Get the Facts: Supporting cervical screening in your community webinar – webinar recording

Kate Armstrong: I'd like to welcome everyone to today's webinar: Get the facts supporting self-collect cervical screening in your community.

We're really grateful to everyone joining from ACCHOs across Australia, but also AMSs and other services that care for Aboriginal and Torres Strait Islander people across the country.

It's a real privilege for me to work with the NACCHO cancer team.

My name is Kate Armstrong, I'm one of the medical advisors at NACCHO and it's a privilege to be part of the team that's based on the beautiful Ngunnawal and Ngambri lands.

And I'd like to pay respects to elders past and present, acknowledge the lands that you're all dialling in from across Australia today and also pay respects to Aboriginal and Torres Strait Islander people on the line here with us today.

Just a bit of a brief overview of today's session before I hand you over.

We're excited that this is part of "Let's Own It", our logo there for all things relating to cervical cancer.

We will be really focusing today on cervical screening and self-collect as part of promoting cervical screening.

So there's just a screenshot there of the National Strategy for the Elimination of Cervical Cancer in Australia.

And WHO has set some big targets for the elimination of cervical cancer globally.

And I, I won't go into that any more detail.

Professor Saville will be taking us through that.

Marion Saville.

But Australia has set some elimination targets and as part of that, we're aiming to achieve 70% screening rates.

That's one target, but who knows, we may even be able to do better than that.

So we have Professor Marion Saville, we'll be starting off first from the Australian Centre for the Prevention of Cervical Cancer and she'll be setting the scene talking about elimination HPV self-collection, how we can support choice for community members and support clinicians to understand the guidelines and the pathways that exist, as well as help us to know about resources that are available.

Really thrilled then to be hearing from Nyheema and Dr Natalie from one of our member services at KAMS and hearing about their experiences with self-collection up in WA there as we've got the terrific Stephanie Long from Pika Wiya in SA and Kylie Wagstaff from Albury Wodonga Aboriginal Health Service.

And they'll be talking about their experiences of self-collect in their NACCHO setting.

And then we'll be handing over to Sally Conte from the NACCHO Cancer team to talk about the broader national campaign and some resources that will be available to support us all in this work.

There will be a QR code that will show towards the end.

We'd be so grateful if you could fill in the evaluation.

Helps us to just keep getting better at these webinars and deliver them the way you want them.

And finally the NACCHO Cancer team will be sharing some information with you all on lung cancer screening webinar that's coming up next.

We do have some learning objectives for the webinar today.

We're hoping that by the end of today, these four things you'll feel confident with.

Explain the accuracy and reliability of HPV self-collection as a primary cervical screening test #1 #2 Compare the options for cervical screening to support community members to make an informed choice #3 Discuss the potential for HPV self-collection to engage community members in cervical screening and #4 understanding how to support community members through the cervical screening journey.

We're really pleased that there's CPD points available through NAATSIHWP, ACRRM and RACGP and we will be getting certificates out to people after I think within about 3 weeks you should be able to get your certificates through.

We're grateful to the Australian Government Department of Health and Aged Care for funding this webinar.

The chat line will be open throughout the webinar.

Please we'd love you to get involved and pop your chats in there.

Any questions that you might have.

We've got a team who are monitoring the chat and we'll seek to answer all of your questions.

Any that we don't get to, we'll be sending out frequently asked questions afterwards in the question and answer session.

You can also press that hand symbol and raise your hand and we can throw it to you if you'd rather speak your question as well.

That's about it from me.

Time to hand over to Marion Saville who's going to set the scene for us.

Over to you, Marion. Thank you.

5:12

Professor Marion Saville: Thanks so much, Kate, and thank you everyone.

I'm so excited to be talking to you today about the elimination of cervical cancer and the crucial role of self-collection.

And self-collection is sorry, cervical cancer is almost entirely preventable and certainly the most preventable cancer we have.

And so that means that we can contemplate eliminating this cancer as a public health problem in the in the near future.

Just getting used to the controls here. Thank you.

So there is a global effort to eliminate cervical cancer actually by the end of the century.

So many countries are starting from further back than Australia is.

But by the end of the century, the target is that every country in the world will have an incidence rate of less than four per 100,000 women.

Australia's answered the call to develop a national elimination strategy.

And while we're likely to be one of the first, if not the first country in the world to reach this target because of our long term screening programme, our early adoption of HPV screening and our early adoption of HPV vaccination, this elimination strategy focuses on the need to get there equitably.

We know that we have equity issues in Australia and we don't want to be the first country in the world leaving people behind.

And so in Australia, cervical cancer inequities, mirroring inequities we see in other disease areas, depend on who you are, where you live and what your access to resources might be.

We know that a cervical cancer incidence in Aboriginal and Torres Strait Islander women is a shade over double that in non Indigenous counterparts and the mortality rate is almost four times as high.

These gaps are unacceptable, but I have to note that they have been closing over the 20 years that I've been involved in cervical screening in Australia and we've got more work to do to really finally close these gaps.

The National Elimination Strategy calls out the vision that you see there.

I won't read it out to you, but you can see that its focus is on equitable access to information and to culturally safe, inclusive services across the cervical cancer control spectrum and calls out priority populations where we need to work harder to bring everyone along with us.

So currently the most important risk factor for developing cervical cancer in Australia is not being up to date with screening or never having been screened at all.

So that's 70% of all cancers that occur in Australia.

Over time, because of the really fantastic and strong participation of Aboriginal children in HPV vaccination, that that will change and people getting cervical cancer will be people maybe who haven't been vaccinated or screened.

As has been alluded to, the Australian Government is funding a national campaign to raise awareness about cervical screening and the availability of self-collection as a choice for community members and for the population in relation to how they wish to screen.

