Treatment Uptake Indicators

In Australia, assessment by colposcopic examination of the cervix is an integral part of the diagnostic pathway once a person is deemed to be at a sufficient underlying risk of a high-grade cervical abnormality through the screening process. Factors that may impact an individual’s attendance for diagnostic assessment include whether they received and understand their screening result, understand the need for further assessment and are referred in a timely way, their ability to access colposcopy (service availability, cost, transport, time) and the acceptability of the procedure to that person. Australia’s cervical screening registries have long played a role as a safety net to support participant and clinician’s awareness of results requiring further follow-up through systematic reminders and escalating alerts where the recommended pathway has not been followed. Assessment at colposcopy is necessary to identify lesions (via biopsy of suspicious areas) requiring treatment, for which there is a 2030 WHO scale up target of 90% of identified lesions treated. High rates of timely attendance for colposcopy are needed to ensure that screening is effective in the Australian setting. Prior to the transition to HPV based screening in Australia, it was recognised that in the first screening round of the new program, a higher than historically observed rate of referral to colposcopy services would require services to scale up to meet this demand (1). 

Of the people aged 25–74 years classified as higher risk (colposcopy referral recommended by NCSP Guidelines) in 2022, 69.4% had a colposcopy within 12 months of the test that led to their referral, according to the NCSR data. There was minimal variation by socioeconomic status but more substantial variation by remoteness (lower for remote and very remote residents, highest for regional), jurisdiction (highest in Tas and lowest in WA), and reason for referral (highest (96.1%) for primary screening result HPV (not 16/18) with high grade cytology and lowest (66.6%) by a substantial amount for referral indication of repeat positive HPV at 24 months follow-up in those initially classified as intermediate risk (new follow up category introduced in 2021)) (2). This variation was also observed in relation to colposcopy within 3 months (a period that better captures timeliness of colposcopy; Figure 8.1). Overall, 46.5% had a colposcopy within 3 months (2.5% lower than for the 2021 cohort). The proportion having a colposcopy by 3 months varied by the reason for referral, with those with a screening result of HPV positive (not 16/18) and high-grade cytology having the highest proportion of colposcopy within 3 months (73.9%), followed by the repeat positive test at 12 months group (73.8%), HPV 16/18 positive women (61.7%), those positive on program exit test (41.4%), then those repeat positive at 24 months (34.2%). Women resident in the most advantaged quintile of socioeconomic status were 4.1 percentage points more likely to have a colposcopy by 3 months than those resident in the lowest quintile.

Women aged 30-34 years were the least likely age group to have colposcopy within 3, 6  or 12 months (at 45.3%, 57.9% and 65.1% respectively) and the oldest group (age 70-74) the most likely (at 52.4%, 70.1% and 78.9% respectively) (data not shown). The age groups with the highest proportion of women attending within 3 months by referral category were those 50-54 years with HPV 16/18 (66.1%), aged 55-59 for HPV (not 16/18) with high-grade cytology (92.1.7%), and with 12 month repeat HPV (75.6%), and aged 70-74 years with 24 month repeat HPV (51.2%) (data not shown).  

The 2018 referral cohort (Figure 8.1, 2018 data tab) provides an indication of whether those classified as higher risk ever reach colposcopy as they pass into the next routine five-year screening interval. By 61-72 months (5-6 years) follow up (depending on the month screened in 2018), 95.0% had a record of colposcopy attendance according to the NCSR (with 97.3% of those referred with HPV (not 16/18) and high-grade cytology ever attending). Ever attendance was slightly lower for those in remote and very remote areas and in the NT compared to other jurisdictions. Of note, a further 6.0% of women reached colposcopy in the period between 12 and 61-72 months follow up and this proportion was highest for those positive on an exit test (28.7%) or referred with repeat 12-month positive HPV (10.4%), resident in the lowest socioeconomic quintile (7.1%), remote and very remote areas (9.3 and 11.0% respectively) and for those that reside in the NT (9.5%).

Comparing colposcopy attendance over time, timeliness in reaching colposcopy has declined over time. Three-month attendance was 63.6% for those classified as higher risk in 2018, 56.3% in 2019, 55.6% in 2020, and 49.0% in 2021 and 46.5% in 2022, with 6- and 12-month attendance showing similar patterns. Important context is that there was a large variation in the number of participants classified as higher risk (which peaked in 2019), reason for referral across the four years and reductions in access to health care across Australia during the COVID-19 pandemic in 2020 and 2021. In 2018 the most frequent reason for classification as higher risk was due to HPV16/18 (in 77.2%), in 2019 and 2020 it was due to repeat HPV positive at 12 months (50.8% and 73.7%) and in 2021 and 2022 it was due to repeat HPV positivity at 24 months (53.6% and 61.1%) after the change to the intermediate risk pathway resulted in this new referral category, and a large proportion of those who were previously in the repeat HPV positive at 12 months were instead referred for another 12-month follow-up test. 

