New Zealand Medical Journal

National and regional projections of gynaecological cancers in Aotearoa New Zealand: a projection model to 2045 highlighting an opportunity for collective action

introduction: Gynaecological cancers are an increasing concern in Aotearoa New Zealand, with rapid growth in uterine cancer incidence in recent years. Understanding future incidence patterns is essential for planning and service delivery at a sub-national level. methods: Cancer registry data (2001–2022) were combined with population projections to estimate incidence of gynaecological cancers to 2045. Projections were generated using age-period-cohort Poisson regression models, with non-parametric bootstrapping to quantify uncertainty. results: Annual gynaecological cancer cases are projected to increase 82% by 2045, reaching 2,497 (95% uncertainty interval [UI] 2,263–2,774) compared with 1,375 in 2020–2022. The overall age-standardised rate is projected to rise 21% from 36.6 (95% confidence interval [CI] 35.5–37.8) to 44.2 per 100,000 (95% UI 38.9–50.3). Uterine cancer contributes the largest increase, more than doubling from 717 to 1,506 cases annually (110%). Among Māori, cases rise 132% from 214 to 497 per year (95% UI 449–553); for Pacific women, they rise 137% from 165 to 391 (95% UI 340–449). Uterine cancer age-standardised rates are projected to increase from 27.3 to 39.6 per 100,000 for Māori, and from 74.3 to 97.5 for Pacific women. Regional variation is expected: the Northern Region is projected to have the largest absolute increase (+506 cases, 527 to 1,033) and the largest percentage increase (96%). conclusion: Gynaecological cancer incidence in Aotearoa New Zealand is projected to rise substantially over the next 20 years, driven by demographic change and increasing incidence of uterine cancer likely associated with risk factors such as excess body weight and diabetes. Findings highlight the need to prioritise prevention, proactive service planning and equity-focussed early detection.

Recommendations for the use of functional medical imaging in the management of cancer of the cervix in New Zealand: a rapid review

aim: We aimed to review the role of functional imaging in cervical cancer to underscore its significance in the diagnosis and management of cervical cancer and in improving patient outcomes. methods: This rapid literature review targeting the clinical guidelines for functional imaging in cervical cancer sourced literature from 2017 to 2023 using PubMed, Google Scholar, MEDLINE and Scopus. Keywords such as cervical cancer, cervical neoplasms, functional imaging, stag*, treatment response, monitor* and New Zealand or NZ were used with Boolean operators to maximise results. Emphasis was on English full research studies pertinent to New Zealand. The study quality of the reviewed articles was assessed using the Joanna Briggs Institute critical appraisal checklists. results: The search yielded a total of 21 papers after all duplicates and yields that did not meet the inclusion criteria were excluded. Only one paper was found to incorporate the New Zealand context. The papers reviewed yielded results that demonstrate the important role of functional imaging in cervical cancer diagnosis, staging and treatment response monitoring. Techniques such as dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI), diffusion-weighted magnetic resonance imaging (DW-MRI), computed tomography perfusion (CTP) and positron emission tomography computed tomography (PET/CT) provide deep insights into tumour behaviour, facilitating personalised care. Integration of artificial intelligence in image analysis promises increased accuracy of these modalities. conclusion: Functional imaging could play a significant role in a unified approach in New Zealand to improve patient outcomes for cervical cancer management. Therefore, this study advocates for New Zealand’s medical sector to harness functional imaging’s potential in cervical cancer management.

Preliminary assessment of using mobile point-of-care human papillomavirus (HPV) testing with the option of immediate colposcopy in a rural area in a high-income country: a case study

aim: Cervical cancer is now preventable with human papillomavirus (HPV) vaccination and HPV screening. However, structural health system barriers in rural areas can inhibit screening access. Inequitable access for rural Māori is exacerbated by social determinants and racism. Pro-equity tools, such as self-taken swabs point-of-care (POC) testing, now exist. This study aimed to investigate whether POC HPV testing and immediate offer of colposcopy by a mobile colposcopy service is possible at a rural community event. methods: This case study was a collaboration between a research centre, a women’s health bus, a molecular diagnostics company, a Māori health provider and a community charity, and took place prior to the new cervical screening programme introduction at a 2-day community event—a shearathon. Eligible participants were offered a self-taken swab for HPV, which was analysed by POC testing. If high-risk HPV was detected, they were offered an immediate colposcopy. The Māori-centred qualitative component explored women’s experiences of the process. results: Fourteen women undertook a self-test for HPV. High-risk HPV was detected in six women and all were offered immediate colposcopy. Six women were interviewed. All were supportive of the service. Culturally safe staff taking time to put women at ease contributed to acceptability and positive experiences. conclusion: This case study shows that provision of POC HPV testing and colposcopy at a rural community event setting is possible through cross-sector collaboration. This service was acceptable to rural transient workers who face barriers to healthcare in a highincome country.

