NHS Cervical Screening Programme Introducing HPV Triage

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NHS Cervical Screening ProgrammeIntroducing
HPV Triage
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Human Papilloma Virus (HPV)

• There are over 100 subtypes of HPV. Most do not
  cause significant disease.
• The high risk HPV subtypes are 16, 18, 31 33
  types 16 18 are found in 70 of cervical
  cancers. Non oncogenic types are 6 11, which
  cause visible genital warts.
• Transient HPV is common especially in women under
  35 years.
• It persists in 20-30 of women putting them at
  increased risk of developing cervical cancer.
• Women or their partners may have had HPV for many
  years without knowing it.
• There is no reliable treatment to clear the virus.

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HPV testing for women with first Borderline
Nuclear Change (BNC) or mild dyskaryosis test
result

• Six cytology centres will soon become sentinel
  sites for introducing HPV Triage into the
  cervical screening programme.
• MAVARIC is a randomised trial set up in August
  2005 to compare two automated screening
  technologies with manual screening.
• Women registered in the MAVARIC Trial already
  receive HPV triage. After 16th April 2007 all
  samples will be tested for HPV if the cytology
  result is first BNC or mild dyskaryosis.

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Pilot Studies

• Studies showed that
• HPV testing is acceptable to women because it
  reduces the number of early repeat tests that
  need to be done and speeds up referral to
  colposcopy where indicated.
• 46 of women with (first) BNC changes were HPV
  positive.
• 83 of women with (first) mild dyskaryosis were
  HPV positive.
• Women who are high risk HPV negative are unlikely
  to develop cervical cancer.
• HPV testing will result in some additional
  colposcopy referrals.
• Rana et al (2004) reported that in the
  long-term, 40 of women with BNC test results are
  eventually referred to colposcopy.

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What is HPV Triage?

• All cervical samples with first BNC or mild
  dyskaryosis test result will be tested for HPV to
  distinguish between women who need referral to
  colposcopy and women who can be safely returned
  to routine recall.
• Women who test positive for HPV will be referred
  to colposcopy. Women who are HPV negative will be
  returned to routine recall.

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Test of Cure Protocol(Follow up of treated CIN)

• HPV testing will be used following treatment for
  CIN.
• Women who are cytology negative and HPV negative
  will proceed to a three year recall period
  avoiding the need for 10 years of annual tests.
• Untreated CIN1 will be followed up at
  colposcopists discretion.
• Women who are cytology ve or HPV ve at 6 months
  post treatment will be colposcoped.

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The Screening Programme with HPV Triage

• The screening programme with HPV Triage will
  follow the current procedure.
• The PCT will send an HPV information leaflet with
  the invitation letter to all women.
• The usual procedure for obtaining informed
  consent for cervical screening will include HPV
  testing should it be indicated by the test
  result.
• The original LBC sample will be used if HPV
  testing is indicated, no other sample is
  necessary.
• HPV test results will be included in the cytology
  report along with appropriate management
  recommendations.

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The Screening Programme with HPV Triage

• (continued)
• Women will receive their cytology (and HPV)
  result in a letter from the PCT.
• The subsequent procedure for each type of
  recommended action (routine recall, repeat test,
  or refer to colposcopy) will remain as currently
  set out in the practice guidelines.
• Women under 25 are excluded from the protocol as
  routine screening does not commence until age 25.
• HPV testing will apply whether women attend their
  GP practice, GUM or a Family Planning Clinic.

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Other Considerations

• Local call and re-call computer software has been
  amended to incorporate HPV results.
• New result letters have been written to include
  HPV test result if performed.

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Guidance on Explaining HPV Triage to Women

• We cannot know when an individual woman became
  infected.
• We cannot know from whom this infection was
  transmitted.
• High risk HPV does not cause genital warts and
  wart associated types do not cause CIN.
• HPV infection cannot be treated, only CIN.
• HPV vaccination will help prevent HPV
  infection/CIN in the future.