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Cytology and the new NCSP

Main Features of the new National Cervical Screening Program    

  • Screening to commence at age 25 and finish at age 74
  • Women will be invited to participate and will be reminded to attend for follow-up
  • Primary screening will be a test for oncogenic HPV (human papillomavirus), with partial genotyping, performed on a sample collected from the cervix into LBC (liquid based cytology) medium
  • Samples which test positive for oncogenic HPV will have reflex cytology testing
  • Samples which test positive for HPV types 16/18 or which show changes suggestive of high grade intraepithelial disease or invasive disease on cytology will be referred for colposcopy
  • Comprehensive evidence-based guidelines for clinical management will include recommendations for repeat testing, further investigations and follow-up protocols
  • Guidelines for testing in special circumstances will be available, including recommendations for management of immunocompromised women and those with other special risk factors
  • Women with symptoms or signs suggestive of intraepithelial or invasive disease can be tested at any time
  • Self-sampling will be permitted in certain circumstances
 

Clinical Management 

National Cervical Screening Program: Guidelines for the management of screen-detected abnormalities, screening in specific populations and investigation of abnormal vaginal bleeding
have been developed by Cancer Council Australia and will be published early in 2017.

The 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.

The Guidelines address the 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, and screening for women who are transitioning from the old into the new program. The Guidelines also include guidance on the management of symptomatic women.
The Guidelines are available as a wiki at: 
http://wiki.cancer.org.au/australia/Guidelines:Cervical_cancer/Screening
 

Report Format

It is proposed that cervical screening reports will consist of four sections:

  1. Cervical screening result
    Cervical screening results will be reported as low, intermediate or higher risk of significant cervical abnormality, or as unsatisfactory for evaluation, based on both the HPV test and (where indicated) reflex liquid based cytology
  2. Specimen type
  3. Test results
    HPV test type and result, including partial genotyping (HPV 16/18/other oncogenic type)
    Reflex cytology test type and result (if performed)
  4. Concise recommendation for further management, based on the current result and the woman’s screening history as recorded with the National Cancer Screening Register (NCSR).
     

Approaching Cervical Cytology as a Diagnostic Test in the NCSP

The NCSP Renewal provides for the primary cervical screening test to be a molecular test for oncogenic HPV with partial genotyping. These tests will be performed on a liquid based cervical sample so that positive samples can be further tested using liquid based cytology as a reflex test. Cytologists involved in cervical screening will be performing diagnostic testing on samples for which a positive oncogenic HPV result has been recorded, or on samples from women who have presented with signs or symptoms suggestive of intraepithelial or invasive disease.

The following points should be considered when cytologically assessing cervical samples for which there is a raised level of suspicion as to the presence of cellular abnormalities:

  • The cytologist must be familiar with the presentation of cellular abnormalities in liquid based samples and must be trained in the use of any associated technology, such as image-assisted screening. The methods prescribed by the suppliers of the technology should be followed.
  • The focus when performing reflex diagnostic cytology testing on HPV-positive samples is on the accurate classification of any cellular abnormalities detected within the sample.
  • Samples which test positive for oncogenic HPV may not display cellular abnormalities on cytological examination and the cytologist should avoid over-calling benign changes in such cases. It is important to note that cases which are positive for oncogenic HPV and negative on cytology will be further investigated according to NCSP Guidelines, either with colposcopy for HPV 16/18 positivity or with repeat screening in one year for other HPV genotypes.
  • The application of strict cytological criteria is important in order to distinguish between low-grade and high-grade lesions. This cytological distinction has a significant impact upon clinical management.
 

Standards and Quality Monitoring in Cervical Screening

New standards and quality monitoring requirements have been developed to ensure the quality of the renewed NCSP. 
Requirements for Laboratories Performing Cervical Screening Tests have been drafted by NPAAC (National Pathology Accreditation Advisory Council). These Requirements, when finalised, will set out the standards for laboratories using HPV nucleic acid testing (NAT) as the primary screening method for Cervical Cancer screening with reflex LBC in cases positive for oncogenic HPV types.