Source: Analysis of NCSR data (NCSR RDE 6/1/2024); data prepared by the Screening Analysis and Monitoring Unit of the Australian Institute of Health and Welfare.

Includes women classified as “higher risk”, based on their screening test results and history; according to program classifications in use during the year of the test. For 2021, women designated as higher risk due to repeat HPV positivity at 12 months as a result of having an under screened status, Indigenous status or age, are not included; women referred for colposcopy outside screening pathways (for example due to symptoms) without an explicit risk classification are excluded. The closest proxy available to assess whether a woman ‘ever’ had a colposcopy was to include all data as recorded on the NCSR at close of the available dataset, which allowed 61-72 months follow-up for all women referred in 2018, 49-60 months for all women referred in 2019, 37-48 months for all women referred in 2020 and 25-36 months for all women referred in 2021 and 13-24 months for all women referred in 2022 (noting that this means follow-up time for the 'ever' measure differs depending on the year when the person was classified as higher risk.  Data presented are as per the methodology of the AIHW National Cervical Screening Program monitoring report (3). Time to colposcopy is taken from the date of a person’s first higher risk screening episode. Rates are reported for women in the screening age range 25-74 years.

It should be noted that this report does NOT use the primary screening episode risk classifications (J5) or recommendations (J6) assigned to the participants by the pathology laboratory including the ‘refer to colposcopy’ recommendation as its data source. Each participant's risk classification is calculated using their test results and history and the requirements of the program pathways in order to report by reason for higher risk status, the method also used for reporting colposcopy attendance as a national indicator by the AIHW. We are aware that results will differ if laboratory assigned classifications (which are not validated by the NCSR) or NCSR assigned status (not available) are used. 

Completeness of colposcopy data within the NCSR is unknown, with reports submitted by clinicians supplemented by the use of Medicare rebate data and biopsy/histology data to capture the fact of a colposcopy event (although colposcopy may also be used for other indications with no unique MBS code). Thus the estimates represent minimum values based on notifications to the NCSR, and colposcopy data may be more complete for earlier years than for more recent years. Only some higher risk groups have nationally stated targets for time to further assessment (being 2 weeks for women suspected to have cancer on reflex cytology (not separated in routine data) and 8 weeks for HPV positive women with high-grade cytology) within the national guidelines (4) (reported for those with HPV (not 16/18) detected, but not for those with HPV16/18 detected). These findings include women classified as higher risk, and thus represent colposcopy attendance through the screening pathway (including 12-month follow-up); timeliness of attendance for colposcopy outside screening pathways (for example due to symptoms) is also important for early detection of cancer, but is not captured here.

Timely colposcopy attendance appears to vary by socioeconomic status and remoteness, which may relate to access barriers and service availability. This is of concern given that women residing in remote and very remote areas and who reside in areas of lower socioeconomic status are known to have higher rates of cervical cancer (3) (see indicator 1). Previous data from Queensland suggested that barriers to timely colposcopy follow up may impact Indigenous women to a greater extent than non-Indigenous women (5); NCSR data remains unavailable for publication by Indigenous status. Note that colposcopy follow up rates for the NT in 2021 and 2022, and for those residents in very remote areas in 2021, are suppressed due to small numbers. 

The available data suggest that many women may be experiencing suboptimal times to further assessment in this period of high colposcopy demand during transition to HPV based screening and from the 2-year to 5-year interval, but that prioritisation of women by referral indication (and possibly age group) is occurring. The COVID-19 pandemic is also likely to have increased waiting times from 2020 onwards across much of Australia. In February 2021, on the basis of program data indicating that most people with a repeat non-16/18 positive result at 12 months were at a very low risk of high-grade disease or cancer (6), the program follow-up pathway was adjusted to recommend that most people now have a third HPV test at 24 months, allowing further time for clearance, prior to referral to (2,7).  This category of result (persistent positivity at 24 months) is experiencing the lowest rate of colposcopy by 12 months (56.2% in the 2022 cohort) and, given that this risk group is comprised over 60% of those classified as higher risk in 2022 (62.1%), impacts upon the overall attendance rate by 12 months which fell from 88.9% for the 2018 cohort to 69.4% for the 2022 cohort.

1 Smith MA, Gertig D, Hall M, et al. Transitioning from cytology-based screening to HPV-based screening at longer intervals: implications for resource use. BMC Health Services Research 2016; 16: 147. 

