202305_Bay of Plenty Screen-Takers Presentation 1_2 May 2023

RoadtoRollout

THEVISION–futurestate

Reachingmoreparticipantsintheirowncommunitiesthrough:

Empoweringparticipantswithgreaterconsumerchoiceaboutwhatand howtheycanparticipate.

DrivingequitableoutcomesforMāoriandPacificpeople.

Greater,morediverseworkforce–includinggreaterintegrationof Kaiāwhinaintopathways.

Bringingtogethertheservicesaroundthecommunityandconsumer.

BRINGINGDOWNTHEBARRIERSTOSCREENINGFORALLPARTICIPANTSANDWHĀNAU

EquityPriorities

•Newpathwaysthatempowerparticipantswithchoice;aimtoincrease participationinMāoriandPacificgroupsthroughproactivecommunicationand support.

•EnhancedhealthequityforwāhineMāoriandPacificwomenthroughlessinvasive clinicalpathwaysthatmeetculturalandaccessneedscombinedwithtargeted outreachtotheunder-screenedpopulation.

•ExpandingtheworkforcewithmoreMāoriandPacificclinicalandnon-clinicalstaff utilisedinthedeliveryoftheinitialscreening.

NationalCervicalScreeningProgramme

HPVPrimaryScreening

Theprojectwillsupportnewclinicalpathwaysthatwillprovidegreaterchoicetoparticipantsto liftuptake,increasescreeninginprioritygroupsandreducemortalityratesinourcommunities.

Whatwewillachieve:

a)HPVastheprimaryscreeningtest–HPVtestingwillfindmorepre-cancersandprevent morecasesofcervicalcancer,supportedbythespeculumandcolposcopytestswithinthe pathways.

b)NewNCSP-Register–Asinglesourceoftruthforscreeningrecordsandindividual schedules.

c)NewPathways–Embeddingmorechoiceandflexibilityintoscreeningincludingthe optiontoselftest,removingbarrierstoentryandbettersupportingandincreasing equitableoutcomesforMāoriandPacificpeople.

d)AdditionalWorkforceandTraining–Accreditedscreen-takers/GPs/midwivestodoHPV testingaswellasLBCtest,otherRegisteredNursescancompleteHPVtestwithtraining.

NationalCervicalScreeningProgramme

PHASE1–FOUNDATIONALSTEP

Participantsabletochooseself-orclinician-takenHPVswabtest,oraspeculumtest

26JULY2023

NewclinicalpathwaysrolledoutacrossPrimaryCare.TheNCSP-Registerhasbeenimplementedand adoptedbyexistingusersandtheeligiblepopulationisimprovedtosupportbetteruptakein screening.LabsandColposcopyclinicspreparedforthenewtestsandarereadyforfluctuating volumes.Increasedmediacampaignactivitynationwidetopromotethenewtest.Whileall participantswillbeabletochooseself-orclinician-takenHPVscreeningtest,thefocuswillbeon MāoriandPacificparticipantsandincreasingscreeningintheunder-orunscreenedpopulations.

Self-orclinician-takenHPVswabtest.

HPVself-testswabmaybeavailableathome,whereclinicssupportthis

NationalCervicalScreeningProgramme

PHASE2–EXPANDINGREACH

Buildingonthebasicsbywideningtheparticipantbaseandincreasinguptake.

EstimatedtimingAUG–DEC2023

Increasingreachthroughnotificationsandexpandingwheretestingbecomesavailable, movingtestingclosertoourcommunities.PrimaryCarenowhavetheabilitytoeasily accessscreeninghistory.

Self-orclinician-takenHPVswabtest–withmoreoptionsforlocationsoutsideofaclinical setting.

