Australia is on track to become the first country to eliminate cervical cancer by 2035.¹ However, there remains a disparity in cervical cancer incidence and mortality for First Nations women. In the latest cervical cancer progress report,¹ cervical cancer incidence is 11.7 per 100,000, which is double that of the non-indigenous population in Australia and three times that of the elimination target of 4 per 100,000. Cervical cancer mortality is 4.3 per 100,000 which is three times that of the non-indigenous population.

This disparity represents a public health failure and systemic inequities in what is a largely preventable disease. The incidence of cervical dysplasia and carcinoma in situ are similar in both populations, which suggests that structural barriers and social determinants of health are responsible for the higher incidence and mortality,² rather than any inherent biological susceptibility. Under current vaccination and screening rates in Australia, cervical cancer elimination among First Nations women was projected to occur in 2047, 21 years later than projected for Australian women overall.³

Human Papilloma Virus (HPV) Infection and Vaccination

The prevalence of HPV non 16/18 in First Nations women is 10.5% (vs 5.6%) and for HPV 16/18 the prevalence is 2% (vs 1.3%). In terms of overall HPV prevalence (all types), the rate is 12.1% (vs 6.7%).¹ HPV vaccination coverage for First Nations females by age 15 years old is 76.7% (vs 81.3%). Vaccine coverage had been slowly increasing until 2020, when it peaked at 87.8%, but has since slowly declined. The reasons for this are unclear, but there is a need to improve school-based vaccination rates as well as a focus on catch-up vaccination, which is funded for women up to the age of 25 years old.

Cervical Screening Rates

National cervical screening rates for First Nations women are not available, as Indigenous status information is not collected on pathology forms in all jurisdictions, however there is evidence from a range of sources that First Nations women are under-screened. National Key Performance Indicator (NKPI) data from Aboriginal Community Controlled Health Services (ACCHS’s) suggests a participation rate of 47% of eligible First Nations women. The poor Indigenous identification on pathology forms is a longstanding issue, and one that needs to be resolved in order to be able to accurately monitor cervical screening rates.

The introduction of a self-collected cervical screening test as an alternative option was hoped to increase the participation rate of under-screened populations such as First Nations women. The “Own It” health promotion campaign aimed to raise awareness of the self-collection option for screening, and the National Aboriginal Community Controlled Health Organisation (NACCHO) delivered the campaign in member organisations as the “Let’s Own it!” project, with client facing as well as clinician facing resources. Resources can be accessed through their website Cervical Screening Program – NACCHO.

Accurate national data collection of cervical screening tests will allow us to develop meaningful participation data to assess and monitor the impact of changes such as the self-collection option and health promotion campaigns.

Colposcopy

It is unethical to have a screening test that cannot be followed by timely assessment and treatment. For a higher risk of abnormal cervical abnormality, this means having a colposcopy performed within three months. The NCSR collects Indigenous status on colposcopy forms, and as colposcopists, it is critical that this information is diligently and accurately collected to allow us to monitor this aspect of the elimination strategy. The reported colposcopy rate within three months for First Nations women is 38.3% (vs 48.4%).⁴ Lower colposcopy rates are reported for remote and very remote areas, suggesting a barrier to access.

The PREVENT project is a novel screening approach integrating self-collection, point-of-care HPV testing, and same-day specialist assessment for Aboriginal and Torres Strait Islander women in remote Western Australia.⁵ Thirty six percent of the eligible women were invited to participate and 36% of these responded. A high participant satisfaction rate was reported.

Contributing Factors

Known risk factors for developing cervical abnormalities from persistent HPV infection include smoking and higher parity. Immunosuppression from medical comorbidities may also contribute to the burden of cervical cancer in First Nations women. This highlights the importance of addressing issues First Nations women face holistically, beyond just cervical screening.

SISTASCREEN

SISTASCREEN is a Cancer Australia funded project administered through Southern Cross University. The project aims to improve the uptake of opportunistic cervical screening in First Nations women during pregnancy and the postpartum period in a way that is culturally safe, informed, and effective. A strengths-based approach will be taken with positive messaging that will empower women to participate in a meaningful way that will lead to longer term participation beyond the pregnancy. Additional strategies will be explored to improve catch-up HPV vaccination in women under 25 years old and develop effective colposcopy pathways when indicated. It will build on the successful SISTAQUIT project which provides training and resources to support smoking cessation for First Nations women in pregnancy.