Cervical cancer screening
Summary of recommendations
GUIDELINE UPDATES - This guideline was last updated 8/14/2018
UPCOMING GUIDELINES - This guideline was updated and comes into practice on 7/1/2022. Download PDF
Author(s):
This guideline contains evidence-based recommendations (EBR), consensus-based recommendations (CBR) and practice points (PP) as defined in Table B.4 NHMRC approved recommendation types and definitions.
Table B.5. Key to types of recommendations in these guidelines outlines the types of recommendations appearing in these guidelines.
This is a summary of the recommendations in these guidelines, numbered according to chapter to which they relate. Please note that some chapters do not have associated recommendations.
Recommendations
4. Unsatisfactory cervical screening results
| Practice point |
| REC4.1: Attempt adequate repeat preparations for an unsatisfactory LBC test In the case of unsatisfactory LBC, laboratories should ensure that adequate repeat preparations are attempted, after dealing with potentially remediable technical problems. |
| Practice point |
| REC4.2: Report cellular abnormality for LBC specimens with abnormal cells Any LBC specimen with abnormal cells should not be reported as ‘Unsatisfactory’. The identified cellular abnormality should be reported. |
| Practice point |
| REC4.3: Recall women in 6−12 weeks if they have an unsatisfactory screening report A woman with an unsatisfactory screening report should have a repeat sample collected in 6–12 weeks. If the reason for the unsatisfactory sample has been identified then this problem should be corrected if possible before the repeat sample is collected. |
6. Management of HPV test results
Oncogenic HPV types not detected
| MSAC evidence-based recommendation |
| REC6.1: Oncogenic HPV types not detected at routine screening Women who have a screening HPV test in which oncogenic HPV types are not detected should rescreen in 5 years. |
Oncogenic HPV types 16 and/or 18
| MSAC evidence-based recommendation |
| REC6.2: Women with a positive HPV (16/18) test result Women with a positive oncogenic HPV (16/18) test result should be referred directly for colposcopic assessment, which will be informed by the result of reflex LBC. |
| Consensus-based recommendation* |
| REC6.3: Referral to gynaecological oncologist for LBC prediction of invasive disease Women who have a positive oncogenic HPV (16/18) test result with a LBC report of invasive cancer (squamous, glandular or other) should be referred to a gynaecological oncologist or gynaecological cancer centre for urgent evaluation, ideally within 2 weeks. |
| Practice point |
| REC6.4: Referral of women with a positive HPV (16/18) test result and unsatisfactory LBC When reflex LBC is unsatisfactory, but the woman requires colposcopic referral regardless of the LBC result (i.e. when HPV 16/18 is detected), then the screening episode should be classified as ‘Higher risk for cervical cancer or precursors’. A cervical sample for LBC should be collected at the time of colposcopy (see Chapter 4. Unsatisfactory cervical screening results). |
| Practice point |
| REC6.5: Referral of women with a positive HPV (16/18) test result and reflex LBC pHSIL/HSIL Women with a positive oncogenic HPV (16/18) test result and reflex LBC prediction of pHSIL/HSIL should be referred for colposcopic assessment at the earliest opportunity, ideally within 8 weeks. |
Oncogenic HPV types not 16/18
| Evidence-based recommendation | Grade |
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. | C |
| Practice point |
| REC6.7: Referral of women with a positive oncogenic HPV (not 16/18) test result and LBC prediction of pHSIL, HSIL or any glandular abnormality Women with a positive oncogenic HPV (not 16/18) test result, with a LBC prediction of pHSIL/HSIL or any glandular abnormality, should be referred for colposcopic assessment at the earliest opportunity, ideally within 8 weeks. |
| Consensus-based recommendation* |
| REC6.8: Referral to gynaecological oncologist for LBC prediction of invasive disease Women who have a positive oncogenic HPV (not 16/18) test result with a LBC report of invasive cancer (squamous, glandular or other) should be referred to a gynaecological oncologist or gynaecological cancer centre for urgent evaluation, ideally within 2 weeks. |
| Evidence-based recommendation | Grade |
REC6.9: Management after follow-up HPV test at 12 months, following initial positive oncogenic HPV (not 16/18) test result At follow-up HPV testing 12 months after a positive oncogenic HPV (not 16/18) test result with reflex LBC negative or pLSIL/LSIL:
| C |
| Consensus-based recommendation |
REC6.10: Management after follow-up HPV test at 12 months, after initial positive oncogenic HPV (not 16/18) test result
|
| Practice point |
REC6.11: Management after follow-up HPV test at 12 months, following initial positive oncogenic HPV (not 16/18) test result, for women who:
|
| Consensus-based recommendation |
REC6.12: Management after second follow-up HPV test, following initial positive oncogenic HPV (not 16/18) test result
|
Self-collected vaginal samples
| MSAC evidence-based recommendation |
| REC6.13: Oncogenic HPV types not detected in self-collected sample Women who have undergone HPV testing on a self-collected sample and in whom oncogenic HPV is not detected should be invited to re-screen with a HPV test in 5 years and should be advised to have a clinician-collected sample. Note: recommendation numbering changed Feb 2021, this was previously 6.10 |
| MSAC evidence-based recommendation |
| REC6.14: Referral of women with positive oncogenic HPV (16/18) test result (self-collected sample) Women who have undergone HPV testing on a self-collected sample and have a positive oncogenic HPV (16/18) test result should be referred directly for colposcopic assessment. A cervical sample for LBC should be obtained at the time of colposcopy and is not required prior to referral. Note: recommendation numbering changed Feb 2021, this was previously 6.11 |
| Consensus-based recommendation |
REC6.15: Women with a positive oncogenic HPV (not 16/18) test result (self-collected sample)
|
| Consensus-based recommendation |
