Clinical Management Guidelines

The Department of Health commissioned and funded Cancer Council Australia to develop National Cervical Screening Program: Guidelines for the management of screen-detected abnormalities, screening in specific populations and investigation of abnormal vaginal bleeding (the 2016 Guidelines) to 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 NCSP. They also include guidance on the management of symptomatic women.

These new Guidelines, which apply within the renewed NCSP from 1 December 2017, replace the 2005, evidence based NHMRC endorsed guidelines Screening to Prevent Cervical Cancer: Guidelines for the Management of Women with Screen Detected Abnormalities. The target audience includes all health professionals involved in cervical screening and the clinical care of women presenting with symptoms. Sections of the Guidelines, including recommendations for management and those related to terminology and report preparation, are of particular relevance to laboratory medicine professionals.

The Guidelines are available as a wiki at:
http://wiki.cancer.org.au/australia/Guidelines:Cervical_cancer/Screening

This web-based wiki platform allows for feedback and easy, regular updating in the light of emerging evidence. Some sections of the Guidelines are available for download in pdf format.

The Guidelines offer guidance as to best practice in the clinical management of women with positive oncogenic HPV test results and abnormalities detected on subsequent LBC. They 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.

Guidance on the management of symptomatic women is included, with a particular focus on those with signs or symptoms suggestive of cervical cancer, such as postcoital, intermenstrual and postmenopausal bleeding. 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 Guidelines are arranged in sections and chapters which contain comprehensive information, discussion and, where relevant, recommendations for management. These are expressed as evidence-based recommendations (EBR), consensus-based recommendations (CBR) and practice points (PP) (as defined in Table B.4 NHMRC approved recommendation types and definitions in Appendix B of the Guidelines). References are provided throughout the Guidelines.

The following outlines the main sections (click on the section title to go to the Guidelines) and gives a brief indication of the contents in each section:

Foreword

The Foreword is by Professor Ian Frazer AC

Introduction

The Introduction by Professor Ian Hammond summarizes the process by which the Renewal of the NCSP and the development of these Guidelines has occurred.

Summary of recommendations

This important section summarizes the recommendations in these guidelines, numbered according to the chapter to which they relate. It provides ready access to all of the recommendations in the Guidelines; for explanation of the supporting evidence for the individual recommendations it is necessary to refer to the individual chapter in which they appear.

For example,

REC6.6: Positive oncogenic HPV (not 16/18) test result at routine screening
Women with a positive oncogenic HPV (not 16/18) test result, with a LBC report of negative or prediction of pLSIL/LSIL, should have a repeat HPV test in 12 months.
 
  1. Cervical cancer in Australia

    This chapter provides a detailed review of the incidence and mortality of cervical cancer in Australia and the effects of the organized approach to cervical screening through the NCSP.

  2. The rationale for primary HPV screening

    This chapter provides an overview of the role of HPV in the pathogenesis of cervical cancer, the impact of HPV vaccination and the rationale forHPV testing as a primary cervical screening test.

  3. Terminology

    This chapter provides the recommended terminology for HPV, cytology and histology testing within the NCSP. It includes information of the preparation of cervical screening test reports.

  4. Unsatisfactory cervical screening results

    This brief chapter outlines the recommendations for managing unsatisfactory HPV and/or LBC tests in the context of cervical screening testing.

  5. Benefits, harms and cost-effectiveness of cervical screening in the renewed NCSP

    This brief chapter outlines the recommendations for managing unsatisfactory HPV and/or LBC tests in the context of cervical screening testing.

  6. Management of oncogenic HPV test results

    This large chapter provides the recommendations for management of cervical screening test results. The recommendations are supported by explanatory notes and are designed to support the NCSP policy which recommends.

    Five-yearly cervical screening using a primary HPV test:

    • partial HPV genotyping and LBC triage
    • in HPV-vaccinated and unvaccinated women aged 25–69 years
    • exit testing of women up to age 74 years.

    The recommendations in this chapter are those which laboratories are required, by NPAAC, to include in cervical screening test reports.

    Note that these recommendations are also available in the Guidelines - Summary of Recommendations.