2 Important changes to the National Cervical Screening Program's Clinical Guidelines pathway for women at intermediate risk. Department of Health and Aged Care, Australian Government. Jan 2021. Available at: https://www.health.gov.au/news/important-changes-to-the-national-cervical-screening-programs-clinical-guidelines-pathway-for-women-at-intermediate-risk 

3 Australian Institute of Health and Welfare (2023) National Cervical Screening Program monitoring report 2023, catalogue number CAN 157, AIHW, Australian Government. 

4 Cancer Council Australia Cervical Cancer Screening Guidelines Working Party. National Cervical Screening Program: Guidelines for the management of screen detected abnormalities, screening in specific populations and investigation of abnormal vaginal bleeding. Sydney: Cancer Council Australia. [Version URL: https://wiki. cancer.org.au/australiawiki/index.php?oldid=214429]. Available from: https://wiki.cancer.org.au/australia/Guidelines:Cervical_cancer/Screening   

5 Whop LJ, Baade PD, Brotherton JM, et al. Time to clinical investigation for Indigenous and non-Indigenous Queensland women after a high-grade abnormal Pap smear, 2000-2009. Medical Journal of Australia 2017; 206(2): 73-7. 

6 Smith MA, Sherrah M, Sultana F, et al. National experience in the first two years of primary human papillomavirus (HPV) cervical screening in an HPV vaccinated population in Australia: observational study. BMJ. 2022 Mar 30;376:e068582 

7 Canfell K, Saville M, Smith M, Brand A, Armstrong B, Hammond I and the Cancer Council Australia Cervical Cancer Screening Guidelines Working Party. Oncogenic HPV types not 16/18. In: National Cervical Screening Program Guidelines for the management of screen-detected abnormalities, screening in specific populations and investigation of abnormal vaginal bleeding. Last updated: July 2022. Available at: https://www.cancer.org.au/clinical-guidelines/cervical-cancer-screening/management-of-oncogenic-hpv-test-results/oncogenic-hpv-types-not-16-18 

Cervical screening is important to expedite elimination of cervical cancer, as it will take decades for the impact of HPV vaccination to be reflected in overall cervical cancer incidence (1,2). For screening to prevent cervical cancer, treatment of screen-detected high-grade abnormalities is essential.

A target has been set in the WHO strategy to accelerate elimination of cervical cancer for treatment of women with identified disease (1). Australia has raised the target to 95% as a commitment to achieving equity in elimination (2). 

In 2022, there were 12,961 women diagnosed with histologically-confirmed high-grade cervical disease (12,326 aged 25-74 years) in Australia. Overall, 58.0%, 84.5%, and 88.7% were treated within 8 weeks, 6 months, and 12 months, respectively (Figure 9.1). Nationally, there was a small decrease in the proportion treated within in each timeframe in 2022 compared to 2021.

The target of 90% treated was not met within 8 weeks in any group, but was met by 6 months among women diagnosed with AIS (and was 89.5% for those with CIN3), and in some age groups (50-59 and 65-69 years) (Figure 9.2). By 12 months, the 90% target was additionally met in Western Australia, South Australia, Tasmania, and the Northern Territory; among those with CIN3, and in all age groups between 35-74 years. The proportion treated did not reach 90% within 12 months in any remoteness area category, but reached 89.5% in inner regional areas. The proportion treated was close to, but did not reach 90% within 12 months in any remoteness area category (ranging from 88.6-89.5%). The Australian target of 95% treated was met by 6 months among women diagnosed with AIS, but was not met in any other group including at 12 months. 

The proportion treated was higher at 8 weeks, 6 months and 12 months for non-Indigenous women than it was for Aboriginal and Torres Strait Islander women. The difference was much more pronounced at 8 weeks (58.5% vs 51.6%) but had narrowed at 6 months (85.2% vs 83.0%) and 12 months (89.4% vs 88.4%). 

The proportion treated was consistently lowest (regardless of treatment timeframe) in remote and very remote areas. Since 2021 the proportion treated within 8 weeks notably reduced in remote areas, whereas the proportion treated within 12 months increased across both remote and very remote areas (while this proportion decreased in major cities and regional areas).The proportion treated within 12 months was below 80% among those outside the screening age range (aged <25 or 75+); and in those whose high-grade lesion was 'HSIL not otherwise specified'. 

There was some variation in the proportion treated within 8 weeks by remoteness area and area-level socioeconomic status (range: 49.0%-59.2% for remoteness area; 53.8%-60.6% for socioeconomic status). The variation had become relatively small by 6 months for socioeconomic status (range: 83.8-85.2%) and by 12 months for remoteness area (range: 88.6-89.5%).

