Cervical screening care pathway
Published 18 August 2021
Applies to England
© Crown copyright 2021
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These flowcharts (illustrations and text descriptions below) describe the care pathway for NHS cervical screening. The pathway is divided into 3 flowcharts:
- invitation, sample taking and HPV testing and cytology triage
- colposcopy (including histopathology)
- abnormal colposcopy result management (including sample taking, colposcopy and histopathology)
Flowchart part 1: sample taking and HPV testing and cytology triage
1. Send out the invitation. Does the woman opt out of screening?
Yes: The Cervical Screening Call and Recall Service (CSAS) is notified and the woman is ceased from screening. End of screening test pathway.
No: Woman attends screening. Go to question 2.
2. Carry out the test. Is the result high risk human papillomavirus (hrHPV) negative or positive?
hrHPV negative: return individual to routine recall. End of screening test pathway.
hrHPV positive: carry out cervical cytology test. Go to question 3.
Note: If a test result is unavailable or cervical cytology is inadequate at any stage in the screening pathway, the sample must be repeated in no less than 3 months. Allow up to 2 consecutive unavailable or inadequate repeats – always refer to colposcopy at the second.
3. Is cytology negative or abnormal?
Cytology negative: screen again in 12 months’ time. Go to question 4.
Cytology abnormal: refer to colposcopy. End of screening test pathway.
4. Is hrHPV test result negative or positive?
hrHPV negative: return individual to routine recall. End of screening test pathway.
hrHPV positive: carry out cervical cytology test. Go to question 5.
5. Is cytology negative or abnormal?
Cytology negative: rescreen in 12 months’ time. Go to question 6.
Cytology abnormal: refer to colposcopy. End of screening test pathway.
6. Is hrHPV test result negative or positive?
hrHPV negative: return individual to routine recall. End of screening test pathway.
hrHPV positive: carry out cervical cytology test and refer to colposcopy (regardless of the cytology test result as this is the third consecutive hrHPV positive result). End of screening test pathway.
Flowchart part 2: colposcopy (Including histopathology)
1. Carry out the colposcopy examination. Is the examination adequate?
Yes: go to question 3.
No: go to question 2.
2. What were the results of the hrHPV and cytology tests (leading to colposcopy referral)?
hrHPV positive, cytology low grade or less (excluding borderline change in endocervical cells): repeat colposcopy in 12 months. If repeat colposcopy examination has inadequate outcome, consider large loop excision of the transformation zone (LLETZ) patient choice. End of colposcopy management pathway (for this colposcopy episode).
hrHPV positive, cytology high grade or worse, or borderline (endocervical): undertake LLETZ. End of colposcopy management pathway (further management based on findings from LLETZ).
3. What did the colposcopy examination show?
Abnormal biopsy showing cervical intra-epithelial neoplasia (CIN)1 or worse, or colposcopic impression of CIN1 (no biopsy): manage as an abnormal colposcopy examination. Go to Flowchart 3 (abnormal colposcopy result management pathway) below.
No CIN on biopsy, no biopsy, or no colposcopic impression of CIN: go to question 4.
4. What were the results of the hrHPV and cytology tests (leading to colposcopy referral)?
Second consecutive hrHPV unavailable or HPV positive with cytology inadequate: recall in 12 months. End of colposcopy management pathway (for this colposcopy episode)
hrHPV positive, cytology low grade or less: recall to screening in 36 months. End of colposcopy management pathway (for this colposcopy episode). If HPV test is negative at 36 months, return to routine screening interval. If HPV test is positive at 36 months, follow the process outlined in pathway part 1 above.
hrHPV positive, cytology high grade or worse, or borderline (endocervical): discuss at multidisciplinary team (MDT) meeting within 2 months. End of colposcopy management pathway (for this colposcopy episode). Further management based on results of MDT meeting.
Flowchart part 3: abnormal colposcopy result management (including sample taking, colposcopy and histopathology)
1. Abnormal biopsy result: was the result CIN1?
Yes: the CIN1 pathway only applies to individuals with CIN1 confirmed on biopsy or colposcopic impression of CIN1 (no biopsy) who were referred with low grade cytology, or hrHPV positive/cytology negative referrals. Recall in 12 months. Go to question 2.
No: CIN2, CIN3 or cervical glandular intra-epithelial neoplasia (CGIN): Go to question 6.