HPVself-testswabmaybeavailableathome,whereclinicssupportthis

Continuously Evolving

NationalCervicalScreeningProgramme

PHASE3–FULLBENEFIT

AchievingtheFutureStateandmovingintocontinuousimprovement

EstimatedtimingJAN–MARCH2024

Moreparticipantsareencouragedintoscreening,increasingourscreeningcoverage, patientexperienceandwhānausatisfaction.Participantscanchoosetoself-testathome orinawidevarietyofsettingsthatworkforthem.Ourworkforcefeelsempowered throughtrainingandaccreditationtoadviseandsupportwomenthroughthenew pathways.ThenewNCSP-Registerisembeddedintoourwaysofworking.

Continuously Evolving

NationalCervicalScreeningProgramme

HPVPrimaryScreeningDeliveryRoadmap

PHASEONE:FOUNDATIONALSTEP-26JULY2023

PARTICIPANTS

Inowhavenewchoicesforscreening,includingtheabilitytoself-testfortheHPVvirus.Imaybeofferedtheopportunitytotakethetestathome.Iwillcontinueto receivenotificationsfrommyPrimaryCareprovider.

PRIMARYCARE

WehavecompletedourtrainingonHPVPrimaryScreeningandareconfidentinthenewpathways,includingsupportingpeoplethroughinformedconsentandthenew HPVprimaryscreeningtests.

COLPOSCOPYCLINICS

Weareconfident,understandtheguidelinesandhaveplannedtoaccommodatethevariationinvolumethatmightariseforColposcopywiththeintroductionofHPV primaryscreening.WehavetransitionedtoGynae+v11andcanaccessandinteractwithinformationfromthenewNCSP-Register.

LABORATORIES

WehavecompletedourtrainingandunderstandthenewHPVprimaryscreeningprocessandusageofthenewrecommendationcodes.WeareequippedtoprovideHPV primaryscreeningteststoaccreditedsampletakers(e.g.PrimaryCare)andtestforbothHPVandcytology.

REGIONALCO-ORDINATION&SUPPORTTOSCREEN

Wehavecompletedourtrainingandareconfidentinpromoting,providingadviceon,andsupportingnewchoicesforscreening,withparticularfocusonpriority groups.OuraccreditedscreentakerswillbetrainedinHPVPrimaryScreeningandwillbeabletoaccesspatientdatatostayinformed.Weunderstandtheroleeveryone hastoplayinthenewpathways.

CENTRALISEDREGISTER

WewillusetheNCSP-RegisteruserguideandcompletethetrainingtocontinuetomanagedataonthenewNCSP-Register.Acrosstheteams,wewillensurethedata consistencyandrobustness,ensuringintegrationbetweenthedifferentNCSP-Registerusersandprovideresolutiontocomplexdataandclinicalissues.

Manawhakahaere|Governance

Outlineoftheprojectgovernanceusedthroughoutdesignandintoimplementation.

DesignAuthorityGroup

PlatformResilienceSteerCo.

DataGovernanceGroup

SecurityGovernanceGroup

SalesforceGovernance Group

MāoriMonitoringEquity Group

NationalScreeningAction andAdvisoryCommittee

NationalKaitiakiGroup–Cervicalonly

NCSPAdvisoryandActionRōpū

LaboratoryWorkingGroupPacificResources&Media CampaignAdvisoryGroup

DataMigrationSteering Group

MāoriResources&Media CampaignAdvisoryGroup

ColposcopyWorkingGroupKaimanaakiWorkingGroup

RegisterServicesWorking Group Screen-takersWorkingGroup

HPVResearchProjects

Sectorworkinggroups

NationalScreeningUnitSteering Committee

TeAkaWhaiOra–MāoriHealth Authority

ProjectLeadership

Campaignsandoutreach

Changeandtraining

TheRegister

Labs,ColpandPrimaryCare

Monitoring,dataandreporting

Supportcentre

Clinicalandequity

Equityunderpinsalltheworkstreams

Initialareasofinputandadvicewillsitwithinthe followingworkstreams:

1.Campaignsandoutreach–particularlyfor campaignsdesignedforMāori

2.Clinicalandequity

3.Notificationstrategy

4.Supportcentre–diverseworkforceexpansion.

