Original Title: Initier un test de dépistage du cancer du col de l’utérus par test VPH et en assurer le suivi

Authors' objectives: Cervical cancer is the third most common cancer in women aged 25 to 44 years, and almost all cases are caused by HPV infection. When the infection persists over time, it can cause the formation of cancerous or precancerous cervical lesions. Since the infections and lesions are mostly asymptomatic, screening is an essential tool for detecting and contributing to the elimination of this cancer. Lesions caused by HPV progress slowly, which provides an opportunity for screening and treatment during the early stages. In Quebec, the HPV test, a safe and highly sensitive screening tool, is currently being implanted as a replacement for the Pap test, as the first-line cervical cancer screening test. The Ministère de la Santé et des Services sociaux asked the Institut national d’excellence en santé et en services sociaux to develop a national medical protocol to initiate an HPV test and follow up on results for cervical cancer screening and an accompanying collective prescription template to support the test’s implementation in this province. These tools should be used within the context of the gradual implementation plan of the new HPV test in the different regions of Quebec.

Authors' results and conclusions: The data analysis and the iterative process with the advisory committee’s members, while developing the screening tools, revealed the following information and issues. (#1 A CLINICAL SITUATION IN LINE WITH THE NEW RECOMMENDATIONS CONCERNING THE HPV TEST): In keeping with the recommendations issued by INESSS in its 2022 report, the protocol is intended for the screening of persons between the ages of 25 and 65 years with a cervix. The clinical situation covered by the protocol is also in line with the recommended 5 years HPV testing interval for immunocompetent individuals. If the last screening test was a Pap test, one should wait 3 years before doing a first screening with an HPV test. (#2 THE INCLUSION OF IMMUNOCOMPROMISED INDIVIDUALS PROMOTING THEIR TIMELY ACCESS TO SCREENING): The protocol allows for the use of the HPV screening test in immunocompromised individuals to offer them timely screening and prevent additional delays in follow-up, in the event of a positive result. In coherence with this population’s particular needs, different screening intervals are recommended, that is, 3 years after the last HPV test screening or one year after the last Pap test screening. In the event of a positive result, however, the follow-up differs, and it stipulates that it must, in all cases, prompt a referral for a colposcopy. (#3 SITUATIONS BEYOND THE SCOPE OF THE NATIONAL MEDICAL PROTOCOL): The protocol was developed with the intention to allow the screening of the largest possible number of people. However, the following situations were identified as being contraindications to apply the protocol: • Total hysterectomy, since the specimen is obtained from the cervix. If a hysterectomy was performed due to malignancy, an individualized follow-up is required; • Postmenopausal bleeding, an individualized follow-up is required (#4 TWO SPECIMEN COLLECTION PROCEDURES PROPOSED): As recommended by INESSS in 2022, screening will be carried out with an HPV test, and positive results will be triaged by cytological analysis of cervical cells. There are two possible options: • A cervical specimen obtained by a clinician, which makes it possible to perform the HPV test and triage cytology on the same specimen; • A self-collected specimen obtained in-clinic, with a second visit for triage cytology in the event of a positive HPV result. (#5 PROBLEMS ACCESSING PREVIOUS SCREENING RESULTS): Access to previous screening results is a concern for the clinicians consulted. Although crucial for facilitating their work and ensuring the effectiveness and relevance of medical procedures, access to patient records is limited. Adherence to the recommended screening interval can be achieved only if information about the previous screening is available. This information is essential to avoid overscreening and, consequently, needless resource utilization. CONCLUSION: The development of the national medical protocol and the accompanying collective prescription template is based on clinical practice recommendations and the stakeholders’ perspectives. The protocol and template should adequately equip clinicians during the gradual implementation of the HPV test in the different regions of the province and promote the harmonization of screening practices.

Authors' recommendations: The recommendations established following the iterative process with the advisory committee’s members are highlighted throughout the report and are integrated into the clinical tools that have been developed, i.e., a national medical protocol and an accompanying collective prescription template allowing colposcopy referrals when screening results so warrant. These tools are designed to assist front-line health professionals in using the HPV test as a first-line screening method.

Authors' methods: Recommendations on cervical cancer screening were issued by INESSS in two recent publications. Consequently, these recommendations are included in the national medical protocol that has been developed. In accordance with INESSS‘s quality standards, a systematic literature search was conducted to answer the other assessment questions contributing to the development of the protocol. The methodological quality of the selected publications was assessed by two scientific professionals using the AGREE II instrument criteria. An advisory committee consisting of clinicians from different specialties was formed to gather the stakeholders’ perspectives and harmonizing the information compiled from the clinical practice guidelines with the context of Québec practice. The quality, acceptability and applicability of the protocol and collective prescription template were evaluated by outside reviewers and future users, who were not involved in their development.

Authors' identified further research: The advisability of updating the protocol and template will be determined 4 years after their publication. However, the publication of new evidence or new guidelines or changes in the organizational context surrounding the implementation of the HPV test and the option of self-collection may accelerate the update.

Project Status: Completed

URL for project: https://www.inesss.qc.ca/publications/repertoire-des-publications/publication/depistage-cancer-uterus-recommandations.html

Year Published: 2024

URL for published report: https://www.inesss.qc.ca/publications/repertoire-des-publications/publication/depistage-cancer-uterus-recommandations.html

English language abstract: An English language summary is available

Publication Type: Other

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: L'Institut national d'excellence en sante et en services sociaux (INESSS)