REC6.16: Management of 12 month repeat HPV test result after initial positive oncogenic HPV (not 16/18) test result on a self-collected sample
|
| Practice point |
REC6.17: Clinician-collected sample for follow-up HPV test after initial self-collected sample Women should be advised that a clinician-collected sample is preferred because it is more effective and reflex LBC can be performed on the same sample, which avoids a further visit to collect a cervical sample for LBC. If the woman declines the clinician-collected sample, she can have a self-collected sample and is eligible for reimbursement under the Medical Benefits Schedule. |
| Practice point |
REC6.18: Clinician-collected sample after invitation to re-screen †Not eligible for reimbursement under the Medical Benefits Schedule unless they meet the eligibility criteria for self-collection (age >30 years, at least 2 years overdue for cervical screening test, or never been screened) as per NCSP policy. |
Women undergoing exit testing
| MSAC evidence-based recommendation |
| REC6.19: Women aged 70–74 years in whom oncogenic HPV is not detected (exit testing) Women can be discharged from the NCSP if they are aged 70–74 years and have a screening test at which oncogenic HPV is not detected. Note: recommendation numbering changed Feb 2021, this was previously REC 6.16 |
| Consensus-based recommendation |
| REC6.20: Referral of women aged 70–74 years with a positive oncogenic HPV test result (exit testing) Women aged 70–74 who have a positive oncogenic HPV (any type) test result should be referred directly for colposcopic assessment, which should be informed by the result of reflex LBC. Note: recommendation numbering changed Feb 2021, this was previously REC 6.17 |
Screening in women older than 75
| NCSP recommendation |
| REC6.21: Women aged 75 years or older who request screening Women who are 75 years or older who have never had a cervical screening test, or have not had one in the previous five years, may request a test and can be screened. Note: recommendation numbering changed Feb 2021, this was previously REC 6.18 |
7. Colposcopy
Colposcopy terminology
| Practice point |
| REC7.1:New colposcopy terminology The new terminology adopted by the IFCPC in 2011 should be incorporated into Australian practice. |
History, examination and investigation
| Practice point |
| REC7.2: Colposcopy and acetic acid Acetic acid should be applied for 2 minutes to allow sufficient time for aceto-white changes to become apparent. This is especially important when the lesion is low grade as it may take more time to become visible. |
| Practice point |
| REC7.3: Colposcopy and VAIN When the LBC report predicts a squamous abnormality and there is no colposcopically visible cervical lesion, careful colposcopic examination of the vagina should be performed to exclude VAIN, using acetic acid and Lugol’s Iodine. |
| Practice point |
REC7.4: Repeat LBC usually not necessary at time of colposcopy
|
| Consensus-based recommendation* |
| REC7.5: Biopsy of high grade lesions The cervix should be biopsied when the LBC prediction is pHSIL or HSIL and the colposcopic appearance shows major change (see IFCPC definition above) and the abnormal TZ is visible (Type 1 or Type 2 TZ). |
| Practice point |
| REC7.6: Biopsy visible lesion if suspicious for invasion when T3 TZ colposcopy In some situations, when there is a visible high-grade lesion on the ectocervix but there is a T3 TZ (lesion extends into canal out of visual range), it may be reasonable to take a cervical biopsy of the visible lesion if there is any suspicion of superficially invasive or invasive carcinoma. |
| Practice point |
| REC7.7: Biopsy of low-grade lesions is encouraged but not always necessary Women with a LBC prediction of pLSIL or LSIL and a colposcopic impression of low-grade disease or less may not always require a biopsy. However, biopsy is accepted practice for confirmation of the colposcopic impression and exclusion of high-grade disease, and should be encouraged, especially for less experienced colposcopists. |
| Practice point |
| REC7.8: Upper genital tract imaging Upper genital tract imaging should be considered in cases where no lower genital tract abnormality is detected at colposcopy after referral with abnormal glandular cytology (including atypical glandular cells or endocervical cells of undetermined significance). In some women, further investigation, such as endometrial sampling to exclude an endometrial origin for atypical glandular cells, may be required. |
Treatment
| Consensus-based recommendation* |
REC7.9: Colposcopy prior to treatment †adequate: the cervix is clearly seen (IFCPC 2011 terminology) |
| Consensus-based recommendation* |
| REC7.10: Histopathological confirmation prior to treatment Treatment should be reserved for women with histologically confirmed HSIL (CIN2/3) or AIS, except for women requiring diagnostic excisional biopsy. |
| Consensus-based recommendation* |
| REC7.11: Biopsy prior to ablative treatment Women should have a cervical biopsy prior to any ablative treatment. |
| Consensus-based recommendation |
| REC7.12: Pathology review of discordant test results For women who have had a colposcopy with significant discordance between the histopathology and the referral cytology, both specimens should be reviewed by a pathologist from at least one of the reporting laboratories who should then convey the results of the review to the colposcopist in order to inform the management plan. |
| Practice point |
REC7.13: Tertiary referral may be necessary
|
| Practice point |
| REC7.14: Second opinion When there is any concern about diagnosis or patient management, a second opinion should be sought and documented. |
| Practice point |
REC7.15: The role of multidisciplinary team review
|
| Practice point |
| REC7.16: Colposcopy at time of treatment All treatments should be performed under colposcopic vision, with the exception of cold-knife cone biopsy. |
| Consensus-based recommendation* |
REC7.17: Criteria for ablative treatment
|
| Practice point |
| REC7.18: Depth of ablation A Type 1 TZ with a HSIL (CIN2/3) lesion requires 6–8 mm (and not more than 10 mm) of cervical ablation to be adequately treated. |
| Consensus-based recommendation* |
