WHO Guideline for Screening and Treatment of Cervical Pre-Cancer Lesions for Cervical Cancer Prevention

Overview

This new Guidelines summary covers the World Health Organization (WHO)'s guidance on screening and treatment to prevent cervical cancer. Recommendations include screening and treatment of cervical pre-cancer lesions for women in the general population and for women living with HIV. This summary is for use by medical and clinical oncologists in a secondary care setting.

For information on methods, important considerations for the recommendations, and research gaps, refer to the full guideline.

Approaches to Screening and Treatment

• To prevent cervical cancer, women can be screened using various tests to identify those who have or are at risk of cervical pre-cancer
• In a screen-and-treat approach, treatment is provided based on a positive primary screening test alone, without triage (that is, no second screening test and no histopathological diagnosis)
  • when the patient is eligible for ablative treatment, this should ideally be done immediately, at the same visit as the screening test (the single-visit approach). At some facilities, this is not feasible and a second visit is needed (the multiple-visit approach)
  • women who are not eligible for ablation can have excisional treatment on the same day if the clinic has the capacity for large-loop excision of the transformation zone (LLETZ). If LLETZ is not available on-site, women need to be referred for the excisional treatment or for further evaluation
• In a screen, triage, and treat approach, the triage test is done if the primary screening test is positive, and the decision to treat is made when both the primary test and the triage test are positive
  • a positive triage test can lead to colposcopy with biopsy and histopathological examination for diagnosis to determine the appropriate treatment. The implementation of colposcopy and biopsy can be challenging, however, so this guideline also considers triage strategies that are not dependent on the availability of colposcopy
  • when the primary screening test is positive, and the triage test is negative, women need appropriate follow-up evaluation at a specified date according to the recommendations.

Treatment Considerations

• In a screen-and-treat approach, women who screen positive are treated without histological diagnosis. The treatment aims to destroy or remove the transformation zone of the cervix, or remove areas of the cervix that have been identified as abnormal by screening
• The methods of treatment may be ablative (destroying abnormal tissue by heating it with thermal coagulation or freezing it with cryotherapy) or excisional (surgically removing abnormal tissue with LLETZ or cold knife conization). Ablative treatments do not result in a tissue specimen for histological evaluation
• Before treatment, all women who have screened positive with any test other than visual inspection with acetic acid (VIA) should be visually inspected with acetic acid by a trained health worker to determine the transformation zone type, rule out suspected cervical cancer, and determine eligibility for ablative therapy.

Recommendations and Good Practice Statements

General Population of Women

• WHO recommends using human papillomavirus (HPV) DNA detection as the primary screening test rather than VIA or cytology in screening and treatment approaches among the general population of women^[A] (strong recommendation, moderate-certainty evidence)
• WHO suggests using a HPV DNA primary screening test either with or without triage to prevent cervical cancer among the general population of women (conditional recommendation, moderate-certainty evidence)
• In a screen-and-treat approach using HPV DNA detection as the primary screening test, WHO suggests treating women who test positive for HPV DNA among the general population of women (conditional recommendation, moderate-certainty evidence)
• In a screen, triage, and treat approach using HPV DNA detection as the primary screening test among the general population of women, WHO suggests using partial genotyping, colposcopy, VIA, or cytology to triage women after a positive HPV DNA test (conditional recommendation, moderate-certainty evidence)
• When providing HPV DNA testing, WHO suggests using either samples taken by a healthcare provider or self-collected samples among the general population of women^[A] (conditional recommendation, low-certainty evidence)
• WHO recommends starting regular cervical cancer screening at the age of 30 years^[B] among the general population of women (strong recommendation, moderate-certainty evidence)
• After the age of 50 years,^[B] WHO suggests screening is stopped after two consecutive negative screening results consistent with the recommended regular screening intervals among the general population of women^[A] (conditional recommendation, low-certainty evidence)
• Priority should be given to screening women aged 30–49 years^[B] in the general population of women. When tools are available to manage women aged 50–65 years, those in that age bracket who have never been screened should also be prioritised (good practice statement)
• WHO suggests a regular screening interval of every 5–10 years when using HPV DNA detection as the primary screening test among the general population of women (conditional recommendation, low-certainty evidence)
• Where HPV DNA testing is not yet operational, WHO suggests a regular screening interval of every 3 years when using VIA or cytology as the primary screening test among the general population of women^[A] (conditional recommendation, low-certainty evidence)
• While transitioning to a programme with a recommended regular screening interval, screening even just twice in a lifetime is beneficial among the general population of women^[A] (good practice statement)
• WHO suggests that the general population of women who have screened positive on a HPV DNA primary screening test and then negative on a triage test are retested with HPV DNA testing at 24 months and, if negative, move to the recommended regular screening interval (conditional recommendation, low-certainty evidence)
• WHO suggests that women from the general population who have screened positive on a cytology primary screening test and then have normal results on colposcopy are retested with HPV DNA testing at 12 months and, if negative, move to the recommended regular screening interval^[A] (conditional recommendation, low-certainty evidence)
• WHO suggests that women from the general population who have been treated for histologically confirmed cervical intraepithelial neoplasia grade 2/3 (CIN 2/3) or adenocarcinoma in situ (AIS), or treated as a result of a positive screening test are retested at 12 months with HPV DNA testing when available, rather than with cytology or VIA or co-testing and, if negative, move to the recommended regular screening interval (conditional recommendation, low-certainty evidence)
• As programmes introduce HPV DNA testing, use this test at the woman's next routine screening date regardless of the test that was used at prior screening. In existing programmes with cytology or VIA as the primary screening test, rescreening with the same test should be continued until HPV DNA testing is operational among the general population of women^[A] (good practice statement).

