Screening Coverage Indicators

Vaccination against HPV will take decades to reduce overall cervical cancer incidence, due to the time taken for vaccinated cohorts to reach the age at which they would have developed cancer and also to make up a large enough proportion of the population to affect overall incidence rates. Cervical screening therefore is important to expedite elimination of cervical cancer (2,32,33). The WHO strategy to accelerate the elimination of cervical cancer sets a target of screening women at least twice, at around age 35 and 45 years. Based on data from Victoria, around 40% of the women diagnosed with cervical cancer had never been screened (34-36), emphasising the importance of this indicator, even though more frequent screening is recommended in the NCSP.

Since primary HPV screening has only been recommended in Australia since 1st December 2017, not enough time has passed for any woman to have had a primary HPV test by age 35 and another by age 45. The second part of this indicator therefore reports on the proportion of women aged 45-49 who have been screened at least twice, including at least one primary HPV test and at least one cytology test prior to 1st December 2017 at least two years apart, as an interim measure.

By the end of 2022, 79.6% of women aged 35-39 years had been screened at least once with an HPV test, and this proportion exceeded 70% in all areas. Being screened twice with a high-performance test by age 45 cannot be properly assessed until primary HPV screening has been available for longer in Australia, but 76.6% of women aged 45-49 years have been screened at least twice, including at least once with an HPV test (Figure 6.1b). The proportion of women aged 35-39 who have been screened at least once with an HPV test varies most by area-level SES (from 73.7% in the middle SES quintile to 84.2% in the least disadvantaged quintile) and remoteness of residence (from 71.9% in very remote areas to 80.3% in major cities). There was much less variation by state/territory.

The proportion of women aged 45-49 who have been screened at least once with an HPV test plus at least once previously with a cytology test also reached at least 70% in all areas.  This proportion varied most widely by area-level SES (from 72.1% in the middle quintile to 83.8% in the least disadvantaged quintile). There was less variation by remoteness area or by state/territory, where the difference between areas was 5-6%.

As expected, the proportion of eligible women aged 35-39 years who have had at least one HPV test has increased with each year since the HPV screening program began, from 31.3% at the end of 2018, to 79.6% by the end of 2022 (Figure 6.2). This increase has been seen in every population group for which data were available to report on; however the difference between the groups with the lowest and highest uptake has increased somewhat over time, particularly for area-level socioeconomic status (range: 29.1% to 34.0% in 2018; 73.7% to 84.2% in 2022) and, to a lesser extent, remoteness area (range: 27.1% to 31.4% in 2018; 71.9% to 80.3% in 2022).

Some similar patterns were seen for the proportion of eligible women aged 45-49 years with at least one HPV test plus at least one earlier screening test (noting this is an interim measure and not the same as the WHO target, which requires two appropriately spaced HPV tests), including the groups where this proportion was consistently lowest and highest. As expected, very substantial increases (42% or more) have been seen in this proportion since 2018 in all areas (Figure 6.3).

Source: Analysis of NCSR data (NCSR RDE 14/1/2023, extracted January 2023); data prepared by the Screening Analysis and Monitoring Unit of the Australian Institute of Health and Welfare. Remoteness areas and socioeconomic areas were allocated to records at the time of the HPV test, primarily using an SA2 2016 correspondence. Where this was not available a postcode correspondence was used. The correspondences produced by the Australian Bureau of Statistics (ABS) can now be found on data.gov.au by searching for: ‘ASGS’, the 'year', and ‘correspondences’ (ABS 2018).

Women who are eligible for screening comprise the estimated resident female population, minus an estimate of the number of women who have had a hysterectomy and the number of women enrolled in the Compass trial, consistent with routine AIHW reports (1-5). Data to calculate the screen-eligible population by single year of age were not available. ABS population estimates have been updated to use those based on the 2021 Census (at the time of the previous report, only estimates based on the 2016 Census were available) (3-5), and for end-2022 are extrapolated from mid-2021 and mid-2022 (the most recent available data).

This WHO indicator was designed to be a minimum target for low and lower-middle income countries and does not necessarily reflect the preferred approach for higher income countries. Being screened at least once substantially reduces a woman’s risk of cervical cancer (6,7). The WHO target for this measure was set for 2030; modelling used to inform the WHO targets assumed that screening uptake would scale up further after this time (to 90%) (8,9). As Australia has a well-established screening program, it could be expected to reach the 2030 target and scale screening up to reach the 90% target earlier than other countries. 

