Introduction

The management of screen-detected cervical abnormalities in asymptomatic women, and the care of women presenting with symptoms that may be due to cervical cancer or its precursors, involve health professionals across a broad spectrum of disciplines. These guidelines have been developed to assist women and health professionals to achieve the best outcomes.

The target audience for these guidelines includes all health professionals involved in cervical screening and the clinical care of women presenting with symptoms. It may also be of interest to policy makers and researchers.

In October 2011, the Australian Department of Health announced the renewal of the National Cervical Screening Program (NCSP). In April 2014, following a robust and transparent process involving a commissioned evidence review and health outcome and economic modelling, the Australian Medical Services Advisory Committee (MSAC) made several recommendations for the renewed NCSP. These included 5 yearly primary human papillomavirus (HPV) testing with partial genotyping and liquid-based cytology (LBC) triage, self-collection of an HPV sample for under- or never-screened women, and invitations and reminders to be sent to women aged 25–69 years, with exit testing from age 70–74 years.

In December 2017, the NCSP will change from 2 yearly cervical cytology testing to 5 yearly HPV testing for women aged 25–74 years. An HPV test every 5 years is more effective, just as safe, and is expected to result in a significant reduction (24%-36%) in incidence and mortality from cervical cancer in Australian women, compared with the program it replaces, which is based on 2 yearly Pap smears.

In 2005, the evidence based NHMRC endorsed guidelines Screening to Prevent Cervical Cancer: Guidelines for the Management of Women with Screen Detected Abnormalities.[1] were published and were introduced into practice in 2006. These guidelines were accepted by health professionals as a useful guide to the management of women with cervical abnormalities detected by cervical cytology. With the change to primary HPV testing, it is necessary and timely to review the 2005 guidelines and to consider recent evidence to formulate guidelines that are relevant to primary HPV testing and triage using LBC.

Following the MSAC recommendations and their acceptance by the Australian Government, the Department of Health requested that the 2005 guidelines be reviewed and updated to assist the implementation of the renewed NCSP. Cancer Council Australia was commissioned and funded by the Department of Health Australia to develop these guidelines with the assistance of an expert clinical management guidelines working party (see Working party members and contributors) and technical support from Professor Karen Canfell and her Cancer Screening Group at Cancer Council NSW.

These guidelines have been developed and published by Cancer Council Australia in accordance with NHMRC recommended processes (see Guideline development process). The web-based wiki platform allows for feedback and easy, regular updating in the light of emerging evidence.

These new guidelines offer guidance to health professionals and women as to best practice in the clinical management of women with positive oncogenic HPV test results and abnormalities detected on subsequent LBC. These guidelines address the current epidemiology of cervical cancer in Australia, the benefits and harms of cervical screening, the natural history of cervical HPV infection, the terminology for HPV testing, LBC, cervical histopathology and colposcopy, management of older women and those undergoing exit testing, management of women with positive oncogenic HPV test results, colposcopy, management of histologically confirmed squamous and glandular abnormalities, screening in specific populations, screening for women who are transitioning from the old into the new program, psychosocial issues and economic issues.

For the first time, guidance on the management of symptomatic women has been included, with a particular focus on those with signs or symptoms suggestive of cervical cancer, such as postcoital, intermenstrual and postmenopausal bleeding. These guidelines do not address issues related to the quality control aspects of the cervical screening test or detailed information about the treatment of invasive cervical cancer.

There are specific recommendations regarding the adoption of a new system for reporting cervical histopathology based on the Lower Anogenital Squamous Terminology (LAST) Standardization Project and new terminology recommended by the International Federation for Colposcopy and Cervical Pathology for use in reporting colposcopic findings and treatment.

The development of these guidelines has involved widespread consultation with relevant professional bodies and a wide range of clinicians and consumers. These guidelines have been reviewed and endorsed by The Royal Australian College of General Practitioners (RACGP), The Royal College of Pathologists of Australasia (RCPA), The Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG), The Australian Society for Colposcopy and Cervical Pathology (ASCCP) and The Australian Society of Gynaecologic Oncologists (ASGO).

Clinicians must, of course, make individual decisions in consultation with their patients, based on individual clinical circumstances. However, it is anticipated that, in most circumstances, women with screen-detected abnormalities would be managed according to these guidelines. It is important that the NCSP monitors compliance with these guidelines using the NCSP Quality Framework developed by the Quality and Safety Monitoring Committee.

These guidelines are a distillation of the latest research and data, brought together by some of the leading experts in this field. We commend the guidelines to you in the belief that they will result in further significant improvements in the care and treatment of Australian women.

Professor Ian Hammond
Chair, Cancer Council Australia Cervical Cancer Screening Guidelines Working Party,
Clinical Professor
School of Women’s and Infants’ Health
University of Western Australia

Professor Marion Saville
Deputy Chair, Cancer Council Australia Cervical Cancer Screening Guidelines Working Party
Cytopathologist and Executive Director, Victorian Cytology Services Ltd.
Melbourne, Victoria
Department of Obstetrics and Gynaecology, University of Melbourne

Author(s):

• Professor Ian Hammond — Author
• Professor Marion Saville — Author
• Cancer Council Australia Cervical Cancer Screening Guidelines Working Party — Co-author

References

1. National Health and Medical Research Council. Screening to prevent cervical cancer: guidelines for the management of asymptomatic women with screen detected abnormalities. Canberra: NHMRC; 2005.