Women Living with HIV

• WHO recommends using HPV DNA detection as the primary screening test rather than VIA or cytology in screening and treatment approaches among women living with HIV^[C] (strong recommendation, moderate-certainty evidence)
• WHO suggests using a HPV DNA primary screening test with triage rather than without triage to prevent cervical cancer among women living with HIV (conditional recommendation, moderate-certainty evidence)
• In a screen, triage, and treat approach using HPV DNA detection as the primary screening test among women living with HIV, WHO suggests using partial genotyping, colposcopy, VIA, or cytology to triage women after a positive HPV DNA test (conditional recommendation, moderate-certainty evidence)
• When providing HPV DNA testing, WHO suggests using either samples taken by a healthcare provider or self-collected samples among women living with HIV^[C] (conditional recommendation, low-certainty evidence)
• WHO suggests starting regular cervical cancer screening at the age of 25 years^[B] among women living with HIV (conditional recommendation, low-certainty evidence)
• After the age of 50 years,^[B] WHO suggests screening is stopped after two consecutive negative screening results consistent with the recommended regular screening intervals among women living with HIV^[C] (conditional recommendation, very low-certainty evidence)
• Priority should be given to screening women living with HIV aged 25–49 years.^[B] When tools are available to manage women living with HIV aged 50–65 years, those in that age bracket who have never been screened should also be prioritised (good practice statement)
• WHO suggests a regular screening interval of every 3–5 years when using HPV DNA detection as the primary screening test among women living with HIV (conditional recommendation, low-certainty evidence)
• Where HPV DNA testing is not yet operational, WHO suggests a regular screening interval of every 3 years when using VIA or cytology as the primary screening test among women living with HIV^[C] (conditional recommendation, low-certainty evidence)
• While transitioning to a programme with a recommended regular screening interval, screening even just twice in a lifetime is beneficial among women living with HIV^[C] (good practice statement)
• WHO suggests that women living with HIV who have screened positive on a HPV DNA primary screening test and then negative on a triage test, are retested with HPV DNA testing at 12 months and, if negative, move to the recommended regular screening interval (conditional recommendation, low-certainty evidence)
• WHO suggests that women living with HIV who have screened positive on a cytology primary screening test and then have normal results on colposcopy are retested with HPV DNA testing at 12 months and, if negative, move to the recommended regular screening interval^[C] (conditional recommendation, low-certainty evidence)
• WHO suggests that women living with HIV who have been treated for histologically confirmed CIN2/3 or AIS, or treated as a result of a positive screening test are retested at 12 months with HPV DNA testing when available, rather than with cytology or VIA or co-testing, and, if negative, are retested again at 12 months and, if negative again, move to the recommended regular screening interval (conditional recommendation, low-certainty evidence)
• As programmes introduce HPV DNA testing, use this test at the woman's next routine screening date regardless of the test that was used at prior screening. In existing programmes with cytology or VIA as the primary screening test, rescreening with the same test should be continued until HPV DNA testing is operational among women living with HIV^[C] (good practice statement).

Footnotes

[A] Recommendations and good-practice statements marked with [A] do not differ from the corresponding items listed in the section, Women Living with HIV

[B] Refer to local guidance on age ranges for starting and stopping regular cervical cancer screening

[C] Recommendations and good practice statements marked with [C] do not differ from the corresponding items listed in the section, Women in the General Population