Updated Review for Guidelines for Cervical Cancer Screening in Immunosuppressed Women Without HIV Infection

Area of Science:

• Oncology
• Immunology
• Public Health

Background:

• Individuals with compromised immune systems, including those with solid organ transplants (SOT), end-stage renal disease (ESRD), hematopoietic stem cell transplants (HSCT), and autoimmune diseases (AID), face elevated risks for human papillomavirus (HPV) infection, squamous intraepithelial lesions, and cervical cancer (CC).
• Existing guidelines for CC screening in non-HIV immunocompromised populations require updates to incorporate new evidence and emerging therapies, such as disease-modifying therapies (DMTs) and monoclonal antibodies (MABs).

Purpose of the Study:

• To review recent evidence on CC screening and HPV vaccine efficacy in non-HIV immunocompromised populations since the 2019 guidelines.
• To provide updated recommendations for CC screening and HPV vaccination in individuals with SOT, ESRD, HSCT, and specific AIDs (SLE, RA, IBD, MS), including those on newer DMTs/MABs.

Main Methods:

• A comprehensive literature search was conducted through March 2023, focusing on CC, squamous intraepithelial lesions, and HPV infection risks in specified immunocompromised groups.
• Data on newer DMTs/MABs and their impact on HPV vaccine response (antibody titers) were analyzed.
• Recommendations were formulated based on literature review and expert consensus, adapting existing HIV screening guidelines where appropriate.

Main Results:

• Individuals with SOT, ESRD, HSCT, and SLE consistently showed an increased risk of HPV, squamous intraepithelial lesions, and CC, irrespective of immunosuppressant use.
• Evidence for increased risk in IBD, RA, and MS was weak unless patients were on immunosuppressants; data on DMT/MAB use were conflicting.
• Some immunosuppressants were associated with lower antibody titers post-HPV vaccination; no studies directly assessed HPV vaccine efficacy in these populations.

Conclusions:

• CC screening following US CDC HIV guidelines is recommended for SOT, ESRD, HSCT, SLE (with or without immunosuppressants), and IBD, RA, MS (on immunosuppressants).
• Shared decision-making for increased surveillance is advised for IBD/RA not on immunosuppressants and those on DMTs/MABs due to conflicting data.
• A 3-dose HPV vaccine series is recommended for all eligible individuals (ages 9-26, with consideration up to 45), ideally before SOT or DMT/MAB initiation. HSCT recipients should have the vaccine series readministered.