Lithuanian Cervical Cancer Implementation Guide
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Lithuanian Cervical Cancer Implementation Guide, published by Lithuanian Medical Library. This guide is not an authorized publication; it is the continuous build for version 0.0.1 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7LT/ig-lt-cervical/ and changes regularly. See the Directory of published versions

Workflow

Cervical Cancer Screening Workflow

This page describes the clinical workflow modeled by the Lithuanian Cervical Cancer Prevention Implementation Guide. The pathway follows the national cervical cancer early diagnosis programme (ADP).

Overview

The cervical cancer screening pathway consists of four sequential diagnostic stages, each producing a structured DiagnosticReport:

  1. HPV Testing — Primary screening with high-risk HPV DNA detection
  2. Cervical Cytology (Pap Test) — Microscopic examination of cervical cells
  3. Colposcopy — Clinical examination of the cervix with scoring
  4. Histopathology — Tissue analysis from biopsy or excisional specimens

All reports are linked into a single Cervical Cancer Screening Episode Composition wrapped by a Cervical Report.

1. HPV Testing

Women in the screening programme undergo high-risk HPV DNA testing as the primary screening method. The HPV test procedure code is always SNOMED 35904009 (HPV DNA detection). The screening context (primary, routine, targeted, repeat, or control after treatment) is conveyed via ServiceRequest.reason referencing the screening programme, not via the DiagnosticReport code.

Profile: HpvDiagnosticReportLtCervical

The HPV diagnostic report contains:

  • HPV Test Result — overall result (detected/not detected/unsatisfactory)
  • Genotype panel — individual HPV types (16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 66, 68)
  • Risk group classification — highest (16, 18), medium (31, 33, 35, 45, 52, 58), lower (AR HPV)

Examples:

2. Cervical Cytology (Pap Test)

Cervical cytology is performed either as a co-test with HPV or as a follow-up to positive HPV results. The specific test type is indicated in DiagnosticReport.code using CervicalCytologyTestTypeVS, which includes routine PAP (440623000), liquid-based screening (417036008), general cervical cytology (416107004), diagnostic cytology after colposcopy (609040007), and immunocytochemistry p16/Ki-67 (395126005).

Morphological sub-features within Bethesda categories (e.g., koilocytes in LSIL, reparative changes in NILM) are captured via the ESPBI Questionnaires rather than in the structured observation profiles.

Profile: CytologyDiagnosticReportLtCervical

The cytology report contains:

  • Cytology Conclusion — Bethesda classification (NILM, ASC-US, LSIL, ASC-H, HSIL, AGC, AIS, SCC)
  • Specimen suitability assessment
  • Pathogen findings (candida, trichomonas, actinomyces, herpes)
  • Microflora classification
  • Immunocytochemistry (p16/Ki-67 dual staining)

Examples:

3. Colposcopy

Colposcopy is indicated when HPV is positive and/or cytology shows abnormalities (ASC-US+).

Profile: ColposcopyDiagnosticReportLtCervical

The colposcopy report contains:

Examples:

4. Histopathology

Histopathological examination is performed on tissue obtained from biopsy or excisional procedures. This stage reuses profiles from the Laboratory IG for specimen management, tumor measurement, and pathology reporting.

Profile: HistopathologyDiagnosticReportLtCervical

The histopathology report contains:

  • Histopathology Conclusion — WHO classification diagnosis, histological grade (G1–G3), pLVI (6-level classification from Lab IG), surgical margins
  • Pathology Composition — synoptic document with Pre-Analytic, Macroscopic, Microscopic, and Synthesis sections (reused from Lab IG)
  • Specimen Measurement — tissue fragment dimensions (x,y,z mm per container) and ectocervix measurements (reused from Lab IG)
  • Tumor Measurement — 3D tumor dimensions in mm (reused from Lab IG)
  • Specimen — cervical tissue specimen with fixation type via processing.additive (formalin = SNOMED 434162003) (reused from Lab IG)
  • Cervical Condition (TNM Staging) — pT (pTX–pT4), pN (pNX–pN2), pR (pRX–pR2) staging with ICD-O morphology

Practitioner roles: The performer element captures the test conductor (pathologist); resultsInterpreter captures the confirmer/approver (senior pathologist). The referring doctor is linked via basedOn → ServiceRequest.requester.

Examples:

5. Screening Episode Composition

At the end of the diagnostic workflow, all reports are linked into a single structured document — the Cervical Composition.

The composition sections include:

  • Clinical History — pre-analytic observations (cycle day, menopause, therapies, conization history)
  • HPV Report — HPV DiagnosticReport
  • Cytology Report — Cytology DiagnosticReport
  • Colposcopy Report — Colposcopy DiagnosticReport
  • Histology Report — Histopathology DiagnosticReport
  • Lifestyle Factors — cross-IG references to Lifestyle IG (tobacco use, physical activity)
  • Vital Signs — cross-IG references to VitalSigns IG (BMI)

The composition is wrapped by the Cervical Report which aggregates all structured results.

Examples:

Clinical History Context

Pre-analytic clinical observations are captured using the Cervical Screening Clinical History profile with components for:

  • Menstrual cycle day (SNOMED 161713000)
  • Menopause status (SNOMED 276477006)
  • Hormone therapy (SNOMED 1346510001)
  • Pregnancy (SNOMED 77386006)
  • Lactation (SNOMED 225604004)
  • Radiotherapy history (SNOMED 429479009)
  • Chemotherapy history (SNOMED 161653008)
  • Intrauterine device (SNOMED 312081001)
  • Previous conization (SNOMED 1089410001)
  • Sample collection site
  • HPV vaccination status

Examples: