Are your patients asking you about HPV testing? Mine are and some are willing to pay in advance of the upcoming funded program. If the result is positive, this led me to questions about what to do next. So, I reached out to our local cervical screening lead, Dr. Andra Nica, to ask for help. Here is her very helpful advice:
Despite most Canadian provinces and territories having available organized screening programs (with the exception of Yukon), an estimated 1500 patients will be diagnosed with cervical cancer in Canada, with approximately 550 of those in Ontario alone. The vast majority of these cases are related to infection with the Human Papilloma Virus (HPV) and thus preventable.
Routine screening with cervical cytology (Pap smears) has successfully led to a sustained gradual decrease in the incidence of cervical cancer in Canada in the last 3 decades, and further reductions are expected due to the introduction of HPV vaccination.
Strong evidence within the last decade supports the use of testing for oncogenic HPV subtypes within primary screening, to replace or complement the use of cervical cytology. Subsequently, the Ontario Cervical Screening Program (OCSP), as part of Cancer Care Ontario under Ontario Health (OH-CCO), is planning the implementation of HPV testing in Ontario within the next 18-24 months. Until then, cytology-based screening continues to be recommended starting at age 25 in patients who have ever been sexually active, every 3 years.
At this time, there is no universal coverage for HPV testing under the Ontario Health Insurance Plan (OHIP). Funded HPV testing is available to patients in rare instances where it is covered as part of colposcopy examination by a hospital or institution.
When patients chose to pay out of pocket for an HPV test, these results must be taken into account when physicians make further recommendations about next screening interval or referral to colposcopy. Referral to colposcopy is generally recommended for patients whose immediate risk of CIN3+ histology is ≥5%.
Follow-up Recommendations depending on Cytology & HPV type
| Cytology | HPV | Risk of CIN3+ | Recommendation |
| HSIL, ASC-H, LSIL-H, AGUS | Any result + or – | High | Refer to colposcopy |
| Any result | HPV 16/18+ | 5-15% | Refer to colposcopy |
| LSIL x 1 | HPV neg | <1% | Pap in 3 years |
| HPV+ (other) | 2-4% | Pap in 12 months | |
| ASCUS x 1 | HPV neg | <1% | Pap in 3 years |
| HPV+ (other) | 2-4% | Pap in 12 months | |
| LSIL/ASCUS x 2
(12 months apart) |
Unknown | 10% | Refer to colposcopy |
| LSIL/ASCUS -> normal -> LSIL/ASCUS | Unknown | 1-3% | Pap in 12 months |
Thank you Dr. Nica!
If you have any doubt about how to interpret results, or what the appropriate next steps should be, please send her an e-consult for the fastest response.
While investigating HPV testing, I also learned that a lab report indicating a positive HPV for my lab (Lifelabs) means positive to ONCOGENIC subtypes of HPV. There are over 100 subtypes of HPV and only just over a dozen of them are known to be oncogenic with subtypes 16 and 18 of particular concern. It is persistent HPV infection with an oncogenic subtype that is the main cause of cervical cancer. The lab will report HPV as positive ONLY IF there is an oncogenic subtype and will further report if 16 or 18 are found to help us further evaluate risk level as per Dr. Nica’s helpful chart.
We will be holding webinars closer to the time of the launch of the provincially funded HPV program. Stay tuned for more information!
Let’s all stay healthy!
Dr. Meghan Davis, B. Eng. MD FCFP
Primary Care Lead, HNHB Regional Cancer program