Source: Analysis of NCSR data (data extracted on 12 August 2024), provided by the NCSR.

High-grade abnormality is defined as HSIL NOS (S3.1), HSIL-CIN2 (S3.2), HSIL-CIN3 (S3.3), or AIS (E3.2, E3.3). A record of ablative or excisional treatment is identified through any of colposcopy records, histology records, or MBS claims for ablative or excisional treatment or a hysterectomy. Date of diagnosis is defined as the biopsy sample collection date and allows for treatment on the same date as biopsy. The proportion of people treated is reported as a crude rate across all ages, as for most demographic groups, age-specific data were not available in sufficient detail to allow for age-standardisation or restriction to ages 25-74.

Aboriginal or Torres Strait Islander identification was based on whether a person had ever self-reported their status, as recorded in the National Cancer Screening Register (3). 

Currently, this report is the only source of published data on this indicator in Australia. A combination of colposcopy and histology records, and MBS claims for treatment (including hysterectomy) were used to identify if treatment had occurred. While this was as complete as could be identified using NCSR data, it is possible that some ablative treatments were missed if they were not recorded on colposcopy forms and not associated with an MBS claim.

The 2030 WHO target does not stipulate a timeframe over which to measure whether treatment has occurred. We have presented results at multiple timepoints to enable better visibility of whether treatment does eventually occur (by 12 months) as well as whether it occurs in a shorter timeframe, more consistent with best practice (8 weeks; 6 months), but it is not clear to which of the timeframes we have reported the 90% target should apply. Overall, most of those with high-grade cervical disease detected were treated within 8 weeks (and a very large proportion of the remainder had been treated by 6 months), but only a minority of those aged less than 30, those with CIN2 and those living in remote and very remote areas were treated within 8 weeks.  There was relatively little increase in the proportion of people treated between 6 and 12 months. Even over the relatively long timeframe of 12 months, however, the 90% target was not met in most cases, and Australia did not meet the target nationally. In some cases, there may have been an explicit choice to undergo a period of observation prior to treatment, which the NCSP Guidelines allow for, for example young women or those who had not completed childbearing with CIN2, which may explain the lower treatment rates in these groups (4).

Data by country of birth are still very incomplete on the NCSR.

1 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.

2 Australian Centre for the Prevention of Cervical Cancer. National strategy for the elimination of cervical cancer in Australia : A pathway to achieve equitable elimination of cervical cancer as a public health problem by 2035. November 2023. Available at : https://www.health.gov.au/resources/publications/national-strategy-for-the-elimination-of-cervical-cancer-in-australia?language=en  

3 Australian Institute of Health and Welfare. National Cervical Screening Program monitoring report 2023, catalogue number CAN 157, AIHW, Australian Government. 

4 Anderson L, Pather S, Wright G, Hammond I, Saville M, and the Cancer Council Australia Cervical Cancer Screening Guidelines Working Party. Treatment of high-grade squamous abnormalities. In: National Cervical Screening Program Guidelines for the management of screen-detected abnormalities, screening in specific populations and investigation of abnormal vaginal bleeding. Last updated: July 2022 Available at: https://www.cancer.org.au/clinical-guidelines/cervical-cancer-screening/management-histologically-confirmed-high-grade-squamous-abnormalities/treatment-of-hsil

Management of invasive cervical cancer in accordance with accepted guidelines is an important pillar of cervical cancer elimination (1). Incidence nationally was 6.4 per 100,000 in the period 2016-2020 and notably higher amongst Aboriginal and Torres Strait Islander people and other population groups (see Indicator 1), despite the national cervical screening program. Given that the full impact of HPV vaccination in reducing cervical cancer incidence remains decades away, continued screening and early detection, in conjunction with optimal stage-appropriate treatment of cervical cancer, is vital to reduce suffering and mortality from invasive cervical cancer in the Australian population.

A single study from NSW was the only source of new data identified since the previous report.

Jacobs et al (2024) conducted a retrospective cohort analysis of women in NSW diagnosed with cervical cancer between 2009 and 2018 using linked cancer registry, admitted patient, radiotherapy and death data. (2) They assessed receipt of surgery (including cone biopsy) or radiotherapy within one year of diagnosis by summary stage, Aboriginal and Torres Strait Islander status, remoteness and quintile of area level socioeconomic disadvantage. No data on receipt of chemotherapy was available, meaning that treatment estimates do not refer to receipt of any treatment for cervical cancer but to either surgery or radiotherapy only. People resident in border areas whose closest treatment centre was interstate were excluded from the analysis (161 of 2558 cases). 

