Cervical screening and HPV — structured SAQ (15 marks)

(a) NCSP eligibility, frequency, and self-collection (3 marks)

One mark each for age range, frequency, self-collection. ^[2]

• Age range: women and people with a cervix aged 25 to 74 years.
• Frequency: every 5 years, with an HPV-based Cervical Screening Test (CST).
• Self-collection: universally available for all eligible participants since 1 July 2022, in clinic or at home; concordance with clinician-collection is high when validated PCR-based assays are used.

(b) Next step after HPV 16 positive on self-collection (3 marks)

One mark for the action, one for the rationale, one for the workflow. ^[2]

• Refer to colposcopy now. HPV 16 is referred to colposcopy regardless of the reflex cytology result.
• Because reflex cytology could not be performed on the self-collected sample, the woman returns for a clinician-collected sample to allow cytology triage AND proceed to colposcopy.
• HPV 16 alone causes about 55 to 60 percent of all cervical cancer; a negative cytology does not exclude a high-grade lesion that cytology has missed.

(c) NCSP reflex cytology triage pathway (4 marks)

One mark per row. ^[2]

• HPV not detected: return to 5-yearly routine screening.
• HPV 16 or 18 detected: refer colposcopy regardless of reflex cytology.
• Other high-risk HPV with pHSIL, HSIL or greater on reflex cytology: refer colposcopy.
• Other high-risk HPV with LSIL or negative reflex cytology: repeat HPV test in 12 months; if still positive at 12 months, refer colposcopy.

(d) Post-LLETZ test of cure (2 marks)

One mark for the test, one for the action on each result. ^[2]

• HPV test at 6 to 12 months after LLETZ is the test of cure.
• If HPV is not detected, return to 5-yearly routine screening.
• If HPV is still detected, refer back to colposcopy.

(e) Rationale for start age of 25 and the symptoms-override rule (3 marks)

One mark for three reasons (any three), one for the symptoms-override caveat, one for completeness. ^[2][4]

Three reasons Australia moved the start age from 18/20 to 25 in December 2017:^[2][4]

• Very low cancer incidence under 25 (about 1 to 2 percent of all cases).
• High HPV clearance in young women (up to 40 to 50 percent HPV-positive at any time, most clearing within one to two years) — screening produces many false positives.
• The harms of over-treatment — excision of CIN 2/3 in young women increases the risk of preterm birth, premature rupture of membranes and low birthweight (Kyrgiou 2016), with no benefit for CIN that would have regressed.
• HPV vaccination of adolescents has further reduced high-grade CIN in this age group.

The one exception: a woman under 25 with symptoms (postcoital or persistent intermenstrual bleeding, or a visible lesion) needs diagnostic colposcopy — the screening age is for asymptomatic screening only.