| REC7.19: Excision specimen quality and pathology Excisional therapy should aim to remove the entire TZ with a pre-determined length of cervical tissue, ideally in one piece, with minimal distortion or artefact to the final histological specimen.† †This is critical for management of suspected or histologically confirmed AIS. |
| Practice point |
| REC7.20: Excision specimen quality, pathology and very large ectocervical lesion A very large ectocervical lesion may require removal in two pieces in order to remove the entire lesion. It is still important that the endocervical and stromal margins are suitable for pathological interpretation and that the specimens are accurately oriented and labelled. |
| Practice point |
| REC7.21: Excisional techniques and surgical competency Therapeutic colposcopists should use the excisional techniques with which they are comfortable and competent and that produce the best histological specimen. |
| Practice point |
| REC7.22: Cold-knife cone biopsy: setting Cold-knife cone biopsy should be performed in an operating theatre, under general anaesthesia, by a gynaecological oncologist or gynaecologist competent in the technique. |
| Practice point |
| REC7.23: Loop excisional biopsy technique (LEEP/LLETZ) A single pass of the loop (side to side or posterior to anterior) to produce a specimen in one piece is optimal. |
| Practice point |
| REC7.24: Loop ‘top-hat’ excisions should be avoided (LEEP/LLETZ) The ‘top-hat’ excision techniques using a wire loop, in which a second piece of endocervical tissue is removed after the first excision, is not an alternative to a properly performed single-piece Type 3 excision, and should be avoided. |
| Practice point |
| REC7.25: Cold-knife cone biopsy and AIS Predicted or histologically confirmed AIS should be treated by a Type 3 excision (usually a cold-knife cone biopsy) performed in an operating theatre, under general anaesthesia, by a gynaecological oncologist or gynaecologist competent in the technique. |
| Practice point |
| REC7.26: Role of repeat excision in management of SISCCA In the presence of a superficially invasive squamous carcinoma, if HSIL (CIN2/3) extends to any excision margin, a repeat excision (usually by cold-knife cone biopsy) is recommended. |
| Practice point |
| REC7.27: Do not treat at first visit with a LBC report of a low-grade lesion Women who have a LBC prediction of pLSIL/LSIL should not be treated at the first visit. |
| Practice point |
| REC7.28: Excision required for recurrent disease after ablation If there is recurrence of high-grade disease after previous ablation, treatment should be by excision. |
| Practice point |
REC7.29: Repeat excision not necessarily required for incomplete excision of high-grade lesions
|
8. Management of discordant colposcopic impression, histopathology and referral LBC prediction
Normal colposcopic findings following LBC prediction of LSIL or HSIL
| Consensus-based recommendation |
REC8.1: Normal colposcopy following LBC prediction of negative or pLSIL/LSIL
|
| Practice point |
| REC8.2: Normal colposcopy following LBC prediction of HSIL: cytopathology review Cytopathology review is recommended to confirm HSIL before proceeding to excisional treatment for women with a normal colposcopy after a positive oncogenic HPV (any type) test result and an initial LBC prediction of pHSIL/HSIL. |
| Practice point |
| REC8.3: Normal colposcopy following LBC prediction of HSIL: exclude VAIN When colposcopic impression is discordant with a referral LBC prediction of HSIL, colposcopic examination of the vagina is indicated to exclude a vaginal intraepithelial neoplasia before diagnostic excisional treatment. |
| Consensus-based recommendation |
| REC8.4: Normal colposcopy following LBC prediction of HSIL: diagnostic excision of TZ For women who have a positive oncogenic HPV (any type) test result, normal colposcopy, and a LBC prediction of HSIL on cytopathology review, diagnostic excision of the TZ should be performed. |
| Consensus-based recommendation |
| REC8.5: Normal colposcopy following LBC prediction of pHSIL: consider diagnostic excision of TZ For women who have a positive oncogenic HPV (any type) test result, normal colposcopy, and a LBC prediction of pHSIL on cytopathology review, diagnostic excision of the TZ should be considered, though observation is an option. |
| Practice point |
REC8.6: Normal colposcopy following LBC prediction of pHSIL: diagnostic excision or observation
|
| Consensus-based recommendation |
| REC8.7: Downgrading of discordant results For women who have a positive oncogenic HPV (any type) test result, normal colposcopy, and a subsequent LBC report of pLSIL/LSIL or less on cytopathology review, management should be according to the reviewed cytological report (i.e. repeat HPV test in 12 months). |
| Practice point |
| REC8.8: Colposcopist should manage discordant results Women with discordant colposcopy and LBC results should have their management supervised by the colposcopist until both the colposcopist and the woman are satisfied with the proposed management plan. |
Type 3 TZ (previously termed ‘unsatisfactory’) colposcopy following LBC prediction of LSIL or HSIL
| Consensus-based recommendation |
REC8.9: Repeat HPV test after Type 3 TZ colposcopy and referral LBC negative or pLSIL/LSIL
|
| Practice point |
REC8.10: Cytopathology review prior to observation for pLSIL/LSIL and Type 3 TZ at colposcopy
|
| Practice point |
| REC8.11: Role of ECC in Type 3 TZ colposcopy following LBC prediction of pLSIL/LSIL Despite a lack of evidence, endocervical curettage can be considered for women who have a positive oncogenic HPV test result (any type) with a LBC report of persistent pLSIL/LSIL and colposcopy reported as Type 3 TZ.† A negative ECC may provide additional reassurance for a conservative (observational) approach. †Type 3 TZ indicates failure to visualise the upper limit of the TZ, or the entire TZ is within the endocervical canal. It corresponds to ‘unsatisfactory’ in previous terminology. |
| Consensus-based recommendation |
