to make no practical suggestions as to how to increase screening coverage. SECTION 2: Invalid and unsatisfactory cervical screening results Name / Title Organisation Feedback Aroha Morgan, Phyllis Tangitu and Trish Solomon Maori Health, Lakes District Health Board Non applicable from a non-clinical perspective. Dr Vicki Robertson, Lead Colposcopist West Coast DHB No additional comments. We support these recommendations. Beth Henderson, Education Nurse Well Women & Family Trust Good. Waikato DHB Good to give time frame for repeat testing and great to see recommendation for use of vaginal oestrogen in post-menopausal women – Need to ensure there are no CONTRA-INDCATIONS before prescribing (eg history of oestrogen sensitive tumours – such as breast cancer). Other evidence/information to consider: P10 amendment: Pip Egerton, Rural Practice Nurse (smear taker), Primary Care representative Otago / Southland NCSP regional MDT Tuatapere and Otautau Medical Centre Good to see 2.04 included. evidence/information to consider: Good to see this removed as a Quality measure for cervical smear takers Fiona Moscrop – on behalf of Clinical Quality Board Compass Health Acceptable. Respondent’s name redacted at request. Member of the public In my opinion postmenopausal women should be offered self HPV testing in the first instance rather than vaginal oestrogen when a test is invalid. CWH & CHL - Refer Section 1 Collaborative feedback CWH and CHL Support recommendations.
Lucina Kaukau & Jane Grant 12.04 Assessing entire anogenital tract is very sensible in this group of women. 12.08 Thank you for the clarity around immune deficient women. These guidelines are helpful. 12.10 Thank you for this clarity. 12.12 We think there should be a separate section to these guidelines that provides recommendations and guidelines HPV testing outside of routine screening.’ Guidance on testing immune deficient young women could be included in this section. 12.13 We would like to ask if there is a plan to inform specialists in secondary care and private practice of the changes regarding immune deficient women? It is common practice for specialists to recommend appropriate vaccination for immune deficient patients, it would be excellent to see appropriate cervical screening recommendations from specialists. Drs Jay Sirisena, Anand Gangi, Jenny Blasingame, Kristy Wolff, Donna Hardie Northland Colposcopy Services Good. Other evidence/info to consider: If an immuno deficient is diagnosed with a histologiaclly confirmed abnormality should they be referred to a specialist practiced in anoscopy? Dr Gillian Gibson RANZCOG 12.02 What does “informed by the result of the reflex LBC test” mean here? Other evidence/info to consider: HIV positive women may not be at increased risk if low viral loads – is there evidence to suggest this? Annette Davis Hawkes Bay DHB Agree. Rae Duff, Ailsa Stewart National Council of Women of NZ Health Standing Committee Para 17, Table 1 (p3) Dr Sandra Hall, Policy Analyst On behalf of the Cartwright Collective We think information should be included about auto immune diseases which result in higher risk.
SECTION 13. Cervical screening for women exposed to diethylstilbestrol Name Organisation Feedback Aroha Morgan, Phyllis Tangitu and Trish Solomon Maori Health, Lakes District Health Board Non applicable from a non-clinical perspective. Dr Vicki Robertson West Coast DHB No additional comments. We support these recommendations. Beth Henderson WWFT This means we will have to ask every women born from 1940 to 1980 if their mother took DES. I am sure most women would have no idea – what then? Should we be co-testing all women born in those years? Respondent’s name redacted at request. Waikato DHB Good practical advice. Pip Egerton Tuatapere and Otautau Medical Centres Was NOT of this group –had no knowledge that this group of women have an increased risk of clear cell carcinoma of the vagina and cervix. Would be interested to know how many other smear takers are aware. Other evidence/info to consider: How best to identify these women in our practice??? Especially considering they should be offered annual testing Fiona Moscrop Compass Health Acceptable. CWH & CHL - Refer Section 1 Collaborative feedback CWH and CHL Support recommendations. This is a minority group. Drs Jay Sirisena, Anand Gangi, Jenny Blasingame, Kristy Wolff, Donna Hardie Northland Colposcopy Services Should the smear be from cervix only or should the vagina also be smeared? Dr Gillian Gibson RANZCOG 13.01 “and colposcopic examination of both the cervix and vagina indefinitely” is this annual colposcopy as well or just if an abnormal HPV test or co-test? Annette Davis Hawkes Bay DHB Agree. Howard Clentworth CCDHB Gynaecology Dept. The last time Diethylstilboestrol was used in pregnant worldwide was 1971 and in New Zealand in 1968. All of those women have been screened multiple times they are now 50. The section is simply redundant.
Rae Duff, Ailsa Stewart National Council of Women of NZ Health Standing Committee Para 17, Table 1 (p3) Howard Clentworth CCDHB Gynaecology Dept. The transition to primary HPV screening should be reviewed within 5 years. The present tests use HPV DNA which is not a particularly good surrogate for viral activity. The program should encourage and participate into research to interrogate whether HPV RNA is a better surrogate marker of disease and to trials of other markers of HPV activity. I see no vision in these guidelines about the obvious refining of what is measured. The final comment about AIS as the only Australasian terminology is simply inaccurate and relies on a single reference which is seriously flawed. Mary Webster CHL Definitely look at a study of self-sampling HPV prior to transition to Primary HPV. Dr Margaret Sage presentation at Scientific Day ‘Screening for cervical disease’ Starting slide 26 - HPV testing and cytology for women with invasive cancer and slide 27 - Selective co-testing will be used for women who …’ is an improvement on earlier guidelines From the same event Dr Gary Fentiman regarding Safety of change slide – 10 Safety monitoring will be ongoing during transition. evidence/info to consider: The risks of HPV –Alone screening Pap + HPV Together Evidence from the Study publication 6.0% CIN 3+ missed by 8.7% CIN3+ missed by Pap-alone 1.2% CIN3+ missed by Pap+HPV together Lynda Williams AWHC The AWHC supports co-testing as an initial transition pathway step. For recommendations 15.01 and 15.02 and 15.07 we want to see co-testing on all samples until the evidence from real world screening programmes confirms that HPV testing is both safe and is the better test.
However, we do not feel our continued concern about move to HPV primary screening should prevent us from giving feedback on the updated guidelines. We have made some general comments first and then addressed some of the specific sections. General comments: In general the guidelines appear very focused on the mechanics of testing and the prescribed route of those requiring further investigations and tests. While this is obviously important we think not enough attention has been given to patient interactions, informed consent and allowing for women to make informed decisions about their screening and /or investigation pathway. We believe the sections on management of test results and equity and priority screening should also issues such as education and public perception of both the tests and the results and how health practitioners should manage these. In addition the process for informed consent for the changes to HPV testing should be defined. It should also be defined for the process of further screening and investigation. should also be a process for women who wish to continue with LBC testing. The data management strategies that will be put in place are not described. How women will be informed about the changes to the register and what information will be retained on the register is not described. Nor is managing the possibility that some women may wish to withdraw and not be part of the register which could record a diagnosis of HPV. The document should contain more information about the changes to the register and what this will mean for women including what information will be held. We are particularly concerned about monitoring of the move to HPV primary testing as any issues with a new programme would need to be identified early and openly discussed. It appears the current data analysis driving the program monitoring is contracted to the same group who designed the HPV modelling that drove the decision to use HPV screening in NZ. We believe the Independent Monitoring Group needs to be independent and not composed of the proponents of the new programme. It should also be independent of any industry links. The guidelines should include information about how the composition of the monitoring and evaluation group will be determined, what consumer representation will be included and how unscreened and under screened groups be represented /included? Finally the guidelines should include a description of