Perceived barriers to self-collected HPV testing for cervical cancer screening, and knowledge of HPV: a survey of primary healthcare smear-takers across Aotearoa New Zealand

aims: Cervical cancer remains a burden within Aotearoa New Zealand, with 2022 screening rates sitting 12.7% below target. The National Cervical Screening Programme has changed to primary human papillomavirus (HPV) testing for all screen-eligible people, with the aim for home self-testing. Little is known about the readiness of primary care for the change to self-testing and its associated challenges. A pilot HPV cervical cancer screening programme is being conducted in 17 practice centres. The aim of this study is to explore smear-taker knowledge at these centres about the use of primary HPV testing for cervical cancer screening. methods: This is an ethically approved questionnaire study, with data from a structured web-based questionnaire sent to all smear-takers at the pilot centres. results: We achieved a total completion rate of 57.8%. The average score for “Knowledge of HPV” was 56.5% (range=20–100%). The challenges to patient home HPV self-testing were felt to be overall “not at all” to “mildly challenging”. Up to 73.3% of participants identified ongoing needs for further education. conclusions: The findings indicate knowledge deficits regarding HPV testing for cervical cancer screening and a desire for the provision of further education. Overall, respondents felt that no major barriers to implementing HPV self-testing would occur.

Retrospective survey of colposcopy experience for wāhine Māori across two time periods (2016 and 2021) in Waitematā and Auckland districts, New Zealand

To examine wāhine Māori experiences of colposcopy services in New Zealand based on surveys conducted in 2016 and 2021. The surveys included a total of 201 wāhine Māori who had attended one of the three colposcopy clinics in the Waitematā and Auckland districts. Participants were retrospectively surveyed about their experience via telephone using a pre-tested questionnaire. Pre-defined responses were analysed quantitatively, and narrative comments were analysed thematically. Response rates were 27.6% in 2016 and 34.2% in 2021. Prior to their appointment, most women reported receiving the information leaflet and a reminder. At the clinic visit, overall interaction with staff, comfort, listening and explanation of the procedure all scored highly, with maintenance or improvements from 2016 to 2021. Wāhine reported feeling culturally safe. Areas for improvement included content of information, access to Māori community liaison, appointment waiting time and delivery of colposcopy results. The findings indicated that wāhine Māori had overall excellent experiences of colposcopy services, maintained over a five-year period with some suggested improvements to context of information and communication. This provides reassurance for wāhine Māori in the diagnostic and treatment part of the cervical screening pathway ahead of the upcoming change to HPV primary screening.

Aotearoa New Zealand Deaf women’s perspectives on breast and cervical cancer screening

Since the introduction of both cervical and breast screening programmes in Aotearoa New Zealand, mortality rates have dropped. Both screening programmes track women's engagement, but neither capture the level of engagement of Deaf women who are New Zealand Sign Language users or their experiences in these screening programmes. Our paper addresses this knowledge deficit and provides insights that will benefit health practitioners when providing screening services to Deaf women. We used qualitative interpretive descriptive methodology to investigate the experiences of Deaf women who are New Zealand Sign Language users. A total of 18 self-identified Deaf women were recruited to the study through advertisements in key Auckland Deaf organisations. The focus group interviews were audiotaped and transcribed. The data was then analysed using thematic analysis. Our analysis indicated that a woman's first screening experience may be made more comfortable when staff are Deaf aware and a New Zealand Sign Language interpreter is used. Our findings also showed that when an interpreter is present, extra time is required for effective communication, and that the woman's privacy needs to be ensured. This paper provides insights, as well as some communication guidelines and strategies, which may be useful to health providers when engaging with Deaf women who use New Zealand Sign Language to communicate. The use of New Zealand Sign Language interpreters in health settings is regarded as best practice, however their presence needs to be negotiated with each woman.

Feasibility and acceptability of telehealth and contactless delivery of human papillomavirus (HPV) self-testing for cervical screening with Māori and Pacific women in a COVID-19 outbreak in Aotearoa New Zealand

To determine the feasibility and acceptability of a telehealth offer and contactless delivery of human papillomavirus (HPV) cervical screening self-test during the 2021 COVID-19 Level 4 lockdown in Auckland, New Zealand. A small proof-of-concept study was undertaken to test telehealth approaches in never-screened, due or overdue Māori and Pacific women enrolled in a local Primary Health Organisation (PHO). Study invitation, active follow-up, nurse-led discussions, result notification and a post-test questionnaire were all delivered through telehealth. A sample of 197 eligible Māori and Pacific women were invited to take part, of which 86 women were successfully contacted. Sixty-six agreed to take part. Overall uptake was 61 samples returned (31.8%) and uptake of all contactable women was 70.9%. Six of the 61 HPV self-tests (9.8%) were positive, all for non 16/18 types, and were referred for cytology. Three had negative cytology results, and three with positive cytology results were referred for colposcopy. The offer of HPV self-testing during COVID-19 lockdown was both feasible and highly acceptable for Māori and Pacific women. Importantly, HPV self-testing via telehealth and mail-out, alongside other options, offers a potential pro-equity approach for addressing the impact of deferred screens due to COVID-19 and other longstanding coverage issues.