| REC8.12: Diagnostic excision of the TZ should not be performed if there is no cytological or histological evidence of a high-grade lesion after Type 3 TZ colposcopy For asymptomatic women who have a positive oncogenic HPV (any type) test result, Type 3 TZ† colposcopy, and no cytological, colposcopic or histological evidence of a high-grade lesion, further diagnostic procedures (such as diagnostic excision of the transformation zone) should not routinely be performed. †Type 3 TZ indicates failure to visualise the upper limit of the TZ, or the entire TZ is within the endocervical canal. It corresponds to ‘unsatisfactory’ in previous terminology. |
| Practice point |
REC8.13: Role of diagnostic excision: exceptions to recommendation against diagnostic excision of TZ in the absence of high-grade cytology or histology
|
| Consensus-based recommendation |
| REC8.14: Diagnostic excision: Type 3 TZ colposcopy after LBC prediction of pHSIL/HSIL For women who have a positive oncogenic HPV (any type) test result, a LBC prediction of pHSIL/HSIL after cytopathology review, and Type 3 TZ† colposcopy, diagnostic excision of the TZ should be performed. †Type 3 TZ indicates failure to visualise the upper limit of the TZ, or the entire TZ is within the endocervical canal. It corresponds to ‘unsatisfactory’ in previous terminology. |
| Practice point |
| REC8.15: Cytopathology review: Type 3 TZ colposcopy following LBC prediction of pHSIL/HSIL Cytopathology review should be considered to confirm a high-grade cytological abnormality before excision, after a positive oncogenic HPV (any type) test result and an initial LBC prediction of pHSIL/HSIL, when there is a Type 3 TZ colposcopy. This is particularly important when the LBC prediction is pHSIL because pHSIL has a lower PPV for high-grade disease and the subsequent excision specimens show no evidence of cervical pathology in 45–55% of cases. |
| Practice point |
REC8.16: Deferral of treatment following cytopathology review: Repeat HPV test and colposcopy in 6 months
|
9. Management of histologically confirmed low-grade squamous abnormalities
| Consensus-based recommendation |
REC9.1: HPV test 12 months after histologically confirmed LSIL (≤ CIN1)
|
| Consensus-based recommendation |
| REC9.2: LSIL (≤ CIN1) should not be treated Women who have a positive oncogenic HPV (any type) test result with a LBC report of negative or pLSIL/LSIL, who have undergone colposcopy and have a histologically confirmed LSIL (≤ CIN1), should not be treated, because these lesions are considered to be an expression of a productive HPV infection. |
| Consensus-based recommendation |
| REC9.3: Diagnostic excision when HSIL confirmed on cytopathology review Women who have a positive oncogenic HPV test result (any type) with a LBC report of HSIL (confirmed after cytopathology review), and who have undergone colposcopy and have a histologically confirmed LSIL (≤ CIN1), should be offered diagnostic excision of the TZ. |
| Consensus-based recommendation |
REC9.4: Option for observation following cytological prediction of pHSIL
|
| Practice point |
REC9.5: Criteria for observation following cytological prediction of pHSIL
|
| Practice point |
| REC9.6: Cytology review essential when test results are discordant For women who have a positive oncogenic HPV (any type) test result with a histologically confirmed LSIL (≤ CIN1) after LBC prediction of pHSIL/HSIL, both the cytology and the histopathology should be reviewed by a pathologist from at least one of the reporting laboratories, who should then convey the results of the review to the colposcopist in order to inform the management plan. |
10. Management of histologically confirmed high-grade squamous abnormalities
Diagnosis of HSIL
| Consensus-based recommendation* |
| REC10.1: Histological diagnosis prior to treatment For women who have a visible lesion at colposcopy, histological confirmation of HSIL is recommended before undertaking definitive treatment. |
Treatment of HSIL
| Consensus-based recommendation* |
| REC10.2: Treatment for HSIL (CIN2) Women with a histological diagnosis of HSIL (CIN2) should be treated in order to reduce the risk of developing invasive cervical carcinoma. |
| Practice point |
| REC10.3: p16 should be used to clarify diagnosis of HSIL (CIN2) The use of p16 immunohistochemistry is recommended to stratify the management of HSIL (CIN2) into immediate treatment or a period of observation. |
| Practice point |
REC10.4: HSIL (CIN2) and observation
|
| Consensus-based recommendation* |
| REC10.5: Treatment of HSIL (CIN3) Women with a histological diagnosis of HSIL (CIN3) should be treated in order to reduce the risk of developing invasive cervical carcinoma. |
| Consensus-based recommendation* |
| REC10.6: Referral of women with invasive disease A woman with a histologically confirmed diagnosis of invasive or superficially invasive (squamous cell carcinoma) should be referred to a gynaecological oncologist or a gynaecological cancer centre for multidisciplinary team review. |
Test of Cure after treatment for HSIL (CIN2/3)
| Consensus-based recommendation |
| REC10.7: Test of Cure after treatment for HSIL (CIN2/3) A woman who has been treated for HSIL (CIN2/3) should have a co-test† performed at 12 months after treatment, and annually thereafter, until she receives a negative co-test on two consecutive occasions, when she can return to routine 5 yearly screening. †Co-testing can be performed by the woman’s usual healthcare professional. |
| Consensus-based recommendation |
| REC10.8: Abnormal Test of Cure results: positive oncogenic HPV (16/18) test result If, at any time post treatment, the woman has a positive oncogenic HPV (16/18) test result, she should be referred for colposcopic assessment (regardless of the reflex LBC result). |
| Consensus-based recommendation* |
| REC10.9: Abnormal Test of Cure results: LBC pHSIL/HSIL or glandular abnormality If, at any time during Test of Cure, the woman has a LBC prediction of pHSIL/HSIL or any glandular abnormality, irrespective of HPV status, she should be referred for colposcopic assessment. |
| Consensus-based recommendation |
| REC10.10: Abnormal Test of Cure results: positive oncogenic HPV (not 16/18) test result If, at any time post-treatment, the woman has a positive oncogenic HPV (not 16/18) test result and a LBC report of negative or prediction of pLSIL/LSIL, she should continue to have annual co-testing until the she has a negative co-test on two consecutive occasions, when she can return to routine 5-yearly screening. |
