted by the NSW PTR, and is 6. therefore based on each woman’s most current known address.

The number of women recorded as screened by the NSW PTR excludes women who have elected to ‘opt-off ’ the 7. Register. The term ‘opt-off ’ applies to women who withhold personal details from the NSW PTR which prevents allocation to AHS or LGA. During the 24-month reporting period, 1.03% of all Pap tests performed in NSW involved women who opted–off the NSW PTR.

Appendix 2: Number of women screened

62


The target population of the Program is the number of NSW-resident women who are estimated to be at risk of cervical 1. cancer, are aged between 20 and 69 years and who would benefi t from screening. This age group is also the target age group of the National Cervical Screening Program.

The target population (Table A1) is derived from the 2001–2005 Estimated Resident Female Population of NSW, from 2. the Australian Bureau of Statistics (ABS), and adjusted for the proportion of women estimated to have undergone a total hysterectomy.

The age-specifi c hysterectomy fractions can be obtained from the proportion of women with an intact cervix as a 3. percentage of the population of NSW in the corresponding fi ve-year age group (Table A2).

Table A1 Number of women at risk of cervical cancer by age and year, NSW, 2001–2005

Source: ABS 2001, 2002, 2003, 2004 and 2005 Estimated Resident Population adjusted for hysterectomy fraction derived from the 2004 NSW Population Health Survey.

Table A2 Proportion of women with an intact cervix, NSW, 2005

Source: NSW Population Health Survey 2004, NSW Department of Health.

Appendix 3: Target (denominator) population

Age group

(year)

No. of women in NSW

2001 2002 2003 2004 2005

20–24 212,346 218,769 221,591 224,525 223,417

25–29 239,319 233,933 229,169 226,057 222,867

30–34 245,693 250,096 253,577 257,691 256,983

35–39 245,131 239,130 235,029 231,653 238,696

40–44 227,100 229,648 231,494 238,590 237,322

45–49 187,298 187,108 190,627 200,070 204,814

50–54 162,064 161,270 162,348 179,796 181,728

55–59 108,823 114,461 120,989 142,827 148,101

60–64 94,357 94,646 96,323 101,882 105,305

65–69 75,913 76,324 78,046 80,928 82,530

20–49 1,365,522 1,371,266 1,377,698 1,378,587 1,384,099

50–69 469,628 481,790 493,556 505,433 517,663

20–69 1,835,150 185,3056 1,871,254 1,884,020 1,901,762

Age group (year) Percentage (%) of women with an intact cervix

20–24 100.0

25–29 99.1

30–34 99.8

35–39 95.7

40–44 92.9

45–49 83.9

50–54 82.4

55–59 72.3

60–64 67.5

65–69 62.4

63

The proportion of women screened is calculated from the number of women who had a Pap test at least once during 1. the reporting period, as a percentage of the target population of NSW women residents.

The proportion of the target population who are screened in a two-yearly period (biennial screening rate) is based on 2. the number of women screened at least once during the last 24-month reporting period.

In addition to the proportion of women screened in the target 20–69 year age group, screening rates have also been 3. presented in 20–49 years, 50–69 years, and also in fi ve-year age breakdowns for the 24-month reporting period.

Data are presented for the proportion of women screened within each LGA, AHS and for the whole state, with regional 4. breakdowns according to the ‘Accessibility/Remoteness Index of Australia’ (ARIA).

The maximum value for the two year screening proportion has been set at 100%, and estimated values which exceed 5. this level have been set to 100%. This may occur in LGAs with high-screening and / or small populations or LGAs with a high proportion of women working in seasonal occupations, or in commercial centres where women may supply a work address or post box number rather than her home address.

Appendix 4: Proportion of screened women

64


I. Regional Classifi cation

Women living in rural and remote areas are a key target group for the Program. A key objective of the Program’s 1. general recruitment efforts is to increase screening in at-risk women in rural and remote areas where screening rates are generally low compared to the NSW overall.

Within each AHS, local government areas (LGAs) have been assigned to one of six area classifi cations based on 2. population and remoteness index (ARIA) developed by the National Key Centre for Social Applications of Geographical Information Systems (GISCA),17 University of Adelaide and was sponsored by the Department of Health and Aged Care. Individual LGAs are designated as metropolitan (capital city or other metropolitan centre) or non-metropolitan (large rural centre; small rural centre; other rural area; and other remote area). Non-metropolitan statistical local areas are assigned according to their index of remoteness based on population density and distance to large population centres. The target population of NSW women eligible for cervical screening according to the six Area classifi cations is summarised in Table A3.

There are currently no accurate data available on hysterectomy fractions at individual LGA level. Consequently, 3. estimates of target women at risk of cervical cancer at the LGA level are not as accurate as would be desired.

Appendix 5: Sub-populations

Area classifi cationNo. of women by age group (year)

20–49 50–69 20–69

Major City 819,362 263,055 1,082,417

Inner Regional 429,989 183,663 613,652

Outer Regional 90,340 45,898 136,238

Remote 12,007 4,745 16,752

Very Remote 2,852 881 3,733

Not assigned†† 26,793 12,986 39,780

Table A3 Target female population in NSW by remoteness classifi cation and age

Source: 2004 and 2005 ABS Estimated Resident Population for NSW adjusted for hysterectomy fractions derived from the 2004 NSW Population Health Survey

††Refers to PTR 2005 assigned LGAs that could not be classifi ed based on the ARIA classifi cations (2001).

65

II. Socioeconomic status (SES) classifi cation

For the purpose of this report the Socioeconomic Indexes for Areas (SEIFA) was used. The variables used to create this index derive from attributes such as income levels, educational attainment and unemployment levels.

Local government areas (LGAs) were assigned as an indicator of SES, using the 2001 ABS Socioeconomic Index for Areas (ABS 2003). LGAs were partitioned into fi ve quintiles of SES, with approximately equal populations in each quintile as appeared below:

Code Description

1 Highest SES quintile

2 Second highest SES quintile

3 Median

4 Second lowest SES quintile

5 Lowest SES quintile

III. Proportion of screened women by Division of General Practice (DGP)

Biennial cervical screening rates for individual DGPs were obtained by using data from two different sources as follows:

NSW Pap Test Register (Number of screenings by postcode data). 1.

General Practice Branch of the Australian Government Department of Health and Ageing (Postcode to 2. DGP data).

IV. Area Health Service and local government area

The Area Health Services boundaries presented are designated geographic areas created by the NSW Department of Health. The LGAs in NSW are spatial units that represent the whole geographical area of responsibility of an incorporated Local Government Council. Details of the 2005 LGA boundaries used in this report are contained in the 2005 edition of the Australian Standard Geographic Classifi cation (ASGC) produced by the Australian Bureau of Statistics.18 These boundaries are used by the NSW Department of Health for LGA and AHS allocation. A woman on the NSW Pap Test Register currently has her address allocated to a local government area using National Localities Index and the LISA18 localities fi le. If a change of address has been recorded since a woman received her Pap test, the NSW Pap Test Register reallocates that woman to the most recent LGA of residence.