Data on Indigenous status are not yet sufficiently complete on the NCSR to allow reporting by Indigenous status. Given cervical cancer incidence rates are much higher among Indigenous women, and cervical screening is critical to reduce cervical cancer incidence in the short-term, understanding and reporting screening coverage in Indigenous women is critical to achieving timely elimination among Indigenous women. Earlier studies of the cytology-based screening program, based on analyses of ad hoc linked data for Qld, NSW, and the NT (10,11), found that Indigenous women were less likely to have been screened in the previously recommended interval of two years, and over a longer interval of five years.

The proportion of women aged 35-39 years who have had at least one HPV test was expected to increase over time (although all screen-eligible women would have been due to attend for their first HPV test by 31st December 2019). The impact of providing self-collection as a choice for all people eligible for screening (which only became available in July 2022) on the proportion of women aged 35-39 years screened with an HPV test at least once is likely to be relatively small in the timeframe reported on here, as by then it had only been available for 6 months and its effect would be confined to the comparatively small proportion of people aged 35-39 who were not screened at all between December 2017 and July 2022.  It is anticipated that the national scale-up of this choice could help to increase equity in screening participation and may be particularly helpful in reaching women living in very remote areas, who consistently had the lowest uptake on these two measures.

The hysterectomy prevalence estimates that are used to derive the population eligible for cervical screening are from an AIHW analysis of National Hospital Morbidity Database, and so consistent with previous AIHW and elimination reports: however, these estimates are not broken down by state/territory, remoteness area, or area-level SES. Potentially the prevalence of hysterectomy does vary across these strata, so using national age-specific estimates may under- or over-estimate the population who are eligible for screening in some cases.

1 Canfell K, Saville M, Caruana M, et al. Protocol for Compass: a randomised controlled trial of primary HPV testing versus cytology screening for cervical cancer in HPV-unvaccinated and vaccinated women aged 25-69 years living in Australia. BMJ Open 2018; 8(1): e016700.

2 Australian Institute of Health and Welfare. National Cervical Screening Program monitoring report 2021. Cancer Series 134. Cat. no: CAN 141 Canberra: AIHW; 2021.

3 Australian Bureau of Statistics. Regional population by age and sex [Internet]. Canberra: ABS; 2021. Available at: https://www.abs.gov.au/statistics/people/population/regional-population-age-and-sex/latest-release.

4 Australian Bureau of Statistics. People Topics. 2022. [cited 2022 31st Aug 2022]; ERP by SA2 (ASGS 2016), Age and Sex, 2001 Onwards. Available at: https://explore.data.abs.gov.au/vis?pg=0&tm=erp%20sa2%202016&hc[dataflowId]=ERP_ASGS2016&df[ds]=PEOPLE_TOPICS&df[id]=ERP_ASGS2016&df[ag]=ABS&df[vs]=1.0.0&pd=2020%2C&dq=...STE%2BAUS..A&ly[cl]=AGE&ly[rw]=ASGS_2016%2CREGION_TYPE&ly[rs]=SEX%2CTIME_PERIOD

5 Australian Bureau of Statistics. SEIFA 2016 by Statistical Area 2 (SA2), 2018 [accessed 4th March 2021]; SEIFA 2016 by SA2. Available at: http://stat.data.abs.gov.au/Index.aspx?DataSetCode=ABS_SEIFA_SA2

6 Smith M, Lew JB, Simms K, et al. Impact of HPV sample self-collection for underscreened women in the renewed Cervical Screening Program. Medical Journal of Australia 2016; 204(5): 194e1-e9.

7 Sankaranarayanan R, Nene BM, Shastri SS, et al. HPV screening for cervical cancer in rural India. New England Journal of Medicine 2009; 360(14): 1385-94.

8 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; 395(10224): 591-603 

9 Brisson M, Kim JJ, Canfell K, et al. Impact of HPV vaccination and cervical screening on cervical cancer elimination: a comparative modelling analysis in 78 low income and lower-middle-income countries. Lancet 2020; 395(10224): 575-90.