And this campaign is targeting priority populations, including, of course, Aboriginal and Torres Strait Islander people.

It's our great hope that this will drive demand for self-collection from community.

And the purpose of this webinar is, you know, a lot of the purpose of this webinar is to make sure that you in your services feel ready to meet this hopeful community driven demand for self-collection.

So just getting into the fundamentals.

Self-collection involves taking a sample from the vagina using a swab.

Some patients get concerned about it, thinking that they have to reach the cervix.

That's not the case.

We're looking for human papilloma virus, the cause of almost all cervical cancer.

And because it's shed from the cervix into the vagina, this works really well.

But of course it's not something that we can use for cytology.

So at points in the pathway where we need cytology that needs to be taken from the cervix in the way our Pap smears were always taken using a speculum exam.

And so since the beginning of 2022, based on evidence that I'll show you shortly of the accuracy of self-collection for detecting precancerous disease.

The Australian government opened up access to self-collection from the previous restricted access to making this a choice for all people participating in screening whether they wanted to have a clinician collected cervical screening test.

And there are people who are comfortable with that and who wish to keep doing that.

And then there are others who will prefer self-collection and including people including myself who've had that pelvic exam over the years.

But great, I greatly prefer to self-collect my samples.

And then the people that we haven't been able to reach before that we are seeing are being reached with self-collection.

So this should be centred as a choice for the screening participant.

And self-collection can be used anywhere in the screening pathway at any point where we only need an HPV test, where we need psychology including Co tests, then we need a clinician collected sample.

So the vast majority of people, this is their five yearly routine screening test and fewer than one in 10 people will have HPV detected and will need further follow up.

But for those in whom we don't detect HPV, they've self-collected a test, it's tested negative and they can be safely reassured to return to bio yearly screening having been reminded that if they experience any symptoms of cervical cancer, they should return to you.

For further work up, self-collection can also be used in follow up tests in the pathway and I'll talk in more detail about that later.

Currently self-collection can't be used for people who've had high grade squamous disease sin two and three and they're in test of cure.

But a review of the evidence has suggested that we can move to just using 2 HPV tests for test of cure and we're no longer requiring Co tests.

The guidelines are in the process of being updated and we expect that later this year or early next year.

So who can't be offered self-collection?

Anyone with symptoms that require further investigation.

So most commonly this is abnormal bleeding, specifically unexplained into menstrual bleeding, any post coital bleeding and persistent, sorry any post-menopausal bleeding and persistent post coital bleeding.

An unexplained persistent and unusual vaginal discharge might also raise suspicions.

But of course, we know that patients have breakthrough bleeding on the pill, they have heavy menstrual bleeding and many, many people have vaginal discharges that are not unexplained, persistent or unusual.

And those are not symptoms of cervical cancer.

I'll just pause to say that when we use self-collection, nobody is looking at the cervix.

And so it is important to ask those questions about potentially having symptoms that require more work up.

We do see people sometimes with symptoms who come in for a screen thinking it's a low confrontational way of getting some reassurance about something they're worried about and perhaps not telling you about symptoms unless they're asked.

So it is important to explicitly ask about any symptoms.

People who have ever had adenocarcinoma insight you require ongoing annual Co testing for protracted periods and are not suitable for self-collection and those who have been exposed to diethyl, stelbestro and utero are also not suitable for self-collection.

This latter 2 groups are small numbers of people and particularly actually those with DES are well aware that they've been exposed.

The history of adenocarcinoma inside you is something that patients may know about and certainly that history is available on the register fee and CSR.

So again, just to reiterate, before offering self-collection, make sure you check for the symptoms that might be concerning for cervical cancer and check that screening history and then you and then for most patients, they will indeed be eligible for self-collection.

The most commonly used device for self-collection is this particular Copan floq swab with those part numbers you see there.

It is important that you talk to your lab and make sure you get the swab that they use in self-collection because we don't want these returned to you because it's not the right swab.

This is a part of laboratory practises very highly regulated by the TGA and if we don't stick to the TGA rules, it puts the lab accreditation at risk.

So the lab isn't being precious, but it is important that you're ready for self-collection by having that conversation with your lab before you get started.

Typically the dry swab is used by many labs, but there are a number of labs now using this Roche method.

This requires resuspension of the swab into a thin prep vial by the clinician, by the healthcare practitioner.

That's you guys and it's, it's a bit tricky from a couple of points of view.

1 is I will, I will remind you how important it is if you're having to use this method with your lab that you label both the vial preferably and the request form as a self-collected sample.

Because if the lab is not aware that this is a vaginal sample and HPV is detected, they may do a reflex cytology.

This sample is not from the cervix and we can't really tell that by looking at it as cytologists.

And there is a risk and reasonable risk of false negative cytology in this setting.

So labelling, labelling, labelling in that setting and unfortunately also on the manufacturer's label, it specifically says not suitable for use in pregnancy.

So this method can't be used for pregnant patients for regulatory reasons, not for safety or accuracy reasons.

So if your lab is using this method and you want to offer self-collection to pregnant patients, perhaps you we can talk about later about sending those swabs to another lab because the dry swab method is commonly used in the antenatal setting.

So how do you support your patients to make this choice and what do they need to know?

Well, firstly, self-collection is highly accurate and these are the graphs from the meta analysis that drove our policy decision nationally to make this available to everyone.

And if you look at the right-hand graph in with the green border there, you can see here self-collection in the purple versus clinician collected in the orange.

Now these graphs have the most perfect test up here in the top left where I'm pointing where sensitivity is 100% and specificity is 100%.

So the most accurate tests are up here, these older assays that were based on a technology called signal amplification, it's not quite as sensitive as PCR.

