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Cervical Screening and HPV testing. Dr Tracy Owen Quality Assurance Director, NICSP. Aim of screening. To reduce mortality and morbidity associated with cervical cancer by identifying and treating pre-cancerous changes Screening can prevent 70% of cervical cancers
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Cervical Screening and HPV testing • Dr Tracy Owen • Quality Assurance Director, NICSP
Aim of screening • To reduce mortality and morbidity associated with cervical cancer • by identifying and treating pre-cancerous changes • Screening can prevent 70% of cervical cancers • Liquid based cytology – introduced 2007/08 • ? Role of HPV testing in screening pathway - HPV detected in 99.7% of cervical cancers
Coverage rates by Trust NI coverage = 77.32% (2010/11) Coverage = % of eligible women with a screening result in last 5 years
Is there anything else that you can do to improve informed choicein your practice?
Reminder - policy change • From Jan 2011 Evidence based, endorsed by UK National Screening Committee, in line with WHO recommendations
What do we know about HPV? • >100 types – only small number cause cervical cancer (HR-HPV) • Transient infection very common - 8 in 10 people infected in lifetime • Prevalence decreases with age (Manchester study) • 40% of 20-24yr olds with HR HPV, 5% of 60-64 yr olds • Can’t be treated but can clear on its own • Infection persists in 20-30% of women
HPV – a complicated issue • Women or their partners may have HPV for many years without knowing it • 99% of cervical cancers associated with persistent infection with high risk types of HPV (70% linked to HPV 16 or 18). • Transmitted by close skin-to-skin contact • Condoms help but don’t provide full protection
HPV testing and screening • HR-HPV testing at two points in screening pathway - Triage and Test of Cure • Improved management of ‘low grade’ abnormalities • Introduced for smears taken from Monday 28 January 2013 • Applies to women in screening age range (25-64 yrs) • HPV test is carried out on the same sample
HPV triage • 15-20% of women with borderline/mild changes have a significant abnormality that needs treatment • HR-HPV testing is effective in identifying which women may need treatment • All borderline/mild samples are tested for HR-HPV (Triage) • HR-HPV positive are referred immediately to colposcopy • HR-HPV negative can be safely returned to routine recall
Benefits of triage • Reduces the need for multiple repeat tests – reduces anxiety & cost • Colposcopy is focused on the women who are more likely to have significant disease • Women get to colposcopy sooner • Negative predictive value of HR-HPV test is reported between 93.8 and 99.7% • ?reduced DNA rate at colposcopy
STANDARD PROTOCOL HPV TRIAGE PROTOCOL
Test of Cure (TOC) • To assess women who have been treated for any grade of CIN for risk of having residual or recurrent disease • Women with normal cytology and negative for HR-HPV at follow up are at very low risk of residual disease • HR-HPV test on women with normal, mild or borderline cytology result at 6 month follow up after treatment (excluded if treated for CGIN/invasive disease) • If HR-HPV negative are returned to routine recall • If HR-HPV positive are referred back to colposcopy
Benefits of TOC • Approx 80% of treated women avoid annual cytology tests • Cost savings to primary care and laboratory • Improved service for women - shorter patient journey time with return to routine recall
STANDARD PROTOCOL HPV TOC PROTOCOL
Information forsmear takers • Packs issued to all practices • **ensure all smear takers in practice have seen this**
HPV testing will be done as appropriate on same sample – you do not need to request it • Cytology and HPV result will be issued on same report • Patient consent • Be prepared to answer patient questions • risk of cancer • transmission of HPV
Psychological impact of HPV infection • Surprise and anxiety. • Guilt and shame are closely linked to concerns about transmission and disclosure to future sexual partners. • Providing clear and accurate information to women can considerably reduce the anxiety they experience and the possible stigma associated with HPV. • Women should be assured that having sex just once exposes them to many subtypes of HPV and this exposure should be viewed as normal.
Terminology • Women are frequently confused by the term ‘wart virus’. It is incorrect and should be avoided. • Using the term ‘HPV positive’ can arouse concern and may be confused with ‘HIV positive’. • Result letters should indicate that ‘high-risk HPV’ has been detected.
How do I protect myself against HPV? • HPV infection cannot be treated, only CIN. • Attend cervical screening regularly. • Vaccination is now available to protect against 16, 18 subtypes. • HPV vaccination will help to prevent HPV infection/CIN in the future.
Further information/contact • Quality Assurance Reference Centre (QARC) • Public Health Agency • 18 Ormeau Avenue • Belfast • Tel: 028 9027 9381 • www.cancerscreening.hscni.net • www.cancerscreening.nhs.uk