10 Zhang X, Condon J. Cancer screening in the Northern Territory 2019. Department of Health, Darwin, 2019. Available at: https://digitallibrary.health.nt.gov.au/prodjspui/handle/10137/7938

11 Whop LJ, Garvey G, Baade P, et al. The first comprehensive report on Indigenous Australian women’s inequalities in cervical screening: A retrospective registry cohort study in Queensland, Australia (2000–2011). Cancer 2016; 122(10): 1560-9.

Cervical screening is important to expedite elimination of cervical cancer, as HPV vaccination requires several decades to have its full effects across the population. As Australia has a well-established screening program with screening recommended aligned with the broader WHO screening recommendations (1) but more frequently than in the WHO elimination strategy (2), the proportion of women screened according to Australian recommendations is additionally reported. Since 1st December 2017, Australia has recommended 5-yearly primary HPV screening starting at age 25 and an exit test to occur between the ages of 70-74 years; prior to this, 2-yearly cytology was recommended for women aged 20-69 years (starting at age 18-20 years or two years after first sexual intercourse, whichever was later). Women were due to attend for their first HPV test two years after their last negative routine cytology test, or when they turned 25, whichever was later.

Nationally, 76.5% of eligible people were up to date with recommended screening at the end of 2022. Data were not available to report on this measure for Indigenous women. There was some variation across different areas of Australia (Figure 7.1). The widest variation in the proportion up to date was by age, where it ranged from 53.4% in those aged 25-29 years to 85.5% in those aged 50-54 years. This proportion reached 80% or more in the age groups between 40 and 64 years, and exceeds 70% in all age groups others than those aged 25-29 and 70-74 years (66.0%). There was also fairly wide variation by socioeconomic status: the proportion up to date was highest among those living in the least disadvantaged areas (85.3%) and lowest in the middle quintile (70.4%), but was fairly similar across quintiles 1, 2 and 4 (74.4 in quintile 2 to 76.0% in quintile 4).  By the end of 2022, the proportion who were up to date was very similar for those living in inner regional, outer regional and remote areas (73.0-73.3%), but the proportion up to date was still highest in major cities (77.6%) and lowest in very remote areas (68.9%).  There was a little less variation by state and territory, where the proportion who were up to date ranged from 72.7% (Tas) to 79.3% (ACT).

As expected, coverage has continued to increase in all groups in each year after the first two years since the transition to HPV screening, due to the longer screening interval. The absolute increase is broadly similar across most groups, and around 20 percentage points. An exception is those aged 70-74 years, where the proportion of eligible women up to date with screening increased from 26.7% at the end of 2018 to 66.0% by the end of 2022, an increase of 39.3% (Figure 7.2).  The proportion of eligible women who were up to date with recommended screening at the end of each year (over 2018 to 2022) was consistently lowest for women living in very remote areas, and highest for women living in the least disadvantaged areas, major cities, and those aged 50-54 years.

Source: Analysis of NCSR data (NCSR RDE 14/1/2023, extracted January 2023); data prepared by the Screening Analysis and Monitoring Unit of the Australian Institute of Health and Welfare. Remoteness areas and socioeconomic areas were allocated to records at the time of the HPV test, primarily using an SA2 2016 correspondence. Where this was not available a postcode correspondence was used. The correspondences produced by the Australian Bureau of Statistics (ABS) can now be found on data.gov.au by searching for: ‘ASGS’, the 'year', and ‘correspondences’ (ABS 2018).

Women who are eligible for screening comprise the estimated resident female population, minus an estimate of the number of women who have had a hysterectomy and the number of women enrolled in the Compass trial, consistent with routine AIHW reports (3-7). ABS population estimates have been updated to use those based on the 2021 Census (at the time of the previous report, only estimates based on the 2016 Census were available) (5-7), and for end-2022 are extrapolated from mid-2021 and mid-2022 (the most recent available data). Hysterectomy prevalence from AIHW analysis of National Hospital Morbidity Database (4). Aggregate numbers of Compass participants were extract from the Compass Trial Register.

Percent is age-standardised across women aged 25-74, using the Australia 2001 standard population (8).

