printemailclick to share buttonfacebooktwitterlinkedin
Healthcare Provider Resources - Cervical Screening
 

Ontario Cervical Screening Cytology (Pap Test) Guidelines

icon for Cervical Screening app QR code for Cervical Screening app
Free App – Guidelines at Your Fingertips!
For more information and/or to download the Cancer Screening App (now updated to include breast cancer screening guidelines), scan the QR code or choose your app store below:


Regional Cervical Screening/Colposcopy Leads

Six colposcopists from across the province have been appointed as the Regional Cervical Screening/Colposcopy Leads (CSCLs). The CSCLs fulfill a critical role in improving the quality, safety, and accessibility of cervical cancer screening and colposcopy services in Ontario. The CSCLs will help to advance the priorities of the Ontario Cervical Screening Program (OCSP), including colposcopy services.

Working closely with primary care and other providers within their respective regions, the CSCLs will participate in the implementation and management of changes to the program. Further, the CSCLs will help to advance the priorities of the Ontario Cervical Screening Program (OCSP), including colposcopy services.

Regional Cervical Screening/Colposcopy Leads (CSCLs)
LHIN
Name
Email Address
Provincial Lead
Joan Murphy
Joan.murphy2@cancercare.on.ca
LHIN 4 - Hamilton Niagara Haldimand Brant Dustin Costescu
costescu@hhsc.ca
LHIN 5/6 - Central West/Mississauga Halton
Paul Gurland
Paul.Gurland@gmail.com
LHIN 8 - Central Erica Mantay emantay@southlakeregional.org
LHIN 10 - South East Julie Francis julie.francis@queensu.ca
LHIN 11 - Champlain Susan McFaul smcfaul@ottawahospital.on.ca
LHIN 14 - North West Nicholas Escott escottn@tbh.net

Cervical Screening Evidence-Based Series

The Organization of Colposcopy Services in Ontario: Recommended Framework
EBS: January 2015
Status: CURRENT
Cervical Screening
15-9 EBS: October 2011
Status: CURRENT

Screening Activity Report

  • Screening Activity Report
    The Screening Activity Report (SAR) is an online tool to support primary care physicians in improving their cancer screening rates and appropriate follow-ups.

Publications

HPV and HPV Vaccine

For more information on the updated guidelines:

Order hard copies of the clinical tools or public materials through ServiceOntario. Call 1-866-410-5853 or go to the ServiceOntario website .


Cervical Cancer Screening - Frequently Asked Questions (FAQs)


About cervical cancer and screening

1. What is the cause of cervical cancer?

The necessary cause of virtually all cervical cancers and their precursors is persistent infection with high-risk (oncogenic) human papillomarvirus (HPV) types, especially types 16 and 18, which are implicated in the development of 70% of cervical cancer cases. Other co-factors that are not well understood are also involved. HPV is a common infection among sexually active males and females. Most HPV infections resolve spontaneously (i.e., go away on their own without medical intervention).

Risk factors for acquiring HPV infection

  • high number of intimate partners (of either sex)
  • early age of first sexual activity
  • new sexual partner
  • no matter how many partners a woman has had, male sexual partners with a high lifetime number of partners

Co-factors that have been associated with cervical cancer

  • smoking tobacco and exposure to second-hand smoke
  • long-term (more than five years) use of hormonal contraceptives
  • more than five full-term pregnancies
  • other sexually transmitted infections
  • poor diet (especially low antioxidant intake)
  • immunosuppression (e.g., human immunodeficiency virus [HIV], organ transplant, immunosuppressive drug therapy or chemotherapy)

2. What are the benefits and potential harms of screening?

Benefits

  • The Pap test can generally detect early changes in the cells of the cervix that precede cervical cancer, usually by many years, long before invasive cancer develops.
  • The Pap test can reduce cervical cancer incidence and mortality over the long term.

Potential harms

False-positives

  • Only a fraction of women with abnormal results will actually have cervical cancer.
  • Diagnostic interventions are needed to determine whether or not a woman with abnormal Pap test results has cervical cancer.
  • Women with abnormal screening results experience increased anxiety and fear. False-positive results need to be minimized to reduce patient worry and morbidity.

False-negatives

  • No test is perfect. False-negative Pap tests occur.
  • Women with false-negative Pap test results may mistakenly believe that they have no risk for cancer, which may cause them to ignore symptoms and not have them investigated.
  • Pap testing is less effective in detecting pre-invasive glandular lesions of the cervix than squamous cell carcinoma and has had limited impact in preventing adenocarcinoma.

Over-diagnosis

  • There is a risk of over-diagnosing pre-cancerous lesions that may not progress to cancer.
  • There is a risk of treating lesions not destined to become cancer.

Over-treatment

  • Research demonstrates that very few low-grade cervical intraepithelial neoplasia in women in their early 20s would progress to cancer within five years if left untreated.
  • Treating young women with cervical dysplasia is linked to a small but significant risk of adverse future pregnancy outcomes (e.g., preterm delivery or low birth weight).


