Guidance

2. Management and referral guidelines for colposcopy

Updated 5 January 2023

1. Waiting times

1.1 Cancer waiting times: national policy

Referral times to colposcopy are governed by Improving Outcomes: A strategy for cancer and the 18 week pathway. Screening results that warrant referral to colposcopy and the relevant pathway are given below.

?invasion, high grade dyskaryosis (moderate and severe), ?glandular neoplasia, borderline changes in endocervical cells must be referred on a 2 week wait pathway. At least 93% of people referred with these results must be offered colposcopy within 2 weeks. Those found not to have cancer on colposcopic examination at the first visit transfer to the 18 week pathway for the remainder of their care.

Low grade dyskaryosis, borderline changes in squamous cells, persistent hrHPV positive cytology negative or persistent inadequate samples are referred in line with the 18 week pathway and programme standards. At least 99% of individuals must be offered a colposcopy appointment within 6 weeks of referral.

The NHS CSP standards are available on GOV.UK.

1.2 Faster diagnosis standard

The new Faster Diagnosis Standard ensures that all patients who are referred for the investigation of suspected cancer find out within 28 days if they do or do not have a cancer diagnosis. The NHS will introduce the standard in April 2020.

2. Standards for the cervical screening programme

2.1 Consolidated cervical screening programme standards

The consolidated cervical screening programme standards are a set of measures that providers must meet to ensure local screening services are safe and effective. The data reported against the standards can feature in reports to support commissioners and health professionals in providing a high-quality programme.

The standards ensure a consistent approach to cervical screening provision. The consolidated standards enable assessment of the screening process and help support continuous improvement. They focus on particular parts of the screening pathway and are meaningful at service provider levels.

There are other standards known as structural standards. Structural standards are not included in the consolidated standards. They describe the structure of the programme and must be fully met. They are a requirement of the screening programme and monitored through the Screening Quality Assurance Service (SQAS) and commissioning.

2.2 Quality indicators

The SQAS collects data to monitor the screening standards referred to above, along with other data to monitor the quality of services at clinic, organisation, regional and national level. SQAS data collection includes important clinical quality indicators outlined in this document. All colposcopy services must be able to provide accurate and validated data, at clinic or individual clinician level, as requested. The quality indicators outlined in this document are suitable for services to include as part of local audit.

3. Cervical screening reports

Colposcopy is a continuation of the screening process, providing further evidence about the nature of observed changes in the cervix. Colposcopists must therefore have access to an individual’s cervical screening test results, including any free text comments, at the time of the examination. The screening pathway and colposcopy pathway are available in the flowcharts accompanying this guidance.

4. hrHPV tests and results

4.1 hrHPV tests available for use within the cervical screening programme

There are a number of hrHPV tests available in the UK. The cervical screening programme performs a comparative analysis of the CE-marked tests to assess their suitability for use within the programme. Details of hrHPV tests considered appropriate for use in the cervical screening programme are available.

4.2 Inadequate samples

Referral on the basis of consecutive inadequate samples

When the hrHPV test result is unavailable or cytology is inadequate at any screening episode in the pathway, the sample must be repeated in no less than 3 months. Individuals who have inadequate cytology at the 24 month repeat test are an exception and are referred to colposcopy. Individuals who have 2 consecutive HPV unavailable or inadequate cytology results, in any combination, are referred to colposcopy.

Individuals referred following 2 consecutive HPV unavailable or inadequate cytology results

Following a referral due to 2 consecutive screening tests reported as either HPV unavailable or cytology inadequate, individuals who have a normal and adequate colposcopy examination should be followed up in the community at 12 months.

If HPV testing is negative at 12 months, individuals are returned to routine recall. When colposcopy is inadequate, individuals should have a repeat screening test and colposcopy examination in 12 months. If the repeat colposcopy is normal and HPV negative, the individual is discharged to routine recall. If the colposcopy is abnormal, management is as set out in national protocols (see the cervical screening pathway requirements guidance).

4.3 hrHPV Negative results

Samples that test negative for hrHPV are classified as ‘negative’. Individuals who receive a negative result can be safely returned to routine recall unless on:

• the test of cure (TOC) pathway
• the untreated CIN1 pathway
• follow-up for incompletely excised CGIN/SMILE or cervical cancer
• follow-up for borderline changes in endocervical cells

4.4 hrHPV positive results and negative cytology

Negative cytology

Individuals who are hrHPV positive and receive a negative cytology report as part of routine primary HPV screening should have the HPV test repeated at 12 months. If HPV testing is negative at 12 months, individuals can be safely returned to routine recall. Individuals who remain hrHPV positive, cytology negative at 12 months should have a repeat HPV test in a further 12 months. Individuals who become hrHPV negative at 24 months can be safely returned to routine recall.

As part of the TOC pathway, individuals who are hrHPV positive and receive a negative cytology report should be referred to colposcopy.