| Practice point |
| REC10.11: Fluctuating Test of Cure results: positive oncogenic HPV (not 16/18) test result and/or pLSIL/LSIL Some women may experience fluctuating results with a positive oncogenic HPV (not 16/18) test result and/or LBC prediction of pLSIL/LSIL. These women do not need colposcopic review but, if the woman is anxious, a colposcopic assessment may be appropriate to provide reassurance. |
| Practice point |
REC10.12: Colposcopy is not necessary at the initial post-treatment visit The post-treatment review should:
Subsequent post-treatment Test of Cure surveillance should be performed by the woman’s GP or health professional, who should follow the recommendations for the management of any abnormal test results. |
11. Management of glandular abnormalities
Investigation of cytological glandular abnormalities
| Consensus-based recommendation* |
| REC11.1: Colposcopy referral for atypical glandular/endocervical cells Women who have a positive oncogenic HPV (any type) test result with a LBC report of atypical glandular/endocervical cells of undetermined significance should be referred to a gynaecologist with expertise in the colposcopic evaluation of suspected malignancies or a gynaecological oncologist. |
| Consensus-based recommendation* |
REC11.2: Follow-up after normal colposcopy and LBC prediction of atypical glandular/endocervical cells
|
| Practice point |
REC11.3: Exclusion of upper genital tract disease before diagnostic excision
|
| Practice point |
REC11.4: Role of immediate diagnostic excision of TZ versus observation
|
| Consensus-based recommendation |
REC11.5: Colposcopy for possible high-grade glandular lesions Diagnostic excision of the endocervical TZ should be performed in most cases. |
| Practice point |
REC11.6: Women who decline treatment for possible high-grade glandular lesions
|
| Consensus-based recommendation* |
REC11.7: Colposcopy referral for AIS Diagnostic excision of the endocervical TZ should be performed. |
| Consensus-based recommendation* |
| REC11.8: Referral to gynaecological oncologist for LBC prediction of invasive disease Women who have a positive oncogenic HPV (any type) test result with a LBC prediction of invasive adenocarcinoma should be referred to a gynaecological oncologist or a gynaecological oncology centre for urgent evaluation, ideally within 2 weeks. |
| Consensus-based recommendation* |
| REC11.9: Specimen for histological assessment of glandular abnormalities When diagnostic excision of the TZ is performed in the investigation of glandular abnormalities, the method chosen should ensure that a single, intact specimen with interpretable margins is obtained for histological assessment. |
| Practice point |
| REC11.10: Cold-knife cone biopsy is the ‘gold standard’ for glandular abnormalities’ Cold-knife cone biopsy should be considered the ‘gold standard’ for the diagnostic assessment of glandular lesions. However, a diathermy excisional procedure may be appropriate in some circumstances and could provide an appropriate surgical specimen when performed by a gynaecologist with appropriate training, experience and expertise. |
| Practice point |
| REC11.11: Size of cone biopsy The depth and extent of the cone biopsy should be tailored to the woman's age and fertility requirements. A Type 3 Excision of the TZ is usually required. |
| Practice point |
| REC11.12: Cone biopsy excision margins and multifocal AIS Multifocal disease has been reported in 13–17% of cases of AIS, though the majority of lesions are unifocal. If the margin is close but apparently excised (less than 5 mm), close surveillance by Test of Cure, as recommended in these guidelines, is considered appropriate. In this situation further excision is not considered necessary. |
Follow-up after excisional treatment for AIS
| Consensus-based recommendation* |
REC11.13: Follow-up of completely excised AIS If any abnormal result is obtained on follow-up co-testing, the woman should be referred for colposcopic assessment. |
| Consensus-based recommendation* |
| REC11.14: Repeat excision for incompletely excised AIS If AIS is incompletely excised (positive endocervical margin and/or deep stromal margin, not ectocervical margin) or if the margins cannot be assessed, further excision to obtain clear margins should be performed. |
| Consensus-based recommendation |
| REC11.15: Role of hysterectomy in AIS In women who have been treated for AIS by excision, with clear margins, there is no evidence to support completion hysterectomy. In this situation, hysterectomy is not recommended. |
12. Screening in Aboriginal and Torres Strait Islander women
| Consensus-based recommendation |
| REC12.1: Cervical Screening for Aboriginal and Torres Strait Islander women Aboriginal and Torres Strait Islander women should be invited and encouraged to participate in the NCSP and have a 5-yearly HPV test, as recommended for all Australian women. |
| Practice point |
| REC12.2: Invitations to screen for Aboriginal and Torres Strait Islander women Specific efforts should be made to maximise delivery of invitations to Aboriginal and Torres Strait Islander women. |
| Practice point |
| REC12.3: Cervical screening services for Aboriginal and Torres Strait Islander women Specific efforts should be made to provide screening, diagnostic and treatment services that are accessible and culturally appropriate to Aboriginal and Torres Strait Islander women. |
| Practice point |
| REC12.4: Data collection and recording Aboriginal and Torres Strait Islander status Healthcare professionals should ask all women whether they identify as Aboriginal or Torres Strait Islander, and a woman’s Aboriginal and Torres Strait Islander status should be recorded on the pathology request form in accordance with the ABS classification and standards. |
13. Screening after total hysterectomy
| Consensus-based recommendation* |
| REC13.1: Total hysterectomy for benign disease Women with a normal cervical screening history, who have undergone hysterectomy for benign disease (e.g. menorrhagia, uterine fibroids or utero-vaginal prolapse), and have no cervical pathology at the time of hysterectomy, do not require further screening or follow up. |