Screening guidelines

3. What does the evidence say about triennial (every three years) screening vs. annual screening?

The three-year screening interval is consistent with knowledge about the natural history of cervical cancer. There is no evidence that annual screening is superior to screening every three years. Rather, there is evidence that more frequent screening increases harms without significantly increasing benefits. See question 2.

Screening every three years is safe and effective

  • Pre-malignant changes in the cervix develop slowly, usually over many years, before cervical cancer develops.
  • Cervical changes that are abnormal can be detected through regular screening every three years.
  • If these abnormal changes do not resolve on their own, then they can be treated so that cervical cancer is prevented.

The recommendation for a three-year screening interval was based on solid evidence showing that screening every three years is safe and effective.

4. Why should sexually active women now wait until age 21 to be screened?

Cancer Care Ontario, along with many Canadian jurisdictions and professional organizations, has increased the recommended age to initiate screening to 21 years in its screening guidelines. Most Western European countries do not start screening women for cervical cancer until they are even older than age 21.

Because the necessary cause of virtually all cervical cancers and their precursors is persistent infection with high-risk (oncogenic) human papillomarvirus (HPV) and HPV is transmitted through intimate sexual contact, women who are not sexually active by age 21 should delay cervical cancer screening until they are sexually active.

Sexual activity includes intercourse, as well as digital or oral sexual activity involving the genital area with a partner of either gender.

The evidence says:

Screening women early provides no benefit

  • Cervical cancer is rare in women under age 21.
    • In the five-year period from 2005 to 2009, there were fewer than six cases in women aged 15 to 19 across Ontario.
  • Most younger women clear HPV infections without long-term consequence to their cervical health.
    • Although young women have high rates of low-grade cytological abnormalities, they are, in most cases, transient HPV infections.
    • Approximately 90% of young women will clear an HPV infection within 24 months.

Screening women under age 21 can lead to harms—regardless of when they become sexually active

  • Detecting low-grade abnormalities causes unnecessary interventions, anxiety and fear.
    • Treating young women with cervical dysplasia may have harmful effects on future pregnancies, such as preterm delivery or low birth weight.
    • Research demonstrates that very few low-grade cervical intraepithelial neoplasia in women in their early 20s would progress to cancer within five years if left untreated.

5. Under what circumstances should I screen women before age 21?

  • Under special circumstances, women younger than age 21 may require individual assessment to determine whether screening for cervical cancer is appropriate. Special circumstances include women who are immunocompromised or who have suffered sexual abuse.
  • HPV vaccination is also important for women under age 21 . Appropriate vaccine coverage for girls and young women holds the greatest potential for decreasing or eradicating cervical cancer and its precursors.

Note: The updated cervical screening guidelines do not override your clinical judgment in evaluating your patients’ circumstances. You may also choose to consult with a specialist to determine appropriate screening.

6. Under what circumstances should I screen women over the age of 70?

  • Screening should be continued in women over the age of 70 if they have not had three or more negative tests in the previous 10 years (inadequate negative screen history).
  • There is no evidence to suggest continued screening in women with an adequate negative screen history who are over age 70 if they have new partners.

Note: The updated cervical screening guidelines do not override your clinical judgment in evaluating your patients’ circumstances. You may also choose to consult with a specialist to determine appropriate screening.

7. Under what circumstances should I screen women more frequently than what is recommended in the guidelines?

Certain populations of women benefit from more frequent screening than the average risk population. Annual cervical cytology screening for women age 21 or older is advised for:

Women who are immunocompromised , including:

  • women who are human immunodeficiency virus (HIV)-positive
  • women who are currently taking long-term immunosuppressants

Women who have been treated for high-grade cervical dysplasia (CIN II/CIN III) or cervical cancer

  • See question 8.

8. How frequently should I screen my patients who have had previous treatment for high-grade cervical dysplasia (CIN II/CIN III) and/or cervical cancer?

  • There is insufficient evidence to make an evidence-based recommendation regarding ongoing screening/surveillance of women who have had high-grade cervical dysplasia (CIN II/CIN III) and/or cervical cancer.
  • There is evidence that these women are at greater risk of future lower genital tract neoplasia. Therefore , current practice is for more frequent screening than the average risk population. Annual screening is commonly advised.

9. How often do I screen women who have been referred to colposcopy and discharged without treatment?

The colposcopist is the best source of guidance for specific recommendations for individual women. However, in general:

Women referred for colposcopy and found not to have high-grade cervical dysplasia (CIN II/CIN III)

  • If coloposcopic examination has been negative and cytology returns to normal, it is likely safe and appropriate to return to the standard screening algorithm.
  • In future, human papillomavirus (HPV) testing could play a role in ongoing screening for this group.

Women referred for colposcopy and treated for high-grade cervical dysplasia (CIN II/CIN III)

  • There is very little literature informing screening after the diagnosis and treatment of cervical dysplasia.
  • Our current advice is annual screening over the long term for women treated for CIN II/CIN III.


Follow-up

10. What is the recommendation for follow-up when the result on the Pap test shows atrophy?

Atrophy is an observation that may or may not be of clinical importance. It requires action only if clinically indicated (e.g., for symptoms or for re-evaluation of a woman’s cytology).