2. Is screening result hrHPV negative or positive?
hrHPV negative: recall in 36 months. End of abnormal colposcopy result pathway (for this colposcopy episode). If HPV test is negative at 36 months, return to routine screening interval. If HPV test is positive at 36 months, follow the process outlined in pathway part 1 above.
hrHPV positive: carry out cervical cytology test. Go to question 3.
3. Is cytology negative or abnormal?
Cytology negative: recall in 12 months. Go to question 4.
Cytology abnormal: refer to colposcopy. End of abnormal colposcopy result pathway (for this colposcopy episode). Further management based on findings from repeat colposcopy.
4. Is hrHPV result negative or positive?
hrHPV negative: recall in 36 months. End of abnormal colposcopy result pathway (for this colposcopy episode). If HPV test is negative at 36 months, return to routine screening interval. If HPV test is positive at 36 months, follow the process outlined in pathway part 1 above.
hrHPV positive: carry out cervical cytology test. Go to question 5.
5. Is cytology negative or abnormal?
Cytology negative: recall in 36 months. End of abnormal colposcopy result pathway (for this colposcopy episode). If HPV test is negative at 36 months, return to routine screening interval. If HPV test is positive at 36 months, follow the process outlined in pathway part 1 above.
Cytology abnormal: refer to colposcopy. End of abnormal colposcopy result pathway (for this colposcopy episode). Further management based on findings of repeat colposcopy.
6. Was result CIN2 or CIN3, or CGIN?
CIN2 or CIN3: provide treatment and recall in 6 months. Go to question 7.
CGIN: Provide treatment. Individuals who have been adequately treated (complete excision margins) for CGIN or stratified mucin producing intraepithelial lesions (SMILE), recall in 6 months. Go to question 8. For management of those incompletely excised, or la1 cervical cancer, see section 4 of Cervical screening: programme and colposcopy management.
7. Is screening result hrHPV negative or positive?
hrHPV negative: recall in 36 months. End of abnormal colposcopy result pathway (for this colposcopy episode). If HPV test is negative at 36 months, return to routine screening interval. If HPV test is positive at 36 months, follow the process outlined in pathway part 1 above.
hrHPV positive and cytology negative, inadequate or abnormal: refer to colposcopy. End of abnormal colposcopy result pathway (for this colposcopy episode). Further management based on findings of repeat colposcopy.
8. Is hrHPV result negative or positive?
hrHPV negative: recall in 12 months. Go to question 9.
hrHPV positive: carry out cervical cytology test. Go to question 10.
9. Is hrHPV result after 12 months negative or positive?
hrHPV negative: recall in 36 months. End of abnormal colposcopy result pathway (for this colposcopy episode). If HPV test is negative at 36 months, return to routine screening interval. If HPV test is positive at 36 months, follow the process outlined in pathway part 1 above.
hrHPV positive: carry out cervical cytology test. Go to question 10.
10. Is cytology result negative, inadequate or abnormal?
Cytology negative or inadequate: refer to colposcopy. If colposcopy normal, recall in 12 months. Go to question 11.
Cytology abnormal: Refer for colposcopy. End of abnormal colposcopy result pathway (for this colposcopy episode). If colposcopy is normal and/or there is no re-excision, complete 10 year follow up. If hrHPV positive at any point during 10 year follow up, refer to colposcopy (regardless of the presence or absence of endocervical cells). If there is re-excision, begin follow up of CGIN according to this pathway (pathway part 3).
11. Is hrHPV result after 12 months negative or positive?
hrHPV negative: recall in 36 months. End of abnormal colposcopy result pathway (for this colposcopy episode). If HPV test is negative at 36 months, return to routine screening interval. If HPV test is positive at 36 months, follow the process outlined in pathway part 1 above.
hrHPV positive: carry out cervical cytology test. Go to question 12.
12. Is cytology result negative, inadequate or abnormal?
Cytology negative or inadequate: refer to colposcopy. If colposcopy normal, recall in 12 months. End of abnormal colposcopy result pathway (for this colposcopy episode). Note: after 12 month recall, go to question 11 above.
Cytology abnormal: refer to colposcopy. If normal colposcopy and/or no re-excision, complete 10 year follow up. If hrHPV positive at any point during 10 year follow up, refer back to colposcopy (regardless of the presence or absence of endocervical cells). End of abnormal colposcopy result pathway (for this colposcopy episode). If there is further excision, begin follow up of CGIN according to this pathway (pathway part 3).