Data on Indigenous status are not yet sufficiently complete on the NCSR to allow reporting by Indigenous status. Given cervical cancer incidence rates are much higher among Indigenous women, and cervical screening is critical to reduce cervical cancer incidence in the nearer term, understanding and reporting screening coverage in Indigenous women is critical to achieving timely elimination among Indigenous women. There have been earlier studies of cervical screening coverage in Indigenous women, in the pre-renewed NCSP, based on analyses of ad hoc linked data for Qld, NSW, and the NT (9-11). In all three of these jurisdictions, Indigenous women were less likely to have been screened in the previously recommended interval of two years, and over a longer interval of five years (data for five years only reported for Qld and NSW).

The proportion of women who are up to date with screening was expected to remain approximately stable in 2018 and 2019, then naturally increase in 2020, 2021 and for most of 2022.  This is because by the end of November 2022, the proportion who are up to date with screening will include anyone with an HPV test in the 5-year period since the transition to primary HPV screening, as no women who have had their first HPV test will become overdue until at least 1 December 2022. Data from the cytology-based NCSP suggest that the proportion of women screened continues to increase over three and five-year periods compared to a two-year period (12). In December 2022, some women with an HPV test in December 2017 who were recommended to return in 5 years will become due, but this number may be smaller than the number of people who have their first HPV test during the first 11 months of 2022.

The estimates here are not directly comparable with estimates in routine AIHW reports, as the estimates here include HPV tests performed for any purpose (including for symptoms, follow-up of a previous abnormality, at colposcopy, or any other purpose, consistent with monitoring conducted up until 2019), to capture all of those who are engaged with screening or being followed up in some way. Additionally, we report the proportion up to date at the end of each calendar year and therefore age is as at the end of each calendar year; whereas AIHW reports calculate age at the time that the test occurred. This difference would potentially most affect estimates for the 25-29 year age group, and our markedly lower estimate for this age group suggests that, while most people may initiate screening at some point between the ages of 25 and 29 years, in many cases this does not appear to occur when they are aged 25. A more detailed analysis of the timeliness of initiating screening is needed to explore this in more detail.

The proportion of women aged 70-74 years who are up to date was initially very small, and much lower than for other age groups, reflecting that prior to December 2017 screening was not actively recommended for this age group, and therefore that most women in this age group would have already been discharged from screening. As for other groups, the proportion in this age group who are up to date has increased over time, and the increase of 39.4% since 2018 in this age group has been larger than for any other age group (predominantly because of the low starting point).  Increasingly over time, people in this age group have comprised those who were recommended to attend for an exit test between the age of 70-74 years rather than to cease screening after 69 years (and by the end of 2022, all screen-eligible people in the 70-74 year age group had reached the age of 70 after the recommendation for an exit test between 70-74 years was introduced). Nevertheless, the proportion in this group who are up to date is lower than in every other age group apart from those aged 25-29 years, and has not yet reached 70%.

Screening coverage estimates for 2020 and 2021 in this report differ from those published in earlier reports. This is due to a number of factors: firstly, updated records on the NCSR since the previous report indicate that more people had a test; secondly, the denominator population has changed in this report to use population estimates based on the 2021 Census (which were not available at the time of the previous report); and thirdly, population estimates for end-2021 were not available at all at the time of the previous report and so were extrapolated from the available data from mid-2020 and mid-2021, whereas in the current report population estimates are available up until mid-2022. The updated estimates in the current report will be more reliable than the earlier estimate. Changes to the estimated eligible population in 2021 were particularly marked for those aged 25-29 and 70-74 years. This suggests that changes over 2021 and 2022, compared to those that were anticipated based on 2016 Census data and earlier trends, differed more substantially in these age groups than for other age groups (1.8% increase for 25-29 years and 1.7% decrease for 70-74 years, compared to less than 1% in other age groups). Potentially this may be related to changes in migration or mortality relating to COVID-19.

