Tag Archives: Screening

WHO issues new Recommendations for Cervical Cancer Screening (6 July 2021)

The World Health Organization (WHO) has issued new, updated recommendations for cervical cancer screening.

Background Information:

Cervical cancer is a leading cause of mortality among women.

In 2020, an estimated 604 000 women were diagnosed with cervical cancer worldwide and about 342 000 women died from the disease.

It is the most commonly diagnosed cancer in 23 countries and is the leading cause of cancer death in 36 countries. The vast majority of these countries are in sub-Saharan Africa, Melanesia, South America, and South-Eastern Asia.

There are different approaches to screening and treatment:

Screen-and-treat approach: The decision to treat is solely based on a positive primary screening test.

Screen, triage and treat approach: The decision to treat is based on a positive primary screening test followed by a positive second (“triage”) test, with or without histologically confirmed diagnosis.

Key Recommendations:

Primary screening test

For the general population of women, as well as women living with HIV,

WHO recommends using HPV DNA detection as the primary screening test rather than Visual Inspection with Acetic Acid (VIA) or cytology (‘pap smear’) in screening and treatment approaches.

Remarks: Existing programmes with quality-assured cytology as the primary screening test should be continued until HPV DNA testing is operational; existing programmes using VIA as the primary screening test should transition rapidly because of the inherent challenges with quality assurance.

Screening Approach

General population of women

For the general population of women, WHO suggests using an HPV DNA primary screening test either with or without triage. When using HPV DNA detection as the primary screening test:

  • a. In a screen-and-treat approach: WHO suggests treating women who test positive for HPV DNA.
  • b. In a screen, triage and treat approach: WHO suggests using partial genotyping, colposcopy, VIA or cytology to triage women after a positive HPV DNA test.

Women living with HIV

For women living with HIV, WHO suggests using HPV DNA primary screening test with triage rather than without triage. In such an approach, WHO suggests using partial genotyping, colposcopy, VIA or cytology to triage women after a positive HPV DNA test.

Sample collection

When providing HPV DNA testing, WHO suggests using either samples taken by a health-care provider or self-collected samples among both the general population of women and women living with HIV.

Screening Age and Frequency

General population of women: WHO recommends starting regular cervical cancer screening at the age of 30 years, and regular screening every 5 to 10 years up to the age of 50 years. After the age of 50 years, WHO suggests screening is stopped after two consecutive negative screening results. When tools are available to manage women aged 50 to 60 years, those in that age bracket who have never been screened should also be prioritized.

Women living with HIV: WHO suggests starting regular cervical cancer screening at the age of 25 years, and regular screening every 3 to 5 years up to the age of 50 years. After the age of 50 years, WHO suggests screening is stopped after two consecutive negative screening results. When tools are available to manage women aged 50 to 60 years, those in that age bracket who have never been screened should also be prioritized.

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 both the general population of women and women living with HIV.

While transitioning to a programme with a recommended regular screening interval, screening even just twice in a lifetime is beneficial among both the general population of women and women living with HIV.

As programmes introduce HPV DNA testing, use HPV DNA 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 both the general population of women and women living with HIV.

Retesting after testing positive for a positive screening test

General population of women:

Positive on HPV DNA primary screening test then negative on a triage test: Retest with HPV DNA testing at 24 months and, if negative, move to recommended regular screening interval.

Treated for histologically confirmed CIN2/3 or adenocarcinoma in situ (AIS), or treated as a result of a positive screening test: Retest at 12 months with HPV DNA when available, rather than with cytology or VIA or co-testing, and if negative, move to the recommended regular screening interval.

Women living with HIV:

Positive on HPV DNA primary screening test then negative on a triage test: Retest with HPV DNA testing at 12 months and, if negative, move to recommended regular screening interval.

Treated for histologically confirmed CIN2/3 or adenocarcinoma in situ (AIS), or treated as a result of a positive screening test: Retest at 12 months with HPV DNA 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.

WHO suggests that women from the general population and 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.

Recommended Good Practice statements for treatment other than those above:

Once a decision to treat a woman is made – whether from the general population of women or women living with HIV – it is good practice to treat as soon as possible within six months to reduce the risk of loss to follow-up.
However, in women who are pregnant, good practice includes deferral until after pregnancy.

In circumstances when treatment is not provided within this time frame, it is good practice to re-evaluate the woman before treatment.

WHO suggests large-loop excision of the transformation zone (LLETZ) or cold knife conization (CKC) for women from the general population and women living with HIV who have histologically confirmed adenocarcinoma in situ (AIS).
Remarks: Loop excision may be preferred in women of reproductive age, in settings with greater availability of LLETZ and by providers with greater expertise performing LLETZ. CKC may be preferred when interpretation of the margins of the histological specimen is imperative.

Useful Links:

Link to the related WHO news release:

https://www.who.int/news/item/06-07-2021-new-recommendations-for-screening-and-treatment-to-prevent-cervical-cancer

Link to the new WHO Guidelines:

https://www.who.int/publications/i/item/9789240030824