There was no significant difference between Aboriginal and Torres Strait Islander patients and non-Indigenous patients in the rate of surgery within one year of diagnosis or in receipt of radiotherapy within one year of diagnosis. Over 90% of those with localised or regional disease received an appropriate treatment (surgery, radiotherapy or both), with no significant differences between Aboriginal and Torres Strait Islander women and other women (local 90% vs 92% (p=0.52) and regional 94% vs 95% (p=0.32) respectively). There was also no difference in the time from diagnosis to receipt of surgery or radiotherapy by Indigenous status, remoteness, or disadvantage (2). 

In total 9.5% of Aboriginal and Torres Strait Islander women and 7.5% of non Indigenous women women did not receive either a recommended surgical procedure or radiotherapy for the treatment of localised or regional-stage disease (p = 0.47). There was a significant association between non-receipt of treatment and disadvantage amongst Aboriginal and Torres Strait Islander women (50% of Aboriginal and Torres Strait Islander women who did not receive radiotherapy or surgery were in the most disadvantaged quintile compared to 24% of non-Indigenous patients (p=0.009).) There was a similar association between non-receipt of treatment and remoteness, with significantly more Aboriginal and Torres Strait Islander patients resident in remote or very remote areas, as compared to non-Indigenous patients (p ≤ 0.00001) (2).

As previously reported, in Queensland, a Cancer Quality Index was developed to track progress in delivering safe, quality cancer care within health care services using State level linked data (3). In the 2016-2020 time period, age adjusted cervical treatment rates (defined as at least one of major resection, radiotherapy or chemotherapy) improved compared to previous periods to reach 95% across all areas of residence (Table 10). The number of patients that received treatment within 30 days has declined slightly over time and was just under one third (27%) in 2016-2020. In the 2016-2020 period, there is still an ongoing large disparity in the proportion of patients receiving treatment within 30 days by use of public vs private facilities, little difference by remoteness and slightly increased timeliness for patients aged under 75 years compared to older. The proportion of patients receiving treatment within 30 days was higher amongst all Indigenous people (30%) than among non-Indigenous people receiving treatment in public facilities (18%), but non-Indigenous people treated in private facilities had a greater proportion treated within 30 days (47%). There was also a gradient by socioeconomic status, whereby rates of treatment receipt within 30 days increased with higher socioeconomic status (23% versus 24% between disadvantaged and affluent). The proportion of cervical cancer patients that were documented to have been reviewed by a multidisciplinary team (MDT) in 2016-2020 was low, at 13% (decreased from 24% in 2011-2015), noting however that MDT review was only able to be documented through use of a specific platform that not all facilities use.

Source: There are no routinely published national data available reporting cervical cancer treatment rates. Therefore, data presented, unchanged from the previous reporting period, are from state-level linked data. The Queensland Oncology Repository links patient data from the Queensland Cancer Register, Queensland Hospital Admitted Data Collection, on surgery, radiation therapy, and IV systemic therapy and data collected from multidisciplinary team meetings primarily in the public sector (3,4). More recent data form the most recent Queensland Cancer Quality Index report (2007-2021) (5) was not used due to a change in methodology which excluded all but major surgery as surgical treatment for cervical cancer. Refinement of the method for determining adequate surgical treatment for cervical cancer is currently underway. 

Australia’s national cervical cancer elimination strategy has recognised the current lack of national data to monitor its 95% optimal cancer treatment target, with one of the three treatment pillar strategic objectives being to “Drive improvements in cervical cancer management through a data collection framework supporting systemic monitoring and enhancement of the quality of care, in alignment with Australian Cancer Plan” (6).

The NSW study data suggests a rate of treatment for localised or regional stage cervical cancer within one year of diagnosis with surgery or radiotherapy of 90%-95%, with no significant difference for Aboriginal and Torres Strait Islander patients overall (2). However, for all stage cases, non-receipt of surgery or radiotherapy treatment is correlated with remoteness and disadvantage amongst Aboriginal and Torres Strait Islander women. These data support that strategies to improve access to cervical cancer treatment must prioritise those resident in remote areas and in areas of disadvantage. 

Queensland data also suggest that 95% of cervical cancer patients receive treatment, it is unknown whether this finding is generalisable to other jurisdictions. Previous analyses of Victorian data using the same methodology suggested lower rates of treatment (78-86% by area) despite treatment rates per modality being similar to those reported for Queensland: updated data are awaited, as are data from other States and Territories (7). In 2024 Cancer Alliance Queensland convened an expert panel to undertake a detailed review of the methodology and interpretation of the cervical cancer indicators produced as part of the Queensland Cancer Quality Index. We look forward to their further analyses and updated methodology to inform this indicator, which is expected in 2025. 