NationalPublicHealthService TechnologyPortfolioBoard

TeWhatuOra–HealthNewZealand

PreventionPortfolioBoard

HPVProjectSteeringCommittee

Cervicalcancerispreventable

•AimistoeliminatecervicalcancerforallethnicgroupsinAotearoainlinewiththeWorld HealthOrganization(WHO)goal2030.

•Toachievethisweneedtoimproveourvaccinationandscreeningrates.

•ChangingtoHPVtestingisexpectedtoimproveparticipationincervicalscreening.

Reachingequityincervicalscreening

Equityandperformancematrix

•Thematrixbringstogetherthetwomeasuresofequity andperformance.

•Performanceisthedifference(percentagepoint)between thepopulationofinterestandProgrammetarget.

•Equityisthedifference(percentagepoint)betweenthe performanceofthepopulationofinterestandthe referencepopulation(non-Māori,non-Pacific).

Māori

Differencefromequity=-19.4

Differencefromperformance=-25.3

Pacific

Differencefromequity=-18.7

Differencefromperformance=-24.6

NationalCervicalScreeningProgramme

ChangingtoHPVprimaryscreening

•Thisnewscreeningmethodwilltestforthepresenceofhumanpapillomavirus (HPV),thevirusthatcausesmorethan95%ofcervicalcancers.

•Itisnotthesameasthecurrenttest.

•Willdetectmorehighgradechangesthanthecurrentcytologybasedprogramme

•Thecurrenttestlooksforcellchanges…theHPVtestlooksforthepresenceofthe virusthatcausesthosechanges.

•ThosewhohaveHPVdetectedwillneedfurtherinvestigationwithacytologytestor areferraltocolposcopy.

AverysmallnumberofcervicalcancersarenotHPVrelated:mostareadenocarcinomas. EvenifanHPVtestisnegative,symptomsofcervicalcancerstillneedtobeinvestigated.

Screeningeligibility?

•Anypersonaged25to69yearswhohasacervixwhoisdueoroverduetheircervical screenandeligibleforpubliclyfundedhealthcare.

•Thisincludestrans-menandnon-binarypeople.

•Womenwhohavesexwithwomenshouldbescreened.

•Thoseaged70to74yearswhohaveneverbeenscreenedorareunder-screenedshould haveanegativeHPVtestbeforeceasingscreening.

•Māori,Pacificpeoplesandthosewhoareunder-screened(>5yearssincelastcytology) andneverscreenedshouldbeprioritised.

•ThenewNCSP-Registerwillbepopulationbased,fromNHIdata.

•Participantsarestillabletooptoff.

WhatisHPV?

•Humanpapillomavirus(HPV)isaDNAvirusthatinfectstheskinandmucousmembranes.

•Thereareover200typesofHPV,around40thateffectthegenitalregion.

•HPVispassedonbyintimateskintoskincontact.

•It’sextremelycommon–fouroutoffiveadultswillbeinfectedwithHPV.

•MostHPVinfectionsresolvespontaneouslyandareasymptomatic.

•90%resolvewithin2yearsofinfection.

HPVandCancer

•HPVtestingtestsfor:

14oncogenictypescancausecancer(16,18,31,33,35,39,45,51,52,56,58,59,66,88).

16and18arethehighestrisktypesandassociatedwith75%ofsquamouscellcervical cancers.

•ForHPVtocausecancerthreethingsarenecessary:

HighrisktypeofHPV

Persistenceofthatinfection

Time.

Vaccinationisvital

•ThefirstlineofdefenceagainstcervicalcancerispreventionbyHPVimmunisation.

•TheWorldHealthOrganization(WHO)targetisforaglobal90%vaccinationrateforgirls bytheageof15.

•InAotearoa,HPVimmunisationisFREEforeveryoneaged9to26years(inclusive).

•Offeredtorangatahiinyear8atschoolandcanalsobegiveninPrimaryCare.

•Itslicencedforuseforwomenupto45years(atacost).

•Gardasil-9isthecurrentvaccine,whichincludes:

7high-riskHPVtypes(16,18,31,33,45,52,58).

