Cervical screening in Canada, 2023-24
About this section
After an abnormal primary screening test result (Pap or HPV test result), participants may be referred for a colposcopy. Colposcopy is the primary follow-up test after an abnormal Pap to confirm the presence of pre-cancerous and cancerous cells and determine appropriate care. Following a positive HPV test, participants may receive a Pap test before being referred for a colposcopy. There are guidelines available to inform the management of a positive HPV test and risk-based colposcopy surveillance. This section describes colposcopy services in Canada.
Colposcopy services
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Referral to colposcopy services
Individuals with abnormal Pap test results requiring follow-up may be referred for a colposcopy. Criteria for referring participants to colposcopy services vary across jurisdictions.
Criteria for referral to colposcopy services
| P/T | ASC-US (1st result) | LSIL (1st result) | ASC-US and HPV+ result | Repeated ASC-US/LSIL after previous ASC-US/LSIL | Age ≥ 50 with LSIL and HPV+ result | AGC | HSIL+ | Other |
|---|---|---|---|---|---|---|---|---|
| YT* | ✓ | ✓ | ✓ | Yukon follows BC criteria | ||||
| NT | ✓ | ✓ | ✓ | ✓ | ✓ | ✓ | ||
| NU | Individuals <30 ASC-US repeat cytology in six months | Repeat test twice at six-month intervals | ✓ (age ≥30) |
No specific guidelines for >50 | ✓ | ✓ | ASC-H Squamous carcinoma Adenocarcinoma Other malignant neoplasms Suspicious cervix |
|
| BC | ✓ | ✓ | ✓ | |||||
| AB | ✓ (age ≥30) |
✓ | ✓ | ✓ | ✓ | ASC-H Adenocarcinoma squamous carcinoma Other malignancy |
||
| SK | ✓ (age ≥30)Planning implementation in 2023 |
✓ ASC-US: 25–29 years old LSIL: 25–49 years old Planning implementation in 2023 |
✓ (age ≥ 50) Planning implementation in 2023 |
✓ | ✓ | ASC-H AIS^ |
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| MB | ✓ (age ≥30) |
✓ | ✓ | ✓ | ✓ | Atypical endocervical cells, visual abnormality of the cervix, or all cytological abnormalities (including low-grade lesions) of individuals who are immunosuppressed (HIV+ with CD4 count <400 or transplantation with immunosuppressive therapy >3 years) Exposure to diethylstilbestrol (DES) in utero |
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| ON | ✓* | ✓ | ✓ | ✓ | ✓ | ASC-H, ASCUS/LSIL followed by a normal cytology result and then followed by ASCUS/LSIL |
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| QC | ✓ | ✓ (age >30) |
✓ | ✓ | ✓ | Postcoital bleeding Cervicitis |
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| NB | ✓ (age ≥30) |
✓ | ✓ | ✓ | ✓ | ASC-H Squamous carcinoma Adenocarcinoma Other malignancy |
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| NS | ✓ | ✓ | ✓ | ASC-H | ||||
| PE** | ✓ (Pap primary screening)Implemented HPV testing as primary screen in May 2023No, HPV-positive for other high-risk, not HPV 16, 18, 45, and ASC-US or LSIL (other follow-up recommended — not colposcopy) |
✓ (Pap primary screening) |
✓ (Pap primary screening)Implemented HPV testing as primary screen in May 2023Yes, HPV-positive for other high-risk, not HPV 16, 18, 45, and AGC |
✓ (Pap primary screening)Implemented HPV testing as primary screen in May 2023Yes, HPV-positive for other high-risk, not HPV 16, 18, 45 |
ASC-H (Pap primary screening)
Implemented HPV testing as primary screen in May 2023 Yes, HPV-positive for HPV 16, 18, 45 Yes, HPV-positive for other high-risk, not HPV 16, 18, 45, and ASC-H/HSIL or worse (AGC, AIS, carcinoma, or suspicious for carcinoma) |
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| NL | ✓ (age <30 repeat ASC-US three times at six-month interval; if the third Pap is abnormal, refer to colposcopy) |
✓ | ✓ | ✓ |
*YT: YT will be following BC’s criteria.
^SK: Refer to specialist in gynecologic oncology; squamous cell carcinoma, adenocarcinoma, malignant neoplasm.
~ON: HPV testing is not currently funded by the Ministry of Health. Healthcare providers can consider HPV testing for those with ASCUS results on a patient-pay basis or where available (i.e. in some hospital settings) for people age 30 and older. People who are HPV-positive (16/18) can be referred directly to colposcopy. People who are HPV-positive (other) should repeat their cytology in 12 months.
**PE: Implemented HPV testing as primary screen in May 2023.
Abbreviations:
- ASC-US: atypical squamous cells of undetermined significance
- LSIL: low-grade squamous intraepithelial lesion
- AGC: atypical glandular cells
- HSIL: high-grade squamous intraepithelial lesion
Definitions:
- HSIL+: high grade squamous intraepithelial lesions or worse (HSIL+ includes HSIL, AIS and invasive carcinoma)
- ASC-H: atypical squamous cells, cannot exclude HSIL
Colposcopy services in Canada
Colposcopy services are most often provided in hospitals, colposcopy clinics and by individual practitioners. Seven provinces and two territories currently use HPV testing in colposcopy care, and HPV testing is used by many jurisdictions to determine whether participants can return to routine cervical screening.
