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
Age
Screening interval
25 – 49 yrs
3 years
50 – 64 yrs
5 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. Borderline/Mild Dyskaryosis
Triage pathway
Borderline/Mild Dyskaryosis
HR-HPV test
HR-HPV Negative
Routine recall
HR-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. Repeat at 6 months – borderline result
STANDARD PROTOCOL
HPV TRIAGE PROTOCOL
Routine screen
Borderline cytology
Repeat at 6 months – borderline result
COLPOSCOPY
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 Normal/Borderline/ Mild Dyskaryosis HR-HPV test
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 HPV TOC PROTOCOL Colposcopy – CIN 3 detected LLETZ
Annual follow up cytology for 10 years
RETURNED TO ROUTINE RECALL
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. Psychological impact of HPV infection
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.

21. Terminology
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.

22. How do I protect myself against HPV?
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.

23. Patient information

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