We're showing a loss of sensitivity.

And that's why we started renewal with those restrictions around self-collection because we were worried about trading off the acceptability of the programme with the effectiveness and the accuracy of the test.

And then we had this later update looking at the accuracy when you only use PCR tests.

And here you can see this is the most beautiful thing I've ever seen.

And I do remember seeing this for the first time and realising we could be justified and changing our policy and having a test now that was more acceptable to more people and is equally as accurate.

So these tests, these are what we call the point estimates here.

That's what was measured in the studies with the confidence intervals around, and those tiny differences there are not statistically significant with these massively overlapping confidence intervals.

You couldn't get better evidence of equivalent performance there.

And these studies are studies in which participants prior to colposcopy collect a sample from the vagina themselves.

The practitioner doing colposcopy collects a sample and then we know the biopsy outcome.

And for sensitivity, we look at the women who proved to have CIN 2 plus and how frequently their test was positive.

And that gives us that answer there.

So you can be very, very confident in the accuracy of self-collection.

We find that patients find self-collection is easy to do.

It's good to talk patients through how to do this process and most patients, overwhelming majority have absolutely no problem with it.

When you're talking to patients about how to do self-collection, it's important to make sure they understand their own anatomy.

And we have had I think one or two cases of the swab going either into the urethra or the vagina amongst thousands and thousands and thousands of cases.

So just a bit of a chat about the swab is going into the vagina.

It needs to go in there and be turned around several times and then the swab can be put back into the cover and handed back to staff for submission to the laboratory.

So it really is highly, highly acceptable in our studies and what we're hearing since it's been available and a breakthrough in acceptability of our screening programme.

The other thing about self-collection to understand is it's, it's safe from the point of view of if the test hasn't worked, we know about it.

We have a control in these tests.

Typically it's the beta globin gene present in all human cells, and that gene is amplified in the lab next to the amplification of any HPV that might be there.

And so if we haven't got any cells that that won't, that control won't work.

And similarly, if the PCR assay is inhibited and the assay has failed, that won't be there.

But one thing is, unlike the old days when I was looking at pap smears, we can't tell you what the problem is with whether it's cellularity or assay failure and whether it's due to infection or blood as we used to.

So we do need to have these tests repeated, but we can't really shed any light on what might be the cause.

And sometimes we know from a range of studies in a range of settings, patients are actually opening and closing that swab and not putting it in the vagina.

And that's usually because they feel under a bit of pressure to do the test, but they don't really want to.

So a sensitive discussion about that with the patient before repeating it can be really useful.

Our studies have found that self-collection is highly acceptable, particularly for people who are under and never screened.

And there's a lot of literature about that.

I won't go into it, but you know, people find they feel empowered about being able to collect their own tests as opposed to lying on their back and having to have the speculum inserted.

And I'm sure that none of those reasons will be any surprise to anyone here.

So just to come back to comparing the options, self-collection is a test for is suitable for HPV and not suitable for cytology.

For 90% of people.

Either way we test, they will come back in five years.

And for 2% of people, we're likely to find HPV 16 or 18 and either way they'll go to colposcopy.

If the sample was self-collected, cytology will be collected by the colposcopist at the time of colposcopy.

And for around 6% of people overall will detect a type of HPV other than those nasty 1618 types.

And those people need a sample collected from the cervix for triage purposes to decide whether they go to colposcopy immediately or whether they can be followed up in a year and then a further year.

But for that non 1618, you, you need to know that that self-collection the detection of non 1618 is highly age dependent.

These types have not yet been impacted by the new 9 valent vaccine, just the Gardasil 4 which protects against 16 and 18.

And the other types still have that age specific prevalence that we see here.

So for your patients who are youngest, it might be a one in six chance of needing that two-step process that someone's just talked about in the chat.

But by the time you get to my age, it is a 3% chance of needing to come back for a further test.

So the overwhelming majority of people only have that one step of self-collection.

Patients who are in the age range of 70 to 74, if they have self-collection and we detect HPV, they also are going directly to colposcopy if any HPV is found.

And so if the sample is self-collected, there's no need for them to come back for that second stage.

They can go directly to colposcopy and they do go directly to colposcopy under the guidelines.

And at that point a sample will be taken for LBC.

We do get some people coming back and asking about certain questions.

The invalid result of explained.

This means that we couldn't see that control gene and either the sample was not taken from the vagina or there aren't enough cells there, or there's inhibition due to blood or inflammation.

We find that patients find it very straightforward to collect the sample.

It's important to understand if patients would prefer to have a swab taken but have a disability or some difficulty collecting the sample themselves and being very big can cause problems with collecting a sample yourself.

These patients can be assisted with a vaginal swab taken by a nurse or doctor if they would prefer that.

It's still regarded as self-collected sample.

It's really important not to assume that people hasn't ever had people haven't ever had any sexual contact and remembering it's not recent sexual activity.

This is a virus a little bit like the chicken pox virus that can hide in the body and then come back later and cause problems.

So it can be in the cervix for decades.

The need for a pelvic exam is not there for asymptomatic people, and certainly people with symptoms need a pelvic exam.

But there is no evidence to support regular pelvic exams for asymptomatic people.

It is something we've been doing out of necessity in the old Pap programme, but that doesn't mean that we should keep doing it in the absence of evidence.

I'm just going to talk very quickly about self-collection in the intermediate pathway because this is a little bit complex and really want to let you know we've got resources to help you with this.

So as I run through this, please don't feel that you need to memorise everything as I go.

What you'll see here in the pathway is that in a number of occasions where we're using cytology is triage, it says LBC reflex.

So that's if it's clinician collected or recollect a sample for cytology.

So here and here.