66


Appendix 6: Re-screening

Table A4 Number and proportion (%) of women aged 20–69 years with initially negative test result* who had a repeat Pap test within two years by

Area Health Service, 2005

*Excluding women with negative cytology result with recommendation to screen in less than two years or with a recorded history of CIN.

Area Health Service No further test (%) One further test (%) >1 further test (%)

Northern Sydney & Central Coast 6,376 (63.5) 3,160 (31.5) 498 (5.0)

South Eastern Sydney 6,543 (64.5) 3,010 (29.7) 597 (5.9)

Sydney South West 6,810 (65.7) 2,968 (28.6) 593 (5.7)

Sydney West 5,502 (68.8) 2,122 (26.5) 376 (4.7)

Metropolitan 25,231 (65.4) 11,260 (29.2) 2,064 (5.4)

Greater Southern 2,419 (72.9) 777 (23.4) 120 (3.6)

Greater Western 1,464 (74.7) 428 (21.8) 68 (3.5)

Hunter & New England 4,232 (70.1) 1,607 (26.6) 201 (3.3)

North Coast 2,085 (67.8) 836 (27.2) 152 (4.9)

Rural 10,200 (70.9) 3,648 (25.4) 541 (3.8)

AHS Not Available 507 115 17

NSW 35,938 (67.9) 15,023 (28.4) 2,622 (5.0)

67

Table A5 Biennial screening rate by metropolitan Divisions of General Practice and age, NSW

Appendix 7: Biennial (2004–2005) cervical

screening rates

Metropolitan

DGP

20–49 50–69 20–69

No. of women

screened

Biennial rate

(95% CI)

No. of women

screened

Biennial rate

(95% CI)

No. of women

screened

Biennial rate

(95% CI)

Bankstown 18,641 55.2 (54.7–55.7) 6,236 53.8 (52.9–54.7) 24,877 54.8 (54.4–55.3)

Blue Mountains 8,620 57.5 (56.7–58.3) 3,831 63.9 (62.6–65.1) 12,451 59.3 (58.7–60.0)

Canterbury 15,714 51.0 (50.4–51.5) 5,414 51.1 (50.1–52.0) 21,128 51.0 (50.5–51.5)

C. Sydney 53,667 57.7 (57.4–58.0) 14,406 55.6 (55.0–56.2) 68,072 57.2 (57.0–57.5)

E. Sydney 28,553 65.4 (65.0–65.9) 7,316 64.4 (63.5–65.3) 35,869 65.2 (64.8–65.6)

Fairfi eld 23,908 51.6 (51.2–52.1) 7,784 53.2 (52.4–54.0) 31,693 52.0 (51.6–52.4)

Hawkesbury 31,030 59.1 (58.6–59.5) 9,715 58.2 (57.5–59.0) 40,745 55.9 (55.6–56.3)

Hornsby Ku–Ring–

Gai50,390 58.6 (58.2–58.9) 22,204 64.8 (64.3–65.3) 72,594 60.3 (60.1–60.6)

Hunter (Urban) 52,444 61.2 (60.9–61.6) 19,032 61.1 (60.6–61.6) 71,476 61.2 (60.9–61.5)

Illawarra 31,131 57.8 (57.4–58.2) 10,984 53.2 (52.5–53.8) 42,115 56.5 (56.2–56.9)

Liverpool 19,225 50.3 (49.8–50.8) 4,934 47.6 (46.6–48.5) 24,160 49.7 (49.3–50.2)

Macarthur 26,654 52.9 (52.4–53.3) 7,513 50.3 (49.5–51.1) 34,124 52.2 (51.8–52.6)

Manly Warringah 32,157 66.0 (65.5–66.4) 11,472 63.0 (62.3–63.7) 43,629 65.1 (64.8–65.5)

Nepean 19,903 50.3 (49.8–50.8) 5,497 51.7 (50.7–52.6) 25,400 50.6 (50.1–51.0)

N. Sydney 32,772 62.9 (62.5–63.3) 11,481 67.9 (67.2–68.6) 44,253 64.1 (63.8–64.5)

C. Coast 33,609 59.8 (59.4–60.2) 13,250 57.0 (56.4–57.7) 46,859 59.0 (58.7–59.4)

S.E. Sydney 26,123 58.2 (57.8–58.7) 7,626 58.8 (57.9–59.6) 33,749 58.3 (57.9–58.7)

St George 26,635 55.1 (54.7–55.5) 9,768 57.7 (56.9–58.4) 36,403 55.8 (55.4–56.2)

Sutherland 28,038 63.4 (63.0–63.8) 10,126 62.2 (61.4–62.9) 38,164 63.1 (62.7–63.5)

W. Sydney 48,750 48.5 (48.2–48.8) 14,828 51.8 (51.2–52.4) 63,577 49.2 (48.9–49.5)

Metropolitan

DGP Total607,964 57.1 (57.1–57.2) 203,417 57.8 (57.6–58.0) 811,338 57.2 (57.1–57.2)

68


Table A6 Biennial screening rate by rural Divisions of General Practice and age, NSW

Rural DGP

20–49 50–69 20–69

No. of women

screened

Biennial rate

(95% CI)

No. of women

screened

Biennial rate

(95% CI)

No. of women

screened

Biennial rate

(95% CI)

Barrier 2,144 51.6 (50.1–53.1) 978 57.2 (54.9–59.6) 3,122 53.2 (52.0–54.5)

Barwon 5,227 53.6 (52.6–54.6) 2,102 53.8 (52.3–55.4) 7,329 53.6 (52.8–54.5)

Dubbo Plains 9,133 51.5 (50.7–52.2) 3,845 55.7 (54.5–56.9) 12,978 52.7 (52.0–53.3)

Hunter (Rural) 20,520 60.4 (59.8–60.9) 9,007 58.1 (57.4–58.9) 29,527 59.7 (59.2–60.1)

Mid North Coast 13,586 63.7 (63.1–64.4) 6,215 70.1 (69.1–71.0) 19,802 65.6 (65.1–66.1)

Murrumbidgee 6,343 56.4 (55.4–57.3) 2,519 56.8 (55.4–58.3) 8,862 56.5 (55.7–57.3)

New England 7,414 63.7 (62.9–64.6) 3,321 67.0 (65.6–68.3) 10,735 64.7 (64.0–65.4)

North West Slopes 6,793 63.5 (62.6–64.4) 2,922 63.7 (62.3–65.1) 9,715 63.6 (62.8–64.3)

Northern Rivers 18,825 65.6 (65.1–66.2) 7,998 68.3 (67.4–69.1) 26,823 66.4 (65.9–66.9)

Central West 17,877 58.2 (57.7–58.8) 7,092 61.1 (60.2–62.0) 24,969 59.0 (58.6–59.5)

NSW Outback 1,615 49.7 (47.9–51.4) 582 60.4 (57.3–63.5) 2,197 52.1 (50.6–53.6)

Port Macquarie 9,817 63.4 (62.6–64.2) 5,003 65.8 (64.8–66.9) 14,819 64.2 (63.6–64.8)

