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With its long history of successful organized cervical cancer screening, Canada has been also among the pioneer countries conducting large, publicly funded randomized controlled trials of HPV testing in cervical cancer screening. However, progress in adopting molecular-based technologies in screening has been slow. HPV testing has gained acceptance in Canada only as a strategy for the triage of women with ASCUS smears. The most recent Canadian Task Force on Preventive Health Care (CTFPHC) evidence review (2013) was unfortunately silent on HPV testing and based all its recommendations on Pap cytology. The Pan-Canadian Cervical Cancer Screening Network sponsored a consensus conference in 2014 that concluded that HPV testing should be the anchor technology in cervical cancer screening among vaccinated and unvaccinated populations. Health policymaking in Canada is at the provincial level, however, national or federal recommendations are not binding on the provinces. Although published a year earlier (2012) than the CTFPHC’s guideline, the most progressive and well-informed evidence review was that of the Ontario Cervical Screening Guideline Working Group. It recommended standalone primary HPV testing (with a validated assay for oncogenic types) every five years for women aged 30 to 65 years, with Pap cytology triage of women with a positive HPV test result. In light of the logistical complexities and costs associated with implementing this paradigm change, the Ontario Ministry of Health was able to appropriate the budget and rollout the changes only this year (2017). Quebec completed its evidence review in June 2017, and concluded that a case could be made for a move to primary HPV screening but policy decisions can only be made after a detailed cost-effectiveness analysis via mathematical modelling. This analysis is ongoing. Other provinces are gradually considering changes via pilot projects or evidence reviews. Completion of the British Columbia FOCAL trial is expected to provide strong evidence to assist that province and others to move forward with implementation.
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