Audit of cervical excision depth of large loop excision of the transformation zone procedures at Counties Manukau District Health Board

Cervical cancer is the fourth most common malignancy in females worldwide. Large loop excision of the transformation zone (LLETZ) procedures remain the preferred surgical technique to remove squamous cervical intraepithelial neoplasia (CIN) lesions globally. This study aimed to assess whether the depth of LLETZ procedures at Counties Manukau District Health Board (CMDHB) met established standards of care. Hospital records were reviewed for all LLETZ procedures performed at CMDHB between 1 June 2020 to 3 May 2021, and these were compared to Public Health England's (PHE) 2020 Colposcopy Guidelines. One hundred and eighty-four cases were identified. Forty-eight percent of all LLETZ procedures were the correct excision depth relative to PHE's ≥95% threshold, primarily due to excisions being too shallow, particularly in patients with type 2 and 3 transformation zones (TZ), 48% and 86%, respectively. Māori and Pasifika patients represented only 16% and 13% of all LLETZ procedures in this study, respectively. This study identified significant oversampling of LLETZ excisions in patients with type 1 TZs, and significant under-sampling in patients with types 2 and 3 TZs. Ultimately, these findings highlight the need for additional quality improvement processes and emphasise the importance of auditing LLETZ procedures nationwide.

Exploring health professionals’ viewpoint of provision of nutrition advice for women with endometrial cancer

The aim of this study was to explore barriers and facilitators to delivery and uptake of nutrition advice to women diagnosed with endometrial cancer from a health professionals' viewpoint. Fifteen semi-structured interviews with health professionals with experience in providing healthcare to women diagnosed with endometrial cancer were audio-recorded and transcribed. Interviews were analysed using reflexive thematic analysis. Topics included high weight as a risk factor for endometrial cancer, nutrition information sources, and barriers and facilitators to delivering nutrition advice in clinical care. Four themes were identified. The first three exist as barriers to women receiving nutrition advice-how to navigate conversations about high weight, access to limited resourcing and health professionals feeling powerless to overcome system influences. The fourth theme identified a community approach need to facilitate a supportive environment and share knowledge. This study, through the lens of health professionals, highlights barriers to the delivery and uptake of nutrition advice at the patient, community and system levels. Enhancing survivorship for women after the diagnosis of endometrial cancer may be enabled by further understanding of how to overcome barriers and promote facilitators. Communication and partnership with women are imperative to achieving this.

Endometrial cancer diagnoses prompted by routine cervical cytology: a retrospective case study

Endometrial cancer is the commonest gynaecological cancer in New Zealand. Some women have their diagnosis of endometrial cancer prompted by an abnormal cervical cytology screening test. When high-risk human papillomavirus (hr-HPV) testing becomes the primary test for cervical screening, this avenue of incidental diagnosis will be reduced. Therefore, our aims were to estimate the proportion of women whose diagnosis of endometrial cancer follows incidental detection on routine cervical cytology, and to understand the clinicopathologic characteristics of these cases. Retrospective analysis of patient medical records from women of cervical screening age diagnosed with endometrial cancer between 2015-2019 in the South Island of New Zealand. Of 334 women, 26 (7.8%) had endometrial cancer diagnosis prompted by abnormal cervical cytology. Most women had low-grade (17/26, 65.4%), low-stage (18/26, 69.2%) disease of endometrioid histologic subtype (21/26, 80.8%). The small cohort prevented significant correlations with clinicopathologic characteristics and outcomes. Overall, cervical cytology had low sensitivity (32.3%) for the detection of endometrial cancer in the 6 months before diagnosis. A small number of women currently have diagnoses of endometrial cancer prompted by routine cervical screening with cytology. However, the undefined clinical benefit from and poor sensitivity of cervical cytology for detecting endometrial cancer does not justify its use in screening, or opposition to hr-HPV cervical screening.

A quality improvement project: Rapid Access Hysteroscopy Clinics with nurse pre-procedural telephone support in the outpatient setting

aim: Endometrial cancer (EC) is increasing in incidence in women across Aotearoa New Zealand as risk factors such as obesity and diabetes become more prevalent. In 2022, a Rapid Access Clinic (RAC) for hysteroscopy was implemented at Te Whatu Ora Counties Manukau District to increase early detection of EC. method: Plan-Do-Study-Act (PDSA) cycles were used to test and implement RAC supported by a nurse pre-procedural phone consultation. Quantitative data was collected alongside patient experiences of the pre-procedural telephone call. results: A total of 207 women successfully completed RAC, which enabled one less visit to clinic per patient, subsequent travel cost savings (NZ$35,959) and a decrease in CO2 emissions (1,782kg). Lead time from first specialist appointment (FSA) to outpatient (OP) hysteroscopy, previously 25 days (SD: 21 days), was eliminated. Wait time from referral to provisional diagnosis increased from 26 days to 31 days; however, standard variation reduced from 30 days to 15 days. Clinician productivity increased by 25% per hysteroscopy session. Twenty-six out of 30 patients reported positive experiences of their pre-procedural RAC phone consultation. Twenty-seven out of 207 women were diagnosed with endometrial cancer from RAC. conclusion: RAC are patient-centric and have demonstrated valuable benefits for both clinicians and women with a high suspicion of EC.