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WHO guideline for screening and treatment of cervical pre-cancer lesions for cervical cancer prevention [Internet]. 2nd edition. Geneva: World Health Organization; 2021.

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WHO guideline for screening and treatment of cervical pre-cancer lesions for cervical cancer prevention [Internet]. 2nd edition.

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ANNEX 4SEVEN ALGORITHMS PRIORITIZED FOR PHASE 1 OF THE GUIDELINE UPDATE

Screening and treatment approaches

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In the “screen-and-treat approach”, the decision to treat is based on a positive primary screening test only. Image ch6if1.jpg

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In the “screen, triage and treat approach”, the decision to treat is based on a positive primary screening test followed by a positive second test (a “triage” test), with or without histologically confirmed diagnosis. Image ch6if2.jpg

Screen-and-treat approaches:

1.

Visual inspection with acetic acid (VIA) as the primary screening test, followed by treatment

2.

HPV DNA (self- or clinician-collected) as the primary screening test, followed by treatment

Screen, triage and treat approaches:

3.

Cytology as the primary screening test, followed by colposcopy triage, followed by treatment

4.

HPV DNA as the primary screening test, followed by HPV16/18 triage (when already part of the HPV test), followed by treatment, and using VIA triage for those who screen negative for HPV16/18

5.

HPV DNA as the primary screening test, followed by VIA triage, followed by treatment

6.

High-risk HPV DNA as the primary screening test, followed by colposcopy triage, followed by treatment

7.

HPV DNA as the primary screening test, followed by cytology triage, followed by colposcopy and treatment

ALGORITHM 1. PRIMARY VIA SCREENING (SCREEN-AND-TREAT APPROACH).

ALGORITHM 1PRIMARY VIA SCREENING (SCREEN-AND-TREAT APPROACH)

For both the general population of women and women living with HIV

a Ablative treatment includes cryotherapy and thermal ablation.

b Cold knife conization (CKC) if LLETZ not available.

c LLETZ and LEEP (loop electrosurgical excision procedure) indicate the same procedure.

d Histology may not be available in certain settings; women should be advised to attend follow-up after 1 year or to report earlier, if they have any of the symptoms of cervical cancer.

AIS: adenocarcinoma in situ; CIN: cervical intraepithelial neoplasia; LLETZ: large-loop excision of the transformation zone; VIA: visual inspection with acetic acid.

ALGORITHM 2. PRIMARY HPV DNA TEST SCREENING (SCREEN-AND-TREAT APPROACH).

ALGORITHM 2PRIMARY HPV DNA TEST SCREENING (SCREEN-AND-TREAT APPROACH)

For the general population of women

a Ablative treatment includes cryotherapy and thermal ablation.

b Cold knife conization (CKC) if LLETZ not available.

c LLETZ and LEEP (loop electrosurgical excision procedure) indicate the same procedure.

d Histology may not be available in certain settings; women should be advised to attend follow-up after 1 year or to report earlier, if they have any of the symptoms of cervical cancer.

AIS: adenocarcinoma in situ; CIN: cervical intraepithelial neoplasia; HPV: human papillomavirus; LLETZ: large-loop excision of the transformation zone.

ALGORITHM 3. PRIMARY CYTOLOGY SCREENING AND COLPOSCOPY TRIAGE (SCREEN, TRIAGE AND TREAT APPROACH).

ALGORITHM 3PRIMARY CYTOLOGY SCREENING AND COLPOSCOPY TRIAGE (SCREEN, TRIAGE AND TREAT APPROACH)

For both the general population of women and women living with HIV

a Some programmes prefer to use LSIL threshold.

ASCUS: atypical squamous cells of undetermined significance; HPV: human papillomavirus; LSIL: low-grade squamous intraepithelial lesion.

ALGORITHM 4. HPV DNA SCREENING AND HPV16/18 TRIAGE (SCREEN, TRIAGE AND TREAT APPROACH).

ALGORITHM 4HPV DNA SCREENING AND HPV16/18 TRIAGE (SCREEN, TRIAGE AND TREAT APPROACH)

For both the general population of women and women living with HIV

a Ablative treatment includes cryotherapy and thermal ablation.

b Cold knife conization (CKC) if LLETZ not available.

c LLETZ and LEEP (loop electrosurgical excision procedure) indicate the same procedure.

d Histology may not be available in certain settings; women should be advised to attend follow-up after 1 year or to report earlier, if they have any of the symptoms of cervical cancer.

e May or may not be positive for HPV 45.

AIS: adenocarcinoma in situ; CIN: cervical intraepithelial neoplasia; LLETZ: large-loop excision of the transformation zone; VIA: visual inspection with acetic acid.

ALGORITHM 5. PRIMARY HPV DNA SCREENING AND VIA TRIAGE (SCREEN, TRIAGE AND TREAT APPROACH).

ALGORITHM 5PRIMARY HPV DNA SCREENING AND VIA TRIAGE (SCREEN, TRIAGE AND TREAT APPROACH)

For both the general population of women and women living with HIV

a Ablative treatment includes cryotherapy and thermal ablation.

b Cold knife conization (CKC) if LLETZ not available.

c LLETZ and LEEP (loop electrosurgical excision procedure) indicate the same procedure.

d Histology may not be available in certain settings; women should be advised to attend follow-up after 1 year or to report earlier, if they have any of the symptoms of cervical cancer.

AIS: adenocarcinoma in situ; CIN: cervical intraepithelial neoplasia; HPV: human papillomavirus; LLETZ: large-loop excision of the transformation zone; VIA: visual inspection with acetic acid.

ALGORITHM 6. PRIMARY HPV DNA SCREENING AND COLPOSCOPY TRIAGE (SCREEN, TRIAGE AND TREAT APPROACH).

ALGORITHM 6PRIMARY HPV DNA SCREENING AND COLPOSCOPY TRIAGE (SCREEN, TRIAGE AND TREAT APPROACH)

For both the general population of women and women living with HIV

ALGORITHM 7. PRIMARY HPV SCREENING AND CYTOLOGY TRIAGE FOLLOWED BY COLPOSCOPY (SCREEN, TRIAGE AND TREAT APPROACH).

ALGORITHM 7PRIMARY HPV SCREENING AND CYTOLOGY TRIAGE FOLLOWED BY COLPOSCOPY (SCREEN, TRIAGE AND TREAT APPROACH)

For both the general population of women and women living with HIV

FOLLOW-UP TESTS AT 12 MONTHS POST-TREATMENT FOR THE GENERAL POPULATION OF WOMEN.

FOLLOW-UP TESTS AT 12 MONTHS POST-TREATMENT FOR THE GENERAL POPULATION OF WOMEN

a In circumstances where LLETZ not available, use cryotherapy or thermal ablation for retreatment, if eligible.

AIS: adenocarcinoma in situ; CIN: cervical intraepithelial neoplasia; LLETZ: large-loop excision of the transformation zone.

FOLLOW-UP TESTS AT 12 MONTHS POST-TREATMENT FOR WOMEN LIVING WITH HIV.

FOLLOW-UP TESTS AT 12 MONTHS POST-TREATMENT FOR WOMEN LIVING WITH HIV

a In circumstances where LLETZ not available, use cryotherapy or thermal ablation for retreatment, if eligible.

AIS: adenocarcinoma in situ; CIN: cervical intraepithelial neoplasia; LLETZ: large-loop excision of the transformation zone.

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