As reviewed in previous years, available data also suggest that cancer treatment received may be suboptimal (8,9), including studies documenting suboptimal care for Indigenous women (10-12). Access to treatment and to culturally appropriate treatment are substantial barriers for some patients (13). It is unknown how many patients in Australia currently receive cervical cancer care in a tertiary referral centre or according to the optimal care pathway for cervical cancer (14) which includes care informed by a multidisciplinary team. 

A 2023 systematic review of rates of adherence to cancer treatment clinical practice guidelines (CPG) and associated factors in Australia identified four studies published between 2015 to 2017 investigating the rate of CPG adherence to active cancer treatment for cervical cancer (including radiotherapy, brachytherapy, chemotherapy, endocrine therapy and surgery) (14). The median cancer treatment CPG adherence rate for cervical cancer was 83% (54 – 86%) with variation in subgroups for localised (adherence 0-100%) or regional/distant tumours (33-100%). Factors significantly associated with receipt of CPG adherent treatment for cervical cancer were geographic residence, caseload, distant tumours, staging, Indigenous status and age (15). 

A 2023 modelling and data linkage study of NSW Cancer Registry data (2010 – 2014) of 1216 cervical cancer patients linked to radiotherapy (2010-2015) and hospitalisation data (2008-2015) determined the actual radiotherapy utilisation (RTU) rate was lower than the optimal age- and comorbidity- adjusted RTU rates for patients aged 60 years but higher than optimal for patients aged ≤60 years and over (16). Possible explanations for this finding include a preference to opt for radiotherapy vs surgery in older patients, a willingness to consider radiotherapy even for patients with high morbidity due to the lack of alternative therapies or an overutilisation of radiotherapy in older patients (16).

The National Elimination Strategy proposes cervical cancer audits, consolidation of existing resources to develop national guidelines for cervical cancer treatment (which is currently underway) and utilisation of the National Gynaecological Oncology Registry (NGOR) to overcome the current difficulties in measuring progress towards the 95% optimal treatment goal (6).  

The NGOR is a clinical quality registry (https://ngor.org.au) (17), aiming to scale up to invite all newly diagnosed cervical cancer patients to participate in order to ‘inform continuous improvement in care (equity of access, quality, and safety) based on incidence, stage, and mortality data, key clinical quality indicators, as well as patient reported evaluation and outcome measures (PROMs)’. A MRFF Research Data Infrastructure Grant was awarded in 2024 to develop the NGOR cervical cancer module, with linkage to other data sets, which will greatly facilitate future monitoring of cervical cancer treatment uptake and compliance with optimal care. 

1 World Health Organization. Meeting of the Strategic Advisory Group of Experts on Immunization, April 2022: conclusions and recommendations. Weekly epidemiological record 2022; 97, 261–276. 

2 Jacob S, Gabriel G, Yap ML, Vinod S, Griffiths K, Sheehan D, Anderson S, Delaney G. Comparison of Epidemiology, Demography, Treatment (Surgery and Radiotherapy), and Survival Between Aboriginal and Torres Strait Islander and Non-Indigenous Women With Cervical Cancer in NSW, Australia in 2009–2018. Asia-Pacific Journal of Clinical Oncology. 2024. https://doi.org/10.1111/ajco.14140

3 Queensland Government. Queensland Cancer Quality Index: Indicators of safe, quality cancer care. Cancer care in public and private hospitals 2006-2020. Queensland Health, Brisbane, 2023. Available at: https://cancerallianceqld.health.qld.gov.au/Website/media/2066/queensland-cancer-quality-index-2006-2020.pdf 

4 Queensland Government. Queensland Cancer Quality Index 2007-2021 Technical Appendix. Queensland Health, Brisbane, Oct 2023. Available at  https://cancerallianceqld.health.qld.gov.au/media/y42bteim/queensland-cancer-quality-index-2007-2021-technical-appendix.pdf 

5 Queensland Government. Queensland Cancer Quality Index: Indicators of safe, quality cancer care. Cancer care in public and private hospitals 2007-2021. Queensland Health, Brisbane, 2023. 

