Cervical cancer screening: Are the 1989 recommendations still valid?

Table 1: Recommendations from the National Workshop on Screening for Cancer of the Cervix 1989*
The following recommendations should be considered as a whole. The screening frequencies should be established formally only when the following are in place: high-quality laboratory services for reading cytology smears, with adequate internal and external quality-control systems, and information systems to monitor screening frequencies and to issue reminders to attend at the recommended intervals.

Not all jurisdictions will be able to implement all the recommendations rapidly, but this should not prevent them from complying with those recommendations with which they can, when they can.

An organized approach
1. Governments should encourage and support the development or enhancement of organized cervical cytology screening programs involving family physicians, specialists, laboratories and information systems to reduce morbidity and mortality from carcinoma of the cervix.
2. All women aged 18 and over who have had sexual intercourse should be encouraged to participate in a cervical cytology screening program.
  • 3. Care should be taken to incorporate new programs within an overall conceptual and planning framework of care of well women.
    4. The setting and manner of screening for cervical cancer should be sensitive, supportive and culturally appropriate.
    5. Concepts of cervical cancer prevention and screening should be integrated with sex education for students and included in health promotion programs directed to all adolescents.
    Frequency of screening
    6. A second smear should, in general, be taken after 1 year, especially for women who begin screening after age 20.
    7. If the first two smears are satisfactory and show no significant epithelial abnormality, women should, in general, be advised to be rescreened every 3 years to age 69.
    8. Women over age 69 who have had at least two satisfactory smears and no significant epithelial abnormality in the last 9 years and who have never had biopsy-confirmed severe dysplasia or carcinoma in situ (cervical intraepithelial neoplasia [CIN] III) can be dropped from the cervical cytology screening program.
    9. The recommended frequency of rescreening for women aged 18 to 69 is appropriate for all risk groups.
    10. Women entering a screening program at age 67 or older should have two satisfactory smears at least 6 months apart; those over age 69 can then be dropped from the program if the smears show no epithelial abnormality.
    11. The recommended screening frequencies apply to women whose smears show no epithelial abnormality. If abnormalities are detected, schedules for repeat examinations should be dictated by the requirements of surveillance, diagnosis, treatment and follow-up.
    12. Women do not need to be screened if they have never had sexual intercourse or have had a hysterectomy for benign conditions with adequate pathological documentation that the cervical epithelium has been totally removed and previous smears have been normal.
    Management of abnormalities
    13. In women with cytologic abnormalities the degree of abnormality reported by the cytopathologist should be noted.
    (a) Generally, a repeat cytology smear should be recommended in 6 months for women with cytologic evidence of mild dysplasia (CIN I) with or without human papillomavirus (HPV) effects. If there is no evidence of cytologic progression, repeat smears at 6-month intervals are appropriate for up to 2 years, after which colposcopy should be arranged for all women with persistent abnormalities.
    (b) Referral to colposcopy should be arranged for women with cytologic evidence of moderate or severe dysplasia (CIN II or III) or malignant cells.
    14. Colposcopy should be performed by adequately trained gynecologists or other health care professionals who work in a setting that provides a constant source of abnormal material so that their skills can be maintained and enhanced.
    15. Women who have been treated for an epithelial abnormality of the cervix, or have had an epithelial abnormality that regressed spontaneously with no epithelial abnormality on two consecutive follow-up visits, should be rescreened annually for as long as is clinically feasible.
    Information systems
    16. Information systems should be established in all provinces to ensure appropriate organization of all programs.
    17. There should be consultation with all appropriate interests before establishing information systems. The design of information systems should be a result of participatory planning involving all the stakeholders.
    18. Before the system is made operational all stakeholders should be consulted on policy about access to data and the conditions under which identified data can be released. The use of information systems should be compatible with the database requirements in the province.
    19. Agreement on the core data to be included in information systems should be sought among all jurisdictions.
    Training and quality-control requirements
    20. Cytotechnologists should be trained according to the requirements of the Canadian Medical Association's Conjoint Committee on the Accreditation of Educational Programs in Cytotechnology or their equivalent, as recognized by the Canadian Society of Laboratory Technologists.
    21. For most efficient function in a mass screening program a laboratory should process a sufficient number of cases annually to require staffing by a minimum of three qualified and experienced full-time cytotechnologists, supervised by a cytopathologist, plus adequate clerical and technical support staff.
    22. Provincial governments should recognize the need for centralization or regionalization of cervical cytology screening services wherever there are multiple laboratories not fulfilling the criteria set out in recommendation 21.
    23. The jurisdiction responsible for cervical cytology screening programs should ensure that appropriate and satisfactorily functioning quality-control mechanisms are in play.
    Other considerations
    24. The jurisdictions responsible for cervical cytology screening programs should ensure that the mechanisms described in this report are in place to evaluate and monitor the total program, which should be overseen by a broad-based advisory committee established by each province.
    25. When new data on duration of protection from negative smears at age 60 to 69 are available, the recommendation to continue screening to age 69 should be reconsidered.
    26. Current evidence is not sufficient to support the use, in screening for cervical cancer, of laboratory procedures designed to detect specifically the presence of HPV.
    27. No later than 1996, all programs should be reviewed further for the Conference of Deputy Ministers of Health using data obtained through the evaluation and monitoring functions of the recommended information systems.
    *Excerpted from the workshop report,[9] which outlines the rationale for each recommendation.
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