Riverina 11,509 56.8 (56.1–57.5) 4,555 57.7 (56.6–58.8) 16,064 57.0 (56.5–57.6)

Shoalhaven 8,345 57.5 (56.7–58.3) 4,513 53.4 (52.4–54.5) 12,858 56.0 (55.4–56.7)

S. E. NSW 17,218 59.3 (58.7–59.9) 8,428 61.4 (60.6–62.2) 25,646 60.0 (59.5–60.4)

Southern Highlands 5,196 61.3 (60.3–62.4) 2,610 59.7 (58.3–61.2) 7,807 60.8 (59.9–61.6)

Tweed Valley 8,349 65.2 (64.4–66.1) 4,068 64.0 (62.8–65.2) 12,417 64.8 (64.1–65.5)

Rural DGP Total 169,911 59.9 (59.7–60.1) 75,758 61.3 (61.1–61.6) 245,670 60.3 (60.2–60.5)

Division not

allocated15,544 5,100 20,644

69

Tabl

e A

7 B

ienn

ial c

ervi

cal s

cree

ning

by

Are

a H

ealt

h Se

rvic

e an

d 5–

year

age

gro

up, N

SW

Are

a H

ealt

h S

erv

ice

No

. an

d p

rop

ort

ion

(%

) o

f w

om

en

scre

en

ed

by a

ge g

rou

p (

year)

20 –

24

25 –

29

30 –

34

35 –

39

40 –

44

45 –

49

50 –

54

55 –

59

60 –

64

65 –

69

ME

TR

OP

OLIT

AN

Nor t

her

n S

ydney

& C

entr

al

Coas

t

16,3

36

(45.4

)

20,6

22

(56.3

)

27,4

22

(64.7

)

26,7

71

(65.3

)

27,5

12

(63.4

)

23,4

51

(64.7

)

19,7

53

(60.0

)

16,4

63

(68.4

)

11,2

08

(59.8

)7,4

86 (

47.7

)

South

Eas

tern

Syd

ney

& Illa

war

ra

18,1

04

(41.9

)

25,2

01

(56.1

)

29,9

00

(61.2

)

25,8

24

(60.7

)

25,0

72

(65.1

)

21,7

02

(65.5

)

17,7

55

(54.7

)

14,6

75

(54.1

)

10,1

17

(51.5

)7,2

13 (

52.0

)

Sydney

South

Wes

t

19,0

07

(37.9

)

27,6

91

(52.4

)

33,6

24

(58.2

)

29,2

34

(59.6

)

28,2

92

(59.2

)

23,9

36

(60.6

)

18,9

26

(56.8

)

14,3

11

(50.8

)

8,9

70

(48.9

)6,1

39 (

42.0

)

Sydney

Wes

t

15,1

47

(38.5

)

19,6

85

(52.5

)

23,9

07

(54.9

)

22,2

14

(56.5

)

21,6

72

(52.6

)

18,8

87

(58.2

)

15,5

21

(52.9

)

12,0

90

(67.4

)

7,2

47

(54.9

)4442 (

48.1

)

RU

RA

L

Gre

ater

South

ern

6,7

27

(54.0

)

7,1

72

(59.0

)

8,9

43

(60.9

)

8,9

40

(60.3

)

9,5

20

(64.3

)

8,4

00

(60.2

)

7,1

27

(54.6

)5,9

31 (

53.3

)4,5

75

(61.4

)3,2

32 (

52.9

)

Gre

ater

Wes

tern

4,2

87

(52.4

)

4,4

32

(54.7

)

5,3

33

(53.9

)

5,2

78

(54.4

)

5,3

95

(53.7

)

4,8

16

(51.1

)

4,0

21

(53.3

)3,5

09 (

55.1

)2,5

56

(58.4

)1,8

29 (

49.5

)

Hunte

r &

New

Engl

and

13,1

60

(53.9

)

13,7

02

(60.5

)

16,7

97

(62.4

)

16,0

67

(64.2

)

16,9

17

(64.7

)

14,7

53

(63.1

)

12,4

20

(59.8

)

10,5

32

(51.7

)

7,5

74

(57.8

)5,4

66 (

49.9

)

Nort

h C

oas

t6,2

34

(61.7

)

6,4

70

(67.5

)

8,6

07

(64.3

)

9,2

28

(67.9

)

10,7

37

(67.9

)

10,1

47

(70.8

)

8,2

76

(79.2

)6,5

43 (

65.1

)4,9

64

(56.8

)3,8

11 (

51.2

)

AH

S not

avai

lable

1,2

88

1,7

10

1,9

46

1,7

74

1,5

14

1,2

94

1,1

34

1,0

54

705

459

NS

W T

ota

l100,2

90

(44.8

)

126,6

85

(56.4

)

156,4

79

(60.8

)

145,3

30

(61.8

)

146,6

31

(61.6

)

127,3

86

(62.9

)

104,9

33

(58.3

)

85,1

08

(58.6

)

57,9

16

(55.9

)

40,0

77

(49.1

)

70


Table A8 Biennial cervical screening rates (%) by age groups (20–49, 50–69, 20–69), Area Health Service (AHS) and local government area (LGA),

NSW, 2004–2005

AHS / LGA

20–49 50–69 20–69

No.Proportion

(95% CI)No.

Proportion

(95% CI)No.

Proportion

(95% CI)

GREATER SOUTHERN AREA HEALTH SERVICE

Albury 6,186 67.6 (66.7–68.6) 2,204 63.9 (62.3–65.5) 8,390 66.6 (65.8–67.4)

Bega Valley 3,120 61.0 (59.7–62.4) 1,804 58.7 (57.0–60.5) 4,924 60.2 (59.1–61.2)

Bland 500 46.1 (43.2–49.1) 197 38.2 (34.0–42.4) 697 43.6 (41.1–46.0)

Bombala 248 60.3 (55.6–65.1) 130 60.0 (53.4–66.5) 378 60.2 (56.4–64.0)

Boorowa 207 54.0 (49.0–59.0) 104 49.9 (43.1–56.7) 311 52.5 (48.5–56.6)

Carrathool 303 51.4 (47.4–55.4) 107 49.3 (42.7–56.0) 410 50.8 (47.4–54.3)

Conargo 42 15.6 (11.2–19.9) 21 14.4 (8.7–20.1) 63 15.2 (11.7–18.6)

Coolamon 399 60.6 (56.8–64.3) 183 58.4 (52.9–63.9) 582 59.9 (56.8–62.9)

Cooma-Monaro 1,120 68.9 (66.6–71.1) 555 65.3 (62.1–68.5) 1,675 67.6 (65.8–69.5)

Cootamundra 679 54.7 (51.9–57.5) 354 51.5 (47.8–55.2) 1,033 53.6 (51.3–55.8)

Deniliquin 1,061 71.0 (68.7–73.3) 428 67.9 (64.2–71.5) 1,489 70.0 (68.1–72.0)

Eurobodalla 2,925 55.6 (54.2–56.9) 1,956 51.8 (50.2–53.4) 4,881 54.0 (53.0–55.0)

