In the March 2006 “Update on Cervical Disease,” I began with Prof. Margaret Stanley’s exclamation “It could be the end of the affair with HPV!” That Update covered three major areas that have been nudging us closer to the possibility of someday ending cervical cancer.
I thought it time to revisit those three practical advances to see how we’re doing. As you’ll read, much has happened; one exciting prospect in 2006—human papillomavirus (HPV) vaccination—has become established in everyday practice. On the other hand, primary screening with an HPV plus a Pap test (so-called co-testing) has not yet fulfilled its promise, and type-specific HPV testing for HPV 16 and 18, expected in 2006 to be “just around the corner,” is still … just around that corner.
And it isn’t just medicine that has changed. The World of 2009 is a markedly different place than the World of 2006. The economy of the United States is rockier than at any time since the Great Depression, and the skyrocketing cost of medical care has made health-care cost containment more important a goal than it ever has been.
So, allow me to reexamine what was “new in 2006” for cervical cancer prevention and compare where we are in 2009—thanks to interesting, important research and the effects on health care of an economic squeeze that we could not have foretold 3 years ago. I’ll also make an educated prediction about where cervical cancer prevention may be headed in, say, the next 3 years or so.
1 “More sensitive and more objective screening” inches closer
Naucler P, Ryd W, Törnberg S, et al. Efficacy of HPV DNA testing with cytology triage and/or repeat HPV DNA testing in primary cervical cancer screening. J Natl Cancer Inst. 2009;101:88–99.
Solomon D, Breen N, McNeel T. Cervical cancer screening rates in the United States and the potential impact of implementation of screening guidelines. CA Cancer J Clin. 2007;57:105–111.
Dillner J, Rebolj M, Birembaut P, et al; Joint European Cohort Study. Long term predictive values of cytology and human papillomavirus testing in cervical cancer screening: joint European cohort study. BMJ. 2008;337:a1754.
Comforting combo: Negative Pap and HPV tests
In 2006, I discussed the Level-A evidence, cited in the 2005 ACOG Practice Bulletin, that women who have a negative HPV test and a negative Pap (i.e., a co-testing protocol) have a risk of approximately 1 in 1,000 of an unidentified CIN 2,3 or cervical cancer and, therefore, do not need another Pap or HPV test for at least another 3 years. This would seem compelling evidence of the efficacy and safety of co-testing, so the expectation might be that this cervical screening strategy would quickly become the primary protocol for women 30 years or older.
But not so fast! Even though a recent Centers for Disease Control and Prevention (CDC) survey indicates that 66% of clinicians who provide cervical screening already used co-testing by 2004,1 recent estimates are that only one third or fewer of women 30 years or older are being screened with a Pap test + HPV test. What does this mean? Possibly, that co-testing is used by a majority of clinicians, but not routinely. There are, likely, a number of reasons that co-testing has not become standard, but hesitancy to move beyond the annual Pap test is at the top of the list.
Providing an annual Pap test to our patients has reduced the incidence of cervical cancer from second among cancers in women to 11th, and mortality from second to 113th. But a program of annual cervical cytology is not cost-efficient2 even if it is protective for most women, and the degree of protection declines among women who are screened irregularly.