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    Is HPV testing ready for ‘prime’ time in cervical cancer detection?

     

    So what is known about primary HPV screening? Several prospective European studies have shown the improved sensitivity of HPV as compared to Pap in detecting high-grade dysplasia earlier, with improved long-term detection of cancer, although increased rates of colposcopy were noted, as compared to the use of cytology alone for primary screening.2

    The recent FDA approval is based on a well-designed prospective study set in multiple US clinics (known as the ATHENA trial, funded by ROCHE and studying the cobas HPV test and ThinPrep cytology) and comparison of 4 screening strategies in women 25 and older who were managed under a specific study protocol.3 Only 3 years of data are available to date, and they have not yet been published (although they were presented to the FDA). Of note, current guidelines in women older than age 30 recommend cotesting at 5-year intervals; thus the comparison to standard of care is not yet available.

    So far, the data presented show a notably improved rate of detection of high-grade dysplasia among women aged 25–30, especially those who test positive for HPV 16/18.4 Cytology is a particularly poor test in this age group, although HPV is particularly common, and the best balance of testing and increasing rates of colposcopy with actual cancer prevention is not yet clear. More data need to be accrued to understand the relative costs and benefits. The relative benefits for women age 30 and older are less clear, given that dysplasia is less common and cytology or cotesting at currently recommended intervals are reliable approaches in this age group.

    Summary

    Promising data from a well-designed study in US women, with limited long-term data, a very specific set of comparison algorithms, and using only one type of HPV test suggest that use of primary HPV testing for some women (especially in the 25–30 age group) may enable us to detect high-grade dysplasia earlier and more effectively than Pap testing. This might allow us to identify and treat precancers sooner, and thus perhaps focus our resources on greater surveillance of higher-risk women or screening of women who were previously unscreened.

    It is important to note, however, that improved detection of precancerous changes of the cervix may not automatically translate into fewer cancers, as the ability to prevent cancer is related not just to the screening test used, but also to the management and resources used to intervene to prevent cancer. As greater numbers of young women receive HPV vaccination before the onset of sexual activity, a test that could better differentiate women at higher risk of developing cervical cancer may enable us to better focus our resources for cervical cancer prevention on those at higher risk. So, although we need longer-term data, as well as data about other tests in both vaccinated and unvaccinated women, HPV testing is promising and likely to have a role in the future in cervical cancer screening in the United States.

     

    Sarah Feldman, MD, MPH
    Dr. Feldman is Associate Professor of Obstetrics, Gynecology and Reproductive Biology at Harvard Medical School, Director of Ambulatory ...
    Aparna Kamat, MD
    Dr. Kamat is the Director of Gynecologic Oncology in the Department of Obstetrics and Gynecology at the Methodist Hospital, Houston, Texas.

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