Cervical Cancer Screening

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For Who?		By Whom?^b	How Often?
Empowerment
Women of all ages	Educate on: Risk factors, natural history and, symptoms and signs of cervical cancer Primary preventive measures for cervical cancer (Table 1.) Importance and methods of cervical cancer screening	Primary Healthcare Providers	Opportunistically
Assessment
For Women Who Ever Have Sexual Experience
Women of all ages	Assess: (1) Risk for persistent Human Papillomavirus (HPV) infection or cervical cancer: Multiple sexual partner ≥ 3⁴ Early first sexual intercourse Tobacco use Chronic immunosuppression Increasing parity Younger age at full term pregnancy Long term use of oral contraceptive pills for more than 5 years (the risk declined after use ceased, and by 10 or more years returned to that of never users) (2) Presence of symptoms suggestive of cervical cancer: ⁵ Post-coital or abnormal vaginal bleeding Foul smelling vaginal discharge Pelvic pain during intercourse	Nurses Doctors	Opportunistically
Women with symptoms suggestive of cervical cancer	Refer to seek early medical attention^#	^#Nurses	When symptomatic
	OR
	Provide work up assessment^	^Doctors
Women indicated for cervical cancer screening	Address misconceptions and concerns about cervical cancer screening	Doctors Nurses	Opportunistically
Screening
Asymptomatic women aged 21 to 24 at increased risk	Offer screening by Cytology	Doctors Trained Nurses	After two consecutive normal annual screening then every 3-year
Asymptomatic women aged 25 to 29	Offer screening by Cytology	Doctors Trained Nurses	After two consecutive normal annual screening then every 3-year
Asymptomatic women aged 30 to 64	Discuss screening options^@ Offer: Cytology^& OR Primary HPV testing⁺ OR HPV Co-testing⁺	Doctors Trained Nurses	^@Opportunistically ^&After two consecutive normal annual screening then every 3-year ⁺5-yearly
Asymptomatic women aged 65 or above with routine screening	Discontinue screening if routine screening within 10 years is normal	Doctors Nurses
Asymptomatic women aged 65 or above who have never been screened	Offer routine screening: Cytology OR Primary HPV testing OR HPV Co-testing	Doctors Trained Nurses	Opportunistically
Women of all age who are chronically immunosuppressed	Offer: Cytology^@ OR Primary HPV testing^& OR HPV Co-testing^&	Doctors Trained Nurses	^@After two consecutive normal annual screening then every 3-year ^&5-yearly
Women with hysterectomy and removal of cervix for benign diseases and without a prior history of cervical dysplasia	Discontinue screening	Doctors Nurses
Management
For Women Who Have Undergone Cervical Cancer Screening
Women who underwent cervical cancer screening	Manage screening tests according to screening strategy⁶: Cytology alone or HPV co-testing (Table 2; Table 3; Table 4.) Primary HPV testing (Table 5.)	Doctors	As soon as result available

1. Empowerment

a. For Who: Women of all ages

Recommended Care Components^a:

Educate on:

Risk factors, natural history and, symptoms and signs of cervical cancer
Primary preventive measures for cervical cancer (Table 1.)
Importance and methods of cervical cancer screening

By Whom^b: Primary Healthcare Providers

How Often: Opportunistically

2. Assessment (For Women Who Ever Have Sexual Experience)

a. For Who: Women of all ages

Recommended Care Components^a:

                                            Assess:

                                            (1) Risk for persistent Human Papillomavirus (HPV) infection or cervical cancer:
                                            Multiple sexual partner ≥ 34
Early first sexual intercourse 
                                                
Tobacco use
Chronic immunosuppression
Increasing parity
Younger age at full term pregnancy
Long term use of oral contraceptive pills for more than 5 years (the risk declined after use ceased, and by 10 or more years returned to that of never users)

                                            (2) Presence of symptoms suggestive of cervical cancer:5
                                            Post-coital or abnormal vaginal bleeding
Foul smelling vaginal discharge
Pelvic pain during intercourse

                                        

By Whom^b: Nurses / Doctors

How Often: Opportunistically

b. For Who: Women with symptoms suggestive of cervical cancer

Recommended Care Components^a:

                                            Refer to seek early medical attention#

                                            OR

                                            Provide work up assessment^

By Whom^b: ^#Nurses / ^Doctors

How Often: When symptomatic

c. For Who: Women indicated for cervical cancer screening

Recommended Care Components^a:

Address misconceptions and concerns about cervical cancer screening

By Whom^b: Doctors / Nurses

How Often: Opportunistically

3. Screening

a. For Who: Asymptomatic women aged 21 to 24 at increased risk

Recommended Care Components^a:

Offer screening by Cytology

By Whom^b: Doctors / Trained Nurses

How Often: After two consecutive normal annual screening then every 3-year

b. For Who: Asymptomatic women aged 25 to 29

Recommended Care Components^a:

Offer screening by Cytology

By Whom^b: Doctors / Trained Nurses

How Often: After two consecutive normal annual screening then every 3-year

c. For Who: Asymptomatic women aged 30 to 64

Recommended Care Components^a:

                                            Discuss screening options@

                                            Offer:
                                            Cytology&

                                                    OR
Primary HPV testing+

                                                    OR
HPV Co-testing+

By Whom^b: Doctors / Trained Nurses

How Often: ^@Opportunistically / ^&After two consecutive normal annual screening then every 3-year / ⁺5-yearly

d. For Who: Asymptomatic women aged 65 or above with routine screening

Recommended Care Components^a:

Discontinue screening if routine screening within 10 years is normal

By Whom^b: Doctors / Nurses

e. For Who: Asymptomatic women aged 65 or above who have never been screened

Recommended Care Components^a:

