Introduction
Australia established the National Cervical Screening Program (NCSP) in 1991 with the aims of reducing illness and death from cervical cancer in Australia. It originally targeted people aged 20–69 for a 2-yearly Papanicolaou (Pap) smear, or ‘Pap test’ to detect precancerous abnormalities of the cervix. The major advance that raised the possibility of eliminating cervical cancer was the introduction of the National HPV Vaccination Program for girls in 2007.
In October 2011, the Australian Department of Health announced the renewal of the NCSP. In April 2014, following a robust and transparent process involving a commissioned evidence review and health outcome and economic modelling, the Australian Medical Services Advisory Committee made several recommendations for the renewed NCSP.1 In December 2017, NCSP changed to a 5-yearly cervical screening for people aged 25–74, using a primary human papillomavirus (HPV) test with partial HPV genotyping and reflex liquid-based cytology (LBC) triage, designated as a cervical screening test (CST). The next important milestone was expanding the option of self-collection to all eligible people in 2022 to encourage more participation in cervical screening, particularly for disadvantaged groups and those less inclined to have a cervical screening sample collected by a healthcare provider (table 1).
In 2020, WHO published the Global Strategy for cervical cancer elimination,2 underpinned by three main pillars and goals, to be achieved by 2030: 90% of girls fully vaccinated with HPV vaccine by age 15 years, 70% of women screened with a high-performance test by 35 years of age and again by 45 years of age, and 90% of women identified with cervical disease receive treatment. It has called for all nations to strive towards eliminating cervical cancer as a public health problem (incidence rate of below 4 per 100 000 women) in the next 100 years. The latest fourth report on Australia’s progress towards the elimination of cervical cancer as a public health problem was published online in March 2025. This was prepared by members of the National Health and Medical Research Council Centre of Research Excellence in Cervical Cancer Control. Cervical cancer incidence was 6.6 new cases per 100 000 women in 2020, and against the 3 main pillars (1) HPV vaccine coverage for girls by the age of 15 years was 84.2% in 2023, (2) 82.8% of women aged 35–39 screened at least once with an HPV test and 79.8% of women aged 45–49 had been screened at least twice by the end of 2023 and (3) 84.5% and 88.7% of those with precancer detected in 2022 were treated within 6 and 12 months.3
The aim of this review is to highlight the commitment of various stakeholders, from government, health agencies and healthcare providers, working towards the elimination of cervical cancer, with a focus on improving participation among the underscreened, especially the Aboriginal and Torres Strait Islander population.
Overview of the evolving process towards elimination of cervical cancer in Australia
Cervical cancer incidence
In 1982, cervical cancer was the sixth most common cancer in Australian women and by 1991 it had fallen to seventh ranking, presumably related to opportunistic screening for cervical cancer. Following the introduction of the NCSP in 1991, there was a steady fall in the incidence of cervical cancer, and by 2007, it ranked the 12th most common cancer in Australian women. The incidence has plateaued since 2007–2020, the latest available data from the Australian Institute of Health and Welfare (AIHW): Cancer data in Australia.4 (figure 1). In 2020, squamous cell carcinomas comprised 62.7% of all cervical carcinomas, followed by adenocarcinomas at 28.4% and adenosquamous carcinomas at 2.1%. Other specified and unspecified carcinomas were the remaining 6.7%. This is in contrast to 1982, when squamous cell carcinomas comprised 81.2% of all cervical carcinomas, with adenocarcinomas far rarer at 11.4%.5 Improvement of the rate of detection of glandular precursor lesions was one aspect considered in the strategy for renewal of the NCSP, to ensure that Australian women are offered optimal cervical screening. Although there is currently no reliable national data on the diagnosis of cervical cancer for Aboriginal and Torres Strait Islander peoples, analysis on what is available from some states showed the incidence was 2.3 times the rate of non-Indigenous women over the 5 years 2016–2020 (22.8 and 10.0 new cases per 100 000 women in the population, respectively).5
Incidence of cervical cancer in Australia. Australian Institute of Health and Welfare (AIHW): Cancer data in Australia.4
National HPV Vaccination Program
The National HPV Vaccination Program commenced in 2007 with a school programme for girls aged 12–13 years, with catch-up programmes for girls aged 14–18 and for young women between 18 and 26 years. The quadrivalent vaccine against HPV types 6, 11, 16 and 18 (GARDASIL) was used as it is effective in preventing infection with the oncogenic HPV types (16 and 18) that cause 70%–80% of cervical cancer in Australia. HPV types 6 and 11 are the main causes of genital warts. In 2013, boys aged 12–13 were also included with a catch-up programme for year 9 boys aged 14–15.
The National HPV Vaccination Program Register had reported an initial vaccination uptake of 73% for the full course of three doses among eligible girls aged 12–13 years nationally. The next-generation 9-valent vaccine (GARDASIL 9) with the capacity to prevent up to 90% of cervical cancers in effectively vaccinated females was included in the National HPV Vaccination Program in 2018. At the same time, the number of doses required was reduced to two. From February 2023, HPV vaccines were administered as a single-dose vaccine rather than a two-dose vaccine. This change has contributed to the rise in vaccination rates assessed at 15 years of age, 85.9% for females and 83.4% for males in 2023.6
National Immunisation Programme (NIP)-funded single dose catch-up HPV vaccination is now available to all people aged up to and including 25 years.
