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

Summary and Future Implications for Clincal Practice

The 2001 Consensus Guidelines, in several scenarios, give clinicians a choice between follow-up with repeat cytology or HPV testing (Figures 2 and 3). When is HPV testing the best option? Compared to repeat cytology, HPV testing has proven to have higher sensitivity for high-grade cervical intraepithelial lesions and refers a comparable number of women for colposcopy at significantly lower screening costs. Still, the age of a patient warrants consideration, because the specificity and sensitivity of HPV testing for detection of high-grade cervical intraepithelial lesions vary among ages. In younger groups, the specificity of HPV testing is lower than that of cytology.[52] It is well known that HPV infection in younger women is more prevalent and will often spontaneously regress, particularly in those under the age of 30. In contrast, persistent high-risk infection peaks in women over 30.[30,32] As a result, many investigators recommend that HPV testing be reserved for clinical use in evaluation of women over the age of 30 to 35, when the specificity of the test for detection of high-grade cervical intraepithelial lesions increases.[32,52] Previous studies comparing HPV testing in sexually active women over 30 versus women under 30 found that the test has higher specificity in the older group. Confirming this, the ALTS trial also found that consideration of age is pertinent to effective triage of mildly irregular Pap tests. HPV testing remained highly specific for women age 29 and older, resulting in nearly 20% reduction in the number of women referred for colposcopy compared to cytology.[51] Considering that the effectiveness of cytologic screening for detection of dysplasia peaks at age 35 and decreases rapidly thereafter to age 50, HPV testing becomes the obvious choice for this group.[53] In women 30 and older, a single positive HPV test has more clinical significance than in younger populations with more transient viral status, because it is more indicative of high-grade cervical disease and persistent infection.[1] In March 2003, the FDA approved expanded use of the HPV test for screening of women over age 30, in conjunction with the Pap test.[54]

Equivocal and mildly irregular Pap tests are the most frequent abnormal cytologic finding, and follow-up is controversial. Options such as repeat serial cytology or referral for immediate colposcopy have significant drawbacks. Testing for high-risk HPV is the preferred approach to follow-up for all women with ASC-US Pap results, as well as adolescents and low-risk postmenopausal women with LSIL Pap results. The HPV test is highly sensitive and specific for underlying moderate to severe CIN, especially in women over 30. Reflex HPV testing of liquid-based cytology specimens or HPV co-collection at the time of initial screening is the most cost-effective approach.

In the future, prophylactic and therapeutic vaccines against high-risk HPV infection may prove to optimize health benefits and minimize economic costs of cervical cancer prevention. A prophylactic HPV vaccine targeted at one or more high-risk HPV strains is expected to become available within the next decade. Duration of HPV vaccine efficacy, optimal age of vaccination, and approaches to incorporation of vaccines into existing screening protocols are currently under investigation.[12,55,56]

The print version of this article was originally certified for CE credit. For accreditation details, contact the publisher. Journal of Midwifery & Women's Health, published by Elsevier Inc. Corporate and editorial offices: The Curtis Center. Independence Square West, Philadelphia, PA 19106-3399.

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