But where patients are destined to go to colposcopy regardless that cytology can be done at the at the time of colposcopy.

So that's an overarching principle when you're thinking through and talking to your patients.

So self-collection in addition to being able to be used here as the primary screening test with that likelihood somewhere between 1:00 and 1:00 in six and one in 30, that's the primary screening test.

You can also use self-collection in the follow up test at 12 and 24 months.

Being aware that this is a part where we if positive may be using psychology for triage and the issue is here.

At the first follow up test 12 months after detection of non 1618, the likelihood of persistent HPV is around 60%.

So this is a place where for many people they want to have a clinician collected sample to avoid coming back for that extra sample.

However, there are exceptions here and the extended 2 year follow up doesn't apply for Aboriginal and Torres Strait Islander people, people over 50 and those who are overdue for screening by at least two years up here at the initial screen and this is because of the additional risk of harbouring high-grade abnormalities.

So at 12 months for Aboriginal and Torres Strait Islander people in particular, and there will be some overlap in some of these risks, you can still use self-collection with the confidence of not needing to come back because they can go directly to colposcopy and have cytology performed at that point in time if HPV is detected and if HPV is not detected, then they then they're going to go back into the five year follow up here.

At 24 months for all people, any HPV detection is going to lead to colposcopy.

And again, there's no need to return for cytology which can be done at the time of colposcopy.

So I'm just going to run through some case studies and try and be quick.

I don't want to exceed my time.

Linda's a 58-year-old Aboriginal woman and she's come in for a new prescription.

You've diligently looked up her screening history on the register and her last pap smear was done in the in her late 30s and was normal.

She tells you she had a terrible experience with that and she hasn't had another since.

She's got hasn't got any symptoms of concern.

So we're going to let you look at the poll question there.

What are some of the things you might want to discuss with Linda and we'll open the poll now or just I'm in the hands of the organisers here and leave it open for a period of time.

Please participate in the poll because it's completely anonymous and it's great for us to understand what your understanding is.

No judgement.

OK, I think we've got 30 responses and the vast majority of people are saying E all of the above and a is also correct.

However, these other statements are correct too.

So well done everybody.

She self-collects.

There's a small chance that you'll have to return for a speculum test exam.

So her likelihood of return is 3% based on her age.

And we've brought all of these things together for you.

You can't read this now, but it is available to you and we will send you links to this resource.

So this is, this is a document we brought together in our lab to provide to practitioners to support your conversation with patients about what they wish to do.

And importantly, we put all these rates of positivity and the likelihood of return here so that you can be guided in, in that conversation with your patients.

So poll question 2, Linda's results have come back and she's in the 3%.

HPV, not 1618 has been detected.

So what is the correct follow up here?

So we might close the poll I think, I think I closed the poll on my screen I can't see, but I think we've had a bit of an even spread between B&C.

And of course this is her first screening test in a long time.

It's the entry test.

So she needs to come back for a speculum exam for LBC.

Had we been down at the 12-month test, then B would have been correct.

Refer to colposcopy.

She's very overdue for screening so she's up here this part of the pathway and she needs to come back for A to so a vital sample can be collected for triage purposes.

Her she returns for cytology.

The cytology is negative and she's recommended to come back in 12 months for a follow up test.

Although at her previous test she completed the speculum exam for cytology.

With your support you can tell she's anxious and reluctant to have another speculum.

She asks if she can self-collect this time.

What do you talk to her about this time?

All right.

I think we might close the poll now and for most people the answers’ correct.

She can self-collect because she's now at the 12 month follow up test.

If any HPV is found, she'll go to colposcopy.

So just to reiterate, at the first Test she needed to come back for psychology because it was the cervical screening test.

The second test is the follow up test and she and self-collection in that context will not require psychology if HPV is detected again.

So here we're down at this point in the pathway where because she's more than two years overdue, she's going to go directly to colposcopy because HPV, if HPV is detected.

So there is some complexity around that intermediate pathway.

And I, I really want to acknowledge that you need to think about it and get your head around it.

But having said that, I'm sure that patients are going to appreciate self-collection.

There are a lot more resources coming and available in relation to the cervical screening programme and self-collection in particular.

I'll leave things there very happy to ask, answer any questions and thank you very much.

Thanks so much Marian.

That was great and the polls were terrific.

One question that we had that came through and you saw it and mentioned it briefly and you may have already responded enough.

You feel what's the point of the two-stage collection?

Is it preferable in any circumstances?

Yeah.

So look for the vast majority of people undergoing A cervical screening tests of just their regular screen when they'd be negative, Just remember that more than 9 and 10 are going to have HPV not detected and so they're never going to need the speculum.

So what I've tried to focus on in this talk is that trade-off between the likelihood of having HPV detected and needing 2 stages versus having clinician collected.

And the point of this is that it should be the participants choice how they want to screen and that choice should be informed.

And one of the key things in making a decision I think for patients is the likelihood of needing the speculum exam anyway.

So the point of this, all of this is to make screening more accessible, more acceptable and so that we can bring more people into our screening programme for whom the speculum has been really, really challenging.

Our research has shown that when we bring these people into the programme and these in in our studies were people back in the pap days that refused to Pap smear and that were offered self-collection day.

85% of them gave us a swab and about 90% were brought along the pathway within six months whether that was going to get their cytology or going to colposcopy.

So I think another thing to acknowledge is, you know, we are opening up the programme to people and self-collection in itself doesn't mean that people will be, will need, more support to go along the pathway.

But when we're bringing in unscreened and under screened people, it's likely that those people who've not have been reluctant to screen will need more support.

But our research does show that when we find HPV and it's not a screening test, it's then diagnostic and we're working out if there's a problem with the right support, people do progress along the pathway.

The overwhelming majority do.