Goulburn Mulwar 2,753 57.4 (56.0–58.8) 1,077 48.1 (46.1–50.2) 3,830 54.4 (53.3–55.6)

Gt Hume Shire 991 60.5 (58.1–62.8) 499 54.1 (50.9–57.3) 1,490 58.2 (56.3–60.1)

Griffi th 2,790 58.6 (57.2–60.0) 936 56.0 (53.6–58.3) 3,726 57.9 (56.7–59.1)

Gundagai 395 65.0 (61.2–68.8) 192 60.3 (54.9–65.7) 587 63.4 (60.3–66.5)

Harden 322 54.5 (50.5–58.5) 166 47.7 (42.4–52.9) 488 52.0 (48.8–55.2)

Hay 393 65.1 (61.3–68.9) 144 51.8 (45.9–57.6) 537 60.9 (57.7–64.1)

Junee 468 50.7 (47.4–53.9) 182 45.0 (40.2–49.9) 650 48.9 (46.2–51.6)

Leeton 1,092 51.6 (49.5–53.8) 414 50.5 (47.1–54.0) 1,506 51.3 (49.5–53.1)

Lockhart 335 59.3 (55.2–63.3) 171 59.8 (54.2–65.5) 506 59.5 (56.2–62.8)

Murray 640 57.2 (54.3–60.1) 306 51.8 (47.8–55.9) 946 55.3 (53.0–57.7)

Murrumbidgee 256 50.5 (46.2–54.9) 97 51.0 (43.9–58.1) 353 50.7 (47.0–54.4)

Narrandera 557 52.3 (49.3–55.3) 272 52.4 (48.1–56.7) 829 52.4 (49.9–54.8)

Palerang 1,320 62.0 (60.0–64.1) 613 56.8 (53.9–59.8) 1,933 60.3 (58.6–62.0)

Queanbeyan 4,866 62.1 (61.1–63.2) 1,224 49.7 (47.7–51.7) 6,090 59.2 (58.2–60.1)

Snowy River 721 51.9 (49.3–54.5) 250 44.5 (40.4–48.6) 971 49.7 (47.5–52.0)

Temora 615 59.7 (56.7–62.7) 324 64.9 (60.7–69.0) 939 61.4 (58.9–63.8)

Tumbarumba 304 55.6 (51.4–59.7) 166 51.9 (46.5–57.4) 470 54.2 (50.9–57.5)

Tumut Shire 1,193 60.5 (58.3–62.6) 495 53.5 (50.3–56.8) 1,688 58.3 (56.5–60.1)

Upper Lachlan 692 61.6 (58.8–64.5) 365 49.6 (46.0–53.2) 1,057 56.9 (54.6–59.1)

Urana 161 70.3 (64.4–76.2) 90 80.9 (73.6–88.2) 251 73.7 (69.1–78.4)

Wagga Wagga 6,734 58.0 (57.1–58.9) 2,279 56.5 (54.9–58.0) 9,013 57.6 (56.8–58.4)

Wakool 372 48.4 (44.8–51.9) 182 47.8 (42.8–52.8) 554 48.2 (45.3–51.1)

Yass Valley 1,354 57.6 (55.6–59.6) 612 52.7 (49.8–55.5) 1,966 56.0 (54.3–57.6)

Young 1,273 64.3 (62.2–66.4) 508 53.2 (50.0–56.3) 1,781 60.7 (58.9–62.5)

71

Table A8 (Continued from previous page)

AHS / LGA

20–49 50–69 20–69

No.Proportion

(95% CI)No.

Proportion

(95% CI)No.

Proportion

(95% CI)

GREATER WESTERN AREA HEALTH SERVICE

Balranald 273 51.2 (47.0–55.5) 77 46.5 (38.9–54.1) 350 50.1 (46.4–53.8)

Bathurst Regional 4,451 61.7 (60.5–62.8) 1,629 67.7 (65.8–69.5) 6,080 63.2 (62.2–64.1)

Blayney 672 60.0 (57.1–62.8) 271 54.1 (49.7–58.5) 943 58.2 (55.8–60.6)

Bogan 228 44.3 (40.0–48.6) 131 56.7 (50.3–63.1) 359 48.1 (44.5–51.7)

Bourke 298 38.9 (35.4–42.3) 80 37.5 (31.0–44.0) 378 38.6 (35.5–41.6)

Brewarrina 134 32.5 (28.0–37.1) 51 45.5 (36.3–54.7) 185 35.3 (31.2–39.4)

Broken Hill 1,914 53.7 (52.0–55.3) 891 56.2 (53.8–58.7) 2,805 54.4 (53.1–55.8)

Cabonne 1,064 52.6 (50.4–54.8) 498 47.1 (44.1–50.1) 1,562 50.7 (48.9–52.5)

Central Darling 187 42.7 (38.1–47.3) 81 49.5 (41.8–57.1) 268 44.5 (40.6–48.5)

Cobar 479 47.1 (44.0–50.2) 167 57.2 (51.5–62.9) 646 49.3 (46.6–52.1)

Coonamble 417 50.0 (46.6–53.3) 176 55.3 (49.8–60.7) 593 51.4 (48.5–54.3)

Dubbo 4,034 51.2 (50.1–52.3) 1,443 54.1 (52.2–56.0) 5,477 52.0 (51.0–52.9)

Forbes 891 53.3 (50.9–55.7) 399 51.5 (48.0–55.0) 1,290 52.7 (50.7–54.7)

Gilgandra 377 48.7 (45.1–52.2) 167 45.7 (40.6–50.8) 544 47.7 (44.8–50.6)

Lachlan 629 48.0 (45.3–50.7) 273 54.8 (50.4–59.1) 902 49.8 (47.5–52.2)

Mid-Western Reg. 1,968 50.7 (49.1–52.2) 865 49.5 (47.2–51.9) 2,833 50.3 (49.0–51.6)

Narromine 599 47.0 (44.2–49.7) 288 58.3 (53.9–62.6) 887 50.1 (47.8–52.5)

Oberon 490 54.0 (50.8–57.2) 228 54.2 (49.5–59.0) 718 54.1 (51.4–56.8)

Orange 4,454 61.1 (60.0–62.2) 1,463 57.7 (55.8–59.6) 5,917 60.2 (59.2–61.2)

Parkes 1,361 52.1 (50.2–54.0) 511 48.5 (45.5–51.5) 1,872 51.0 (49.4–52.7)

UFW NSW 93 42.7 (36.1–49.2) 35 35.2 (25.8–44.6) 128 40.3 (34.9–45.7)

Walgett 630 42.5 (40.0–45.0) 255 46.3 (42.1–50.5) 885 43.5 (41.4–45.7)

Warren 293 48.1 (44.1–52.0) 119 51.9 (45.4–58.3) 412 49.1 (45.7–52.5)

Warrumbungle 868 53.2 (50.8–55.6) 464 54.1 (50.8–57.5) 1,332 53.5 (51.6–55.5)

Weddin 320 56.1 (52.0–60.2) 189 54.3 (49.1–59.6) 509 55.4 (52.2–58.6)

