• Research is looking at cervical screening and Indigenous women's participation (Universal Images Group Editorial)
A study lead by a young Torres Strait Islander research fellow finds that Indigenous women are not receiving the recommended 2-month clinical follow up on an abnormal pap test result.
By
Sophie Verass

13 Feb 2017 - 11:49 AM  UPDATED 15 Feb 2017 - 10:21 AM

Since the implementation of National Cervical Screen Program (NCSP) in 1991, a significant number of Australian women, gender diverse people and transmen, have been able to control their cervical health and in some cases, prevent cervical cancer.  

Pap smears or Pap tests are recommended every two years for sexually active people with female organs aged 18-69 years to reduce the burden of cervical cancer. Pap tests do not test for cervical cancer, but looks for unhealthy changes in the cervix that can progress to cervical cancer. Survival of cervical cancer relies on the disease being detected early, when treatment is more likely to be successful. If a pap test is reported as ‘High Grade Abnormal’ (HGA) and detects an abnormality which can develop into cancer, NCSP guidelines recommends a clinical investigation by a specialist within 2-months. These clincal investigations or 'follow-ups' can be life-saving.

The burden of cervical cancer is much greater for Aboriginal and Torres Strait Islander people than non-Indigenous, with Indigenous women (and gender diverse people) being four times as likely to die of cervical cancer than other women in Australia. 

Dr Lisa Whop of the Menzies School of Health Research says that there is significant a difference in survival of Indigenous women compared to non-Indigenous women in cervical cancer. 

Dr Whop told the Medical Journal of Australia that, while there has been a great response to the NCSP, whereby incidences of fatalities in Australian women has decreased by more than half in its 25 years of practice, the same positive statistics haven’t been seen amongst Indigenous women. Dr Whop has lead a study into cervical screening and Indigenous women, looking at many different aspects of the prevention continuum for Indigenous women in Australia. Although the study specifies that it focuses on women, it should be considered that transmen and gender diverse people also require cervical screenings. 

Dr Whop's recent investigation found that the 2-month follow-up consultation is key to this health gap. Dr Whop and her team found that information from the NCSP shows that after a diagnosis of a HGA, when the disease is in the early stages, Indigenous women are not receiving recommended timely follow-up.

Dr Whop and her team found that the information from the NCSP shows that after a diagnoisis of a HGA, when the disease is in the early stages, Indigenous women are not recieving the recommended timely follow-up. 

Focusing on the state of Queensland, the report reveals that a mere 34 per cent of Indigenous women aged 20 – 68 with a HGA participated in the recommend 2-month follow up between the years 2000 to 2009. This was compared with 46 per cent of non-Indigenous women, which demonstrates that Australian women as a whole are not recieving promt investigation within clincial guidelines, but Indigenous significantly more so.

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Similar results were found for a 4-month follow up, but by the 6-month follow-up, the ratio between Indigenous and non-Indigenous women was near par. Interestingly, there was a greater proportion of Indigenous women than of non-Indigenous women in recorded clinical investigation within 12 months of a HGA Pap smear result. It appears that Indigenous women are participating in the NSCP, but too slowly. 

Dr Suzanne Moore, a co-author on the paper, believes it is important to recognise that not all Indigenous women are given the opportunity to follow-up on their abnormal pap-test results.  

She says, "It is not known how many women actually receive notification of their abnormal results or are in a position to follow-up in a timely manner”.

"It is not known how many women actually receive notification of their abnormal results or are in a position to follow-up in a timely manner”

Dr Moore also said that health care providers and policy makers should be aware that Indigenous women, often living remotely or in disadvantage, may need to be offered culturally specific and appropriate strategies to improve their time to follow-up, “The best way to ensure improved follow-up is to ask Indigenous women themselves what is needed”.


A video from the Cancer Institute NSW, promoting the importance of cervical screening to Aboriginal and Torres Strait Islander women.

 

The paper lists a number of possible reasons for the delay in follow-up of Indigenous women, considering health systems, health practitioners and individuals;

  • Although Medicare provides a rebate for private outpatient services, an additional payment by the patient is usually required and the cost of the health system can impede on Indigenous people who represent a significant portion of those receiving Centrelink and welfare payments.

 

  • Indigenous Australians are more likely to use the public hospital system than other Australians (90% vs. 57% of hospital separations are from public hospitals), where waiting times for dysplasia clinics can be several months.

 

  • In Queensland, more than half of the Indigenous population live in outer regional, remote or very remote areas, making access to clinics more difficult (However, while access to services in these areas is limited and long distance travel can impede timely follow-up, the study did not find that adjusting for remoteness and area disadvantage did not remove the difference between Indigenous and non-Indigenous women in this regard.)

 

  • Mainstream health care settings can be culturally uninviting. As Indigenous Australians have a history of marginalisation, this can create feelings of alienation, isolation, fear and mistrust of the health care system and health practitioners. Ineffective communication by health practitioners can also compound these problems. Dr Lisa Whop says that there is also ‘never enough’ Aboriginal and Torres Strait health care workers and those Indigenous health workers need to be encouraged and supported more in the space of cervical prevention. Dr Whop also questions whether the needs of  Aboriginal and Torres Strait Islander communities are being met in regards to having access to a female GP.

 

  • Although Medicare provides a rebate for private outpatient services, an additional payment by the patient is usually required and the cost of the health system can impede on Indigenous people who represent a significant portion of those receiving Centrelink and welfare payments.

 

  • Cultural views of cancer may also cause delays in seeking diagnostic or curative treatment; from an Indigenous perspective, cancer could be seen as retribution for a past wrong, and mainstream cancer treatment may be seen as loss of traditional lifestyle. Dr Whop told the Medical Journal of Australia, “particularly for Indigenous women, there’s a lot of stigma around cancer."

 

Dr Whop says the next step for this research is conducting it in other states, confirming that this delayed follow up of NCSP clinical investigation is occurring nation-wide and is responsible for the national crisis of Aboriginal and Torres Strait Islander women dying of cervical cancer four-fold compared to non-Indigenous women.

May 2017 will see major changes to the Australian NCSP, shifting from a Pap test every 2 years to a human papillomavirus (HPV) test every 5 years for women aged 25–74 years. For more information, go to the National Cervical Screen Program, Department of Health site. And for a more satirical public service announcement, watch The Feed's 'Good news for people with vaginas!' video.

The paper, 'Time to clinical investigation for Indigenous and non-Indigenous Queensland women, after a high grade abnormal Pap smear, 2000-2009' is the final paper in Dr Whop's series of publications which formed her PhD.

Dr Lisa Whop is a descendent of the Wagedagam tribe of the Gumulgal people of Mabuiag Island in the Torres Strait.

For information and support on cervical cancer and the pap tests, contact your GP or local Aboriginal Meidical Service

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