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Cervical Screening and HPV testing Dr Tracy Owen Quality Assurance Director, NICSP.

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Presentation on theme: "Cervical Screening and HPV testing Dr Tracy Owen Quality Assurance Director, NICSP."— Presentation transcript:

1 Cervical Screening and HPV testing Dr Tracy Owen Quality Assurance Director, NICSP

2 Aim of screening To reduce mortality and morbidity associated with cervical cancer by identifying and treating pre-cancerous changes Screening can prevent 70% of cervical cancers Liquid based cytology – introduced 2007/08 ? Role of HPV testing in screening pathway - HPV detected in 99.7% of cervical cancers

3 Coverage rates by Trust NI coverage = 77.32% (2010/11) Coverage = % of eligible women with a screening result in last 5 years

4 5 year coverage by age group

5 Is there anything else that you can do to improve informed choice in your practice?

6 Reminder - policy change From Jan 2011 AgeScreening interval 25 – 49 yrs3 years 50 – 64 yrs5 years Evidence based, endorsed by UK National Screening Committee, in line with WHO recommendations

7 What do we know about HPV? >100 types – only small number cause cervical cancer (HR-HPV) Transient infection very common - 8 in 10 people infected in lifetime Prevalence decreases with age (Manchester study) 40% of 20-24yr olds with HR HPV, 5% of yr olds Can’t be treated but can clear on its own Infection persists in 20-30% of women

8 HPV – a complicated issue Women or their partners may have HPV for many years without knowing it 99% of cervical cancers associated with persistent infection with high risk types of HPV (70% linked to HPV 16 or 18). Transmitted by close skin-to-skin contact Condoms help but don’t provide full protection

9 HPV testing and screening HR-HPV testing at two points in screening pathway - Triage and Test of Cure Improved management of ‘low grade’ abnormalities Introduced for smears taken from Monday 28 January 2013 Applies to women in screening age range (25-64 yrs) HPV test is carried out on the same sample

10 HPV triage 15-20% of women with borderline/mild changes have a significant abnormality that needs treatment HR-HPV testing is effective in identifying which women may need treatment All borderline/mild samples are tested for HR-HPV (Triage) HR-HPV positive are referred immediately to colposcopy HR-HPV negative can be safely returned to routine recall

11 Triage pathway Borderline/Mild Dyskaryosis HR-HPV testHR-HPV NegativeRoutine recallHR-HPV Positive Colposcopy referral

12 Benefits of triage Reduces the need for multiple repeat tests – reduces anxiety & cost Colposcopy is focused on the women who are more likely to have significant disease Women get to colposcopy sooner Negative predictive value of HR-HPV test is reported between 93.8 and 99.7% ?reduced DNA rate at colposcopy

13 STANDARD PROTOCOL Routine screenBorderline cytology Repeat at 6 months – borderline result COLPOSCOPY HPV TRIAGE PROTOCOL Routine screen Borderline cytology, HPV +ve COLPOSCOPY

14 Test of Cure (TOC) To assess women who have been treated for any grade of CIN for risk of having residual or recurrent disease Women with normal cytology and negative for HR-HPV at follow up are at very low risk of residual disease HR-HPV test on women with normal, mild or borderline cytology result at 6 month follow up after treatment (excluded if treated for CGIN/invasive disease) If HR-HPV negative are returned to routine recall If HR-HPV positive are referred back to colposcopy

15 Test of cure pathway 6 months post treatment Normal/Borderline/ Mild Dyskaryosis HR-HPV test HR-HPV Negative Routine recall (3yrs) HR-HPV Positive Colposcopy referral

16 Benefits of TOC Approx 80% of treated women avoid annual cytology tests Cost savings to primary care and laboratory Improved service for women - shorter patient journey time with return to routine recall

17 STANDARD PROTOCOL Colposcopy – CIN 3 detectedLLETZ Annual follow up cytology for 10 years RETURNED TO ROUTINE RECALL HPV TOC PROTOCOL Colposcopy – CIN 3 detected LLETZ Test of cure at 6 months: HR-HPV negative RETURNED TO ROUTINE RECALL

18 Information for smear takers Packs issued to all practices **ensure all smear takers in practice have seen this**

19 HPV testing will be done as appropriate on same sample – you do not need to request it Cytology and HPV result will be issued on same report Patient consent Be prepared to answer patient questions risk of cancer transmission of HPV

20 Surprise and anxiety. Guilt and shame are closely linked to concerns about transmission and disclosure to future sexual partners. Providing clear and accurate information to women can considerably reduce the anxiety they experience and the possible stigma associated with HPV. Women should be assured that having sex just once exposes them to many subtypes of HPV and this exposure should be viewed as normal. Psychological impact of HPV infection

21 Women are frequently confused by the term ‘wart virus’. It is incorrect and should be avoided. Using the term ‘HPV positive’ can arouse concern and may be confused with ‘HIV positive’. Result letters should indicate that ‘high-risk HPV’ has been detected. Terminology

22 HPV infection cannot be treated, only CIN. Attend cervical screening regularly. Vaccination is now available to protect against 16, 18 subtypes. HPV vaccination will help to prevent HPV infection/CIN in the future. How do I protect myself against HPV?

23 Patient information

24 Further information/contact Quality Assurance Reference Centre (QARC) Public Health Agency 18 Ormeau Avenue Belfast Tel:


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