Wellington 717 51.1 (48.4–53.7) 366 51.7 (48.0–55.4) 1,083 51.3 (49.1–53.4)

Wentworth 627 49.0 (46.3–51.8) 285 51.0 (46.8–55.1) 912 49.6 (47.3–51.9)

HUNTER & NEW ENGLAND AREA HEALTH SERVICE

Armidale Dumaresq 3,215 67.0 (65.7–68.4) 1,216 70.3 (68.2–72.5) 4,431 67.9 (66.8–69.0)

Cessnock 4,757 54.3 (53.3–55.4) 1,601 43.9 (42.3–45.5) 6,358 51.3 (50.4–52.1)

Dungog 952 68.3 (65.9–70.8) 417 58.2 (54.6–61.8) 1,369 64.9 (62.8–66.9)

Glen Innes Severn 1,048 77.4 (75.2–79.6) 485 61.7 (58.3–65.1) 1,533 71.6 (69.7–73.6)

Gloucester 453 62.8 (59.3–66.3) 300 65.9 (61.5–70.2) 753 64.0 (61.2–66.7)

72



AHS / LGA

20–49 50–69 20–69

No.Proportion

(95% CI)No.

Proportion

(95% CI)No.

Proportion

(95% CI)

HUNTER & NEW ENGLAND AREA HEALTH SERVICE (continued)

Greater Taree 4,198 58.8 (57.7–59.9) 2,173 52.6 (51.1–54.1) 6,371 56.5 (55.6–57.4)

Great Lakes 2,718 58.8 (57.4–60.2) 1,725 49.5 (47.8–51.1) 4,443 54.8 (53.7–55.9)

Gunnedah 1,146 56.8 (54.6–58.9) 476 51.9 (48.7–55.1) 1,622 55.2 (53.5–57.0)

Guyra 455 64.8 (61.2–68.3) 222 61.5 (56.5–66.5) 677 63.7 (60.8–66.5)

Gwydir 514 58.2 (55.0–61.5) 287 57.7 (53.3–62.0) 801 58.0 (55.4–60.6)

Inverell 1,639 63.9 (62.1–65.8) 850 67.0 (64.4–69.6) 2,489 64.9 (63.4–66.5)

Lake Macquarie 21,334 64.4 (63.9–64.9) 9,063 57.7 (57.0–58.5) 30,397 62.2 (61.8–62.7)

Liverpool Plains 761 60.2 (57.5–62.9) 358 51.9 (48.2–55.7) 1,119 57.3 (55.1–59.5)

Maitland 7,513 65.2 (64.4–66.1) 2,283 53.9 (52.4–55.4) 9,796 62.2 (61.4–62.9)

Moree Plains 1,545 48.8 (47.0–50.5) 479 48.5 (45.4–51.6) 2,024 48.7 (47.2–50.2)

Muswellbrook 1,707 61.2 (59.4–63.0) 510 52.5 (49.4–55.6) 2,217 58.9 (57.4–60.5)

Narrabri 1,440 57.1 (55.1–59.0) 535 51.5 (48.5–54.6) 1,975 55.4 (53.8–57.1)

Newcastle 18,309 61.6 (61.0–62.1) 5,644 55.9 (54.9–56.9) 23,953 60.1 (59.6–60.6)

Port Stephens 6,499 60.4 (59.5–61.3) 2,856 54.5 (53.1–55.8) 9,355 58.4 (57.7–59.2)

Singleton 2,552 61.5 (60.0–63.0) 613 43.2 (40.6-45.8) 3,165 56.8 (55.5–58.1)

Tamworth Regional 6,249 65.6 (64.6–66.5) 2,649 61.2 (59.8–62.7) 8,898 64.2 (63.4–65.0)

Tenterfi eld 498 46.0 (43.0–48.9) 290 48.9 (44.8–52.9) 788 47.0 (44.6–49.4)

Upper Hunter Shire 1,537 67.0 (65.1–69.0) 617 57.4 (54.4–60.3) 2,154 64.0 (62.3–65.6)

Uralla 675 64.2 (61.3–67.1) 317 59.9 (55.8–64.1) 992 62.7 (60.4–65.1)

Walcha 359 70.4 (66.4–74.3) 231 81.6 (77.1–86.1) 590 74.4 (71.3–77.4)

NORTH COAST AREA HEALTH SERVICE

Ballina 4,584 69.4 (68.3–70.6) 2,136 67.6 (66.0–69.3) 6,720 68.9 (67.9–69.8)

Bellingen 1,356 68.8 (66.7–70.8) 660 61.9 (59.0–64.8) 2,016 66.4 (64.7–68.0)

Byron 4,432 72.6 (71.5–73.7) 1,642 73.7 (71.9–75.6) 6,074 72.9 (72.0–73.9)

Clarence Valley 4,116 53.5 (52.4–54.6) 2,134 52.5 (50.9–54.0) 6,250 53.1 (52.2–54.0)

Coffs Harbour 7,368 65.0 (64.1–65.9) 3,146 61.6 (60.2–62.9) 10,514 63.9 (63.2–64.7)

Hastings 6,891 65.3 (64.4–66.2) 3,475 56.8 (55.6–58.1) 10,366 62.2 (61.4–62.9)

Kempsey 2,610 58.6 (57.2–60.1) 1,359 58.4 (56.4–60.4) 3,969 58.5 (57.4–59.7)

Kyogle 837 55.9 (53.4–58.5) 395 53.4 (49.8–57.0) 1,232 55.1 (53.1–57.2)

Lismore 5,315 66.3 (65.3–67.3) 1,999 66.6 (64.9–68.3) 7,314 66.4 (65.5–67.3)

Nambucca 1,709 62.7 (60.9–64.5) 990 63.5 (61.1–65.9) 2,699 63.0 (61.5–64.4)

Richmond Valley 2,104 62.2 (60.6–63.8) 825 54.3 (51.8–56.8) 2,929 59.8 (58.4–61.1)

Tweed 8,114 64.0 (63.2–64.8) 3,973 60.7 (59.5–61.9) 12,087 62.9 (62.2–63.6)

73


AHS / LGA

20–49 50–69 20–69

No.Proportion

(95% CI)No.

Proportion

(95% CI)No.