| Consensus-based recommendation* |
| REC13.2: Total hysterectomy after completed Test of Cure Women who have had a total hysterectomy with no evidence of cervical pathology, have previously been successfully treated for histologically confirmed HSIL and have completed Test of Cure, do not require further follow-up. These women should be considered as having the same risk for vaginal neoplasia as the general population who have never had histologically confirmed HSIL and have a total hysterectomy. If unexpected LSIL or HSIL is identified in the cervix at the time of hysterectomy, then these women require follow-up with an annual co-test on a specimen from the vaginal vault until they have a negative co-test on two consecutive occasions. |
| Consensus-based recommendation |
| REC13.3: Total hysterectomy after adenocarcinoma in situ (AIS) Women who have had a total hysterectomy, have been treated for AIS, and are under surveillance, should have a co-test on a specimen from the vaginal vault at 12 months and annually thereafter, indefinitely.† Women who have a total hysterectomy, as completion therapy or following incomplete excision of AIS at cold-knife cone biopsy or diathermy excision, should have a co-test on a specimen from the vaginal vault at 12 months and annually thereafter, indefinitely. † Until sufficient data become available to support cessation of testing |
| Consensus-based recommendation* |
| REC13.4: Total hysterectomy for treatment of high-grade CIN in the presence of benign gynaecological disease Women who have had a total hysterectomy as definitive treatment for histologically confirmed HSIL in the presence of benign gynaecological disease, irrespective of cervical margins, should have a co-test on a specimen from the vaginal vault at 12 months after treatment and annually thereafter until the woman has tested negative by both tests on two consecutive occasions. After two annual consecutive negative co-tests, the woman can be advised that no further testing is required. |
| Consensus-based recommendation* |
| REC13.5: Total hysterectomy after histologically confirmed HSIL without Test of Cure Women who have been treated for histologically confirmed HSIL, are under surveillance or have returned to routine screening without Test of Cure, and have had a total hysterectomy with no evidence of cervical pathology, should have a co-test on a specimen from the vaginal vault at 12 months and annually until the woman has tested negative on two consecutive occasions. After two annual consecutive negative co-tests, the woman can be advised that no further testing is required. |
| Consensus-based recommendation* |
| REC13.6: Total hysterectomy and no screening history Women who have had a total hysterectomy with no evidence of cervical pathology, and whose cervical screening history is not available, should have a HPV test on a specimen from the vaginal vault at 12 months and annually thereafter until they have a negative HPV test on two consecutive occasions. After two annual consecutive negative HPV tests, women can be advised that no further testing is required. |
| Practice point |
| REC13.7: Colposcopy referral for any positive co-test result following total hysterectomy Women who have had a total hysterectomy and are under surveillance with co-testing, and have a positive oncogenic HPV (any type) test result and/or any cytological abnormality, should be referred for colposcopic assessment. |
| Practice point |
| REC13.8: Vaginal bleeding following total hysterectomy Women who have vaginal bleeding† following total hysterectomy should be assessed by their GP or gynaecologist, regardless of the results of any surveillance tests. †Vaginal bleeding is quite common in the early weeks following hysterectomy and, where appropriate, should be investigated by the treating gynaecologist. |
| Practice point |
| REC13.9: Total hysterectomy after genital tract cancer Women who have been treated for cervical or endometrial cancer are at risk of recurrent cancer in the vaginal vault. These women should be under ongoing surveillance from a gynaecological oncologist. Therefore, they will be guided by their specialist regarding appropriate surveillance and this is outside the scope of these guidelines. |
| Practice point |
| REC13.10: Subtotal hysterectomy Women who have undergone subtotal hysterectomy (the cervix is not removed) should be invited to have 5-yearly HPV testing in accordance with the recommendation for the general population. Any detected abnormality should be managed according to these guidelines. |
14. Screening in pregnancy
| Consensus-based recommendation |
| REC14.1: Positive oncogenic HPV (not 16/18) test result with LBC negative or pLSIL/LSIL in pregnancy Pregnant women who have 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. |
| Consensus-based recommendation |
| REC14.2: Positive oncogenic HPV (not 16/18) test result with LBC pHSIL/HSIL or any glandular abnormality in pregnancy Pregnant women who have a positive oncogenic HPV (not 16/18) test result with a LBC prediction of pHSIL/HSIL or any glandular abnormality should be referred for early† colposcopic assessment. † When practical and not deferred until the postpartum period. |
| Consensus-based recommendation |
| REC14.3: Positive HPV (16/18) test result in pregnancy Pregnant women who have a positive oncogenic HPV (16/18) test result should be referred for early† colposcopic assessment regardless of their LBC test result. † When practical and not deferred until the postpartum period. |
| Consensus-based recommendation* |
REC14.4: Referral of pregnant women with invasive disease
|
| Consensus-based recommendation* |
| REC14.5: Colposcopy during pregnancy The aim of colposcopy in pregnant women is to exclude the presence of invasive cancer and to reassure them that their pregnancy will not be affected by the presence of an abnormal cervical screening test result. |
| Practice point |
| REC14.6: Colposcopy during pregnancy Colposcopy during pregnancy should be undertaken by a colposcopist experienced in assessing women during pregnancy. |
| Consensus-based recommendation* |
