Cervical screening and HPV — structured oral station (12 minutes)

Opening prompt — "She is anxious and asks whether self-collection is real. What do you tell her?"

Model response — reassure with the evidence: ^[1][2]

• "Yes. Since 1 July 2022, all women and people with a cervix aged 25 to 74 in the NCSP can self-collect a vaginal sample, in clinic or at home. You can do it in a private space here today if you like."
• "Self-collection is as accurate as clinician-collection for detecting HPV when validated PCR-based assays are used — the Arbyn 2022 meta-analysis confirmed high concordance between the two methods. If HPV is detected, you will need a follow-up clinician-collected sample for cytology, or a direct referral to colposcopy depending on the HPV type."^[1][2]

Probe 1 — "Her result returns positive for HPV 16. Reflex cytology could not be performed on the self-collected sample. What is the next step?"

• "Refer to colposcopy. HPV 16 is referred to colposcopy regardless of the reflex cytology result."
• "Because reflex cytology could not be performed on the self-collected sample, I would also arrange a clinician-collected sample at the colposcopy visit, so the cytology can be reviewed alongside the colposcopic impression." ^[1]

Probe 2 — "Reproduce the reflex cytology triage pathway for a clinician-collected HPV-positive sample."

• "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." ^[1]

Probe 3 — "Colposcopy confirms CIN 3 and she undergoes LLETZ with clear margins. What surveillance does she need?"

• "An HPV test at 6 to 12 months is the test of cure. If negative, return to 5-yearly routine screening; if positive, refer back to colposcopy." ^[1]

Probe 4 — "Why does the NCSP start screening at 25 rather than 18 or 20?"

• "Three reasons: very low cancer incidence under 25 (about 1 to 2 percent of cases); high HPV clearance in young women (most infections clear within 1 to 2 years, so screening generates many false positives); and the obstetric harms of over-treatment — excision of CIN 2/3 increases 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 the yield of screening under 25." ^[3]
• "The one exception is a symptomatic young woman — postcoital or persistent intermenstrual bleeding, or a visible lesion — who needs diagnostic colposcopy at any age, regardless of the screening start age." ^[1]

Probe 5 — Communication probe: "She asks whether her 13-year-old daughter should get the HPV vaccine. What do you say?"

This is a scored communication domain — demonstrate it out loud: ^[4]

• "Yes, absolutely. The HPV vaccine is offered through the school-based programme around age 12 to 13, ideally before sexual debut. It is given as two doses at 0 and 6 to 12 months for ages 9 to 14. The 9-valent vaccine covers seven cancer-causing types (16, 18, 31, 33, 45, 52, 58) plus the two wart-causing types (6, 11), and prevents about 90 percent of cervical cancer. Australia is on track to eliminate cervical cancer — incidence under 4 per 100,000 — within the next decade, partly because of vaccination."
• "Even vaccinated, your daughter will still need screening from age 25, because the vaccine covers about 90 percent, not 100 percent, of cancer-causing types."^[4]