B-QuiCK: Cervical cancer

Cervical cancer – early detection and referral

Prevention and early detection

• Recommend prophylactic HPV vaccination (funded for females and males aged 9 – 26 years inclusive)
  • Vaccination is most effective when administered prior to the onset of sexual activity but vaccinating those who have already commenced sexual activity is still recommended
  • The vaccine can be administered (not funded) to people aged 27 years and older if they have not been vaccinated before and are likely to benefit, e.g. people who are newly sexually active
• Encourage and remind all eligible people, including those who have been vaccinated against HPV, to undergo regular cervical screening. HPV testing is now the primary cervical screening test in New Zealand, replacing the previous cytology-based test.
  • The HPV test can be performed from a vaginal swab taken by the patient (i.e. a self-test), a vaginal swab taken by a screen taker or a LBC sample taken by a cervical sample taker (this sample type will only be tested for HPV initially and if detected, reflex cytology will then be performed)
  • HPV testing (including self-testing) requires clinical oversight including a discussion about which method of sample taking is most appropriate for the patient. A vaginal swab sample will not be suitable in some cases – click here for details.
  • The National Cervical Screening Programme now recommends cervical screening every five years (or three years if immune deficient) following a “HPV Not detected” test result for people with a cervix aged 25 – 69 years who have ever been sexually active. Screening is extended to people aged 70 – 74 years who are unscreened or under-screened.
• Perform a pelvic examination, including speculum examination, and take a LBC sample for both HPV and cytology testing for patients with symptoms or signs of cervical cancer. Initiate further investigations if symptoms are reported irrespective of HPV and cytology results.
  • Symptoms and signs may include abnormal vaginal bleeding (including inter-menstrual, post-menopausal and post-coital bleeding), unusual and persistent vaginal discharge, dyspareunia, non-specific pelvic or low back pain or pressure, abdominal pain, loss of appetite, weight loss, fatigue, bowel or bladder changes
  • If the cervix is visually abnormal during a speculum examination, refer the patient for colposcopy irrespective of HPV and cytology results

A brief HPV testing guide summary is available from: https://bpac.org.nz/2023/hpv-testing-guide.aspx

Management of cervical screening results

If HPV testing was facilitated by a HPV screen taker or HPV screening kaimahi, the overseeing clinician (the “responsible clinician”) is responsible for the management of the patient’s results, e.g. arranging appropriate referrals, follow-up and recalls. Click here for an overview of the management of HPV test results.

Invalid/unsatisfactory tests or samples

• HPV test invalid or unsuitable for analysis – repeat test when practically possible
• Unsatisfactory cytology sample – recall for repeat cytology in 6 – 12 weeks. If the reason for the unsatisfactory sample has been noted, correct this where possible before taking the repeat LBC sample. Refer patients with HPV Type Other detected for colposcopy after two consecutive reports of unsatisfactory cytology.

HPV Not detected

• Place a recall to return for cervical screening in five years, or three years if immune deficient

HPV Detected Type 16/18

• Refer directly for colposcopy. If cytology has been reported and:
  • There is high suspicion of cancer, annotate this on the referral and mark as urgent
  • Atypical endometrial cells are detected, refer to local HealthPathways or discuss with/refer the patient to gynaecology

HPV Detected Type Other

Management depends on cytology results. If the HPV test was initially performed from a vaginal swab, a return visit is required for a LBC sample to be taken (by a cervical sample taker). Cytology will automatically be reported if the HPV test was conducted on a LBC sample.

• High-grade changes detected on cytology – refer for colposcopy. If there is high suspicion of cancer, annotate this on the referral and mark as urgent.
• Atypical endometrial cells detected on cytology – refer to local HealthPathways or discuss with/refer to gynaecology. Colposcopy referral is only indicated if there is a co-existing reason that requires colposcopy, e.g. patient is immune deficient, high-grade cervical lesions also detected.
• Normal or low-grade changes detected on cytology – place a recall to return in 12 months for a repeat HPV test; manage according to the result:
  • HPV Not detected – return to regular cervical screening interval
  • HPV (any type) detected and immune deficient – refer for colposcopy
  • HPV Type 16/18 detected – refer for colposcopy
  • HPV Type Other detected – cytology informs management:
    • High-grade changes – refer for colposcopy. If there is high suspicion of cancer, annotate this on the referral and mark as urgent. If atypical endometrial cells are also reported, refer to local HealthPathways or discuss with/refer to gynaecology.
    • Normal or low-grade changes and the patient is aged ≥ 50 years – refer for colposcopy. If the patient is aged < 50 years – place a recall to return for a further HPV test in 12 months. If HPV is detected (any type), refer directly for colposcopy (irrespective of cytology results if reported). If HPV is not detected, return to regular cervical screening interval.

Follow-up after colposcopy

• If the results from colposcopy are normal following referral for normal/low-grade changes on cytology, place a recall for a repeat HPV test at 12 months post-discharge from colposcopy; manage according to the result:
  • HPV Not detected – return to regular cervical screening interval
  • HPV Type 16 or 18 – refer for colposcopy
  • HPV Type Other – cytology informs management:
    • High-grade changes – re-refer for colposcopy. If there is high suspicion of cancer, annotate this on the referral and mark as urgent. If atypical endometrial cells are also reported, refer to local HealthPathways or discuss with/refer to gynaecology.
    • Normal or low-grade changes – place a recall to repeat the HPV test in 12 months or if the patient is immune deficient, re-refer directly for colposcopy. If HPV (any type) is detected, re-refer for colposcopy (irrespective of cytology results if reported). If HPV is not detected, return to regular cervical screening interval.
• If the results from colposcopy show LSIL that has been histologically confirmed via biopsy, place a recall to repeat the HPV test at 12 months post-discharge from colposcopy and manage according to the results, as above
• If the results from colposcopy show HSIL or a glandular abnormality that has been histologically confirmed via biopsy, the patient will undergo treatment and management in secondary care
  • Once a patient has successfully completed treatment for HSIL, they will be referred back to primary care for a test of cure. Recall patients at 6 and 18 months post-treatment for both HPV and cytology testing (‘co-tests’):
    • If both tests are negative/normal on both occasions, return to regular cervical screening interval
    • If HPV is detected (irrespective of cytology results) at 6 or 18 months, or if HPV is not detected, but cytology results show possible/definite high-grade, refer for colposcopy
    • If a patient does not have HPV detected but has two consecutive low-grade cytology results, refer for colposcopy
    • Place annual recalls for repeat HPV and cytology testing until two consecutive negative/normal co-tests are taken 12 months apart; routine interval screening can then re-commence
  • Patients who have undergone complete excision (with adequate margins) for adenocarcinoma in situ that was HPV positive will have their initial follow-up appointment in colposcopy clinic at six months where the first co-test for a test of cure will occur. If both results are negative/normal, the second co-test will occur in primary care; place a recall for repeat HPV and cytology testing in 12 months post-discharge from colposcopy.
    • If both tests are negative/normal, return to regular cervical screening interval
    • If HPV is detected or cytology is abnormal, re-refer for colposcopy
  • Patients who have undergone complete excision for adenocarcinoma in situ that was HPV negative or HPV status unknown require annual co-tests indefinitely; place a recall for annual HPV and cytology testing

Abbreviations: HPV = human papillomavirus; LBC = liquid-based cytology; LSIL = low-grade squamous intraepithelial lesion; HSIL = high-grade squamous intraepithelial lesion