Guidance

6. Screening and management of immunosuppressed individuals

Updated 5 January 2023

1. Definition of immunosuppression

This chapter includes guidance for the management of individuals on immune suppressing medication, transplant recipients of any organ, and all other forms of immunosuppression.

2. Management of immunosuppressed individuals

2.1 Individuals with renal failure requiring dialysis

All individuals eligible for screening but who have renal failure requiring dialysis (or any other disease with a high chance of needing organ transplantation) must have a cervical screening sample at or shortly after diagnosis if they are not already up to date with screening. Individuals with an abnormal result should be referred to colposcopy in accordance with the current pathway.

All individuals eligible for screening who are about to undergo organ transplantation should have had a cervical screening sample performed within the previous year. Co-existing cervical intraepithelial neoplasia (CIN) should be managed according to the information given in chapter 3.

2.2 Individuals taking maintenance immunosuppression medication post-transplantation

Individuals taking maintenance immunosuppression medication after transplantation who have no history of CIN should have cervical screening in accordance with the national guidelines for the general population. Any abnormal screening result should be managed as per the current pathway.

There should be effective education of both organ transplant recipients and their carers about the need to participate in the cervical screening programme, with the production of leaflets and other educational materials specifically for this group. A variety of immunosuppressant drugs increase the risk of contracting hrHPV (for example, drugs used following organ transplantation, or for treatment of autoimmune or neurological disorders). However they have no impact on the rate of progression through hrHPV and CIN to cervical cancer, which takes many years. The increased risk of contracting hrHPV however means it is important that people taking immunosuppression medication engage with cervical screening when invited.

2.3 Individuals with multifocal disease

The screening and management of an immunosuppressed individual is a complex area of assessment and management. This is especially true for those with multifocal disease. These individuals must be managed in a centre with demonstrable skill and expertise, and sufficient access to patient numbers to maintain that expertise.

There must be a compromise between the increased risk of CIN and the additional psychological and physical trauma of assessment and treatment, with due consideration paid to the co-morbidity of the underlying disease process. These patients should be assessed by symptom enquiry, cervical screening sample (within the context of the cervical screening programme), colposcopy, vulvoscopy, and biopsy where indicated at least every 6 months.

Consideration should also be given to performing high resolution anoscopy if there are available resources. Anal screening is still being evaluated, but anal cytology is available in specialist settings.

2.4 Other individuals who are immunosuppressed

There is no indication for increased surveillance for individuals receiving:

• cytotoxic chemotherapy for non-genital cancers
• ioestrogen antagonists such as tamoxifen
• alemtuzumab
• cytotoxic drugs for rheumatological disorders or biologic agents for other disorders

These individuals should have cervical screening according to the national guidelines for the general population. If there is an indication for increased surveillance relating to the prescribing of long term biologic agents, local protocols should be developed as this indication for more intensive screening is outside cervical screening programme standard practice.

2.5 Individuals who have been exposed to diethylstilbestrol (DES)

Daughters of individuals exposed to DES are at increased risk of clear cell cancer of the cervix and vagina but not other forms of cervical cancer. There is estimated to be no more than 1 case per year in England and Wales. Routine call and recall is appropriate. Local arrangements should be made for the follow up of individuals who are DES daughters and have the stigmata of DES exposure. This is usually via annual colposcopy. Requesting cytology even if individuals are hrHPV negative requires local service agreements. Management of any abnormal cytology is outside the programme. Granddaughters of those exposed to DES are not at any increased risk of cervical or vaginal cancer.

2.6 Individuals who are human immunodeficiency virus (HIV) positive

All individuals newly diagnosed with HIV should have cervical surveillance performed by, or in conjunction with, the medical team managing the HIV infection. Annual screening should be performed with an initial colposcopy if resources permit. Subsequent colposcopy for any screening abnormality should follow national guidelines. The age range screened should be the same as for HIV negative individuals.

Despite the higher cervical treatment failure rate, high grade CIN should be managed according to national guidelines. Lesions less severe than CIN2 should generally not be treated as these are likely to represent persistent hrHPV infection of the cervix which responds poorly to treatment and may clear spontaneously. Regular cytological surveillance will detect progression.

Research published in 2005, 2012 and 2013 advises close co-operation between colposcopists and medical teams managing individuals with HIV to ensure that individuals are not over treated if there is a possibility of enhancing immunocompetence (for example by raising CD4 counts following compliance with antiretroviral therapy).

Individuals who are HIV positive can cease cervical screening at age 65 if they fulfil the other general criteria for ceasing.