Proportion

(95% CI)

NORTHERN SYDNEY AND CENTRAL COAST

Gosford 18,719 60.6 (60.1–61.2) 7,435 53.6 (52.8–54.5) 26,154 58.5 (58.0–58.9)

Hornsby 19,079 57.5 (57.0–58.1) 8,089 63.6 (62.8–64.5) 27,168 59.2 (58.8–59.7)

Hunter’s Hill 1,595 62.4 (60.5–64.3) 778 65.6 (62.9–68.3) 2,373 63.4 (61.9–65.0)

Ku-Ring-Gai 12,854 63.8 (63.1–64.5) 6,945 68.9 (68.0–69.8) 19,799 65.5 (65.0–66.0)

Lane Cove 4,788 62.6 (61.6–63.7) 1,732 68.0 (66.1–69.8) 6,520 64.0 (63.0–64.9)

Manly 6,504 69.4 (68.5–70.3) 1,919 67.2 (65.5–68.9) 8,423 68.9 (68.1–69.7)

Mosman 5,147 75.8 (74.8–76.9) 1,808 73.8 (72.1–75.6) 6,955 75.3 (74.4–76.2)

North Sydney 10,971 62.0 (61.3–62.7) 3,267 65.9 (64.5–67.2) 14,238 62.8 (62.2–63.5)

Pittwater 7,429 65.0 (64.1–65.9) 3,311 64.4 (63.1–65.7) 10,740 64.8 (64.1–65.5)

Ryde 12,475 53.2 (52.6–53.8) 4,372 57.1 (56.0–58.2) 16,847 54.2 (53.6–54.7)

Warringah 18,844 63.0 (62.4–63.5) 6,648 59.3 (58.3–60.2) 25,492 62.0 (61.5–62.4)

Willoughby 9,045 57.8 (57.1–58.6) 3,079 63.6 (62.2–64.9) 12,124 59.2 (58.5–59.9)

Wyong 14,736 54.4 (53.8–55.0) 5,623 47.4 (46.5–48.3) 20,359 52.3 (51.8–52.7)

SOUTH EASTERN SYDNEY & ILLAWARRA AREA HEALTH SERVICE

Botany Bay 4,110 51.7 (50.6–52.8) 1,505 48.7 (46.9–50.4) 5,615 50.8 (49.9–51.8)

Hurstville 9,743 60.7 (59.9–61.4) 3,510 59.2 (57.9–60.4) 13,253 60.3 (59.6–60.9)

Kiama 2,250 64.6 (63.0–66.2) 1,062 56.6 (54.4–58.9) 3,312 61.8 (60.5–63.1)

Kogarah 6,045 51.0 (50.1–51.9) 2,206 50.8 (49.3–52.3) 8,251 51.0 (50.2–51.7)

Randwick 17,979 56.9 (56.4–57.5) 5,189 56.8 (55.8–57.8) 23,168 56.9 (56.4–57.4)

Rockdale 10,677 51.8 (51.1–52.5) 3,917 51.5 (50.4–52.6) 14,594 51.7 (51.2–52.3)

Shellharbour 6,989 55.4 (54.5–56.2) 2,132 43.1 (41.8–44.5) 9,121 51.9 (51.2–52.7)

Shoalhaven 8,467 56.9 (56.1–57.7) 4,552 48.8 (47.8–49.8) 13,019 53.8 (53.2–54.4)

Sutherland Shire 28,050 63.0 (62.6–63.4) 10,202 57.8 (57.1–58.5) 38,252 61.5 (61.1–61.9)

Sydney 12,908 57.4 (56.8–58.0) 2,562 57.6 (56.1–59.0) 15,470 57.4 (56.8–58.0)

Waverley 11,441 71.0 (70.3–71.7) 2,637 59.6 (58.2–61.1) 14,078 68.6 (67.9–69.2)

Wollongong 21,755 57.1 (56.7–57.6) 7,733 49.8 (49.0–50.6) 29,488 55.0 (54.6–55.4)

Woollahra 9,101 72.8 (72.1–73.6) 3,283 67.3 (66.0–68.6) 12,384 71.3 (70.6–72.0)

74



AHS / LGA

20–49 50–69 20–69

No.Proportion

(95% CI)No.

Proportion

(95% CI)No.

Proportion

(95% CI)

SYDNEY SOUTH WEST AREA HEALTH SERVICE

Ashfi eld 5,214 53.6 (52.6–54.6) 1,514 51.4 (49.6–53.2) 6,728 53.1 (52.2–54.0)

Bankstown 18,988 53.8 (53.2–54.3) 6,394 50.1 (49.3–51.0) 25,382 52.8 (52.4–53.3)

Burwood 3,571 51.1 (49.9–52.3) 1,246 53.6 (51.6–55.7) 4,817 51.7 (50.7–52.8)

Camden 6,472 57.8 (56.9–58.7) 1,654 50.7 (49.0–52.4) 8,126 56.2 (55.4–57.0)

Campbelltown 16,027 49.3 (48.7–49.8) 4,691 43.6 (42.7–44.5) 20,718 47.9 (47.4–48.3)

Canada Bay 9,328 60.1 (59.4–60.9) 3,119 58.6 (57.2–59.9) 12,447 59.7 (59.1–60.4)

Canterbury 15,255 52.1 (51.6–52.7) 5,258 52.4 (51.4–53.4) 20,513 52.2 (51.7–52.7)

Fairfi eld 21,241 52.9 (52.4–53.4) 7,083 51.1 (50.3–51.9) 28,324 52.4 (52.0–52.8)

Leichhardt 9,501 53.6 (52.9–54.3) 2,475 54.6 (53.2–56.1) 11,976 53.8 (53.2–54.5)

Liverpool 19,117 50.9 (50.3–51.4) 4,775 44.8 (43.8–45.7) 23,892 49.5 (49.1–50.0)

Marrickville 11,979 58.8 (58.1–59.4) 2,695 52.3 (51.0–53.7) 14,674 57.5 (56.9–58.1)

Strathfi eld 3,387 49.6 (48.4–50.8) 1,262 54.5 (52.5–56.5) 4,649 50.8 (49.8–51.8)

Sydney 9,348 57.3 (56.5–58.1) 1,855 58.6 (56.9–60.3) 11,203 57.5 (56.8–58.2)

Wingecarribee 4,736 62.5 (61.4–63.6) 2,381 55.6 (54.1–57.0) 7,117 60.0 (59.1–60.9)

Wollondilly 4,509 53.8 (52.7–54.8) 1,352 44.2 (42.5–46.0) 5,861 51.2 (50.3–52.1)

SYDNEY WEST AREA HEALTH SERVICE

Auburn 7,008 50.6 (49.8–51.5) 1,829 55.2 (53.5–56.9) 8,837 51.5 (50.8–52.3)

Baulkham Hills 20,739 61.8 (61.3–62.3) 8,726 72.6 (71.8–73.4) 29,465 64.7 (64.2–65.1)

Blacktown 28,999 47.2 (46.8–47.6) 7,973 48.1 (47.4–48.9) 36,972 47.4 (47.1–47.8)

Blue Mountains 8,539 57.1 (56.3–57.9) 3,808 61.0 (59.8–62.2) 12,347 58.3 (57.6–58.9)

Hawkesbury 7,869 58.6 (57.8–59.5) 2,396 58.9 (57.4–60.4) 10,265 58.7 (58.0–59.4)

Holroyd 10,681 52.7 (52.0–53.4) 3,397 58.1 (56.8–59.3) 14,078 53.9 (53.3–54.5)

Lithgow 1,922 52.1 (50.5–53.7) 832 53.0 (50.6–55.5) 2,754 52.4 (51.0–53.7)

Parramatta 16,239 49.0 (48.4–49.5) 4,974 53.3 (52.3–54.3) 21,213 49.9 (49.4–50.4)

Penrith 19,764 50.4 (49.9–50.9) 5,542 51.6 (50.7–52.6) 25,306 50.7 (50.2–51.1)