11. What is the recommendation for follow-up when the result on the Pap test shows benign endometrial cells?

  • Pre-menopausal women who are asymptomatic require no action (continue to follow usual screening guidelines).
  • Post-menopausal women require investigations, including adequate endometrial tissue sampling.
  • Any woman with abnormal vaginal bleeding requires investigation, which should include adequate endometrial tissue sampling.

12. What is the recommendation for follow-up when the cytology report states, “transformation zone components not present”?

  • Absence of transformation zone (T-zone) components alone does not require earlier re-screening.
  • Women whose cervical cytology is satisfactory for evaluation and negative for intraepithelial lesion or malignancy (NILM) but transformation zone components are lacking, should be re-tested at their regular screening interval as per the recommendations for follow-up of abnormal cytology .
  • Women with abnormal cervical cytology should follow the screening guidelines regardless of the presence or absence of T-zone components.

13. How do I follow up on abnormal screening tests for women who are under age 21?

Perform the appropriate diagnostic workup as per the recommendations for follow-up of abnormal cytology .



The Ontario Cervical Screening Program (OCSP), guidelines and your practice

14. Will provider incentives be changed to reflect the new guidelines?

  • The cervical screening guideline recommendations are based on solid evidence that balances the benefits of screening with the associated potential harms.
  • The following changes were made to align with these evidence-based guidelines:
    • In January 2013, billing rules changed to limit Pap tests (G365) to one per patient every 33 months.
    • The billing code G394, which is used to follow-up abnormal and inadequate Pap tests, was expanded to be used for women who would benefit from annual screening, including women who are immunocompromised (e.g., those who have human immunodeficiency virus infection/acquired immunodeficiency syndrome [HIV/AIDS]) and for women in vulnerable groups who may have difficulty accessing the services within the specified time period. Click here for additional information from the Ontario Ministry of Health and Long-Term Care on the changes to the Schedule of Benefits for Physician Services.
  • Starting in January 2014, the preventive bonuses will also align with the guidelines. Click here for additional information from the Ontario Ministry of Health and Long-Term Care for the 2012–13 Cumulative Preventive Care Bonus Information.

15. What type of reporting is available for my practice?

In the future, all patient enrolment model (PEM) physicians will have the opportunity to receive their patients’ screening information through the Screening Activity Report (SAR), which will:

  • provide information on the screening status of enrolled women
  • identify women requiring follow-up
  • present screening rates in comparison to physician peers

16. What do I tell my patients who want to be screened annually?

  • The recommendation for screening average-risk women every three years was based on evidence showing that a three-year screening interval is safe and effective. See question 3
  • There is no evidence that annual screening for average-risk women is superior to screening every three years. Rather, there is evidence that it is harmful to screen women more often than every three years.
  • Some women have special circumstances that require annual screening. See question 7.
  • Women at average risk who elect to be screened more frequently as per the guidelines can do so on a patient-pay basis.

17. What do I tell my patients who want to be screened for human papillomavirus (HPV)?

  • HPV testing should only be considered as a triage following an atypical squamous cells of undetermined significance (ASCUS) cytology result for women who are age 30 and older.
  • The HPV test is not funded by the Ontario Ministry of Health and Long-Term Care (MOHLTC). It is available on a user-pay basis for a cost of about $90 per test. Because this test is not publicly funded and patients have to pay for it, many women choose not to have it. An appropriate alternative following an ASCUS cytology result is to repeat the Pap test in six months.
  • Cancer Care Ontario is working with the MOHLTC to make HPV testing a fully-funded part of the Ontario Cervical Screening Program (OCSP).

18. What educational materials are available for my patients?

Visit our Resources for the Public page, where you can access frequently asked questions and brochures.

19. Were the screening guidelines changed as a cost-cutting measure?

  • No, cost was not a consideration in the development of the screening guidelines. The recommendations were developed based on solid evidence that balances the benefits of screening with the associated potential harms.
  • Cancer Care Ontario’s guidelines were developed by an expert panel based on a systematic review and meta-analysis of high-quality evidence conducted by CCO’s Program in Evidence-Based Care (PEBC).
  • There is no evidence that annual screening is superior to screening every three years. Rather, there is evidence that more frequent screening increases harms without significantly increasing benefits. See question 2.
  • The three-year screening interval is consistent with knowledge about the natural history of cervical cancer.
  • Most Canadian jurisdictions do not screen women annually. Worldwide, several organized programs comparable to Ontario’s screen every five years. Moreover, most jurisdictions initiate screening women for cervical cancer at age 21 and some recommend initiation at an even older age (e.g., 25).


Contact:

The Ontario Cervical Screening Program
1-866-662-9233
screenforlife@cancercare.on.ca

Last modified: Fri, Mar 20, 2015
cancer care ontario | action cancer ontario   620 University Avenue Toronto Ontario, Canada M5G 2L7   Phone: 416.971.9800 Fax: 416.971.6888

Please help improve the quality of our website by answering 10 brief questions in our online survey. Would you like to participate?

YesNo