2HPVtypesagainstgenitalwarts(6,11).

HPVPrimaryScreeningProject

Participantswhohavebeenvaccinatedstillneedscreeningasnot allhrHPVtypesarecoveredbythevaccination.

HPVprimaryscreeningcandetectHPVevenBEFOREcellchangesoccur

SpeculumtestdetectscellchangesAFTERtheyoccur

Empoweringwithchoice

Self-testingisnottheonlyoptionavailablefromJuly2023.

Participantshavechoices:

Choosetoself-test(vaginalswab),inalocationoftheirchoice.

OptforacliniciantoassistwithtakingtheHPVswabtest.

ChooseforthecliniciantotakeanLBCsample(previouslyknown asasmear)whichwillbetestedforHPVandifthevirusis detected,willbetestedforcytology.

Participantsneedtobereassuredthataself-testisjustaseffective asaclinician-takensampleatdetectingthepresenceofHPV.

Detectingcervicalprecancerandreachingunder-screenedwomenbyusingHPVtestingonselfsamples:updated meta-analysesMarcArbynetal.BMJ2018;363:k4823|doi:10.1136/bmj.k4823

HPVPrimaryScreeningProject

ExplainingtheHPVself-test

•Thetestisavaginalswab,sononeedtofindthecervix.

•Theparticipantmayself-testinalocationoftheirchoice,oroptforaclinician-taken sample.

•Self-testingrequiresinformedconsentwithacliniciantakingresponsibilityforfollowing upthetestresultsandarrangingfollow-up.

•Theself-testingoptionhasbeenproventoincreasescreeningratesofunder/never screenedwāhineMāori.

HPVPrimaryScreeningProject

TheHPVself-testisnotadequatefor:

•Anyonewithsymptoms:

bleeding(aftersex,aftermenopause,inbetweenperiods)

abnormaldischarge

painwithsex

pelvicpain.

•AnyoneneedingaTestofCure(TOC)afterahighgradeabnormality.

AnyoneundersurveillanceitisrecommendedtohaveanLBC becauseoftheincreasedlikelihoodthatcytologywillberequired.

Resultsmanagement

•~90%ofpeoplewillhaveHPVnotdetected–nextscreenin5years.

•~2.5%ofpeoplewillhaveHPV16orHPV18detected–refertocolposcopyclinic.

•~7.5%ofpeoplewillhaveHPVOtherdetected–returnforcytologyiftestwas performedonaswab.

Ifhighgradecytology–refertocolposcopy.

Ifnormalorlowgrade–repeatin12months.

WhensomeonehasHPVdetectedaskthemagainaboutsymptoms.

NationalCervicalScreeningProgramme

Alongerscreeninginterval

•ThescreeningintervalfollowinganegativeHPVtestwillchangeto5yearscomparedto thecurrent3years.

•Studieshaveshownthattheriskofpre-cancer5yearsafteranegativeHPVtestis significantlylowerthan3yearsafteranegativecytologytest.

•Sowāhine/whānaucanfeelconfidentwiththisextendedintervalwithHPVprimary screening.

AnHPVtestismoresensitivefordetectingabnormalitiesthana negativecytologytestsowedon’tneedtorepeattheHPVtest12 monthsafterafirstscreen.

CytologyvHPVtesting

Longtermpredictivevaluesofcytology

andhumanpapillomavirustestingin

cervicalcancerscreening:joint Europeancohortstudy

HPVPrimaryScreeningProject

HPVtestscreeningresultsinlowerinvasive cancerratescomparedwithcytologyscreening

HPVandrelationships

•BecausewearenowtestingforHPV,someparticipantswhohavehadnegativecytology testsforyearswillnowtestpositiveforHPV.

•ApersonmayhavehadHPVformanyyearsandneverhadsymptoms.

•Peoplewhohavenothadsexualorintimatecontactformanyyearscantestpositivefor HPV.