75

Table A9 Age-standardised‡‡ incidence of cervical cancer, NSW, 1972–2005

‡‡Standard Australian Population at 30 June 2001

Appendix 8: Age-standardised incidence

Year of diagnosis Number of cases Rate per 100,000 women (95% CI)

1972 343 16.6 (14.9-18.4)

1973 336 16.3 (14.5-18)

1974 345 16.6 (14.8-18.4)

1975 379 17.7 (15.9-19.5)

1976 369 16.9 (15.1-18.6)

1977 355 16 (14.3-17.7)

1978 334 14.8 (13.2-16.4)

1979 298 13.1 (11.6-14.6)

1980 321 13.8 (12.2-15.3)

1981 377 16 (14.3-17.6)

1982 333 13.8 (12.3-15.3)

1983 338 13.7 (12.3-15.2)

1984 344 13.7 (12.2-15.2)

1985 336 13.3 (11.9-14.7)

1986 373 14.4 (12.9-15.9)

1987 375 13.9 (12.5-15.3)

1988 341 12.5 (11.1-13.8)

1989 352 12.6 (11.3-13.9)

1990 371 13.2 (11.9-14.6)

1991 369 12.8 (11.5-14.2)

1992 383 13.2 (11.9-14.5)

1993 352 11.9 (10.7-13.2)

1994 364 12 (10.8-13.3)

1995 326 10.7 (9.5-11.9)

1996 329 10.6 (9.4-11.7)

1997 282 8.9 (7.9-10)

1998 294 9.1 (8-10.1)

1999 275 8.3 (7.3-9.3)

2000 286 8.5 (7.5-9.5)

2001 255 7.5 (6.6-8.4)

2002 223 6.4 (5.6-7.3)

2003 242 6.9 (6-7.8)

2004 256 7.3 (6.4-8.1)

2005 208 5.8 (5-6.6)

76


Table A10 Age-standardised§§ mortality from cervical cancer, NSW, 1972–2005

§§Standard Australian Population at 30 June 2001

Year Number of death Rate per 100,000 women (95% CI)

1972 130 6.4 (5.3–7.6)

1973 146 7.0 (5.9–8.2)

1974 138 6.6 (5.5–7.7)

1975 140 6.6 (5.5–7.7)

1976 131 6.1 (5.0–7.1)

1977 143 6.4 (5.3–7.4)

1978 127 5.7 (4.7–6.7)

1979 122 5.3 (4.3–6.2)

1980 104 4.5 (3.6–5.3)

1981 121 5.0 (4.1–5.9)

1982 141 5.8 (4.8–6.8)

1983 127 5.2 (4.3–6.1)

1984 135 5.4 (4.5–6.3)

1985 143 5.6 (4.7–6.5)

1986 122 4.7 (3.8–5.5)

1987 132 4.9 (4.1–5.7)

1988 132 4.9 (4.1–5.8)

1989 139 5.0 (4.1–5.8)

1990 116 4.1 (3.4–4.9)

1991 100 3.4 (2.7–4.0)

1992 119 4.0 (3.3–4.7)

1993 103 3.5 (2.8–4.2)

1994 134 4.4 (3.7–5.2)

1995 114 3.7 (3.0–4.4)

1996 100 3.1 (2.5–3.8)

1997 100 3.0 (2.4–3.6)

1998 92 2.8 (2.2–3.3)

1999 84 2.4 (1.9–2.9)

2000 91 2.6 (2.1–3.1)

2001 83 2.4 (1.8–2.9)

2002 71 2.0 (1.5–2.4)

2003 77 2.1 (1.6–2.6)

2004 78 2.0 (1.6–2.5)

2005 75 2.0 (1.5–2.4)

Appendix 9: Age-standardised mortality

77

Table A11 Age-specifi c population estimates for NSW against 2001 standard Australian population

Note: In the current report, age-standardised cervical cancer incidence and mortality rates have been calculated using 2001 ABS Estimated Resident Population of Australia as the standard population when calculating age-standardised rates.

Appendix 10: Population estimates

Age group

(year)

Standard

population

Australia

Estimated resident female population in New South Wales

2001 2002 2003 2004 2005

0–4 1,243,946 209,998 208,734 206,786 207,177

5–9 1,332,001 219,545 217,177 215,385 216,445

10–14 1,336,500 222,365 223,040 222,968 224,221

15–19 1,325,210 219,024 220,765 221,368 224,460

20–24 1,241,125 215,476 221,826 224,525 223,417

25–29 1,319,201 235,186 231,172 228,110 224,891

30–34 1,404,329 254,762 258,397 258,207 257,498

35–39 1,431,612 248,713 244,117 242,062 249,422

40–44 1,436,643 255,317 256,930 256,825 255,460

45–49 1,319,732 230,346 234,317 238,463 244,117

50–54 1,248,483 215,417 216,764 218,199 220,544

55–59 970,681 180,476 190,603 197,548 204,842

60–64 788,912 143,193 145,702 150,936 156,007

65–69 660,568 123,633 126,263 129,692 132,259

70–74 619,494 117,855 115,604 113,879 113,179

75–79 504,614 104,309 105,145 106,355 106,402

80–84 323,403 75,377 78,309 81,407 83,411

85+ 262,689 67,203 69,824 71,964 74,928

All ages 18,769,143 3,340,197 3,366,692 3,386,683 3,418,680

78


An unknown number of women may nominate their work address or a post offi ce box rather than their home address for registration with the NSW Pap Test Register. However, population denominator data from the census are based on LGA of residence. The recording of these addresses for Pap tests is likely to overestimate the number and proportion of women screened in those local government areas with signifi cant business or employment activities, such as Sydney, South Sydney or North Sydney, and perhaps some rural centres. The relevant data should therefore be read with caution.

The NSW Pap Test Register does not possess data on the age of a small proportion of screened women (Table A10). Because these women cannot be reported by target age group, they have been excluded from the count of women screened in the tables presented in this report.

A number of women who have had Pap tests do not consent to disclose their personal details to the NSW Pap Test Register. This is referred to as “opting-off”. The number of women who opted off the NSW PTR could not be allocated to an LGA, DGP or by an AHS (Tables A4, A5, A6 and A7). Although the rate of opt-offs are small (Table A10), the effect of this non-disclosure is to underestimate the proportion of women screened in NSW.

Table A12 Number and proportion of women of all ages screened with age unknown, Area Health Service unknown and opt-off rate,

NSW, 2004–2005

*Number of women#Number of tests

Appendix 11: Explanatory notes on screening data

Area Health Service Number of women / tests Proportion (%)of women / tests

Area Health Service unknown 13,004* 1.2

Age unknown 356* 0.03

Opt–off 13,979# 1.03

79

The common population data such as cervical screening rates, incidence of and mortality from cervical cancer etc. have 1. natural variability in numbers in a particular time period, for example, for the year 2005. This variability can be in either direction from the mean rate of the events over many years. Ninety-fi ve per cent confi dence interval (95% CI) is used to describe the degree of the random sample variation from the mean rate. Such variation is small for large population data but large for small numbers. In 95% CI, there is 95% probability that the differences (between the sample data and the population mean) are less than two standard deviations.