  7. Colposcopy

    This chapter details the recommendations for diagnostic colposcopy following an abnormal cervical screening test and includes information on the reporting of colposcopy results to the NCSR.

  8. Management of discordant colposcopic impression, histopathology and referral LBC prediction

    This chapter provides guidance on management when there is discordance between cytological and colposcopic or histopathological reports for women referred for colposcopic assessment on the basis of the results of human papillomavirus (HPV) testing and liquid-based cytology (LBC).

  9. Management of histologically confirmed low-grade squamous abnormalities

    This chapter provides guidance for clinicians on the management of women with histologically confirmed low-grade squamous abnormalities.

  10. Management of histologically confirmed high-grade squamous abnormalities

    This chapter provides guidance for clinicians on the management of women with histologically confirmed high-grade squamous abnormalities.

  11. Management of glandular abnormalities

    This chapter provides guidance for clinicians on the management of women with a cytological or histological diagnosis of glandular abnormalities.

    Chapters 12 – 17 provide recommendations for screening in specific populations and circumstances. Recommendations in these chapters are summarised in the Guideline – Summary of Recommendations. The recommendations in these chapters include those which laboratories are required, by NPAAC, to include in cervical screening test reports.

  12. Screening in Aboriginal and Torres Strait Islander women
  13. Screening after total hysterectomy
  14. Screening in pregnancy
  15. Screening in women who experienced early sexual intercourse or victims of sexual abuse
  16. Screening in immune-deficient women
  17. Screening in DES-exposed women
  18. Investigation of abnormal vaginal bleeding

    This chapter aims to assist healthcare professionals in the management of intermenstrual bleeding or postcoital bleeding, including testing and/or referral to a specialist gynaecologist. It contains a flowchart outlining the steps to follow in investigating abnormal bleeding and provides recommendations for further management.

    The recommendations in these chapters include those which laboratories are required, by NPAAC, to include in cervical screening test reports.

  19. Psychosocial care

    This chapter provides guidance for clinicians in assisting women who experience anxiety or distress related to cervical screening.

  20. Transition to the renewed National Cervical Screening Program

    This chapter provides guidance for the management of women who have had a previous screen detected abnormality and who are currently undergoing investigation, treatment or follow-up for an abnormal Pap test result, a histologically confirmed high-grade squamous intraepithelial lesion or histologically confirmed adenocarcinoma in situ (AIS). It describes how these women should be transitioned to the renewed program after 1 December 2017.

    Appendices

    The appendices provide further information about the development of the Guidelines and the methods used to ensure their safety and relevance.

It is strongly recommended that laboratory medicine professionals working within the National Cervical Screening Program should be familiar with all sections of the Guidelines as they are a vital source of information and reference. They also define the framework for the interaction between the laboratory and treating clinicians, ensuring that the testing and treating components of the NCSP work together harmoniously.

However, there are two sections of the Guidelines that are of particular importance to laboratory medicine professionals because laboratories are required ( See NPAAC Requirements ) to issue Cervical Screening Test results in the format recommended in these Guidelines.

The Summary of Recommendations contains the recommendations for further management that laboratories must include in Cervical Screening Test reports. Laboratories must make a recommendation on each report based on the current test results, the woman’s previous screening history and any other relevant clinical information.

Section 3. Terminology contains guidance regarding the terminology to be used in the reporting of HPV tests, cytology and histology results. The NPAAC Requirements state that laboratories must issues cervical screening test results in a report format consistent with that described in this section of the Guidelines under “Preparation of cervical screening results”. The Guidelines also recommend that laboratories use Lower Anogenital Squamous Terminology (LAST) for histological reporting.

Laboratories may also find the following cervical screening pathway Flowcharts, which are included in the Guidelines, helpful:
Flowchart 6.1. Cervical screening pathway for primary oncogenic HPV testing
https://wiki.cancer.org.au/australiawiki/images/6/61/Cervical_screening_pathway.pdf
Flowchart 6.2. Cervical screening pathway for primary oncogenic HPV testing using self-collected samples
https://wiki.cancer.org.au/australiawiki/images/f/f0/Cervical_screening_pathway_for_self_collection.pdf

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03-May-2019
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