Cervical screening and HPV: the NCSP pathway, self-collection, LLETZ/CKC, and elimination (fellowship depth)

A 32-year-old woman attends your clinic for a routine check and tells you her last Pap smear was in 2015 — she has not had one since the program changed. She has read that she can "do it herself now" and asks you whether that is real. Your job is to explain the renewed NCSP, offer her a self-collected CST or a clinician-collected one, and — if the result comes back HPV-positive — navigate the reflex cytology pathway with her. Cervical screening is one of the most effective public-health interventions in medicine, and the fellowship examiner expects you to defend every step of it.^[8]

Overview and definition

Cervical screening is an organised, population-based programme that tests asymptomatic women and people with a cervix for high-risk HPV (with reflex cytology), triages the abnormal to colposcopy, and treats confirmed CIN 2/3 to prevent invasive cancer. It works because cervical cancer has a single necessary viral cause (HPV), a detectable precursor (CIN) that develops over 10 to 15 years, and an effective excisional treatment (LLETZ or cone).^[3]

The single most important distinction at the bedside is screening versus diagnostic testing. Screening is for asymptomatic women — the screen finds disease before symptoms. Symptoms override the screen: a woman with postcoital or persistent intermenstrual bleeding, persistent abnormal vaginal discharge, or a visible cervical lesion needs diagnostic colposcopy regardless of her screening status or a normal CST.^[8]

The Cervical Screening Test (CST) is a molecular HPV test on a cervical or vaginal sample, with reflex liquid-based cytology performed on the same sample if HPV is detected. It replaced the two-yearly Pap smear in Australia on 1 December 2017 as part of the NCSP renewal, on the strength of four European randomised trials showing HPV-based screening detects high-grade CIN earlier and reduces invasive cervical cancer incidence.^[3][8]

References19ShowHide

1. [1]Curry SJ, Krist AH, Owens DK, et al. Screening for Cervical Cancer: US Preventive Services Task Force Recommendation Statement. JAMA, 2018.PMID 30140884
2. [2]Fontham ETH, Wolf AMD, Church TR, et al. Cervical cancer screening for individuals at average risk: 2020 guideline update from the American Cancer Society. CA Cancer J Clin, 2020.PMID 32729638
3. [3]Ronco G, Dillner J, Elfström KM, et al. Efficacy of HPV-based screening for prevention of invasive cervical cancer: follow-up of four European randomised controlled trials. Lancet, 2014.PMID 24192252
4. [4]Arbyn M, Simon M, de Sanjosé S, et al. Accuracy and effectiveness of HPV mRNA testing in cervical cancer screening: a systematic review and meta-analysis. Lancet Oncol, 2022.PMID 35709810
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6. [6]Stanczuk GA, Currie H, Forson W, et al. Self-sampling as the principal modality for population based cervical screening: Five-year follow-up of the PaVDaG study. Int J Cancer, 2022.PMID 34850395
7. [7]McLachlan E, Anderson S, Hawkes D, et al. Completing the cervical screening pathway: Factors that facilitate the increase of self-collection uptake among under-screened and never-screened women, an Australian pilot study. Curr Oncol, 2018.PMID 29507491
8. [8]Smith M, Hammond I, Saville M, et al. Lessons from the renewal of the National Cervical Screening Program in Australia. Public Health Res Pract, 2019.PMID 31384888
9. [9]Costa S, Verberckmoes B, Castle PE, et al. Offering HPV self-sampling kits: an updated meta-analysis of the effectiveness of strategies to increase participation in cervical cancer screening. Br J Cancer, 2023.PMID 36517552
10. [10]Arbyn M, Kyrgiou M, Simoens C, et al. Perinatal mortality and other severe adverse pregnancy outcomes associated with treatment of cervical intraepithelial neoplasia: meta-analysis. BMJ, 2008.PMID 18801868
11. [11]Kyrgiou M, Athanasiou A, Paraskevaidi M, et al. Adverse obstetric outcomes after local treatment for cervical preinvasive and early invasive disease according to cone depth: systematic review and meta-analysis. BMJ, 2016.PMID 27469988
12. [12]Drolet M, Bénard É, Pérez N, et al. Population-level impact and herd effects following the introduction of human papillomavirus vaccination programmes: updated systematic review and meta-analysis. Lancet, 2019.PMID 31255301
13. [13]Hall MT, Simms KT, Lew JB, et al. The projected timeframe until cervical cancer elimination in Australia: a modelling study. Lancet Public Health, 2019.PMID 30291040
14. [14]Xia C, Xu X, Zhao X, et al. Effectiveness and cost-effectiveness of eliminating cervical cancer through a tailored optimal pathway: a modeling study. BMC Med, 2021.PMID 33653331
15. [15]Joura EA, Giuliano AR, Iversen OE, et al. A 9-valent HPV vaccine against infection and intraepithelial neoplasia in women. N Engl J Med, 2015.PMID 25693011
16. [16]Australian Technical Advisory Group on Immunisation Human papillomavirus (HPV) The Australian Immunisation Handbook, 2025.Source
17. [17]Australian Centre for the Prevention of Cervical Cancer National Cervical Screening Program Guidelines: Cervical Screening Pathway Quick Reference Guide ACPCC / Cancer Council Australia NCSP Guidelines, 2022.Source
18. [18]Barnabas RV, Brown ER, Onono MA, et al. Efficacy of single-dose HPV vaccination among young African women. NEJM Evid, 2022.PMID 35693874
19. [19]Canfell K, Kim JJ, Brisson M, et al. Mortality impact of achieving WHO cervical cancer elimination targets: a comparative modelling analysis in 78 low-income and lower-middle-income countries Lancet, 2020.PMID 32007142