The document discusses guidelines for cervical cancer screening, including incorporating HPV testing. It finds that HPV testing for women over 30 with ASCUS can reduce unnecessary colposcopies by identifying HPV-negative patients with very low risk. However, HPV testing also poses problems like increased anxiety and many HPV-positive women referred for colposcopy having normal results. Overall, HPV testing may help triage some abnormal pap results but also adds new issues to consider.

1. CERVICAL CANCER SCREENING: INCORPORATING HPV TESTING M.A. Bertrand, MD, FRCSC Professor & Head, Division of Gynecologic Oncology, University of Western Ontario, London, Ontario, Canada

3. Epidemiology – Cancer of the Cervix

5. Cervical Cancer Update

6. Cervical Cancer Update

10. Cervical Cancer – Actual / Expected Number of Deaths (Canada)

11. Cervical Screening in Canada CCHOTA, May 2003, No response from PQ, NB, YK TBS 2001 N Y/N N NT/NV Mod. British N N Y BC TBS 2001 N N Y Alberta TBS 2001 N N Y Saskatchewan TBS 2001 N N Y Manitoba TBS 1991 N N Y PEI TBS 2001 N N Y Nova Scotia TBS 2001 On demand N Y Newfoundland TBS 2001 On demand Y Y Ontario Terminology HPV Testing Liquid Based Cytology Screening Program Province/ Territory

12. Ontario Cervical Screening Practice Guidelines Cervical Screening Guidelines Development Committee of the Ontario Cervical Screening Program and the Gynecology Cancer Disease Site Group of Cancercare Ontario

15. Guidelines Revision Process Ontario Cervical Screening Program Cancer Care Ontario Program in Evidence Based Care Cancer Care Ontario GYN Disease Site Group Screening Guidelines Development Committee QMPLS “ Weigh the Evidence”

16. LBC is the preferred method for cervical cytology screening; however conventional Pap smears remain an acceptable method.

17. A province wide cervical screening program with an adequate recall mechanism is recommended.

20. Initiation of Screening ACOG, American College of Obstetricians & Gynecologists; ACS, American Cancer Society; CTFPHE, Canadian Task Force on the Periodic Health Examination; IARC, International Agency for Research on Cancer; NHS, National Health Service, NZGG, New Zealand Guidelines Group; USPSTF, United States Preventive Services Task Force. All sexually active women CTFPHE 20 years of age for sexually active women NZGG 21 year of age or within 3 years of first intercourse ACOG, ACS, USPSTF 25 years of age IARC, NHS

22. Cessation of Screening ACOG, American College of Obstetricians & Gynecologists; ACS, American Cancer Society; CTFPHE, Canadian Task Force on the Periodic Health Examination; IARC, International Agency for Research on Cancer; NHS, National Health Service, NZGG, New Zealand Guidelines Group; USPSTF, United States Preventive Services Task Force. Not enough evidence ACOG Age 65 USPSTF Age 70 NZGG Age 65 NHS Age 70 ACS Age 65 IARC

23. Cessation of screening Screening may be discontinued after the age of 70 if there is an adequate negative screening history in the previous 10 years (i.e. 3-4 negative tests).

24. Screening Interval ACOG, American College of Obstetricians & Gynecologists; ACS, American Cancer Society; CTFPHE, Canadian Task Force on the Periodic Health Examination; IARC, International Agency for Research on Cancer; NHS, National Health Service, NZGG, New Zealand Guidelines Group; USPSTF, United States Preventive Services Task Force. At least every 3 yrs USPSTF Every 3 yrs CTFPHE Every 3 yrs NZGG Every 3 yrs, age 25-50 then every 5 yrs NHS Annually under age 30 Every 2-3 yrs over age 30 ACOG, ACS Every 3 yrs, age 25-49 IARC

25. These recommendations do not apply to those women who have had previous abnormal Pap tests. Screening at a 3 year interval is recommended, supported by an adequate recall mechanism. Screening interval · Screening should be done annually until there are 3 consecutive negative Pap tests. · Screening should continue every 2 to 3 years after three annual negative Pap tests.

26. Women who have sex with women should follow the same screening recommendations as women who have sex with men. Pregnant women should be screened the same as women who are not pregnant . Discontinue cervical screening in women who have undergone total hysterectomy for benign causes. Immunocompromised or HIV positive women should receive annual screening.

29. HPV Testing ?

30. Human Papillomaviruses

31. HPV Genome : Double–stranded DNA virus

38. Management of cytologic abnormalities

39. ASCUS and LSIL Mimics

40. ASCUS

70. Low-Grade Squamous Intraepithelial Lesion - LSIL

71. Low Grade SIL

74. High-Grade squamous Intraepithelial Lesion - HSIL

75. Women with AGC should also receive endocervical and endometrial sampling, where appropriate. High grade SIL, ASC-H, Atypical Glandular cells Colposcopy

78. HPV Vaccines

84. Thank you for your attention

85. Question?

87. Sensitivity for CIN 3

88. Negative Predictive Value

89. Cervical Cancer Screening Programs and Practices, Canada 2001

91. ALTS Trial -ASCUS Triage As compared to prevalence of CIN 3 in immediate colposcopy arm – 11.4% 96% 99% NPV for CIN 3 17% 20% PPV for CIN 3 58% 53% Referred to colp 83.4% 92.4% Sensitivity – CIN 3 ASCUS / ASCUS ASCUS / HPV +

94. ALTS – Results by age % Referred to Colp Sensitivity for CIN 3 50% 64% Cytology follow up 31% 65% HPV testing 91% 88% Cytology follow up 94% 96% HPV testing Age >= 29 years Age 23-28 years

95. CYTOLOGY COLPO .>MOD REPEAT @ 6 MONTHS PERSISTENT OF MILD FOR 2 YRS OR > MOD Recall @ 24 months Neg Mild PRIMARY SCREENING FOR WOMEN OVER 30 Current Practice : Women over 30, 3 consecutive negatives, not high risk, recall @ 24 m .

96. PRIMARY SCREENING FOR WOMEN OVER 30 HPV: Screen every 3 years HPV Cytology Colpo + > Or = mild Recall @ 36 m Neg Repeat @ 12 m. HPV & cytology Neg

97. TRIAGE of MILD DYSPLASIA for WOMEN OVER 30 Current Practice: Women > 30 years, last smear mild Repeat cytology @ 6 months COLPO > Mod or 3rd consec. mild Recall @ 6 months Mild Recall @ 12 months Neg

98. TRIAGE of MILD DYSPLASIA for WOMEN OVER 30 HPV Testing: Use at 6 months Mild repeat @ 6 months HPV Cytology Colpo Repeat @ 12 m. HPV & Cytology Neg > Mild Pos Recall @ 24 months Neg

99. TRIAGE of High Risk WOMEN OVER 30 Current Practice: High risk flag set, last smear Neg (72,000 women) High Risk Cytology Repeat Cytology @ 6 months Mild Colpo > Mod Recall @ 12 months Neg

100. TRIAGE of High Risk WOMEN OVER 30 HPV Testing: Use at 6 months High Risk HPV Cytology Colpo Recall @ 12 months HPV & Cytology Neg > Mild + Turn High Risk & recall @ 24 months Neg