6 Australian Centre for the Prevention of Cervical Cancer. National strategy for the elimination of cervical cancer in Australia : A pathway to achieve equitable elimination of cervical cancer as a public health problem by 2035. November 2023. Available at : https://www.health.gov.au/resources/publications/national-strategy-for-the-elimination-of-cervical-cancer-in-australia?language=en   

7 Department of Health and Human Services. Victorian Cancer Quality Index 2008–2015. Melbourne: State of Victoria, 2018. Available at: https://www.health.vic.gov.au/publications/victorian-cancer-quality-index-2008-2015 

8 Roder D, Davy M, Selva-Nayagam S, Gowda R, Paramasivam S, Adams J, et al. The value of local registry data for describing cervical cancer management and outcomes over three decades in Australia. European Journal of Cancer Care (England). 2018;27(1). 

9 Chiew KL, Chong S, Duggan KJ, Kaadan N, Vinod SK. Assessing guideline adherence and patient outcomes in cervical cancer. Asia Pacific Journal of Clinical Oncology. 2017;13(5):e373-e80 

10 Diaz A, Moore SP, Martin JH, et al. Factors associated with cancer-specific and overall survival among Indigenous and non-Indigenous gynecologic cancer patients in Queensland, Australia: a matched cohort study. International Journal of Gynecological Cancer 2015; 25(3): 542-7. 

11 Diaz A, Baade PD, Valery PC, et al. Comorbidity and cervical cancer survival of Indigenous and non-Indigenous Australian women: A semi-national registry-based cohort study (2003-2012). PLoS One 2018; 13(5): e0196764. 

12 Marcusson-Rababi B, Anderson K, Whop LJ, Butler T, Whitson N, Garvey G. Does gynaecological cancer care meet the needs of Indigenous Australian women? Qualitative interviews with patients and care providers. BMC Health Services Research. 2019;19(1):606. 

13 Anderson K, Diaz A, Parikh DR, et al. Accessibility of cancer treatment services for Indigenous Australians in the Northern Territory: perspectives of patients and care providers. BMC Health Services Research 2021; 21(1): 95. 

14 National Cancer Expert Reference Group (NCERG). Optimal care pathway for women with cervical cancer 2020. Available at: https://www.cancer.org.au/assets/pdf/cervical-cancer-optimal-cancer-care-pathway  

15 Bierbaum M, Rapport F, Arnolda G, et al. Rates of adherence to cancer treatment guidelines in Australia and the factors associated with adherence: A systematic review. Asia Pacific Journal of Clinical Oncology. 2023 Dec;19(6):618-644. doi: 10.1111/ajco.13948.  

16 Mackenzie P, Vajdic C, Delaney G, Comans T, Agar M, Gabriel G, Barton M. Development of an age- and comorbidity- adjusted optimal radiotherapy utilisation rate for lung, rectal, prostate and cervical cancers. Radiotherapy Oncology. 2023 Nov;188:109862. doi:10.1016/j.radonc.2023.109862. 

17 Monash University 2023. The National Gynae-Oncology Registry. Available at: https://ngor.org.au 

Information on cervical cancer survival provides an indication of cancer prognosis at the individual level and the effectiveness of treatment. Relative survival indicates the percentage of people who are still alive for a specific amount of time (typically 5 years) following a cervical cancer diagnosis, relative to the expected rate in women their age in the general population and is expressed as a percentage.

A range of factors influences survival, including characteristics of the patient (such as age, comorbidities, and functional status), the nature of the tumour (such as stage at diagnosis and histology type) and the health system (access to services, whether the cancer was screen-detected, diagnostic and treatment facilities, follow-up services) (1,2).

Overall, 5-year relative cervical cancer survival for Australia was 75.5% in 2016–2020, showing minor improvements over time, rising from 73.6% in the period 1996–2000. In the most recent period, 5-year survival was highest in the ACT (80.6%). The NT (70.7%) continues to have the lowest 5-year survival with some improvements over time (Figure 11.1).

Overall, 5-year relative survival decreased with increasing age from 93.2% among women diagnosed when aged 20–24 years to 24.4% at 85+ years (Figure 11.2).

Relative survival could not be calculated by Indigenous status, socioeconomic status, remoteness area, or country of birth, but observed 5-year survival rates were lowest for Indigenous women (61.5%), women living in the lowest socioeconomic quintile (65.3%) and very remote areas (56.3%). Rates were similar for Australian-born and overseas-born women, noting that these high-level groupings may obscure diversity in survival for different culturally and linguistically diverse groups (Figure 11.3).

Source: 2020 Australian Cancer Database, with additional analyses of Cancer data provided by AIHW.

Relative survival rates provide an objective measure of survival probability from cancer, controlling for differences in mortality from other causes. It is the ratio of the observed survival rate in a group of patients during a specified follow-up period to the expected survival rate in a comparable population. Calculations of expected survival rates require information on the probability of a comparable population living to or dying at a particular age (i.e., life tables). Relative survival for Australia overall and by age group was calculated using national life tables, whereas relative survival by jurisdiction was calculated using jurisdiction-specific life tables. Life tables were not available by Indigenous status, socioeconomic status, remoteness area, or country of birth and observed (crude) survival rates are presented. Relative survival rates for women under the age of 20 years were not published due to an insufficient number of cases to calculate a stable estimate of survival.

