HPV screening and follow-up pathway
Steps 4–6: Colposcopy, treatment and follow-up
The recommendations outlined in these steps are intended to be actioned by decision-makers responsible for the delivery of cervical cancer screening and follow-up care.
Learn more about the intended audience and accountability.
For information about referral to colposcopy, please refer to the Initial triage and follow-up triage page.
Guidelines to support follow-up after a positive HPV test
To support jurisdictions who are planning to update their clinical guidelines, the Partnership has funded the Society of Gynecologic Oncology of Canada (GOC) to develop clinical guidelines on the management of participants with a positive HPV test and risk-based colposcopy and surveillance, with collaboration from the Society of Canadian Colposcopists (SCC). Jurisdictions can use the guidelines to support processes for referral to colposcopy, including but not limited to establishing standard referral times, risk- and cytology-based considerations for referral to colposcopy, and recommendations for initial colposcopic exam and documentation. GOC guidelines are not intended to supersede local guidance. A link to the guidelines will be available here once they are released.
Colposcopy resources, management, quality assurance and follow-up
Recommendation: Plan for a potential initial increase in demand for colposcopy services as a result of the transition to HPV primary screening.
Key evidence and implementation considerations:
- Studies from British Columbia indicate that referral rates to colposcopy could double in the general population in the early stages of HPV testing due to initial detection of both prevalent and incident HPV infections.1 This is expected to stabilize after four years.1 The initial influx in colposcopy referrals may increase anxiety among screening participants and could place more demand on the system. Providers should be prepared to communicate information about the procedure to participants to lessen their concerns.
- Programs may also want to plan implementation strategies that minimize the impact of colposcopy. For example, they could take a staggered introduction to HPV primary screening by start age (i.e., start with participants less than 50 years old, then introduce participants over the age of 40).
- Developing appropriate triage and follow-up protocols based on evidence is critical to avoiding overburdening colposcopy services during the transition to HPV primary testing. To inform their planning, jurisdictions should review promising practices from other areas. For more on triage and referral to colposcopy, please refer to the Initial triage and follow-up triage page.
- For more detailed recommendations about wait times for referral into colposcopy for individuals with an HPV-positive test (e.g., HSIL, ASC-H/AGC, cytology that is suggestive of carcinoma, ASCUS/LSIL), please refer to the guidelines on the management of a positive HPV test and risk-based colposcopy and surveillance.
- The following approaches can increase clinician and lab capacity and minimize impact on colposcopy wait times:
- communicating with existing colposcopists and requesting that capacity be increased if possible2
- providing training to allow other clinician roles to lead colposcopies, such as nurses2
- when some regions and their labs pilot and shift to focusing on HPV primary testing in advance of the broader jurisdiction, these labs may have additional capacity to support backlogs when other regions and labs begin shifting focus as well.2
- Pilot testing new self-sampling pathways can also help generate local data to ensure operational challenges (such as regulatory obstacles for HPV testing in the laboratory setting) are identified early and addressed before broader implementation.2
Recommendation: Establish jurisdictional standards for colposcopy services.
Key evidence and implementation considerations:
- Standards should consider the following:3
- a statement of program mandate and scope
- standardized correspondence to participants and providers
- quality indicators and performance targets, including targets for monitoring clinical, lab and system performance
- minimal data collection and reporting
- training, education, certification and maintenance of competence guidelines for practitioners
- clinical recommendations for diagnosis, treatment and follow-up
- discharge criteria and risk-based recommendations for follow-up screening in primary care (for more information, please refer to the guidelines on the management of a positive HPV test and risk-based colposcopy and surveillance)
- staffing and facility requirements, and accredited locations
- The guidelines on the management of a positive HPV test and risk-based colposcopy and surveillance may be particularly useful where programmatic guidance is absent. However, given the contextual differences in each jurisdiction combined with the need to deliver, evaluate and improve care within the parameters of an organized program, developing program-specific organizational standards, clinical guidelines and quality parameters may be considered.
Communication across the healthcare sector
Considering the multiple personnel involved in screening, colposcopy, treatment and follow-up, communication across the health-care sector is key to ensuring high-quality, person-centered care. This is especially important for participants who are being screened outside their home region. (See Resources for providers for further information.)
Equitable and culturally safe specialized care
Specialized care like colposcopy can be confusing and overwhelming for participants. For First Nations, Inuit and Métis participants, the history of power imbalance, trauma and disenfranchisement related to specialized care can make it especially overwhelming.4 Jurisdictions must obtain informed consent from participants and ensure all levels of care are culturally safe and trauma-informed.4 (See Resources for providers for further information.)
- Coldman AJ, Phillips N, van Niekerk D, et al. Projected impact of HPV and LBC primary testing on rates of referral for colposcopy in a Canadian cervical cancer screening program. J Obstet Gynaecol Can. 2015; 37(5):412-420. doi:10.1016/S1701-2163(15)30255-3
- Canadian Partnership Against Cancer. HPV primary screening and abnormal screen follow-up for cervical cancer environmental scan. 2021. Accessed January 19, 2022. Available from: https://www.partnershipagainstcancer.ca/topics/hpv-primary-screening-environmental-scan/
- Decker K, Baines N, Muzyka C, et al. Measuring colposcopy quality in Canada: Development of population-based indicators. Curr Oncol. 2019; 26(3):e286-e291. doi:10.3747/co.26.4709
- Standing Senate Committee on Human Rights. Forced and coerced sterilization of persons in Canada. SenCan. 2021.