37:41

Kate Armstrong: Terrific. Thanks very much for that, Marion. That was great.

It's a great pleasure now to sort of hear from the from the ground.

I'd like to welcome Nyheemah and Natalie to take us away.

They're calling in from Beagle Bay and Broome.

And it's just really exciting to hear about how Self-collect is going in a nutshell.

Thanks team.

 

38:03

Nyheemah Cox and Dr Natalie Williamson: No worries.

Thank you Kate.

So hi, my name is Natalie Williamson, I'm AJP at the Kimberley Aboriginal Medical Service and I work in the Beagle Bay clinic with the lovely Nyheemah.

I'm very sorry.

I have a toddler in the room.

Hopefully he is quiet.

I thought he would sleep but of course he woke up the moment this started.

So my apologies if you can hear baby bubble in the background.

Look, I am originally from the East Coast of Australia.

I grew up in Sydney, went moved to Dubbo in the middle of NSW and started working at AMSs there and now I'm in the Kimberley.

I can't imagine living anywhere else, because it is so amazing.

I'll hand over to my sidekick, Nyheemah.

Well, hi, my name is Nyheemah.

I am an Aboriginal health practitioner out at Beagle Bay Community.

I work with an amazing team out here in the clinic, including Doctor Nat and several other Aboriginal Health practitioners.

And yeah, so this I'm back to Doctor Nat and look after her.

So I guess self-collect in our space has been a bit of a game changer.

It has made it just it's given you showed that beautiful slide earlier, Marion.

And the biggest word on I think was empowerment.

I think it's just given our women power back the old school.

The old school speculum exam is a skill that's taught in medical school when you're really junior and you know unless you have a good teacher you maybe never get really good at it.

JP is, to be fair, should be really good at it, but I think sadly most women have had a bad experience with a speculum in addition to the shame of having to show someone.

Your general region I just the self-collect gives all that power back to women and we come across lots of women.

And this isn't just specific to Beagle Bay.

This is across the Kimberly who are absolutely behind on their tests.

And when you bring it up, there's lots of, oh, no, not today, not feeling it today.

Lots of women know that you can't have it if you've got your period.

So I will tell you they've got their period.

Turns out they probably don't when you offer them, when you offer them the self-collect.

So being able to hand that back to women and say, no, look, it's, it's really just this swab.

You can do it in the bathroom here, you can take it home with you if you like, do it at home, drop it back into the clinic has been a real game changer.

And we've got women who are historic non-participants in cervical screening, who are really happy to have cervical screening done now and are really reassured by the fact that if it's normal, it's five years and you come back.

And I guess, I guess the other, the other real plus is that our male clinicians can be much more involved.

So certainly when you live in a remote community, you don't often get your choice of Women's Health clinician.

And often some of our patients do want to talk to the doctor about it before they have it done.

I should say that's not that's not many because our Aboriginal health practitioners are amazing.

But it does happen sometimes.

And I think previously there being a male clinician available to talk about it with was yet again, another barrier, the self-collect eliminate that the male GPS and I think, you know, male health workers if they feel comfortable, male nurses sometimes in our remote clinics can all just, you know, there's a lovely little sheet of paper with some very graphic diagrams about how to do it.

They can hand those over.

They can explain that it's just a swab into the vagina and away you go.

So that's all like yeah, but those are probably the two things that I really love about it.

Names? Do you want to?

Yeah, Now I agree with Doctor Nat there, like for the self-collect has been a big improvement with within our community ladies, because it's more private and yeah, it doesn't make them shame.

And shame is a big thing as well in the community.

Like now that this self-collect has been, has come out like it's been a big and a big improvement when eliminating the shame.

So yeah.

And it's, it's easy, straightforward, like we can see our clients, show them the graphic pics and ask them if they're more comfortable doing it here or they can take it home and, you know, bring it back later.

And yeah, it's, it's been very helpful, especially when you want to get that test like sorted.

Yeah, Community.

Thank you, Nyheemah.

Yeah, as there's very little downsides to it.

And I guess that the other thing that I think is really important and something that I was certainly worried about when it first came out is that the urgency of an abnormal result could potentially be lost because it is no longer clinician collected.

But that's certainly not the case.

You know, if someone does a self-collect and it comes back abnormal and pretty much guarantee that's an easy recall across our remote clinics.

And if someone isn't in community, if someone's come to Broome or they're in Kananara or, you know, they're in Derby visiting family, you know, a quick, a quick phone call, a quick text to them to say hi.

Look, can you just pop into your local clinic that everyone's sort of right onto it, which is, yeah, 1 less thing we have to humbug people about humbug people about.

So it's been a big game changer far.

Does anyone have any questions?

I can talk about auditing and stuff because that's really fun too, but you know, there's lots of good ways to audit so that you don't necessarily have to rely on proto so much depending on your technology and your record keeping.

Terrific.

If you could talk about auditing.

And there is one question there from a male saying that, you know, he does find it hard to do the clinician collect after the HPV comes back hard as a male GP visiting very remote community.

Any tips?

Because there's irregular access to female practitioners who do speculum examinations.

So those two things would be great.

Thank you.

Yeah.

So look, I think I think it's always going to be tricky as, as a male clinician when it when it comes to Women's Health.

It's often, you know, it's the same for female clinicians trying to sort out symptomatic men's health issues that are that are urgent.

I think I personally think you can get away with almost anything if you spend some time, you know, and I recognise we're all really busy, that most remote clinics are always pumping.

There's always stuff to do on the doctor day.

But I think that report is really important.

And then engaging your health practitioners.

I know Nyheemah and the gang at Bigo Bay will often get me over the line.

And even if it's just Nah, she's right.

