B-QuiCK: Cervical cancer

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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.
    • The National Cervical Screening Programme currently recommends three-yearly cervical cytology screening for “participants with a cervix who are sexually active” aged between 25 and 69 years
    • The programme will change to HPV testing as the primary method in July, 2023 (see below)
  • Perform a pelvic examination, including a cervical cytology test and initiate further investigations for patients with symptoms or signs of cervical cancer
    • 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, refer the patient for colposcopy irrespective of the cytology report

Getting a good cervical sample

Avoid lubricant if possible; If required, apply a water-based product sparingly to the outer sides/exterior of the speculum blades and avoid the tip so that lubricant does not get into the liquid cytology vial.

Offer a course of vaginal oestrogen cream prior to cytology testing for people who are post-menopausal, post-natal or breastfeeding, or for other people experiencing vaginal dryness, including transgender males. Instruct patients to insert the cream each night for two to three weeks prior to the test and to stop one to two days before the appointment. Patients should also stop use of other vaginal applications, e.g. anti-fungal creams, spermicides, prior to the appointment.

N.B. Although bleeding has less of an impact on the quality of a cervical sample now that liquid-based cytology is used, the general advice is to avoid taking a sample during menstruation, if possible.

Management of cervical screening results

N.B. Clinical Practice Guidelines for Cervical Screening in New Zealand are currently being revised; this section will be updated to reflect these once the guideline is made publicly available.

Non-result (unsatisfactory sample)

  • Recall for repeat cytology in four to six weeks. Refer to a colposcopy service after three consecutive unsatisfactory results.

Negative for squamous or glandular intraepithelial cervical lesion or malignancy (i.e. a normal test result)

  • Recall for repeat cytology in three years. However, if this is the first test or > 5 years have passed since the previous test, recall in 12 months.

Low-grade cervical abnormality

  • Management is dependent on the patient’s age; click here for details
  • If colposcopy is required, manage according to the results:
    • Normal – place a recall for repeat cytology at 12 and 24 months post-discharge from colposcopy. If the results of either test are abnormal, refer back to a colposcopy service. If both results are normal, return to three-yearly cervical screening.
    • Unsatisfactory – the patient’s cytology will be reviewed in secondary care. If LSIL is confirmed, place a recall to ensure patients have had appropriate repeat tests.
    • Abnormal – a cervical biopsy will be taken in secondary care.
      • Normal biopsy – place a recall to ensure patients have appropriate repeat tests (i.e. colposcopy and cytology +/- HPV test) at 12 months
      • LSIL on biopsy – place a recall for repeat cytology at 12 and 24 months
      • HSIL on biopsy – patient will undergo treatment and management in secondary care; see below

High-grade cervical abnormality

  • Refer for a colposcopy if results indicate high-grade squamous intraepithelial lesion (HSIL) or atypical squamous cells – HSIL cannot be excluded
  • Request urgent colposcopic assessment if results indicate HSIL with suspected invasive squamous cell carcinoma; annotate referral with “high suspicion of cancer”
  • Click here for details on the management pathway following colposcopic assessment of a patient with a high-grade lesion detected with cytology
  • Recall patients at 6 and 18 months post-treatment for a high-grade cervical abnormality for cytology and HPV testing (‘co-tests’):
    • If both test results are normal/negative on both occasions, return to three-yearly cervical screening
    • If there are clinical concerns or the test(s) are positive at 6 or 18 months, re-refer for a colposcopy. Place annual recalls for repeat cytology and HPV testing until two consecutive ‘co-tests’ are taken 12 months apart. When achieved, return to three-yearly cervical screening.

Cervical glandular abnormality

  • Refer for colposcopy; patients will undergo treatment in secondary care if required
  • There are currently no New Zealand specific follow-up recommendations. Australian guidelines recommend that patients who have undergone complete excision with clear histological margins for adenocarcinoma in situ, have annual ‘co-tests’ with HPV testing and cytology until data are available to support cessation of testing. If any of the results are abnormal, re-refer for colposcopic assessment.

HPV testing to become the primary cervical cancer screening test from July, 2023

  • Females aged 25 – 69 years who have ever been sexually active will be eligible for HPV testing from July, 2023. Eligibility criteria is extended to age 75 years if the patient is under-screened or never screened.
  • Routine cervical screening will occur every five years; five-yearly screens will commence once the patient has returned a negative test for HPV
  • A PCR test is used to detect HPV DNA. This test can be performed from a:
    • Vaginal swab taken by the patient
    • Vaginal swab taken by a clinician
    • Clinician-taken (speculum) liquid-based cytology (LBC) sample; cytology can then be performed on the LBC sample if the HPV test result is positive
  • All testing options, including self-testing require clinical oversight including a discussion about which method of sample taking is preferred by the patient.
  • If a patient tests positive for HPV from a vaginal swab, a speculum examination is required and a cervical sample taken for LBC, or in some cases, e.g. if HPV type 16/18 is detected, they can choose to be referred directly to colposcopy

Click here to view the proposed HPV testing pathway. Follow-up management is then dependent on the results of cytology (as above).

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