                                            Offer routine screening:
                                            Cytology

                                                    OR
Primary HPV testing

                                                    OR
HPV Co-testing

By Whom^b: Doctors / Trained Nurses

How Often: Opportunistically

f. For Who: Women of all age who are chronically immunosuppressed

Recommended Care Components^a:

                                            Offer:
                                            Cytology@

                                                    OR
Primary HPV testing&

                                                    OR
HPV Co-testing&

By Whom^b: Doctors / Trained Nurses

How Often: ^@After two consecutive normal annual screening then every 3-year / ^&5-yearly

g. For Who: Women with hysterectomy and removal of cervix for benign diseases and without a prior history of cervical dysplasia

Recommended Care Components^a:

Discontinue screening

By Whom^b: Doctors / Nurses

4. Management (For Women Who Have Undergone Cervical Cancer Screening)

a. For Who: Women who underwent cervical cancer screening

Recommended Care Components^a:

Manage screening tests according to screening strategy⁶:

Cytology alone or HPV co-testing (Table 2; Table 3; Table 4.)
Primary HPV testing (Table 5.)

By Whom^b: Doctors

How Often: As soon as result available

HPV = Human Papillomavirus

^a	Grade of recommendation according to colour code: Recommended (Strong) Conditionally recommended Practice points Generally not recommended Not recommended (Strong)

Primary Healthcare Providers – All providers of health services in primary healthcare settings
Primary Healthcare Professionals – Includes doctors, dentists, chinese medicine practitioners, nurses, pharmacists, physiotherapist, occupational therapist, dietitians
“Trained” Healthcare Professionals – Additional post-qualification training required to deliver the respective care component(s)

Table 1. CEWG Recommendation on Primary Preventive Measures for Cervical Cancer³

Primary Prevention of Cervical Cancer
	Certain cervical cancer risk factors are modifiable and related to personal lifestyle and behaviour. Women can lower their risk of getting cervical cancer by pursuing primary preventive measures below: *HPV vaccination prior to sexual debut* *Practice of safe sex* (such as avoid having multiple sexual partners and use condoms) to reduce the chance of contracting HPV and other sexually transmitted diseases *Abstinence from tobacco smoking*

Primary Prevention of Cervical Cancer

Certain cervical cancer risk factors are modifiable and related to personal lifestyle and behaviour. Women can lower their risk of getting cervical cancer by pursuing primary preventive measures below:

HPV vaccination prior to sexual debut
Practice of safe sex (such as avoid having multiple sexual partners and use condoms) to reduce the chance of contracting HPV and other sexually transmitted diseases
Abstinence from tobacco smoking

CEWG = Cancer Expert Working Group

Table 2. Management of Cytology or Co-Testing Results – Normal and Squamous Lesions⁶

Table 3. Management of Cytology Results – Glandular Lesions⁶

Screening Result	Recommended Action
1. AGC-NOS (or atypical endocervical cells)	Refer for colposcopy, endometrial and endocervical sampling
2. AGC-favour neoplastic (AGC-FN)
3. Adenocarcinoma in-situ (AIS)
4. Atypical endometrial cells	Refer to specialist for endometrial and endocervical sampling
5. Adenocarcinoma	Early referral for colposcopy
6. Endometrial cells (in a woman ≥ 45 years of age)	If Post-menopausal state, presence of abnormal vaginal bleeding or Obesity (i.e. BMI ≥ 25kg/m2): Refer to specialist for endometrial assessment Otherwise no further investigation is required

AGC-NOS = Atypical Glandular Cell-Not Otherwise Specified; AGC-FN = AGC-favor Neoplastic; AIS = Adenocarcinoma in-situ; BMI = Body Mass Index

Table 4. Management of Cytology Results – Others⁶

Table 5. Management of Stand-Alone HPV Test Results⁶

Screening Result	Recommended Action
HrHPV Negative	5 yearly-screening interval with stand-alone HPV testing
HrHPV Positive	1. Genotyping if available If HPV 16/18 positive: Refer for reflex cytology if possible Refer to colposcopy irrespective of cytology result If HrHPV non-16/18 positive: Refer for reflex cytology If ASCUS or above: Refer for colposcopy If Normal cytology: Repeat co-testing at 12 months or repeat cytology 6-monthly for 3 times before returning to routine screening (every 5-year for HPV-based testing) 2. Reflex / Triage cytology For all women with positive hrHPV test, regardless of genotype If ASCUS or above: refer for colposcopy If Normal cytology: repeat HPV testing or co-testing at 12 months or repeat cytology 6-monthly for 3 times before returning to routine screening (every 5-year for HPV-based testing)

Screening Result

Recommended Action

HrHPV Negative

5 yearly-screening interval with stand-alone HPV testing

HrHPV Positive

1. Genotyping if available

If HPV 16/18 positive:

Refer for reflex cytology if possible
Refer to colposcopy irrespective of cytology result

If HrHPV non-16/18 positive:

Refer for reflex cytology
If ASCUS or above: Refer for colposcopy

If Normal cytology: Repeat co-testing at 12 months or repeat cytology 6-monthly for 3 times before returning to routine screening (every 5-year for HPV-based testing)

2. Reflex / Triage cytology

For all women with positive hrHPV test, regardless of genotype
If ASCUS or above: refer for colposcopy
If Normal cytology: repeat HPV testing or co-testing at 12 months or repeat cytology 6-monthly for 3 times before returning to routine screening (every 5-year for HPV-based testing)

HPV = Human Papillomavirus; HrHPV = High-risk HPV; ASCUS = Atypical Squamous Cells of Undetermined Significance

Further Readings Community Resources Reference Materials for Healthcare Professionals Education and Self-Help Materials for the General Public References