AFJOG

GUIDELINES Guidelines for treatment Interpretation of screening results Three different interpretations are possible: low-risk [negative for high-risk HPV types], intermediate-risk [positive for high-risk types but non-16/18(/45)] or high- risk [positive for HPV types 16/18 (45)]. • All women with “low-risk” results should return for the next round of screening at a routine (five to ten years according to cervical cancer risk group) interval. • All women with “high-risk” results should be called for a treatment visit, ideally within six weeks, preferably earlier to prevent loss-of-follow-up. • Women with an “intermediate-risk” result can be managed by an immediate second test (triage cytology test), can be followed at an earlier date for a repeat screening test (increased surveillance), or can directly be referred for a treatment visit based on existing risk factors. Triage tests A second test after an intermediate test result gives a further indication of risk. In comparison to treating all these women, it reduces overtreatment; and when compared to following them all, it improves program effectiveness. Immediate reflex to liquid based cytology is chosen here and can be performed only on health care worker collected specimens. Soon there may be molecular solutions for effective triage which can be done on self-collected samples, like extended genotyping or methylation markers. 21 In these guidelines the recommendation is to selective triage of those that test positive for “other high-risk HPV” by immediately referring to treatment those who are either 40 years and older, or HIV-positive as these two groups have a significantly higher risk for disease. On the other hand, women younger than 40 years who are HIV-negative have lower risk, are triaged by reflex cytology, and treated only if their cytology shows HSIL or more. Otherwise they return for the next screening round. Choice of treatment method At the treatment visit, the recommended option is to offer immediate treatment, called “screen-and-treat”, because it enhances program effectiveness and risk reduction. For higher resource environments where colposcopy is available, clinically indicated, and follow-up is guaranteed, it may be used in conjunction with biopsy to confirm the screening results and to guide treatment. Both types of treatment methods available to treat cervical cancer risk and pre-cursor lesions can be used for patients with positive screening tests. Excisional methods provide a histology sample and is suited for lesions suspicious of cancer or extending into the endocervical canal. Large loop excision of the transformation zone (LLETZ or LEEP) is widely offered and effective; cold knife cone should not be used routinely as it causes significant shortening of the cervix and reproductive failure. Ablative methods include cryotherapy and more widely available thermo-ablation which cause limited loss of cervical stroma but does not provide tissue for histology. These methods are not suited to treat lesions that are suspicious for invasion, very large (>2/3 or > three quadrants) or stretching into the canal. Treatment failure, using ablative therapies is common amongst the HIV positive population. 28 Follow-up after treatment is essential. Follow-up after treatment Follow up after excisional or ablative treatment for precancer is essential due to the risk of treatment failure and subsequent development of pre-cancer and cancer. Women who have a negative HPV-test during follow-up can return to the low-risk group with a longer interval. The management of individuals with repeated abnormalities after previous treatment should be Individualised and falls outside the scope of these guidelines. Conclusion We recommend a universal screening strategy for South Africa based on primary HPV-screening, with partial genotyping, starting from 25 years, varying screening interval between five and ten years based on risk and exiting at the age of 50 years only after three negative tests. There is now sufficient evidence to recommend treatment for everyone with the highest risk HPV-types, and for all “other HPV-positive” women who are above the age of 40 years. Reflex cytology should be offered to increase the specificity of screening for women with non-16/18 HPV types who are HIV-positive or younger than 40 years. We recommend nationwide development of screening facilities and wide implementation of thermo-ablation and LLETZ treatment on indication. After treatment, women need yearly follow-up until HPV-negative. TREATMENTALGORITHM *Squamo-columnar junction of cervix Acknowledgments All previous members of the HPV Advisory Board are acknowledged for their vision, support and input into previous guidelines forming the basis of the current work. Funding and support were received from industry sponsors and the HPV Cervical Cancer Research Fund for literature review, research and the working group meeting. We thank Treatment visit Preferably "screen-and-treat" but can do colposcopy with biopsy first Inspect cervix for lesion suspicious of invasion Apply Lugol's iodine to evaluate size of lesion Entire lesion and SCJ* visible Lesion covers <2/3 of cervix OR No LLETZ available Ablative treatment (biopsy if suspicious) Suspicious of invasion Entire lesion or SCJ* not visible Lesion covers >2/3 of cervix LLETZ (and send for histology) African Journal of Obstetrics and Gynaecology | Volume 1 | Issue 1 | 2023 | 40