The Role of Human Papilloma Virus Testing in Cervical Cancer Prevention

Molly C. Fey, FNP, MSN; Margaret W. Beal, CNM, PhD

Disclosures

J Midwifery Womens Health. 2004;49(1) 

In This Article

Abstract and Introduction

A clear causal relationship has been established between human papilloma virus (HPV) infection and the development of cervical cancer. Genital HPV infection is currently the most common sexually transmitted disease worldwide. The recent 2001 American Society for Colposcopy and Cervical Pathology Consensus Guidelines have included HPV testing for management of women with cervical cytological abnormalities. Clinicians now face the challenge of deciding when to use HPV testing in follow-up of abnormal Pap tests. This article includes updates on HPV, cervical cancer screening, and HPV testing technology. Recommendations for integration of HPV testing into clinical practice are provided.

Genital human papilloma virus (HPV) infection is currently the most common sexually transmitted disease worldwide.[1,2,3] It is estimated that 5.5 million people in the United States become infected with HPV each year, and more than 20 million Americans are already infected.[4] Lifetime chance of HPV infection is proposed to be as high as 80% to 85% in sexually active individuals.[5] Acute infection is common soon after the initiation of sexual activity and is highly prevalent among women of reproductive age.[2] HPV infects the genital epithelium and is spread via skin-to-skin contact.[3] Condoms reduce but do not eliminate the risk of transmission, and infection may occur through genital contact without intercourse.[3,6,7,8] Some strains of HPV cause genital warts, but more often HPV infections produce no signs or symptoms. As a result, infected persons are frequently unaware that they are carriers, and transmission occurs unknowingly.[8]

The most significant risk factor for infection with HPV is the number of lifetime sexual partners.[6,7,8,9] Adolescent sexual activity has also proved to be associated with increased risk of HPV infection, yet other factors also influence this risk. The correlation between younger age of first intercourse and subsequent HPV infection is mediated by the number of sexual partners in the last 6 months, a history of sexually transmitted infections, alcohol and drug use related to sexual behaviors, and partner's number of sexual partners.[10]

HPV is a small, non-enveloped, double-stranded circular deoxyribonucleic (DNA) tumor virus, classified in the genus papillomavirus of the Papoviridae family of viruses.[8,11,12] More than 100 distinct types of HPV have been identified to date, and approximately 50 of these infect the epithelial membranes of the anogenital tract.[2,7,8] HPV DNA incorporates itself into the target cell genome, exerting effects through activation of oncogenes and suppression of host cell immune response. HPV protein products prevent DNA repair and programmed cell death, which leads to instability and unchecked cell growth.[9,11,12]

On cytologic examination, cervical cells infected with HPV may appear enlarged, with a clear zone around the nucleus, forming a perinuclear halo. These visible changes are referred to as koilocytosis, a term derived from the Greek word koilos, meaning "hollow." In the past, koilocytic Pap test abnormalities have been considered an indicator of HPV infection, but the reliability of this correlation is now in question and cannot be used to ascertain HPV status.[8,13]

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