Referral on the basis of consecutive hrHPV positive samples as part of primary HPV screening

Individuals who remain hrHPV positive with cytology reported as borderline dyskaryosis or worse at 12 or 24 months should be referred to colposcopy.

Individuals who remain hrHPV positive, cytology negative or inadequate at 24 months should be referred to colposcopy.

Individuals who are hrHPV positive and non-cervical ?glandular neoplasia is detected require referral to gynaecology. Follow-up of the hrHPV result should be managed in the same way as those with hrHPV positive cytology negative results.

4.5 hrHPV positive results and abnormal cytology

All Individuals who are hrHPV positive and have abnormal cytology must be referred to colposcopy.

4.6 Benign endometrial cells in cervical samples

Benign endometrial cells are only reported in samples tested as hrHPV positive from individuals aged 45 or over. Management recommendations made by the programme are based only on the cervical abnormalities.

The significance of cytologically benign endometrial cells in cervical samples varies with the phase of the menstrual cycle, medication, clinical history and age of the individual. However, in a population-based cervical screening programme, some, if not most, of the information listed above is often unavailable. This should be reflected in the clinical management advice provided. For example, if the day of the menstrual cycle is not known and the sample is otherwise negative, it should be reported as negative, with a comment such as ‘Endometrial cells are present but menstrual history not stated. If there is any history of abnormal vaginal bleeding, referral for a gynaecological opinion should be considered.’

4.7 Abnormal cervix

Sample takers must make a suspected cancer pathway referral for individuals if, on examination, the appearance of the cervix is consistent with cervical cancer.

5. Individuals with symptoms

5.1 Management of individuals with symptoms

The cervical screening programme is a population-based screening programme, designed to reduce the incidence of, and mortality from, cervical cancer by detecting disease at an early stage of its development (before symptoms appear). Individuals presenting with symptoms of cervical cancer (for example postcoital bleeding or persistent vaginal discharge that cannot be explained by infection or other causes) are not suitable candidates for screening.

If the common causes of these symptoms have been excluded in general practice (for example infection or contraception usage), the individual must be referred for examination by a gynaecologist experienced in the management of cervical disease (for example a cancer lead gynaecologist). Gynaecologists may refer such individuals on for symptomatic colposcopic examination outside the cervical screening programme if cancer is suspected.

Contact bleeding at the time of cervical sampling may occur, and is not an indication for referral to colposcopy in the absence of other symptoms.

Evidence for the precise predictive value of post-coital bleeding for cervical cancer is poor. The majority of cases of post-coital bleeding are not due to malignant disease, and in younger individuals chlamydial infection or problems with contraception are more likely causes.

Referral guidelines for individuals with symptoms or if the appearance of the cervix is suspicious

An individual must be referred to colposcopy and should be seen within 2 weeks of referral (≥93% of cases) if the appearance of the cervix is suspicious or they have symptoms consistent with cervical cancer.

6. Treatment follow-up

6.1 Follow-up after treatment for cervical intraepithelial neoplasia (CIN) and test of cure

Individuals who have been treated for CIN are at increased risk of developing cervical cancer, but research published in 2016 and 2017 indicates they should be returned to community-based follow-up, irrespective of their excision margin status. A cervical sample should be taken 6 months after treatment. Following that sample:

• all individuals who are negative for hrHPV are recalled for a repeat cervical sample in 3 years
• all individuals who are positive for hrHPV must be referred to colposcopy; a reflex cytology sample will be processed to help inform colposcopy

6.2 Follow-up after treatment for cervical glandular intraepithelial neoplasia (CGIN) and test of cure

Individuals who undergo excision for CGIN are at risk of recurrence. If the CGIN has been completely excised at the time of first excision or subsequent re-excision, a test of cure (TOC) sample is taken 6 months after treatment. The location for follow-up TOC (colposcopy or primary care) should be decided at the multidisciplinary team (MDT) meeting. If negative for hrHPV a second TOC sample is taken 12 months later (18 months after treatment). If this is also negative for hrHPV the individual can be discharged or returned to recall in 3 years.

If at 6 or 18 months after treatment the TOC sample is positive for hrHPV, refer the individual to colposcopy. A reflex cytology sample is processed to help inform colposcopy.

If the individual fails TOC at 6 months only because of a positive hrHPV test (no abnormality detected at colposcopic examination), the individual should have a second TOC sample 12 months later. If this sample is negative for hrHPV the individual is discharged to recall in 3 years. Further recall will depend on the result of this test and the age of the individual.

If a positive cytology result is reported in either of the 6 or 18 months TOC samples, the individual must be referred to colposcopy and managed appropriately. If no colposcopic abnormality is present and re-excision is not appropriate, the individual reverts to follow up for 10 years of annual hrHPV testing.

Individuals who have incompletely excised CGIN and have declined re-excision should be followed up in the colposcopy clinic. hrHPV testing should be performed 6 months after treatment. If the result is negative, the test is repeated 6 months later (12 months after treatment) and then annually for the subsequent 9 years. All CGIN cases must be discussed at the colposcopy MDT.