This Sexual and Reproductive Health and Rights (STARS) - Cervical Cancer Screening and Treatment module allows nurses, midwives, and clinical officers to become confident and competent in understanding human papillomavirus (HPV) testing as part of cervical cancer screening and treatment procedures performed in primary health care facilities and mobile units in resource-constrained settings.
Learning Objectives[edit | edit source]
By the end of this module, learners will be able to:
- explain the natural history of cervical neoplasia and the causal role of HPV infection;
- describe HPV test – sample collection and interpretation of results;
- demonstrate counselling of women for HPV test;
- screen women using HPV detection tests;
- collect cervical samples for HPV testing;
- explain the management algorithms for women with a positive HPV test;
- conduct follow-up of women after treatment;
- follow appropriate infection prevention practices;
- provide quality services as per the standard operating procedures.
Introduction to Cervical Cancer Screening[edit | edit source]
- Cervical cancer is a major cause of morbidity and mortality in the country/region.
- Cervical cancer can be prevented by systematic screening of target populations and ensuring treatment of positive cases.
- Screening should be organized rather than opportunistic or sporadic.
- An organized screening programme must have a protocol that clearly indicates the target population, frequency of screening and screening test to be used.
- There are several screening tests and screening options; each of these has advantages and disadvantages.
- Informed consent prior to screening is necessary. The nature of the consent will depend on existing regulations.
Pathogenesis of Cervical Cancer with Special Reference to HPV Infection[edit | edit source]
- Infection from high-risk HPV is a "necessary but not sufficient" cause of cervical cancer.
- HPV is a very common sexually transmitted virus and the majority of infected women will clear the virus due to natural immunity.
- Women who cannot clear the infection and have persistent infection with any of the high-risk types of HPV will develop cervical neoplasia.
- Cervical intraepithelial neoplasia (CIN) is the premalignant condition of the cervix and is classified into CIN 1, CIN 2 and CIN 3 depending on the severity of the
- CIN 2 and CIN 3 lesions have high probability of progression and must be treated.
- CIN 1 lesions can be followed up as they are mostly transient.
HPV Test and Cervical Sample Collection Techniques for HPV Testing[edit | edit source]
- Majority of tests detect DNA of high-risk type HPV.
- Only a few tests are available that detect HPV RNA.
- Samples can be stored at room temperature for a few days.
- A negative test indicates that the woman does not have high-risk HPV infection or HPV infection sufficient to cause cervical precancers.
- There is no treatment for the virus itself.
- Treatment is available for diseases caused by HPV infection.
- Tests should be repeated after 5 years for women with negative test results.
Materials and Equipment[edit | edit source]
- Supplies for preparation of chlorine solution
- Normal saline
- Ethyl alcohol, glutaraldehyde solution
- Examination gloves (Sizes 6.5,7,7.5), cotton swabs, cotton swab sticks, lubricant jelly
- Focusing lamp, examination table, watch
- HPV test kits, marking pens, ice box
- Self-retaining bi-valve speculum, sponge holding forceps, instrument tray
- Kidney trays, galipots
- Consent forms, case record forms, log sheets, client record card
- Writing desk, stools, chairs, curtains for clinic doors and windows, screen/cover sheets for women to be examined
Checklist for HPV Testing[edit | edit source]
*The highlighted steps are considered as critical
Preparation for HPV Test[edit | edit source]
- Keep necessary equipment ready as per box
- Check availability of consumables as per box
- Ensure that the light source is ready to use
- Arrange instruments and supplies on a high-level disinfected tray or container
Counselling[edit | edit source]
- Greet the woman respectfully and introduce yourself*
- Make the woman sit comfortably and tell her about the necessity of HPV test and the procedure
- Inform what the test results might be and what follow-up or treatment might be necessary*
- Listen to her problems and concerns and respond to her queries
- Obtain informed consent if required by the regulations*
History Taking[edit | edit source]
- Personal information: Name, age, husband's name, address, telephone number and last menstrual period (LMP)
- Obstetric history
- History of past illnesses
- History of previous cervical cancer screening test (s)
- Ask for any of the following symptoms: Persistent foul smelling white discharge, post-coital bleeding, post-menopausal bleeding, irregular menstrual bleeding
- Record all relevant information on a case record form
Step-wise Cervical Sample Collection Procedure for HPV Test[edit | edit source]
- Fill out the HPV test requisition form*
- Label the sample collection vial with the patient's name, screening ID, date of sample collection*
- Check that the woman has emptied her bladder
- Help her onto the examining table, help her to be undressed and drape her
- Wash hands thoroughly with soap and water and dry with clean, dry cloth or air dry
- Put one pair of new examination disposable gloves on both hands
- Inspect external genitalia and check urethral opening for discharge
- Select speculum of appropriate size and lubricate the blades with warm water only and NOT lubricant jelly
- Insert speculum and adjust it so that the entire cervix can be seen*
- Fix the speculum blades in the open position so that the speculum remains in place with the cervix in view
- Adjust the light source so that you can see the cervix clearly*
- Examine the cervix for cervicitis, ectropion, nabothian cysts, growth, ulcers or contact bleeding
- If large quantity of discharge or mucus is present, gently remove by dabbing with a dry cotton swab without disturbing the epithelium
- Identify the external os of the cervix*
- Insert the sample collection brush/broom into the external os till the outer bristles touch the ectocervix (Do not insert the brush/broom completely into the endocervical canal)*
- Gently rotate the brush/broom in a clock-wise direction 3–5 times (check manufacturer's instructions)*
- Remove the brush/broom from the canal while avoiding contact with the outside of the specimen transport tube/vial or any other object*
- Insert the end of the brush/broom into the specimen transport tube/vial*
- If using a brush – snap off the shaft of the brush at the score line, leaving the end of the brush inside the tube
- If using a broom – detach the broom from the end of the shaft leaving it inside the vial
- Replace/tighten the cap on the tube/vial securely
- Place the tube/vial in the specimen bag/container for transport to the laboratory
- Remove the speculum
- Help the woman to get up from the examination table and sit comfortably
Post-HPV Sample Collection Procedure Tasks[edit | edit source]
- Dispose of the swabs in appropriate disposal bags
- Immerse the speculum in 0.5% chlorine solution
- Immerse both gloved hands in 0.5% chlorine solution. Remove gloves by turning them inside out
- Wash hands thoroughly with soap and water and dry with clean, dry cloth or air dry
- Arrange for specimen transfer to the laboratory as per instructions of the test kit manufacturer
- Inform the woman when (day/time) to collect the test report*
- Discuss the necessity of referral and/or treatment with her if the test report is positive
Self Assessment[edit | edit source]
Resources[edit | edit source]
Sections of the STARS - Cervical Cancer Screening and Treatment module are copied or adapted from: Training of health staff in VIA, HPV detection test and cryotherapy - Facilitators' guide. New Delhi: World Health Organization, Regional Office for South-East Asia; 2017. Licence: CC-BY-NC-SA-3.0 IGO; and WHO guidelines for the use of thermal ablation for cervical pre-cancer lesions. Geneva: World Health Organization; 2019. Licence: CC-BY-NC-SA-3.0 IGO. The World Health Organization (WHO) is not responsible for the content or accuracy of any translation. The original English edition shall be the binding and authentic edition.
- Training of health staff in VIA, HPV detection test and cryotherapy - Facilitators' guide. New Delhi: World Health Organization, Regional Office for South-East Asia; 2017. Licence: CC-BY-NC-SA-3.0 IGO. The World Health Organization (WHO) is not responsible for the content or accuracy of any translation. The original English edition shall be the binding and authentic edition.