Cervical cancer prevention and screening

Most cervical cancers result from human papillomavirus (HPV) infection

• HPV can also cause genital warts, cancers of anogenital tract (eg vulval cancer)
• Spread by skin-to-skin contact during sex. Very common. Most people have infection at some time, usually no symptoms and infection clears within 2 years

HPV immunisation

• Prevents infection with 9 types of human papillomavirus (HPV)
• Types 16 and 18 cause most cervical cancers
• Types 6 and 11 cause genital warts
• Best given before onset of sexual activity, before exposure to any HPV
• HPV immunisation does not prevent all cervical cancers. Immunised women still need regular cervical screening, every 5 years

National Cervical Screening Program

• National Cervical Screening Program supports 5-yearly HPV testing for women aged 25–74 years, dependent on woman’s cervical screening history — see national guidelines
• National Cancer Screening Register records screening histories and sends reminders to women when screening is due

Cervical Screening

• Cervical screening looks for HPV infection and cervical changes that may lead to cervical cancer. Diagnosis and early treatment can prevent cancer
• Screening test is a primary HPV test (oncogenic HPV test with partial genotyping). It looks for HPV and then limited genotyping is done to look for type 16/18 HPV — see Table 6.2
• HPV test can be collected in one of two ways
• Speculum examination of the cervix — speculum examination and sample collection enable a reflex liquid-based cytology (LBC) sample to be processed if needed. If HPV detected, the laboratory automatically performs a 'reflex' LBC on the same cervical sample. Women do not need to provide a second sample for cytology test
• Low Vaginal Swab (LVS) - this option is now available to all women eligible for cervical screening. LVS collection does not collect cervical cells for cytology. If HPV is detected women will need to return for speculum exam and collection of LBC
• Laboratory provides report with HPV test result, LBC result (if performed), a ‘risk’ status (low, intermediate, higher risk), and a single recommendation for action. This recommendation must be interpreted in the context of the woman’s cervical screening history

Who should have cervical screening

• All women who have ever been sexually active
  
• Do not start before 25 years unless woman had sexual activity under 14 years of age and was not vaccinated against HPV before start of sexual activity. Offer single cervical screen between 20–24 years of age to these women
• Start at age 25 years and repeat every 5 years until 70-74 years
• Older women
• If cervical screening negative — stop screening between age 70–74 years

• Women who are 75 years or older who have never had cervical screening or have not had one in the previous five years, may request a test and can be screened

• Women who have had hysterectomy
• Testing depends on type and reason for hysterectomy
• See Vaginal vault screening
• Pregnant women can be safely screened
• Do cervical screening if due or overdue and woman likely to be difficult to follow-up postnatally. Best done before 24 weeks pregnant
• Postnatal cervical screening best collected at or after 6 weeks. Can do earlier if needed
• Women with severely weakened immune system (eg solid organ transplant or HIV) more frequent screening recommended — see national guidelines

Managing results and recalls

• When results of screening available, talk with woman about follow-up if needed, remind her of date for next cervical screening
  
• Involve ATSIHP or another person for support
• Offer written material even if she doesn’t read well, she may like to discuss with someone else
• HPV results are reported as
• HPV not detected
• HPV 16/18 detected
• HPV (not 16/18) detected
•  LBC results are reported as
• Negative - normal
• Possible pLSIL or LSIL — low -grade squamous intraepithelial lesion
• Possible pHSIL or HSIL — high-grade squamous intraepithelial lesion
• Abnormal glandular cells
• Suggest invasive cancer
• Follow Flowchart 6.2 to manage results
• Timing of repeat cervical screening is important for prevention and treatment of cervical changes
• Routine interval between cervical screens is 5 years
• Need clinic-based local recall system (eg diary, card-based, computerised) to remind women when cervical screening is due
• Medical consult for all abnormal test results. May need
• Additional tests at specified intervals
• Colposcopy — checking cervix under magnification
• Biopsy of suspicious areas on the cervix

Management of women with cervical screening abnormalities

• Women who have colposcopy should return from gynaecologist with clear plan for follow-up and any tests needed
• If no clear plan — contact gynaecologist
• Women who have colposcopy and confirmed HSIL or glandular abnormality on biopsy are usually offered treatment

Women who have had treatment for HSIL

• Cone biopsy, LLETZ/LEEP or laser treatment for HSIL
• Follow-up by specialist at 6 months not needed unless woman is having problems (eg abnormal bleeding)
• At 12 and 24 months after treatment — cervical sample taken for HPV+LBC co-test. When used to follow-up HSIL this is also called ‘Test of Cure’
• If both HPV and LBC negative at 12 and 24 months — woman returns to routine 5-yearly cervical screening
• If HPV (16/18) detected at any time — refer for colposcopy
• LBC result will be reported and available at time of colposcopy
• If HPV (not 16/18) detected - If LBC negative or pLSIL/LSIL — repeat HPV+LBC co-test in 12 months
• If LBC reports pHSIL/HSIL or glandular abnormality regardless of HPV result — refer for colposcopy

Women who have had treatment for AIS

• Cone biopsy, LLETZ/LEEP for AIS
• Follow-up by specialist at 6 months not needed unless woman is having problems (eg abnormal bleeding)
• Cervical sample taken for HPV+LBC co-test at 12 months, then yearly
• HPV+LBC co-test repeated yearly indefinitely
• If any abnormal test result, HPV detected or LBC abnormal — refer for colposcopy

Managing cervical screening results

Supporting resources

• Cancer Council Australia national cervical cancer screening guidelines
• Self-collection instructions for a HPV test sample