Original Title: Avis: Dépistage du cancer du col de l’utérus au Québec : recommandations pour l’implantation du test de détection des virus du papillome humain (test VPH) comme test de dépistage primaire

Authors' objectives: In Canada, it is estimated that 1 in 168 women will develop cervical cancer in her lifetime. However, both the incidence and mortality of cervical cancer have decreased significantly over the past few decades. This decrease is largely attributable to cytology-based cervical cancer screening (Papanicolaou or Pap test). Another cervical cancer screening option is the human papillomavirus (HPV) detection test, a molecular test that detects the virus’s nucleic acids from a genital specimen. In 2017, the Institut national d’excellence en santé et en services sociaux (INESSS) published a state-of-knowledge report comparing cytology and the HPV test. According to the data compiled in that report, the HPV test compares favourably to cytology. Consequently, the Ministère de la Santé et des Services sociaux (MSSS) informed INESSS of its intention to proceed with the implementation of the HPV test as the primary cervical cancer screening test. The ministry has requested recommendations on the strategies and measures for implementing this test, particularly with regard to optimizing screening participation, the screening pathway to be chosen, the relevance of offering self-sampling, and how to ensure that individuals with abnormal screening test results are optimally managed.

Authors' results and conclusions: RESULTS: The data reviewed suggest that vaccination results in a lower incidence of cervical cancer. This reduction appears to be greater in individuals who were vaccinated before the age of 17 years. As for high-grade precancerous lesions (CIN2+), vaccination appears to have reduced their incidence among women aged 24 and under. One study has also reported a lower prevalence of all grades of cervical lesions in young women who were vaccinated against HPV in elementary school. The data reviewed suggest that the performance of self-sampling HPV testing is similar to that of clinician-sampling HPV testing. One meta-analysis found that the two are equivalent, provided that self-sampling is used in conjunction with an HPV test that uses a polymerase chain reaction (PCR) technique rather than a signal amplification technique. In addition, offering self-sampling to the underscreened (see below) increases their screening participation rate. Mailing the self-sampling kit appears to be more effective in increasing participation than making the kit available in pharmacies or medical clinics. However, there is no evidence concerning the impact of self-sampling on the screening participation rate in the general population. Lastly, self-sampling is considered acceptable by the vast majority of those who have done it. It was considered painless, easy to do and convenient by a large majority of the participants in the included studies. The women who prefer to consult a clinician for their screening expressed concerns about their ability to self-sample correctly and, therefore, about ensuring the validity of the result. The implementation of the HPV test as the primary screening test will be accompanied by the creation of a provincial cervical cancer screening program. As a result, there will be several changes aimed at better organizing the offer of this service. A strategy for inviting those eligible for screening could be implemented to optimize screening coverage and facilitate access to screening for persons without a family physician. The laboratories that will analyze the specimens will have to be designated, and the significant increase in the volume of HPV tests might require purchasing equipment and instituting validation and quality control processes. The shift to HPV testing also means that steps will have to be taken to inform the public and health professionals about the upcoming changes. These measures will help ensure the optimal use of the HPV test.

Authors' recommendations: Regarding the cervical cancer screening pathway, INESSS recommends: • initiating cervical cancer screening with the HPV test at age 25; • stopping HPV test screening at age 65; • that HPV test screening be done at 5-year intervals; • that those who test positive for HPV 16 or 18 be immediately referred for colposcopy and that other HPV-positive results be triaged by cytology; • that those who test positive for a genotype other than HPV 16 and 18 and whose triage cytology result does not warrant a referral for colposcopy be recalled one year later for HPV testing, according to the following: - if the result is positive, the person is referred for colposcopy; - if the result is negative, the person returns to the regular screening program; - those who are referred for colposcopy and subsequently managed should re-enter the screening program according to the current algorithm at the time they are discharged from their gynecological follow-up, on the condition that they are still eligible. INESSS does not recommend adjusting the screening protocol according to individual vaccination status. Such adjustments could become useful when the impact of vaccination in the screening-eligible population is greater or when data to support such adjustments become available.

Authors' methods: To respond to the assessment questions, an extensive search of the scientific literature was conducted. All study designs were included, with the exception of conference abstracts, narrative reviews, and case series. Contextual and experiential data were collected from experts on an advisory committee. Consultations with the screening target population were held to obtain their perspectives on the upcoming changes. All the data (scientific, contextual and experiential) were integrated in order to summarize the findings, which were assigned a level of evidence using the GRADE method. These findings, along with proposed recommendations, were submitted to the Comité d’excellence clinique for deliberation with a view to making the final recommendations.

Project Status: Completed

URL for project: https://www.inesss.qc.ca/publications/repertoire-des-publications/publication/depistage-du-cancer-du-col-de-luterus-au-quebec-recommandations-pour-limplantation-du-test-de-detection-des-virus-du-papillome-humain-test-vph-comme-test-de-depistage-primaire.html

Year Published: 2022

URL for published report: https://www.inesss.qc.ca/publications/repertoire-des-publications/publication/depistage-du-cancer-du-col-de-luterus-au-quebec-recommandations-pour-limplantation-du-test-de-detection-des-virus-du-papillome-humain-test-vph-comme-test-de-depistage-primaire.html

English language abstract: An English language summary is available

Publication Type: Full HTA

Country: Canada

Province: Quebec

Organisation Name: Institut national d'excellence en sante et en services sociaux

Contact Address: L'Institut national d'excellence en sante et en services sociaux (INESSS) , 2021, avenue Union, bureau 10.083, Montreal, Quebec, Canada, H3A 2S9;Tel: 1+514-873-2563, Fax: 1+514-873-1369

Contact Name: demande@inesss.qc.ca

Contact Email: demande@inesss.qc.ca

Copyright: Gouvernement du Québec