• Ontario Cervical Screening Program, Gynecology Cancer Disease Site Group. McLachlin CM, Mai V, Murphy J, Fung Kee Fung M, Chambers A. Cervical screening. Toronto (ON): Cancer Care Ontario (CCO); 2005 May 20. 39 p. [74 references]

The scales for the quality of evidence (I-III) and the strength of recommendations (A-E) are defined at the end of the "Major Recommendations" field.

Optimal Cervical Screening Tool

• Liquid-based cytology (LBC) is the preferred tool for cervical cytology screening (B-II). Conventional smear cytology remains an acceptable alternative (C-III).

Optimal Screening Circumstances

• Given the lower incidence and mortality associated with organized screening programs (with recall systems) elsewhere, a province-wide cervical screening program with an adequate recall mechanism is recommended (A-II).

Screening Initiation

• Cervical cytology screening should be initiated within three years of first vaginal sexual activity (i.e., vaginal intercourse, vaginal/oral, and/or vaginal/digital sexual activity) (C-III).

Screening Interval (These recommendations do not apply to women who have had previous abnormal Pap tests. Please see management of abnormal cytology section for further information).

• Screening should be done annually until there are three consecutive negative Pap tests (C-III).
• Screening should continue every two to three years after three annual negative Pap tests (B-II).
  • Screening at a three-year interval is recommended, supported by an adequate recall mechanism (B-II).
  • Women who have not been screened in more than five years should be screened annually until there are three consecutive negative Pap tests (C-III).

Screening Cessation

• Screening may be discontinued after the age of 70 if there is an adequate negative screening history in the previous 10 years (i.e. 3 to 4 negative tests) (B-II).

Screening Women with Special Circumstances

• Immunocompromised or human immunodeficiency virus (HIV) positive women should receive annual screening (C-III).
  • Examples of situations where women may be immunocompromised include women who have received transplants and women who have undergone chemotherapy.
• Screening can be discontinued in women who have undergone total hysterectomy for benign causes with no history of cervical dysplasia or human papillomavirus (C-III).
  • Women who have undergone subtotal hysterectomy (with an intact cervix) should continue screening according to the guidelines.
• Indications for screening frequency for pregnant women should be the same as women who are not pregnant (B-III). Manufacturer's recommendations for the use of individual screening tools in pregnancy should be taken into consideration.
• Women who have sex with women should follow the same cervical screening regimen as women who have sex with men (B-II).

Recommended Management for Women with Abnormal Cytology

ASCUS (Atypical squamous cells of uncertain significance)

• Human papillomavirus (HPV) deoxyribonucleic acid (DNA) testing with cytology is recommended for women aged 30 or older with atypical squamous cells of uncertain significance (C-III).
  • If the HPV DNA test is positive, women should be referred for colposcopy. If the HPV DNA test is negative, women should have repeat cytology in 12 months. Once a woman has had two negative cytology test results, she should return to routine screening.
  • In the absence of HPV DNA testing, a repeat Pap test in six months is acceptable. If the Pap test is abnormal, women should be referred for colposcopy. If the Pap test is negative, women should have repeat cytology in another six months. Once a woman has had two negative Pap test results, she should return to routine screening.
• In women under the age of 30, a repeat Pap test in six months is recommended (C-III).
  • If the Pap test is abnormal, women should be referred for colposcopy. If the Pap test is negative, women should have repeat cytology in another six months. Once a woman has had two negative Pap tests results, she should return to routine screening.
• Referral to colposcopy, without HPV DNA testing or repeat cytology, is only recommended in situations where there is a high probability of patient loss to follow up, or if there are other symptoms suggesting cervical abnormality (abnormal bleeding, etc.) (A-I).

ASC-H (Atypical squamous cells: cannot exclude high grade squamous)

• Colposcopy is recommended for women with ASC-H (A-II).

LSIL (Low-grade squamous intraepithelial lesion)

• Either colposcopy or repeat cytology in six months is recommended for women with LSIL (B-II).
  • If repeat cytology is used and the Pap test is abnormal, women should be referred for colposcopy. If the Pap test is negative, women should have repeat cytology in another six months. Once a woman has had two negative Pap test results, she should return to routine screening.
  • There is limited evidence to support the use of intravaginal estrogen to reverse the cytologic changes in postmenopausal women with LSIL. A course of intravaginal estrogen followed by repeat cytology approximately a week after completing the regimen is acceptable for women with LSIL who have clinical or cytological evidence of atrophy and no contraindications to using intravaginal estrogen. Referral for colposcopy is recommended if a result of atypical squamous cells of uncertain significance or greater is obtained (CIII).

HSIL (High-grade squamous intraepithelial lesion)

• Colposcopy is recommended for women with HSIL (A-II).

AGC (Atypical glandular cells)

• Colposcopy is recommended for women with AGC (A-II).
• Women with AGC should also receive endocervical and endometrial sampling, where appropriate (A-II).

Definitions:

Strength of Recommendations

1. Good evidence for efficacy and substantial clinical benefit support recommendation for use.
2. Moderate evidence for efficacy or only limited clinical benefit support recommendation for use.
3. Evidence for efficacy is insufficient to support a recommendation for or against use, but recommendations may be made on other grounds.
4. Moderate evidence for lack of efficacy or for adverse outcome supports a recommendation against use.
5. Good evidence for lack of efficacy or for adverse outcome supports a recommendation against use.

Quality of Evidence

1. Evidence from at least 1 randomized controlled trial
2. Evidence from at least 1 clinical trial without randomization, from cohort or case-controlled analytic studies, or from multiple time series studies or dramatic results from uncontrolled experiments
3. Evidence from opinions of respected authorities based on clinical experience, descriptive studies, or reports of expert committees

None provided

The recommendations are supported by technology assessments, systematic reviews, retrospective studies, practice guidelines, in press guidelines, cross-sectional studies, case-control studies, retrospective cohort studies, prospective cohort studies, randomized controlled trials, meta-analyses, and conference reports. In cases where the data did not appear conclusive, recommendations were based on the consensus opinion of the group.

• Ontario Cervical Screening Program, Gynecology Cancer Disease Site Group. McLachlin CM, Mai V, Murphy J, Fung Kee Fung M, Chambers A. Cervical screening. Toronto (ON): Cancer Care Ontario (CCO); 2005 May 20. 39 p. [74 references]

Not applicable: The guideline was not adapted from another source.

2005 May 20

Program in Evidence-based Care - State/Local Government Agency [Non-U.S.]

The Program in Evidence-based Care (PEBC), is a project supported by Cancer Care Ontario and the Ontario Ministry of Health and Long-Term Care.

Cancer Care Ontario
Ontario Ministry of Health and Long-Term Care

Cervical Screening Guidelines Development Committee of the Ontario Cervical Screening Program

Provincial Gynecology Cancer Disease Site Group

The members of the Gynecology Cancer Disease Site Group (DSG) disclosed potential conflicts of interest relating to the topic of this practice guideline. One collaborator is employed by MDS Diagnostic Services and has investments with MDS. Another collaborator is a consultant for MDS Diagnostic Services and receives honoraria from MDS for his contributions. Four collaborators are currently involved in a trial examining the results of the implementation of SurePath in Ontario, and four collaborators are involved in a trial investigating the feasibility of implementing human papillomavirus (HPV) testing in a family practice setting. Two collaborators are members of the Cytobase Data Review Committee, and another collaborator is the chair of cytology at QMP-LS. No other conflicts of interest were declared.

None available

This NGC summary was completed by ECRI on August 11, 2005. The information was verified by the guideline developer on September 13, 2005.