HPV Testing Guidelines

· CCO (2011):

· The proposed algorithm (Figure 1) assumes the existence of an organized province-wide screening program.

· The goal of the interim recommendations is to provide a bridge to the time when HPV testing for primary screening is funded in Ontario.

· This screening algorithm should be reviewed for currency prior to its implementation as results from subsequent screening rounds of the HPV RCTs are expected in the next one to two years.

· Part 1 guidelines (assumes HPV DNA testing is funded in Ontario):

· HPV testing for women age 30+

· Note: there is insufficient evidence at this time to makea recommendation for the age at which to begin cervical screening using HPV testing as the primary screen.

· In women < 30, the rate of transient infections is higher

· Women who have never been sexually active do not require cervical screening

· Repeat every 5 years with a negative HPV test result

· Stop screening at age 65

· provided there is an adequate negative screening history in the previous 10 years (i.e., two or more negative tests) and a final negative HPV test at age 65.

· Positive HPV DNA test, then cytology

· Positive cytology (>= ASCUS) then colposcopy

· Negative cytology then repeat HPV DNA testing at 12 months

· If positive HPV DNA test then colposcopy

· If negative HPV DNA test then go back to HPV DNA testing every 5 years

· A variation on this algorithm includes genotyping for HPV 16 and/or HPV 18 immediately after a positive HPV test and cytology results of normal, ASCUS or LSIL

· Positivity for either of these types may require immediate colposcopy.

· Part 2 (interim) guidelines (to be followed until HPV testing is funded):

· Cytology starting at age 21

· Women who are not sexually active3 by age 21 may delay cervical screening.

· Women who have never been sexually active do not require cervical screening

· Repeat every 3 years

· ASCUS (Atypical squamous cells of uncertain significance):

· HPV DNA testing with cytology is recommended for women aged 30 or older

· If the HPV DNA test is positive, women should be referred for colposcopy.

· If the HPV DNA test is negative, women should have repeat cytology in 12 months

· Once a woman has had two negative cytology test results, she should return to routine screening.

· In the absence of HPV DNA testing, and in women < 30 y, a repeat Pap test in six months is recommended / acceptable.

· If the Pap test is abnormal, women should be referred for colposcopy

· If the Pap test is negative, women should have repeat cytology in another six months

· Once a woman has had two negative Pap tests results, she should return to routine screening

· Referral to colposcopy, without HPV DNA testing or repeat cytology, is only recommended in situations where there is a high probability of patient loss to follow up, or if there are other symptoms suggesting cervical abnormality (e.g., abnormal bleeding)

· ASC-H (Atypical squamous cells: cannot exclude high grade squamous):

· Colposcopy is recommended

· LSIL (Low-grade squamous intraepithelial lesion)

· Either colposcopy or repeat cytology in six months

· If repeat cytology is used and the Pap test is abnormal, women should be referred for colposcopy.

· If the Pap test is negative, women should have repeat cytology in another six months.

· Once a woman has had two negative Pap test results, she should return to routine screening.

· HSIL (High-grade squamous intraepithelial lesion)

· Colposcopy

· AGC (Atypical glandular cells)

· Colposcopy

· Women with AGC should also receive endocervical and endometrial sampling, where appropriate

· Pap test should not be used as the sole assessment of a visible cervical lesion. These patients require biopsy for accurate diagnosis.

· Stop screening at age 70

· provided there is an adequate negative cytology screening history in the previous 10 years (i.e., three to four negative cytology tests).

References:

· Murphy J, Kennedy E, Dunn S, Fung Kee Fung M, Gzik D, McLachlin CM, Shier M, Paszat L. Cancer Care Ontario Evidence-based Series 15-9. Cervical Screening. Oct. 5, 2011.