Like it's OK CEO, you can tell her it's OK is a lot.

So those relationships and using the, the staff that you have in clinic, especially Aboriginal staff in clinic and deferring to their incredible wealth of knowledge and expertise is always really important.

But having said that, it can, like in my experience, it can be really community and like individual independent.

Sadly, there are lots of women, hopefully no younger ones anymore because they're all doing self-collect.

But there are lots of women in their 40s and 50s who have had horrible pap smears, you know, and they'll tell you the story and it sounds awful.

It's like genuinely awful.

So, yeah, so rapport is the is the big one, I think.

And then and then relying on your, your Aboriginal health workers and your health practitioners to to be with the patient and to also give the patient the knowledge that you're actually OK as a clinician.

Those things are really helpful.

With regards to the auditing staff, it's definitely software dependent.

We in the Kimberley, in the AMS sector use a programme called MMEX and we're able to pull like information off our system.

Of course it's reliant on things being recorded correctly, which is often where it gets, it can get tricky.

And of course, we currently pull an audit and then have someone in the background kind of checking Proda as we go just to make sure it is we're on the right track or we certainly don't want to offer more than what we have to.

But yeah, the regular auditing just so you can generate a list every three to six months to encourage people to come in and so you don't miss anyone is vital.

And we're doing that.

We're doing that daily anyway with all our other, with all our other cares.

So with our bowel screening, you know, even simple things like, you know, HPA 1C is needing to be done every couple of months in diabetic patients.

Those are all really like, it's that auditing schedule is actually really important and can enhance the primary care you're providing to people because it's just another thing to sort of to take over and then you know where your patients are AT and who means who needs attention?

Does that names?

Do you want to talk about the talk about the joy of auditing?

No, Doctor, that you kind of yeah, yeah, poor names.

Just have to recall the patients.

Yes, that I have ordered them, yes.

But we're seeing some real success with it.

To be fair, one of our bigger communities that KAMS looks after they do an annual audit and that brings in a lot of people and we use, you know, you can sort of use the cervical screening with the self-collectors, a bit of a draw card and then you can knock off a few of the other really important things that need to be done as well.

Huge thanks to you guys from KAMS.

That was really inspirational and we've seen comments that people are being inspired to do more self-collect as a result of all of this.

So really grateful for your presentation.

So I'd like to take this opportunity now to introduce our next speaker here.

We have Stephanie Long, a fabulous health worker at Pika Wiya in South Australia.

Stephanie's been working in Women's Health for five years and in health generally for more than 10 years.

Stephanie, thanks heaps for joining us today.

Do you want to just, I don't think you had any PowerPoint slides today, but we'd love to, you know, just hear you have a yarn about, you know, how are you finding self-collection at Pika Wiya?

And yeah, just your perceptions of it, what you're hearing from community and what you and your colleagues are finding.

50:39

Stephanie Long: Yep.

So our service, we're, we deliver Primary Health care to all women of the Port Augusta region and outreach services and the Flinders ranges as well.

And we complete the 715 health cheques, STI screening, contraception and ensuring our KPIs are addressed as well.

Our service has held a few pamper sessions over the years to encourage ladies to yarn about health checks and all things health, and we've also had a GP, a female GP, attend our sessions as well.

So the ladies were able to talk to them in a relaxed environment about like things that they're concerned about with the CST collection and that.

So we've provided barbecues, free incentives to the women and free health trims as well, hair trims, sorry.

And we've worked along AXA, the sexual health team, so that were able to give education around sexual health to the staff and the community.

And also with our consultations, we've had one on one with the women.

So when they'd come in for health cheques with where I would have a conversation with them about encouraging them to complete the self-collection as well.

We've developed resources that were culturally appropriate and easy to read and understand.

And also placing them in high traffic areas such as waiting areas and in toilets in the hallways or the doctor's rooms and health workers rooms as well.

Some of the resources included the patient journey, what would happen when they go in and just a flow chart of what happens.

So they'd come in to see the health worker and then the doctor and then get the CST done and then what happens afterwards.

And we've also sent Flyers out to their home address too, so when they forget, we'd aim to send one out every six months just in case.

We've also the community events as well, so in health promotion, trying to promote the self-collection so that the ladies knew that that was an option as well.

And we've also had a chat with the young girls as well, like the different stages and some of the health cheques that you need at different ages as well.

So we've noticed that there's been a 20% increase of women more willing to do the self-collection due to the incentives we've offered and just having that conversation as well.

That's amazing, Stephanie, thanks for that.

And do you find that generally the women are open to self-collection when you have that talk with them about it.

Everyone's clapping, by the way.

Yeah, they are.

Because sometimes, as you know, like with our mob, sometimes they forget and, you know, life gets in the way and they've either got kids that they got to attend to and family and they forget about themselves.

And so we found that the opportunistic cheques are the best way.

So while they're there, we'll try to do everything we can on that day.

Yeah.

Yeah.

So you've really got that whole holistic thing happening there.

Yeah, you're really lucky you've got a female GP.

Have you had any experiences with male GPS?

Like in our last webinar, we heard it's even easier for male health practitioners to engage.

Have you have you had any insights around that at all?

Or it's or it's all women's business?

Yeah, it's just strictly women's business.

Yeah.

Cool.

Stephanie, I reckon a lot of people would love to see some of your local resources.

If it's OK, we might even follow up with you and I don't know if if you'd be willing to share them with other people to so they can see what you're doing.

Of course.

Yeah, yeah.

Thanks, Steph.

Well, lots of comments there and claps and love hearts coming through.

So thanks for your great work there.

Steph, any, any other comments or reflections from you on self-collection?

That's, that's it for now.

Thank you for that, Steph.

All right now we, we're going to have Kylie come through.