Aboriginal or Torres Strait Islander identification was based on whether a person had ever self-reported their status, as recorded by six state and territory cancer registries (NSW, Vic, Qld, WA, ACT and NT) (3).

Cervical cancer survival rates in Australia are above the international benchmarks, which generally show a range in 5-year survival between 50–70% (4). Survival gains over time have been modest, likely due partly to the limited progress in treatment advancements. Recent trial findings suggest a new treatment option that could significantly improve survival and outcomes for patients with locally advanced cervical cancer (5).

Crude survival data show disparities by Indigenous status, socioeconomic status and remoteness, which may be partially explained by diagnosis at a later stage (6,7,8). Nevertheless, comparisons of crude survival rates across the different sub-population groups should be interpreted with caution as they do not control for underlying chances of survival without cervical cancer.

Cancer stage is a strong predictor of survival, but the stage at diagnosis is only routinely collected by the NSW Cancer Registry, and so cannot be accounted for here. 

Data from the previous Pap-based screening program shows that overall cervical cancer survival is notably higher for women with an adequate screening history compared with lapsed or never screened women, and among women who have been screened, for screen-detected cancers (9). This demonstrates the greater survival benefits for women regularly participating in screening (especially when the cancer was screen-detected), which is likely due to cervical cancers detected through screening being diagnosed at an earlier stage and being slower developing cancers than cancers diagnosed in women who were under or never screened.

The Indigenous status variable is not of sufficient quality for analysis of records from SA, Tasmania or the ACT. Therefore, the survival statistics presented by Indigenous status are for NSW, Vic, Qld, WA and NT combined.

The survival figures are not age-adjusted. This could affect the comparison of results between jurisdictions and/or within a jurisdiction over time if the age characteristics of people diagnosed with cervical cancer varies between jurisdiction or changes over time.

Relative survival by jurisdiction for 1990–1994 was not available due to the lack of jurisdiction-specific life tables for this period.

1 Diaz A, Baade PD, Valery PC, et al. Comorbidity and cervical cancer survival of Indigenous and non-Indigenous Australian women: A semi-national registry-based cohort study (2003-2012). PLoS One 2018; 13(5): e0196764.

2 Australian Institute of Health and Welfare 2021. Cancer in Australia 2021. Cancer series no. 133. Cat. no. CAN 144. Canberra: AIHW.

3 Australian Institute of Health and Welfare 2021. Cancer in Australia 2021. Supplementary tables for Chapter 10. Available at: https://www.aihw.gov.au/getmedia/501b86ea-2d72-406e-b609-0d597cd1350b/aihw-can-144-data-tables-Ch-10-Key-Population-Groups.xlsx.aspx 

4 Allemani C, Matsuda T, Di Carlo V, et al. Global surveillance of trends in cancer survival 2000-14 (CONCORD-3): analysis of individual records for 37 513 025 patients diagnosed with one of 18 cancers from 322 population-based registries in 71 countries. Lancet. 2018; 391(10125): 1023-75.

5 Mirza, MR, Chase, DM, Slomovitz BM, et al. Pembrolizumab or placebo with chemoradiotherapy followed by pembrolizumab or placebo for newly diagnosed, high-risk, locally advanced cervical cancer (ENGOT-cx11/GOG-3047/KEYNOTE-A18): A randomized, double-blind, phase 3 clinical trial. The Lancet, 403 (10388), 1305-1314.

6 Australian Institute of Health and Welfare 2019. Cervical screening in Australia 2019. Cancer series no. 123. Cat. no. CAN 124. Canberra: AIHW

7 Diaz A, Moore SP, Martin JH, et al. Factors associated with cancer-specific and overall survival among Indigenous and non-Indigenous gynecologic cancer patients in Queensland, Australia: a matched cohort study. International Journal of Gynecological Cancer 2015; 25(3): 542-7.

8 Australian Institute of Health and Welfare 2018. Analysis of cancer outcomes and screening behaviour for national cancer screening programs in Australia. Cancer series no. 111. Cat. no. CAN 115. Canberra: AIHW.

9 Australian Institute of Health and Welfare 2019. Analysis of cervical cancer and abnormality outcomes in an era of cervical screening and HPV vaccination in Australia. Cancer series no. 126. Cat. no. CAN 129. Canberra: AIHW.