HPV screening and follow-up pathway

Resources for primary care providers and colposcopists

Communicating with participants

Recommendation: Develop resources and support primary care providers and colposcopists in communicating and discussing triage and follow-up protocols with participants who receive a positive HPV test result.

Key evidence and implementation considerations:

• Ensuring that those who have participated in self-sampling are aware of triage and follow-up protocols is especially important as participants may not have had previous contact with primary care providers. There is the potential for harm if there is not a clear path for participants to access follow-up care.
• While primary care providers are responsible for triage, colposcopists will also require support in communicating follow-up protocols with patients and addressing anxieties.
• Materials for primary care providers and colposcopists should include guidance on how to communicate with participants who receive a positive HPV test result, including information on what participants can expect during the triage and follow-up process. Primary care providers and colposcopists should also receive guidance on how to support participants through anxieties and fears that may arise following a positive HPV test result.
  • This is especially important for those who may not have previously participated in screening as a result of past trauma. Extra resources, materials and supports that are culturally sensitive and trauma-informed should be made available to these individuals.
• Primary care providers and colposcopists should be equipped with handouts for participants looking for further details and information on the triage and follow-up pathways.
• Participants who are referred to colposcopy may have anxiety before the procedure. Although information and guidance should be provided at the beginning of the HPV screening pathway, colposcopists should also reiterate any important information about triage and follow-up, as well as take measures to alleviate anxieties.¹
• Participants should be made aware that a positive HPV test does not necessarily indicate a malignancy. It is important to convey to participants the purpose and importance of triage and follow-up in determining if they have cancer or not.
• The difference between a screening test and a diagnostic test should be explained in plain language.

Managing cytology and colposcopy resources

Recommendation: Work with lab partners to plan for expected changes to cytotechnologist/cytopathologist workload based on the transition to HPV primary screening.

Key evidence and implementation considerations:

• While the implementation of HPV primary screening may mean an overall decrease in volume of samples being reviewed by cytotechnologists/cytopathologists, there will be a shift in the type of samples being reviewed.²
• Because HPV testing is more sensitive than cytology, cytotechnologists/cytopathologists will likely see more abnormal cytology samples through the triage pathway that are more complex and require more time to interpret.² As such, a decrease in cytology volumes may not be directly proportional to the decrease in workload for cytotechnologists.² Jurisdictions can retrain staff to support processing of HPV tests.
• Countries that have already implemented HPV primary screening (e.g., Australia, Finland, United Kingdom) managed the change in demand for cytotechnologists through a variety of strategies, such as training/retraining current cytotechnologists in other areas (e.g., histology, molecular pathology, immunology, rapid on-site evaluation).³

Referral to colposcopy and/or treatment

Recommendation: Referral pathways must reflect changes in initial triage, follow-up triage and referral to colposcopy based on evidence and best practice guidelines for transitioning to HPV primary testing.

Key evidence and implementation considerations:

• Please refer to the guidelines on the management of participants with a positive HPV test and risk-based colposcopy and surveillance. With funding from the Partnership, these guidelines were developed by the Society of Gynecologic Oncology of Canada (GOC) with collaboration from the Society of Canadian Colposcopists (SCC) to provide recommendations for the general population and special populations (i.e., those who are pregnant, immunocompromised, menopausal or under the age of 25), referral pathways for low- and high-grade referral pathways, conservative management of patients with moderate cervical intraepithelial neoplasia (CIN2) who are less than 30 years old, treatment for patients with high-grade squamous intraepithelial lesion (HSIL) histology, and post-treatment and glandular pathways.
• Coordination of care between providers is important to ensure accountability throughout transitions in care and for timely referral to colposcopy.

Quality assurance

Recommendation: Develop and integrate standardized triage protocols based on evidence and best practice to help facilitate continuity within jurisdictions.

Key evidence and implementation considerations:

• Quality indicators can be used to monitor effectiveness of triage protocols and inform quality improvement initiatives.
• It is important to monitor participation in the follow-up pathway by screening participants with an HPV-positive result. Primary screening does not work unless those at highest risk move through the triage pathway. Programs should establish regular monitoring of progress through triage for those with HPV-positive results.