I'll just not sure.

Kylie Wagstaff is a practise nurse from Albury Wodonga.

She did have some clinic commitments today.

So I'll just keep an eye out from the team.

If she's able to join us, she can.

But the team at Albury Wodonga have had a lot of success as well.

So, yeah, people are interested in your resources, Steph, So we'll probably follow up with you if that's OK.

55:55

Kylie Wagstaff: I am. I'm here.

Kylie's here.

I just can't get my camera to work.

Awesome.

Kylie, No worries.

Cameras are overrated.

Do you want to do you want to give us a talk about your experiences at Albury Wodonga?

We'd love to hear from you too.

Sure, sure.

So sorry I'm late.

Yeah, I'd just like to, you know, acknowledge the country I'm coming from, which is Wiradjuri, and pay more respects to Elders past president emerging and to all the Aboriginal Torres Strait Islander people online.

And thanks, Stephanie.

I caught your talk there.

It sounds like you're super proactive.

I don't know.

I don't, I don't feel like we're quite as proactive.

I guess the, the, so I'm a practise nurse and have this other moniker as the clinic coordinator, which just means really just within the clinic.

And I'm the team leader for the other registered nurses and the Aboriginal health practitioners.

Not really the whole clinic, just our little team.

Yeah.

So we're really trying to promote self-collection.

And I don't have any numbers.

Yeah, that's something I really have to yeah, pull together.

But what one thing that we, we've started this, but with limited success at this point in time is I've got a, we've made a birthday card that we send to women as they're turning 25, just as the invitation to come on in and have a chat or, you know, go straight to having their cervical, the self-collect.

Just because anecdotally with chit chats, you know, with older women, they would often talk about their young girls saying, Oh, it's time now, you know, when they'd be 18 or 19, you know.

So it was, it seemed to be pretty clear that there wasn't heaps of understanding that the age had changed to 25.

So we made the birthday card and we also ran a series of Facebook and Instagram posts just all about all, sort of, all about sort of cervical screening and focusing on self-collect.

And the art on the card and on the social media is the same as the VACCHO, you know, the, the, the, the wallet and the privacy blanket.

So it's Maddie Connor's artwork that we've used with permission for, for that.

Yeah.

So that that's kind of our that was my little CQI project, but it's very much ongoing.

But in general, self-collect is, you know, one of the best things to happen in Women's Health forever.

And we collectively are talking and promoting self-collect all the time.

The uptake is fantastic and mostly it, it used to sort of just be me doing the cervical screening because, you know, I had that qualification, but we've really worked at broadening that so that there, you know, Aboriginal health practitioners or, or other registered nurses who weren't necessarily providing that service in the past.

Everybody's on board and all the rooms are set up with the wallet or the little they got the privacy blanket.

No one else is doing clinician collect, but just so that the resources are there for, yeah, for anybody to do a self-collect.

So whether it's in an appointment or an opportunistic collection, but it's very well accepted and yeah, it's great.

Yeah, thank you.

Sounds like you're doing lots of stuff.

I think you're selling yourself short.

Any comments there about involvement of male practitioners or is it strictly women's business for you guys as well?

Yeah, it's women's business.

The GPs, male GPs are certainly happy to discuss, but they will generally then just ask one of us to catch up with the woman and do it.

Yeah, but we certainly try to make sure it's Yeah, we do it there and then opportunistically.

And yeah, yeah.

So they'll, they'll, they'll talk about it.

And now women are OK with that, but tending not to be the ones who hand over the swab and discuss how to do it.

Interesting.

I was speaking to a male GP who was really excited that he felt more that he could play a role in in promoting it now in a in a more culturally Safeway.

Great question here.

Can women take the swab home and return or are they encouraged to do it in the clinic?

How do you do it?

And Albury Wodonga Kylie in the clinic.

Yeah, yeah.

Just to this, just so that I can be sure that it's, look, if a woman really wants to take it home, that is fine.

You know that that's fine.

But as a practise, we, we just try to do it here so that we know when it's collected and we know how long it's gonna take.

So we send them to VCS.

So just that just so that they get to VCS, you know, in a reasonable time frame in the mail.

But we're always flexible.

It's all, you know, I don't as a rule send them home.

But if a woman is super keen to take it home and yeah, that's, that's fine.

Yeah.

Might throw to Marion on this.

Marion, are there any considerations for, for the swab storage or taking them home or anything like that that we should know about?

1:02:26

Marion Saville: Look, the only thing about taking them home, which is absolutely allowed under the guidelines and all the rules around screening is that, as has already been, Kylie's already alerted to, you're just a bit less likely to actually get that swab back.

And our research has shown that the main thing is that we need the swabs back within 28 days of collection because after that time, that's, that's how long we've proven the stability of the sample for to the TGA.

And, and that is that is scientifically important.

We don't want a swab that's three months old or something.

We will start losing sensitivity at that sort of point.

So the other thing is if the patient's taking the swab with them and bringing it back to you, it's great if they can write somewhere and the lab can be aware what was the date of collection because that's when the clock starts ticking on that 28 day stability claim.

And also the importance of writing self-collect on it as well, which he said earlier.

There's another question there, Marion.

Is self-collection suitable if previous tests are normal and a woman is in early pregnancy until what gestation would it be appropriate?

Self-collection is appropriate I think at any stage of pregnancy.

And if you think about it, for many patients in in antenatal care, they get quite light swabs taken for Group B strep later in the pregnancy.

So there's no problem at any point in the pathway.

And, and one of the things that we've been really working quite hard on with our obstetric colleagues and public hospitals is trying to get everyone aware that that screening history should be taken because there are some people for whom we will only ever see them when they're having babies, right?

They won't be at the health service at any other time.

