Farewell ‘Pap smear’, hello ‘cervical screening test’

Jan 18, 2018

What will the changes mean for GPs and their patients?

On 1 December 2017, GPs and the women of Australia bid farewell to the Pap smear and hello to the cervical screening test. These evidence-based changes will lead to less screening of low risk women and more intensive management of high risk women. And for all those women who dread the two-yearly Pap smear visit, the new requirement of five-yearly screening will be very welcome.

As a practising GP digesting the changes, I cannot help but look at this process through my medico-legal tinted glasses. As with any change, it is the transition period when most of the risks occur.

I do have a number of concerns so I have been reviewing the National Cervical Screening Program reference guide and thinking about the changes I need to make in my own practice.

Screening intervals and recalls

Firstly, how do women know when to come and have their regular test? It is actually a bit more complex than just changing the screening interval from two to five years and you should check the reference guide, as screening guidelines vary according to symptoms, history, vaccination status and test results. Most asymptomatic women should now commence screening at age 25. Women aged 25 to 74 should generally have their first cervical screening test two years after their last Pap smear. Thereafter, if they screen negative for high-risk HPV types, asymptomatic women can be screened every five years. Note all the qualifications in those sentences though, so I am finding myself frequently checking the reference guide.

Most of my patients come for a Pap smear when they receive the reminder from their state-based register. I have not run a recall system in my practice for Pap smear, as the state register has done this very well. This register will now be transitioning to a National Cancer Screening Register (NCSR), operated by Telstra Health, with the plan to migrate the data from the eight state and territory registers into the NCSR. Although the new test was introduced on 1 December 2017, the NCSR may not be available until possibly March 2018. Some of the states have confirmed they will continue to run a transitional register, until their data are migrated to the NCSR

Of particular concern to me are the patients with low grade intraepithelial lesions, who are currently being monitored at more regular intervals. For these patients in particular, I expect I may need to establish a recall system to cover the transition period.

Patient issues

It will also be important for patients to keep their contact details up to date so the NCSR can remind them when they are due for a test every five years. Another concern for patients may be the safety of their information being contained within a national register operated by Telstra Health. I am reassured that privacy issues have been a central focus of the Department of Health in the roll-out of the NCSR and it is also underpinned by protections in the National Cancer Screening Register Act 2016. I have noted though that women who wish to opt out from being included on the register will need to do so with the NCSR directly, and not by the doctor at the point of ordering the test, as occurs now.

Maintaining opportunistic screenings

Secondly, I reflect on the content of those consultations every two years with otherwise healthy women. Somehow these always seem to take twice the time that is required to just perform the test. It is never solely the Pap smear that I cover in the consultation. It includes a status check for the woman who may not have prioritised her own health at other times. The opportunistic screening for STIs, pre-pregnancy advice, contraception review, menopause management advice, mood, and domestic violence screening as well as other age-related evidence-based screening that should occur in general practice may now occur less frequently. I will need to consider how I can maintain these valuable consultations in the new world.

Eligibility for the Medicare rebate

Thirdly, I am thinking about patient eligibility for screening, and which test to request on the pathology form. Pap smears are no longer eligible for Medicare rebates since 1 December 2017, and patients may be charged if this test is requested. There are new MBS item numbers and naming conventions to write on the pathology request forms. I will need to order the ‘CST’ or ‘Cotest’ or ‘LBC test’ at the appropriate times, or ‘HPV test, self- collected’ when that test is available, or my patient will not be eligible for a Medicare rebate.

I have noted that there is already considerable concern about cervical screening not commencing until age 25 years. The pathology companies are already receiving requests from doctors for CST from women under the age of 25.

Unless the patients fall within one of the specific exceptions, the pathologists will be required to either charge the women privately or discard the test. For some of my patients this would be a financial hardship, others would be upset at the additional expense – particularly if they hadn’t been warned and provided financial consent for the expenditure. Most women would be very upset at having an unnecessary speculum examination if the test were discarded. To avoid the risk of a complaint about this, I will need to give my patients the right information. I have studied the guide and have a summary chart handy when I perform and order the new test under the cervical screening umbrella of tests to assist me.

Cervical screening test results

Finally, I am giving thought to how and what information I will provide to women about the results of their cervical screening tests. The neat tear off slip to send to patients has disappeared from the results sent to me by my pathology provider in the transition to the new world.

As with any change in GP practice, the amount of work to implement it can seem daunting. One thing that I have learned from both my practice and my medico-legal role is that the effort to plan for changes with all of the general practice team definitely pays off in the long run.

Reference:

http://www.cancerscreening.gov.au/internet/screening/publishing.nsf/Content/healthcare-providers

More information

If you would like further information on this issue or other issues, visit our website or for immediate advice, call our Medico-legal Advisory Service on 1800 128 268, 24-7 in emergencies.

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