•SomepeoplecanbecomeworriedaboutwheretheygotHPVandwhethertheirpartner hasbeenunfaithful.

•ThemostimportantthingtoknowisthathavingHPVdoesnotmeanthatapersonor theirpartnerishavingintimatesexualcontactoutsidetheircurrentrelationship.

Stoppingscreening

•EveryoneshouldhaveanegativeHPVtestbeforeexitingtheprogramme.

•Thoseaged>65yearswhohaveHPV'notdetected'canstopscreening(unlessstillin followupforahigh-gradelesion).

•Thoseaged70-74whoareunscreenedorunderscreenedshouldhaveanegativeHPVtest beforeceasingscreening.

•Thosewithatotalhysterectomy(histologicalconfirmationthecervixhasbeenremoved) withanormalscreeninghistorycanstopscreening.

SpecialConsiderations

•Immunocompromisedparticipantsshouldhavescreeningevery3yearsandbereferredto colposcopyifanytypeofHPVisdetected.

•Pregnancy–HPVtestingissafeinpregnancyandshouldbeconsideredpartofroutine antenatalscreeninginthosewhoaredue.

Keymessages

•HPVtestingisabetterprimaryscreeningtestthancytology.

•Forsome,cytologyisstillrecommended–surveillance,TOC,clinicallyindicated.

•About10%willhavehighriskHPVdetected,requiringfollow-up(cytologyorcolposcopy).

•About90%willhaveHPVnotdetected,theirnextscreenwillbein5years.

•Participantscanchoosehowandwheretohavetheirscreeningtest.

•Self-collectedswabsarejustasaccurateasclinician-takensamples.

•Theoptionofself-testingwillreducebarriersandincreaseparticipation.

•ThenewRegisterispopulationbasedsowillidentifymorepeopleeligibleforscreening.

•VaccinationiskeytoreducingcervicalcancerinAotearoa.

Pleaseencourageparticipantstocontinuetohavecytologyscreening ontimepriortoJuly2023,ratherthanwaitingforthenewtest.

Swabandlaboratory

•Instructionsandswabsamplesuppliedbylaboratory

•BayofPlentyscreen-takerswillbeusingPathlab

Trainingandkeydates

Learningapproach

•Ablendedlearningapproachisbeingdevelopedtosupportthesectorthroughthe transitiontoHPVprimaryscreening.

•Differentlearningmediumswillbecreatedtoensurethateachroleinthesectorhasthe appropriateeducation.

•Somelearningwillbedeliveredase-modulesthatmaybetrackedinalearning managementsystem.

•Othermediumswillinclude:

Educationalvideos

Printedresources

Webinars

In-personeducation.

FoundationStepcoree-learningmodules

Willinclude:

•Whyscreeningis important

•CoreinfoaboutHPV

•Whatisthe relationshipbetween HPVandcancer

•HPVvaccination

Willinclude:

•Historyofprogramme

•Informedconsent

•Prioritypopulation

•Culturalperspectiveon screening

•Significanceof communityservices andtheirrole

Willinclude:

•Communicatingwith participantsinamana enhancingway

•Conversation modellingwith participants

Willinclude:

•Clinicalpathways

•Includescenariosto teachpathways

•Resultsconversations

•LinkstoUpdated ClinicalPractice Guidelines,Policies andStandards.

NationalCervicalScreeningProgramme

Formoreinformationandgivingfeedback

•HaveyouseenourSectorUpdatemonthlynewsletter?

Getaddedtothedistributionlistbyemailingusat

HPVScreen@health.govt.nz

•HealthProfessionalspagesontheNSUwebsitecontain

FAQs:here

•Wealsohaveansweredanextensivelistofclinicians’ questionsfromaGoodfellowUnitwebinar,whichcanbe foundhere

Yourfeedbackisimportant.Contactuson hpvscreen@health.govt.nz

We’reheretosupportyouthroughthesechanges.

NationalCervicalScreening Programmeupdate

Aotearoacoveragebyethnicity

BayofPlentyRōhe

AnyPātai?