| REC14.7: Cervical biopsy in pregnancy is usually unnecessary Biopsy of the cervix is usually unnecessary in pregnancy, unless invasive disease is suspected on colposcopy or reflex LBC predicts invasive disease. |
| Consensus-based recommendation* |
| REC14.8: Defer treatment until after pregnancy Definitive treatment of a suspected high-grade lesion, except invasive cancer, may be safely deferred until after the pregnancy. |
| Practice point |
| REC14.9: Follow-up assessment after pregnancy If postpartum follow-up assessment (colposcopy and/or HPV test and reflex LBC if necessary) is required, it should be done no less than 6 weeks after delivery and preferably at 3 months. This interval is optimal to reduce the risk of reflex LBC interpretation difficulties or unsatisfactory reflex LBC. The cervical sample (for HPV test and reflex LBC if necessary) could be collected at the time of postpartum check or at the time of the colposcopic assessment. |
| Practice point |
REC14.10: Vaginal oestrogen prior to postpartum colposcopy
|
| Practice point |
| REC14.11: Cervical screening in pregnancy Routine antenatal and postpartum care should include a review of the woman’s cervical screening history. Women who are due or overdue for screening should be screened. |
| Practice point |
| REC14.12: Cervical screening in pregnancy A woman can be safely screened at any time during pregnancy, provided that the correct sampling equipment is used. A cytobrush or combi-brush should not be inserted into the cervical canal because of the risk of associated bleeding, which may distress women. |
| Practice point |
| REC14.13: Self-collection in pregnancy Self-collection for HPV testing may be considered during pregnancy in never screened or under-screened women, following counselling by a health care professional regarding the risk of bleeding. |
15. Screening in women who have experienced early sexual activity or have been victims of sexual abuse
| MSAC evidence-based recommendation |
| REC15.1: Routine cervical screening is not recommended in young women Routine cervical screening is not recommended in women under the age of 25 years. |
| Consensus-based recommendation |
| REC15.2: Early sexual activity and cervical screening in young women For women who experienced first sexual activity at a young age (<14 years) and who had not received the HPV vaccine before sexual debut, a single HPV test between 20 and 24 years of age could be considered on an individual basis. |
| Consensus-based recommendation |
| REC15.3: Women with abnormal vaginal bleeding Women at any age who have signs or symptoms suggestive of cervical cancer or its precursors, should have a co-test† and be referred for appropriate investigation to exclude genital tract malignancy. † Co-testing (HPV and LBC) is recommended as the presence of blood has the potential to adversely affect the sensitivity of any of the available tests. |
16. Screening in immune-deficient women
| Consensus-based recommendation |
| REC16.1: Immune-deficient women in whom oncogenic HPV is not detected Immune-deficient women who have a HPV test in which oncogenic HPV types are not detected should be screened every 3 years with a HPV test. |
| Consensus-based recommendation |
| REC16.2: Colposcopy referral: positive oncogenic HPV test result (any type) in immune-deficient women Women who are immune-deficient and have a positive oncogenic HPV (any type) test result should be referred for colposcopic assessment informed by the reflex LBC. |
| Consensus-based recommendation* |
| REC16.3: Colposcopy assessment and treatment in immune-deficient women Assessment and treatment of immune-deficient women with screen-detected abnormalities should be by an experienced colposcopist or in a tertiary centre. |
| Consensus-based recommendation* |
| REC16.4: Colposcopy of whole lower genital tract in immune-deficient women The entire lower anogenital tract should be assessed, as the same risk factors apply for cervical, vaginal, vulval, perianal and anal lesions. |
| Consensus-based recommendation* |
| REC16.5: Treatment in immune-deficient women When treatment of the cervix is considered necessary in immune-deficient women, it should be by excisional methods. |
| Practice point |
| REC16.6: Histological abnormalities of the cervix in immune-deficient women Women with histologically confirmed abnormalities should be managed according to the same guidelines as women who are not immune-deficient. |
| Practice point |
| REC16.7: Test of Cure for treated immune-deficient women Women who are immune-deficient and treated for HSIL (CIN2/3) should have follow-up with Test of Cure as recommended in these guidelines. Women who complete Test of Cure should return to routine 3-yearly screening with a HPV test. |
| Practice point |
| REC16.8: Screening before solid organ transplantation Women aged between 25 and 74 years should have a review of cervical screening history when they are added to the organ transplant waiting list and while they remain on the waiting list, to confirm they are up to date with recommended screening for the general population. Women who are overdue for screening, or become due while on the waiting list ,should be screened with a HPV test so that any abnormalities can be investigated or treated as necessary prior to transplantation and commencement of immunosuppressive therapy. |
| Practice point |
| REC16.9: Screening women with a new diagnosis of HIV Women aged between 25 and 74 years who have a new diagnosis of HIV should have a review of their cervical screening history to ensure they are up to date with screening in line with the recommended 3-yearly interval for this group. |
| Practice point |
REC16.10: Other groups that may require special consideration
|
| Practice point |
| REC16.11: Regular screening for immune-deficient women Women who are immune deficient should be educated regarding the increased risk from HPV infection and encouraged to attend for regular screening. |
| Practice point |
| REC16.12: Young women with long term immune deficiency For young women who are sexually active and who have been immune deficient for more than 5 years, a single HPV test between 20 and 24 years of age could be considered on an individual basis (regardless of HPV vaccination status). |
