WHO Guidelines for Screening and Treatment of Precancerous Lesions for Cervical Cancer Prevention

Cervical intraepithelial neoplasia (CIN) is a premalignant lesion that may exist at any one of three stages: CIN1, CIN2, or CIN3. If left untreated, CIN2 or CIN3 (collectively referred to as CIN2+) can progress to cervical cancer. Instead of screening and diagnosis by the standard sequence of cytology, colposcopy, biopsy, and histological confirmation of CIN, an alternative method is to use a screen-and-treat approach in which the treatment decision is based on a screening test and treatment is provided soon or, ideally, immediately after a positive screening test. Available screening tests include a human papillomavirus (HPV) test, visual inspection with acetic acid (VIA), and cytology (Pap test). Available treatments include cryotherapy, large loop excision of the transformation zone (LEEP/LLETZ), and cold knife conization (CKC).

This guideline provides recommendations for strategies for a screen-and-treat program. It builds upon the existing WHO guidelines: Use of cryotherapy for cervical intraepithelial neoplasia (published in 2011) and on the new WHO guidelines for treatment of cervical intraepithelial neoplasia 2/3 and glandular adenocarcinoma in situ (being published concomitantly with these present guidelines). This guideline is intended primarily for policy-makers, managers, program officers, and other professionals in the health sector who have responsibility for choosing strategies for cervical cancer prevention, at country, regional and district levels.

For countries where a cervical cancer prevention and control program already exists, these recommendations were developed to assist decision-makers to determine whether to provide a different screening test followed by a different treatment, or to provide a series of tests followed by an adequate treatment. For countries where such a program does not currently exist, these recommendations can be used to determine which screening test and treatment to provide. In addition to the recommendations, a decision-making flowchart is also proposed in Annex 2 to help program managers choose the right strategy based on the specific country or regional context. Once the strategy has been chosen, the appropriate screen-and-treat flowchart for that strategy can be followed. The flowcharts for all strategies are provided in Annex 3 (specifically for women of negative or unknown HIV status), and Annex 4 (for women of HIV-positive status or unknown HIV status in areas with high endemic HIV infection).