When the number of screens or screened women is greater than 100, the Normal approximation of the binomial is 2. employed. The method of calculating the 95% CIs for the rate using this approach is as follows:19

95% Confi dence Interval = Rate – (1.96 x SE of Rate) to Rate + (1.96 x SE of Rate).Where SE = standard error of the Rate.

When the number of screens or screened women is 100 or less, the Poisson Method is used to determine confi dence 3. intervals because the assumptions of the Normal approximation of the binomial are violated if numbers are small. A Poisson table is used to obtain the 95% lower and upper CI values for the number of screens.19

Where applicable, fi gures presenting screening rates in this report includes 95% CI to facilitate the comparison of 4. screening rate measurements. Where the confi dence intervals of two rates do not overlap, the corresponding rates are statistically signifi cantly different from each other. Such difference is unlikely to have occurred by chance. However, judgement should be exercised while interpreting the statistical confi dence taking into account any practical signifi cance including biological plausibility.

Chi-squared (5. χ2) test for trend analysis is used in this report along with the test for heterogeneity. Wherever trend analysis is used it is mentioned with its corresponding p-value. Where trend analysis is not mentioned, the test for heterogeneity is used.

Appendix 12: Statistical Confi dence Intervals

SE =√

Rate * (1 – Rate) Population

80


Appendix 13: Related publications

Commonwealth Department of Health and Family Services. 1. Pap smear test results: A guide for women with an abnormal pap smear test. AGPS, Canberra, 1997.

Commonwealth Department of Health and Family Services. 2. Screening for the prevention of cervical cancer. AGPS, Canberra, 1998.

Jelfs PL. 3. Cervical cancer in Australia. Australian Institute of Health and Welfare: Cancer series no: 3. AIHW, Canberra, 1995.

Macansh S: 4. The role of the NSW Pap Test Register in monitoring the cervical screening process in NSW. NSW Public Health Bulletin 12:99-102, 2001.

National Cancer Control Initiative. 5. Cancer Control towards 2002. The fi rst stage of a nationally co–ordinated plan for cancer control. The Commonwealth Department of Health and Family Services. AGPS, Canberra, 1997.

NSW Cervical Screening Program. 6. Annual Statistical Report 2004. Cancer Institute NSW, Sydney, 2004. http://www.csp.nsw.gov.au.

NSW Cervical Screening Program. 7. Cervical screening in NSW: Legal Issues. A joint Commonwealth / State initiative managed by the Western Sydney Area Health Service, 1998.

NSW Cervical Screening Program. 8. Preventing cancer of the cervix: An overview for medical students. A joint Commonwealth / State initiative managed by the Western Sydney Area Health Service, 1998.

National Cervical Screening Program. 9. Performance standards for Australian laboratories reporting cervical cytology, November 1996. The Commonwealth Department of Health and Family Services. AGPS, Canberra, 1996.

NSW Cervical Screening Program 1997. NSW Cervical Screening Program Strategic Directions 1996 to 1999, Sydney.10.

National Health and Medical Research Council. 11. Screening to prevent cervical cancer: Guidelines for the management of women with screen detected abnormalities. Commonwealth Department of Human Services and Health. AGPS, Canberra. 1994.

National Pathology Accreditation Advisory Council: Performance measures for Australian laboratories reporting cervical 12. cytology. Department of Health and Ageing. Australian Government. Canberra 2003.

National Pathology Accreditation Advisory Council. 13. Requirements for gynaecological (cervical) cytology. AGPS, Canberra 1997.

Screening to prevent cervical cancer: guidelines for the management of women with screen detected abnormalities. 14. National Health and Medical Research Council. Australian Government. Canberra. 2005.

Wain GV: Cervical cancer prevention: the saga goes on, but so much has changed! Medical Journal of Australia 185:476-15. 477, 2006.

81

NSW Cervical Screening Program: Strategic Plan 2000 - 2004. Sydney, 19991.

SAS Institute Inc: SAS 9.1 for Windows, (ed 9.1.3). Cary, NC, USA2.

Centers for Disease Control and Prevention: Epi Info, (ed 3.4.1). Atlanta, USA, 20073.

Microsoft Corporation: Microsoft Offi ce Excel. USA, 20034.

National Health and Medical Research Council: Screening to prevent cervical cancer: guidelines for the management of 5. women with screen detected abnormalities. Australian Government. Canberra, 2003

Morrell S, Mamoon H, Callaghan J, et al: Early cervical cancer rescreening. Journal of Medical Screening 6. 9:26-32, 2002

Lewis D, Mitchell H: An evaluation of cervical screening in general practice. Medical Journal of Australia 7. 160:628-632, 1994

Commonwealth Department of Health and Ageing: Performance measures for Australian laboratories reporting cervical 8. cytology. Canberra, National Pathology Accreditation Advisory Council (NPAAC), 2003

Mitchell H, Medley G: Longitudinal study of women with negative cervical smears according to endocervical status. 9. Lancet 337:265-267, 1991

Fahey MT, Irwig L, Mackaskill P: Meta-analysis of Pap test accuracy. American Journal of Epidemiology 10. 141:680-689, 1995

Andy C: Is the ThinPrep Better than conventional Pap smear at detecting cervical cancer? Journal of Family Practice 11. 53:313-314, 2004

Holanda Jr F, Castelo A, Veras T, et al: Primary screening for cervical cancer through self sampling International Journal of 12. Gynecology & Obstetrics 95:179-184, 2006

Massad LS, Behbakht K, Collins YC, et al: Histologic fi ndings from the cervix among older women with abnormal cervical 13. cytology. Gynecologic Oncology 88:340-344, 2003

Department of Health and Ageing. Australian Government: Performance measures for Australian laboratories reporting 14. cervical cytology. Canberra, National Pathology Accreditation Advisory Council, 2003

Canfell K, Sitas F, Beral V: Cervical cancer in Australia and the United Kingdom: comparison of screening policy and 15. uptake, and cancer incidence and mortality. Medical Journal of Australia 5:482-486, 2006

Aitken R, Morrell S, Barraclough H, et al: Cancer incidence and mortality projections in New South Wales, 2007 to 2010. 16. Sydney, Cancer Institute NSW, July 2007

The University of Adelaide: Accessibility/remoteness Index of Australia (ARIA), in National Key Centre for Social 17. Applications of Geographical Information Systems (GISCA) (ed): Occasional Papers: New Series Number 14, 2001

Australian Bureau of Statistics: National Localities Index, Australia - ASGC 2002, in Statistics ABo (ed). 18. Camberra, 2002

Gardner MJ, Altman DG: Statistics with confi dence, 198919.

Appendix 14: References

Contact Directory

Cancer Institute NSW Level 1, Biomedical Building Australian Technology Park 1 Central Avenue Eveleigh NSW 2015 Australia

PO Box 41 Alexandria NSW 1435

Tel: + 61 2 8374 5600 Fax: + 61 2 8374 5700 Email: [email protected] Web: www.cancerinstitute.org.au

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