| Practice point |
| REC16.13: Guidance for immune-deficient women and their healthcare professionals It is important that immune-deficient women and their healthcare professionals are guided by a clinical immunology specialist when using these guidelines. |
17. Screening in DES-exposed women
| Consensus-based recommendation |
| REC17.1: Screening in DES-exposed women Women exposed to DES in utero should be offered an annual co-test and colposcopic examination of both the cervix and vagina indefinitely. |
| Consensus-based recommendation* |
| REC17.2: Colposcopy referral for abnormalities in DES-exposed women Women exposed to DES in utero who have a screen-detected abnormality should be managed by an experienced colposcopist. |
| Practice point |
REC17.3: Daughters of women exposed to DES However, if these women have concerns, testing similar to that recommended for their DES-exposed mothers could be considered on an individual basis. Self-collection for HPV testing is not recommended. |
18. Signs and symptoms of cervical cancer – identification and investigation of abnormal bleeding
| Consensus-based recommendation |
| REC18.1: Women with abnormal vaginal bleeding Women at any age who have signs or symptoms suggestive of cervical cancer should have a co-test, and referral for appropriate investigation to exclude genital tract malignancy should be considered. |
| Consensus-based recommendation |
| REC18.2: Abnormal vaginal bleeding and testing for HPV and LBC When women present with abnormal vaginal bleeding, appropriate investigations, which may include a cervical sample for a co-test,† should be performed and not delayed due to the presence of blood. †The woman’s recent cervical screening history should also be considered. |
| Consensus-based recommendation |
| REC18.3: Postcoital bleeding in pre-menopausal women Pre-menopausal women who have a single episode of postcoital bleeding and a clinically normal cervix do not need to be referred for colposcopy if oncogenic HPV is not detected and LBC is negative. If postcoital bleeding recurs or persists despite a negative co-test women should be referred to a gynaecologist for appropriate assessment, including colposcopy, to exclude genital tract malignancy. |
| Practice point |
| REC18.4: Postcoital bleeding and sexually transmitted infections Sexually transmitted infections, including Chlamydia infection, should be considered and, when appropriate, excluded in all women presenting with postcoital bleeding. It is necessary to obtain a sexual health history and perform appropriate tests and investigations. |
| Consensus-based recommendation* |
| REC18.5: Symptomatic women with LBC prediction of cervical cancer Women with symptoms and a LBC prediction of invasive cervical cancer should be referred to a gynaecological oncologist or gynaecological cancer centre for assessment. |
| Consensus-based recommendation |
| REC18.6: Women with intermenstrual bleeding may require specialist referral Women with persistent and/or unexplained intermenstrual bleeding require appropriate investigation and should be referred for specialist gynaecological assessment, regardless of any test results. |
| Consensus-based recommendation |
| REC18.7: Postmenopausal women with vaginal bleeding require specialist referral Postmenopausal women with any vaginal bleeding, including postcoital bleeding, should be referred for a specialist gynaecological assessment, to exclude genital tract malignancy. |
| Consensus-based recommendation |
| REC18.8: Women with abnormal vaginal discharge and/or deep dyspareunia Almost all women with vaginal discharge and/or deep dyspareunia have benign gynaecological disease. They should be investigated appropriately and if due for cervical screening a routine CST would be the most appropriate test. |
| Consensus-based recommendation |
| REC18.9: Women with unexplained persistent unusual vaginal discharge Women of any age with unexplained persistent unusual vaginal discharge, especially if offensive or blood stained) should be investigated with a co-test (HPV and LBC) and referred for gynaecological assessment. |
| Consensus-based recommendation |
| REC18.10: Women with unexplained persistent deep dyspareunia Women with unexplained persistent deep dyspareunia in the absence of bleeding or discharge should have a CST if due and referral for gynaecological assessment should be considered. |
20. Transition to the renewed National Cervical Screening Program
| Practice point |
| REC20.1: HPV test replaces the Pap test All Pap tests are replaced by HPV testing. Conventional Pap tests are no longer used. Reflex LBC will be performed on any sample with a positive oncogenic HPV (any type) test result. Co-testing (HPV and LBC) to be performed only as recommended in these guidelines, in the follow-up of screen-detected abnormalities or the investigation of abnormal vaginal bleeding. |
| Practice point |
REC20.2: HPV testing for women in follow-up after pLSIL/LSIL
|
| Practice point |
| REC20.3: Colposcopic management of a prior screen-detected abnormality should continue Women who have been referred for colposcopic assessment following any cytological abnormality in the pre-renewal NCSP should continue their colposcopic management according to these guidelines. |
| Practice point |
| REC20.4: Prior treatment and Test of Cure Women who have been treated for HSIL (CIN2/3) in the pre-renewal NCSP and are undergoing, or have not yet commenced Test of Cure, should start or continue Test of Cure in accordance with these guidelines. Women should have an annual co-test (HPV and LBC) performed at 12 months after treatment, and annually thereafter, until both tests are negative on two consecutive occasions, when they can return to routine 5-yearly screening. |
| Practice point |
| REC20.5: Prior treatment for AIS Women who have been treated for AIS in the pre-renewal NCSP, and are undergoing or have not yet commenced surveillance, should have annual co-testing (HPV and LBC) indefinitely.† †Until sufficient data become available that may support a policy decision that cessation of testing is appropriate. |
WEBSITE UPDATES - This website was last updated 5/18/2022