Location of colposcopy
| P/T | Hospital | Individual practitioner clinic | Colposcopy clinics | How colposcopy services provided |
|---|---|---|---|---|
| YT | ✓ | YT colposcopies are done in colposcopy clinic at Whitehorse General Hospital. | ||
| NT | ✓ | All colposcopies are performed by the OB-GYN service. The service is based out of Stanton Territorial Hospital in Yellowknife, but travels to other NT hospitals to provide the service. | ||
| NU | ✓ | ✓ | Qikiqtani General Hospital in Iqaluit has a colposcope and provides colposcopies for people in the Qikiqtani Region. Services in the Kivalliq Region may be provided at the Rankin Inlet Health Centre during specialist visits or out of territory in Winnipeg. Services in the Kitikmeot Region are provided by a travelling colposcopy clinic or out of territory in Yellowknife or Edmonton. | |
| BC | ✓ | ✓ | ✓ | Most colposcopy is done in a colposcopy clinic outside of a hospital. A few colposcopists who have completed the BC Colposcopy Training Program provide colposcopy out of their office. |
| AB | ✓ | ✓ | Majority of colposcopies are done in ambulatory clinics in hospitals. Program has standardized colposcopy referral form and procedure report form. | |
| SK | ✓ | ✓ | ✓ | Colposcopy services are provided by colposcopy clinics in large cities and by individual colposcopists in the rest of the province. |
| MB | ✓ | ✓ | ✓ | One formal colposcopy clinic in Winnipeg. Other medical clinics and hospitals also offer colposcopy services by gynecologists. Referring clinician makes colposcopy referral to colposcopy clinic. The program will follow-up with the referring clinician if there is no colposcopy information in cervix registry within pre-set time frames, as per guidelines. |
| ON | ✓ | ✓ | ✓ | Approximately two thirds of colposcopies occur in hospital-based clinics and the rest occur in non-hospital clinics. Clear referral criteria and evidence-based clinical pathways are recommended by the program. |
| QC | ✓ | ✓ | Colposcopy services are conducted in hospital settings or colposcopy clinics. Referrals are done by the hospital and there are no formal programs. | |
| NB | ✓ | ✓ | Colposcopies are provided by each of the eight regional hospitals across NB. Colposcopies are operationalized by the regional health authorities. | |
| NS | ✓ | ✓ | Colposcopy is delivered primarily in hospital-based clinics. There are a few private office-based clinics that provide initial assessment, with treatment performed in a hospital setting. | |
| PE | ✓ | Colposcopy services are provided by individual gynecologists, primarily in an office setting. | ||
| NL | ✓ | ✓ | ✓ | Colposcopy services are provided in 11 hospital-based sites within the province. There are also individual practitioner, private-based colposcopy services available. If treatment is required, it is performed in a hospital-based setting. |
Use of HPV testing in colposcopy care
| P/T | Current use or plans to implement HPV testing in colposcopy care | Type of HPV test for colposcopy care | Use of HPV test to determine return to routine screening |
| YT | Yes — available annually posttreatment | Roche Cobas 4800 | Yes — if HPV-negative posttreatment, will be discharged after appropriate follow-up |
| NT | Yes — limited use (only for participants needing to travel long distances for colposcopy service) | Not known | Yes — occasional use in restricted circumstances |
| NU | No organized screening program available | ||
| BC | Yes — available annually posttreatment | Roche Cobas 4800 | Yes — if HPV-negative posttreatment, will be discharged after appropriate follow-up |
| AB | Yes — for entry and exit testing | Roche Cobas 4800; Aptima | Yes — post-CINII treatment |
| SK | Available for colposcopists upon special request | Hologic Panther — Aptima HPV assay | Yes — negative return to routine screening |
| MB | No current plans | N/A | No |
| ON | Yes – in planning stages. HPV testing is not currently funded at the provincial level; however, HPV testing may be available in some colposcopy facilities through patient-pay or at no cost to the patient. The program has best practice recommendations for use of HPV testing in colposcopy in cases where it is available. | Type of HPV test is not provincially determined and varies by the lab performing the test. In the future state, a single test vendor will be procured. | The program has best practice recommendations for the use of HPV testing, where available, to inform post-discharge screening interval. Recommendations for the use of HPV testing in colposcopy in the future state are currently under development. |
| QC | Yes — used as a diagnosis tool | Roche Cobas 4800 | Not frequently |
| NB | Available for colposcopists in colposcopy clinics upon request | Roche Cobas 4800 | Use is determined and operationalized by some providers and regional health authorities |
| NS | Yes — used as Test of Cure and to help with triage of cases | Roche test | Yes — used at six months with Pap; not used by all colposcopists |
| PE | No current programmatic plans
The future state of HPV testing in colposcopy care is currently in development Available for colposcopists upon request |
BD OnclarityTM HPV Assay | No
The future state of HPV testing in colposcopy care is currently in development Available for colposcopists upon request |
| NL | Examined as part of the transition to HPV primary cervical cancer screening with respect to colposcopy clinical guidelines | N/A | Available upon request |
*PE: HPV test is used for follow-up care in PE, as opposed to colposcopy care or discharge purposes.