Cervical screening in immunosuppressed women: a call for broader clinical awareness

Cervical cancer prevention in immunosuppressed women extends far beyond people living with HIV. We read with great interest the recent American Society for Colposcopy and Cervical Pathology (ASCCP)1 consensus guidelines on cervical cancer screening in immunosuppressed women without HIV infection, which provides a timely, evidence-based framework to inform preventive care, including in Australian practice. Like the Australian National Cervical Screening Programme guidelines (NCSPGs), it covers a comprehensive range of conditions and medications requiring special consideration such as systemic lupus erythematosus and solid organ transplant.2 Our concern is that this information is not widely appreciated by the range of clinicians whose patients may be affected, such as transplant physicians, haematologists and oncologists. Immunosuppression increases the risk of cervical cancer and other human papillomavirus (HPV)-related diseases, although the degree of risk depends on the type and severity of immunosuppression. We commend to all practitioners caring for immunosuppressed patients the NCSPGs with particular reference to Section 7.2, which provides clear and practical guidelines on screening frequency. There are populations with a clearly elevated risk of high-grade squamous intraepithelial lesions and cervical cancer– specifically, women with solid organ transplants, haemopoietic stem cell transplants, end-stage renal disease or systemic lupus erythematosus, irrespective of immunosuppressive therapy use. In this population group, screening every 3 years with an HPV test is recommended if oncogenic HPV is not detected, rather than the standard five-yearly interval.2 In the absence of robust data, shared decision-making is recommended for women with inflammatory bowel disease, rheumatoid arthritis and multiple sclerosis who are not taking long-term immunosuppressants, as well as for those receiving long-term immunosuppressive therapy, including disease-modifying therapies and monoclonal antibodies. In addition, clinicians should also consider whether their patients are eligible for HPV vaccination as outlined in the Australian Immunisation Handbook, via a three-dose schedule for people with immunocompromising conditions such as malignancy, transplant (stem cell/solid organ), immunosuppressive therapy, HIV and inborn errors of immunity.3 In the Australian context, our guidelines include other high-risk populations, such as Aboriginal and Torres Strait Islander women, who already experience a disproportionate burden of cervical cancer and may be further disadvantaged if living with concurrent immunosuppressive conditions. Dissemination of these recommendations should extend beyond gynaecologists and general practitioners to include transplant physicians, haematologists, oncologists, renal physicians, rheumatologists, dermatologists and immunologists. With the number of Australians living with organ transplants, chronic renal failure or autoimmune disease continuing to rise, disseminating these recommendations would address a potential gap and ensure optimal preventive care is provided where it is needed. Data sharing not applicable to this article as no datasets were generated or analysed during the current study.