The results in this report may include some effect from the availability of self-collection as a choice for all people eligible for screening (which became available in July 2022). Understanding this impact in detail requires a more detailed analysis than was possible for this report. The effect was potentially small by the end of 2022, as it would be confined to relatively small proportion of people due to screen in the second half of 2022, who would be either very overdue, new screeners turning 25, or people who attended for their first HPV test in December 2017 and were due to re-attend. It is anticipated that the national scale-up of this choice could help to increase equity in screening participation and may be particularly helpful in reaching women living in very remote areas, who had the lowest uptake on this measure. Analyses of screening tests over July-September 2022 found that the proportion of those using self-collection was highest (and increased most rapidly) in the Northern Territory, Tasmania, and very remote areas [13], which have relatively low coverage.

The hysterectomy prevalence estimates that are used to derive the population eligible for cervical screening are from an AIHW analysis of National Hospital Morbidity Database, and so consistent with other reports, however these estimates are not broken down by state/territory, remoteness area, or area-level SES. Potentially the prevalence of hysterectomy does vary across these strata, so using national age-specific estimates may under- or over-estimate the population who are eligible for screening in some cases.

1 WHO guideline for screening and treatment of cervical pre-cancer lesions for cervical cancer prevention, second edition. Geneva: World Health Organization; 2021. Available at: https://www.who.int/publications/i/item/9789240030824

2 World Health Organization. Global strategy to accelerate the elimination of cervical cancer as a public health problem. 2020. Available at: https://www.who.int/ publications/i/item/9789240014107.

3 Canfell K, Saville M, Caruana M, et al. Protocol for Compass: a randomised controlled trial of primary HPV testing versus cytology screening for cervical cancer in HPV-unvaccinated and vaccinated women aged 25-69 years living in Australia. BMJ open 2018; 8(1): e016700.

4 Australian Institute of Health and Welfare. National Cervical Screening Program monitoring report 2021. Cancer Series 134. Cat. no: CAN 141 Canberra: AIHW; 2021.

5 Australian Bureau of Statistics. Regional population by age and sex [Internet]. Canberra: ABS; 2021. Available at: https://www.abs.gov.au/statistics/people/population/regional-population-age-and-sex/latest-release.

6 Australian Bureau of Statistics. People Topics. 2022. [cited 2022 31st Aug 2022]; ERP by SA2 (ASGS 2016), Age and Sex, 2001 Onwards. Available at: https://explore.data.abs.gov.au/vis?pg=0&tm=erp%20sa2%202016&hc[dataflowId]=ERP_ASGS2016&df[ds]=PEOPLE_TOPICS&df[id]=ERP_ASGS2016&df[ag]=ABS&df[vs]=1.0.0&pd=2020%2C&dq=...STE%2BAUS..A&ly[cl]=AGE&ly[rw]=ASGS_2016%2CREGION_TYPE&ly[rs]=SEX%2CTIME_PERIOD

7 Australian Bureau of Statistics. SEIFA 2016 by Statistical Area 2 (SA2), 2018 [accessed 4th March 2021]; SEIFA 2016 by SA2. Available at: http://stat.data.abs.gov.au/Index.aspx?DataSetCode=ABS_SEIFA_SA2

8 Australian Bureau of Statistics. Australia 2001 Standard Population for Use in Age-Standardisation. 2003. Available at: https://www.abs.gov.au/AUSSTATS/abs@.nsf/DetailsPage/3101.0Mar%202013?OpenDocument

9 Whop LJ, Baade P, Garvey G, et al. Cervical Abnormalities Are More Common among Indigenous than Other Australian Women: A Retrospective Record-Linkage Study, 2000-2011. PLoS One 2016; 11(4): e0150473.

10 Whop LJ, Garvey G, Baade P, et al. The first comprehensive report on Indigenous Australian women’s inequalities in cervical screening: A retrospective registry cohort study in Queensland, Australia (2000–2011). Cancer 2016; 122(10): 1560-9.

11 Dasgupta P, Cramb S, Baade P, et al. Regional variation in cervical cancer screening participation & outcomes among Aboriginal and non-Aboriginal Australian women: New South Wales (2006-2013). 2018. Available at: https://apo.org.au/node/258511

12 Australian Institute of Health and Welfare 2018. Cervical screening in Australia 2018. Cat. no. CAN 111. Canberra: AIHW

13 National Cancer Screening Register. Monitoring of self-collection in the National Cervical Screening Program. Australian Department of Health and Aged Care, March 2024. Available at: https://www.health.gov.au/resources/publications/update-on-cervical-screening-self-collection-uptake