School-based HPV vaccination has improved equity in HPV prevention in Australia, with variation in vaccine uptake far smaller than that for cervical screening, with similar (or better) vaccine impact in Indigenous people, and similar impact regardless of area-level socioeconomic status or remoteness.7 HPV vaccination participation was also enhanced with recommendations to provide avenues for students and parents to obtain information about HPV vaccination via a dedicated national website, HPV education in school curriculum, media campaigns and social media. This included developing and improving HPV vaccination resources in Aboriginal and Torres Strait Islander languages and for Culturally and Linguistically Diverse people.8
National Cervical Screening Program（NCSP）
In December 2017, Australia changed to a renewed NCSP based on 5-yearly cervical screening using a primary HPV test with partial genotyping and reflex LBC triage, for women aged 25–69 years, with exit testing up to age 74 years. HPV testing refers to testing for oncogenic HPV types, defined as those associated with the development of invasive cervical cancer. These include HPV 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 66 and 68.9 HPV testing can be performed using a range of technologies including DNA PCR, DNA hybridisation and testing for RNA, and these need to be approved and have to meet specific requirements set by the National Pathology Accreditation Advisory Council.10
The CST result is reported as low, intermediate or high risk for significant cervical abnormality based on both the HPV test (reported as HPV16, 18 or not 16/18) and (where indicated) reflex LBC. Management and recommendation are provided according to the risk stratification of the CST. NCSP has published Guidelines for the management of screen-detected abnormalities, screening in specific populations and investigation of abnormal vaginal bleeding.11 This provides guidance for screeners and healthcare practitioners involved with colposcopy and management of screened-detected abnormalities (table 2).
National Cancer Screening Register（NCSR）
The NCSP is supported with cervical screening data provided by the NCSR, following the migration and consolidation of state and territory cervical screening register data in 2017.12
The role of the NCSR is to:
maintain a national database of cervical screening records,
invite eligible people to commence cervical screening when they turn 25,
remind participants when they are due and overdue for cervical screening,
provide participants cervical screening histories to laboratories to inform screening recommendations,
provide a ‘safety net’ for participants who are at risk and who have not attended further testing by prompting them to have follow-up tests.
The NCSR Rules 2017 require certain screening information to be notified by pathology providers within 14 days. These include HPV tests, cytology and histopathology.13 To ensure colposcopy practices are audited as well, all colposcopists are also required to report a minimum data set for each colposcopy to the NCSR.14
Monitoring key aspects of the NCSP
Population-based cancer screening programmes require monitoring of their performance, quality and safety. NCSP monitoring reports are produced annually by the Australian Institute of Health and Welfare with performance indicators grouped under each of the five population screening pathway stages of ‘Recruitment’, ‘Screening’, ‘Assessment’, ‘Diagnosis’ and ‘Outcomes’.
Some Performance Indicators from the NCSP monitoring report 20245 are highlighted in this review. All results described pertained to participants aged 25–74 unless described otherwise.
Participation
In 2019–2023, 63.5% of the target population aged 25–74 had a screening HPV test. The highest participation in cervical screening of 75.1% was observed in participants aged 25–29. The lowest group was participants aged 70–74 at 35.0% in 2018–2022 but trending upwards to 43.6% in 2019–2023. This age group has re-entered the renewed NCSP after leaving the previous NCSP after age 69.
For participants aged 25–69 in 2018 with screening HPV tests that did not detect oncogenic HPV, who were recommended to rescreen in 5 years, 16.1% rescreened within 4 years and 9 months (early rescreening). Most participants rescreened adequately—39.9% adequately and on time, and 16.1% adequately but overdue. 7.0% rescreened more than 6 years after their screen in 2018 (late rescreening). 20.9% had not rescreened as at 30 June 2025 (6.5 years after the end of 2018).15
Screening HPV test positivity
In 2023, 7.0% of participants were positive for oncogenic HPV (any) comprising 1.4% for oncogenic HPV (16/18) and 5.6% for oncogenic HPV (not 16/18). Positivity for oncogenic HPV (16/18) dropped from 2.0% in 2018 to 1.4% in 2023 and from 6.5% to 5.6% for oncogenic HPV (not 16/18). Positivity of oncogenic HPV (not 16/18) was highest at 17.3% in participants aged 25–29 and decreases with age to a low of 2.2% in participants aged 70–74.
Screening results
In 2023, 92.5% of participants were assigned as low risk for a significant cervical abnormality, 5.0% were intermediate risk and 1.6% at high risk. The proportion of screening episodes with low risk was only slightly increased from 91.0% to 92.5% between 2018 and 2023, with a corresponding decrease for intermediate risk from 6.2% to 5.0% and from 2.3% to 1.6% for higher risk results. Among the higher risk group, 12.9% was due to HPV (not 16/18) with abnormal cytology of possible high-grade squamous intraepithelial lesion or worst including glandular abnormality. For the rest assigned higher risk due to positivity for oncogenic HPV (16/18), 45.3% of triage LBC cytology was negative.