So we can't miss that opportunity to screen someone probably ideally better a bit sooner in the pregnancy than late.

But who you know, if someone's seeing a pregnant patient who's later in her pregnancy and she hasn't been screened, there's no, there's no real limit to that.

So I, I would really encourage people to get screened and you know, we look after, we want to look after women in their pregnancies and deliver healthy babies, but we also want that mum alive when that kid is 6-8-10 years old.

And that's, that's when families are losing women at that sort of age.

So it's really important that antenatal opportunity.

And we've just got one question there.

Is self-collect as accurate as the one done by our provider?

And yes, I guess totally is 100% is it totally is.

Can I just address something in the comments about some bad experiences please?

Yeah, I mean, I, I, I hope that's becoming less likely as practitioners are getting more educated and we have been out there educating practitioners across Australia.

The message is for all practises in the lead up to this campaign in particular, but before doing self-collection, contact your lab.

The brush is not suitable and we, we don't want people to have that sort of experience.

And that idea that the doctor needed to supervise the self-collect is a misinterpretation of the old MBS item.

And what it's saying is that when you're ordering a pathology test, it's got to be ordered by a doctor or nurse practitioner for an MBS claim.

And that doctor or nurse practitioner has to oversee the results and make sure that be responsible for ensuring that the patient is followed up.

But that doesn't mean that they have to supervise collection in a way of watching you do it.

I mean, that we'd lose a lot of the advantage of self-collection.

That is not a purpose.

Yeah, 100%, 100%.

We hope practitioners are better educated than that these days, and if it's happening, you know, it's probably worth letting the programme know about that because there's obviously an education need somewhere.

Lovely.

Well, thank you very much, Marion, and thank you, Kylie.

We're getting questions about resources, so this is the perfect time to hand over to Sally to, to tell us about some resources that will be coming through to help out.

And apologies if we can't get to all the questions, but we will send something out afterward, after the event and respond to all the queries.

So keep sending them through.

Thanks Sal, your turn.

1:07:15

Sally Conte: Thanks, Kate.

Hi everyone.

My name's Sally.

I work at NACCHO as a project officer in the cancer team.

I'm conscious that we are nearly at time, so I'll try and get through this quickly, but I just wanted to touch on some resources that NACCHO will be sending out to all art shows in the coming months to support the national Let's Own It campaign.

So the purpose of this campaign is to increase awareness and uptake of self-collection in cervical screening and all that, empowering that choice for community members to choose how they screen.

So at the top, top of top left of the screen, you can see the shirts.

So these are the campaign theme polo shirts and the purpose of these is to raise awareness of cervical screening and help staff, you know, to start a conversation.

And then at the bottom of the screen on the left you can see a campaign themed self-collection pouch.

And these have been briefly mentioned before by Kylie, but these are sort of based on some culturally safe self-collection pouches that VACCHO previously made.

And they had, yeah, that beautiful artwork on them.

And they've they had really amazing success.

So yeah, definitely can't take the credit for these.

They're based on VACCHO's pouches.

And these will also be sent out to all art shows.

So the purpose of these, the pouches are for community members to be able to discreetly carry their self-collection swabs for that increased privacy.

And they'll also be able to keep the pouches at the end of their screen.

There'll also be a number of other resources that we'll provide be providing in these packs.

And so these will be printed resources to support both healthcare providers and community members in raising awareness of self-collection.

And whilst we've sort of started putting these together, we're also open to any feedback.

If there's resources that you would find really helpful in your service, please let us know because we can create, create resources to the need that we're seeing.

Just wanted to acknowledge that the purpose of these resources isn't to replace what you're already doing.

From what we've heard, there's a lot of amazing work already going on in ACCHOS.

And so these resources are really just to ensure that all ACCHOs are supported and that everyone is able to raise awareness about self-collection in cervical screening.

And just one final thing, just to acknowledge that I know it's not just ACCHOs staff joining the call today, but unfortunately these resources are only for ACCHOs being our member services.

That's all from me.

Happy to answer any questions.

I'm not sure if any have come through, although Marion, there are, there are resources through ACPCC as well for IMS's and other services as well.

So please reach out and no need to purchase them, they're free.

So just we'll just go to the next slide there, Sal, please keep sending through any questions.

We'll put this QR code for the evaluation and we'll also be sending it out if people can do it.

But lastly, I'd just like to hand over to Sarah McDermott, our, our lung cancer screening guru.

Sarah, would you like to give people an update about the upcoming webinar on lung cancer screening?

1:10:59

Sarah McDermott: Yeah, absolutely.

Thanks Kate.

Hi everyone, I'm Sarah McDermott, I have the pleasure of working in the NACCHO Cancer team alongside Sally and Kate.

You might be aware that there is a new National Cancer screening programme starting in July next year for lung cancer screening and I wanted to quickly jump on at the end whilst we've got a captive audience and let you know that in two weeks’ time on the 28th of August, NACCHO will be hosting a webinar updating the ACHHO sector on what's happening with lung cancer screening.

Providing an introduction and an overview to the programme and also identifying the opportunities for ACCHOs to have input into the programme and that sort of consultation that will happen over the coming months around resources, training and support needs just to make sure that ACCHOs feel really well supported come July 2025 when the programme begins.

So there's AQR code on the screen that you can register for the webinar using.

And also feel free to reach out to the cancer team at any time.

We're always happy to have a chat about lung cancer screening.

Thanks, Kate.

Kate Armstrong: Thanks, Sarah.

Look, that brings us to the end of the webinar.

A minute late, apologies, but thank you all for joining.

Hope you found it useful.

Send us through any questions or queries to the email address there and we'll be in touch Thanks everyone for your time.

That closes our webinar.

Bye.