Clinical update to National Cervical Screening Program guidelines

Anastasia Tsirtsakis

28/01/2021 4:07:34 PM

Important pathway changes for women at intermediate risk of significant cervical abnormality come into effect on 1 February.

A GP consultation.
GPs will need to conduct an individual risk assessment of each patient to assess whether the new recommendation applies.

Women with a 12-month follow up human papillomavirus (HPV) (not 16/18) result with a negative liquid based cytology (LBC) prediction, and possible low-grade squamous intraepithelial lesion (pLSIL) or low-grade squamous intraepithelial lesion (LSIL), will be recommended under the updated guidelines to undertake a further follow up HPV test in 12 months, instead of being referred directly for colposcopy.
The changes to the National Cervical Screening Program’s (NCSP) clinical guidelines follow a review of new Australian data on women at intermediate risk, conducted by the Cancer Council Australia Clinical Guidelines Network.
GP Dr Lara Roeske, a member of the Cancer Council Australia Cervical Cancer Screening Guidelines Working Party and co-author of the National Cervical Screening Guidelines, told newsGP this is an important period of transition.
‘GPs will be managing two different groups of women,’ she said.
‘There’ll be women who come in after 1 February where GPs should be implementing the new change, and then there’ll be women who are currently being managed under the previous recommendation, and some of those women will be waiting for colposcopy.
‘A significant proportion of those women who are waiting for colposcopy can be safely redirected and advised to come in to see their GP for a second follow up HPV test instead.’
Women being managed under the previous clinical recommendation, along with their GPs, can expect to receive an update from the National Cancer Screening Register.
But Dr Roeske says GPs should still be prepared to explain the changes to patients, and address any concerns.
‘For some women, of course, it’ll be a welcome change, and they will accept the advice. Having the colposcopy can be a real nuisance – there’s a financial cost, time off work, side effects, bleeding, infection, and adverse pregnancy outcomes,’ she said.
‘But others might have some questions.
‘That’s where it will be helpful to actually explain that this change has come in for all Australian women who would be in this intermediate risk category and that the change is based on very clear evidence.’

Dr Lara Roeske says the risk for women affected by the change is ‘extremely low’.

The program data, tracked over two years since its implementation, showed women who are at intermediate risk have a low likelihood of histologically-confirmed high grade squamous intraepithelial lesion (CIN 2/3) or worse.
‘The risk for these women is extremely low. In fact, it’s under .02%,’ Dr Roeske said.
‘When the clinical guidelines for the renewed NCSP were released in 2016, there was really a cautious approach adopted, which meant there was universal referral for colposcopy.
‘But what the data is showing very clearly is the majority of women will either clear this infection, or they’ll have a persistent infection without serious abnormality developing in the cervix, and they can be monitored.
‘We also know that should they develop a more significant lesion like a CIN 2/3 that the progression from that point to invasive cancer is in the order of 10–15 years, so there is ample opportunity to intervene. But the important part is that they remain engaged in the management pathway.’
However, the new recommendation does not apply to all women. 
Those considered to be at higher risk of harbouring a high-grade abnormality who should be referred to colposcopy if HPV is detected at the 12-month follow up, regardless of the LBC result, include:

  • women aged 50 years or older
  • women who are two or more years overdue for screening at the time of the initial screen
  • women who identify as being Aboriginal and/or Torres Strait Islander. 
Dr Roeske, who is also a member of the Commonwealth NCSP Self-Collection Expert Advisory Group, says the new guideline also does not apply to women who are being managed via the self-collection pathway.
‘It’s because women who self-collect are technically under-screened,’ she said.
‘They’re a little bit like the ones who are two years overdue for screening, and so they’re at higher risk of developing a serious abnormality of the cervix, and for that reason they need access to colposcopy rather than a second HPV test.’
Other cohorts Dr Roeske suggests may need to be managed via direct referral for colposcopy, rather than a second follow up HPV test, include:
  • women aged 70 or older who have any HPV detected, and are exit testing
  • women in follow up for a histologically confirmed high grade lesion of the cervix
  • women who are immune deficient
  • women who have been exposed to diethylstilboestrol (DES)
As the evidence base grows for screening programs such as the NCSP, Dr Roeske says it is becoming increasingly important for clinicians to be mindful of individual risk factors, for which GPs are well placed.  
‘GPs need to do an individual risk assessment and look for other risk factors, which may mean that this recommendation does not apply to this woman – and, often, we have that knowledge about our patients,’ she said.

‘It’s actually a really good thing when a guideline is updated with robust evidence – we shouldn’t feel nervous or anxious about that.
‘We’re really putting in place a pathway that actually prevents women from undergoing unnecessary investigation and treatment with its associated harms, and they are still safe. GPs should take reassurance in this, and a lot of women should take comfort in that as well.’

For more information, GPs can access the RACGP webinar ‘Essential update for GPs on cervical screening’.
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