Colposcopy referral is recommended for those with higher risk for significant cervical abnormality.
For participants aged 25–74 who were referred for colposcopy based on primary screening tests performed in 2022, the median time to colposcopy was 65 days (calculated from the date the test was performed). Overall, 78.9% of participants whose screening or follow-up test result in 2022 indicated that they should attend colposcopy had a colposcopy within 26 weeks of their screening or follow-up test. The rate was lower for the Aboriginal and Torres Strait Islander participants at higher risk of a significant cervical abnormality, with 50.8% having a colposcopy within 3 months compared with 60.8% of non-Indigenous participants, and this was further impacted by increasing remoteness from major cities.
Correlation of screening results
In 2022, of those participants with an LBC that predicted a high-grade or glandular abnormality or cervical cancer and were followed by histology within 6 months, 71.5% had a histology result of high-grade cervical abnormality or cervical cancer. No cancer was reported within 6 months of the primary screening test for an intermediate risk CST, while 0.6% of HPV(16/18) with negative or low-grade cytology were found to have cancer. When LBC was reported with a high-grade or glandular abnormality, cancer was found in 1.8% (29/1644) when associated with HPV (not 16/18) and 10.1% (109/1084) with HPV (16/18). High-grade histological abnormality was found in 0.2% (7/3640) with low-risk CSTs, 12.7% (91/716) of intermediate CSTs and 42.1% (2246/5331) of higher risk CSTs.
Follow-up results
For participants aged 25–74 who had a primary screening episode in 2022 that indicated they were of intermediate risk, 55.4% had a follow-up HPV test between 9 and 15 months, and 58.7% of participants who had a follow-up episode in 2022 that indicated they were of intermediate risk had a follow-up HPV test between 9 and 15 months.
In 2023, in the first follow-up 12 months after an intermediate risk screening episode result, 39.1% were low risk, 55.0% were intermediate risk, 4.2% were higher risk and 1.7% could not be assigned a risk. For those with second follow-up episodes in 2023, 36.0% were low risk, 63.8% were higher risk and 0.2% could not be assigned a risk.
High-grade cervical abnormality detection rate
In 2023, there were 7.8 participants aged 25–74 with a high-grade abnormality detected by histology per 1000 participants screened. It was 8.2 in 2018, reached a high of 16.5 in 2020 and fell back to 7.8 in 2023. The main components of the high-grade abnormality were CIN2 (31.7%), CIN3 (58.5%) and adenocarcinoma in situ (AIS) 3.4%.
Evolving NCSP Screening Guidelines and Management of Screened Abnormalities
Since commencement in December 2017, a number of changes have been made to the renewed NCSP Guidelines,11 the latest in April 2025. Some of the major updates are highlighted below (table 3).
Colposcopy referral extended till after three intermediate risk CST results.
Initial renewed NCSP guidelines recommended a follow-up HPV test in 12 months after an intermediate risk CST. Revised clinical guidelines in February 2021 recommended a second follow-up a further 12 months later if their first follow-up HPV test is again at intermediate risk, instead of referral to colposcopy.
For women who may be at higher risk of a high-grade abnormality, a referral for colposcopy is recommended if HPV (any type) is detected at the first 12-month follow-up HPV test, regardless of the result of reflex LBC. This includes women who are 2 or more years overdue for screening at the time of the initial CST, women who identify as Aboriginal and/or Torres Strait Islander and women aged 50 years or older.
Expanded option of self-collection
On 1 July 2022, Australia expanded cervical screening with the option of self-collection to all women and people with a cervix aged between 25 and 74. For the year prior, over 70% of diagnosed cancer cases that occurred were in people who were behind in their screening or had never screened.
This important initiative provides choice and agency, particularly to disadvantaged groups and those less inclined to have a cervical screening sample collected by a healthcare provider.
Test of cure
Test of cure following treatment of HSIL was initially by co-testing. It is now annual HPV tests until two consecutive tests are negative. Once the patient has completed the Test of Cure, they can return to 5-yearly screening.
HPV (16/18) with negative LBC
The initial NCSP guidelines were referral to colposcopy if CST is HPV (16/18) positive regardless of any reflex LBC. This applies as well for any repeat HPV test 12 months after if HPV (16/18). There is now an option for those with HPV (16/18) detected, LBC report of negative and normal colposcopy, if their 12-month follow-up results are again HPV (16/18) detected and negative LBC, the HPV test could be repeated in another 12 months rather than immediate re-referral to colposcopy.
Surveillance following excisional treatment of AIS
This requires annual co-tests and referral for colposcopy if any abnormal result. The interval can now be extended to 3 years if all co-tests are negative for 5 years. If all tests are negative for 25 years, they can either return to routine screening (if <70 years old) or exit the programme (if ≥70 years old).