2013 Ob/Gyn & Women's Health Game Changers

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Of all the articles published in women's health this year, which ones are the most likely to affect your day-to-day work? Dr. Peter Kovacs summarizes 4 key studies you need to know about before year's end.

Human Papillomavirus: What Every Provider Should Know

Erickson BK, Alvarez RD, Huh WK
Am J Obstet Gynecol. 2013;208:169-175

Summary

Cancer is among the top 3 leading causes of death among women. Almost one half of cervical cancers are diagnosed in reproductive-aged women. Screening for cervical cancer has resulted in a decline in cervical cancer morbidity and mortality.

Human papillomavirus (HPV) is responsible for malignant changes of the cervix, vulva, vagina, anus, head, neck, and penis. It has numerous genotypes, and not all are equally oncogenic.

HPV is primarily transmitted via sexual contact, although vertical transmission during pregnancy and delivery is also possible. The virus enters the epithelial cells through superficial trauma and targets basal epithelial cells, where it induces characteristic changes. Oncogenic genotypes result in escape from apoptosis, and the affected cells will go through uncontrolled cell cycles.

HPV can be detected in 40% of women, and about 30% involve high-risk genotypes. Prevalence is highest in the early 20s. The risk for HPV infection increases with the number of sexual partners and when other sexually transmitted diseases are present.

Most HPV infections (40%-70%) will be cleared, and only a small proportion induces premalignant or malignant changes. The risk of progressing from lower-grade precursor lesions to higher-grade lesions or cancer is increased among persons with persisting infection.

Various tests are available to screen for HPV. Indications for HPV testing are the following:

• Atypical squamous cells of undetermined significance on cytology in women older than 21 years;

• Screening with cytology in low-risk women older than 30 years;

• During follow-up if cytology shows low-grade squamous intraepithelial lesion or atypical glandular cells; and

• During follow-up after treatment of cervical intraepithelial neoplasia (CIN) 2-3.

Vaccination is also available and can be offered as prevention. There are 2 approved products: Gardasil® and Cervarix. Vaccination is most effective if given to HPV-negative women and is primarily recommended between 9 and 26 years of age.

Background

Cervical cancer is the third most common cancer among women. Despite the availability of screening, an estimated 12,000 new cases of cervical cancer with 4000 deaths were predicted for 2013.^[1] Screening for cervical cancer has resulted in a drop in the number of new cases and severity of disease.^[2] Precursor lesions and early stages of cancer can effectively be treated even with conservative methods.

HPV types 16 and 18 are responsible for 70% of cervical cancers. Screening for HPV allows an individualized approach to patients with cytologic abnormalities. Those who are negative for HPV may undergo routine surveillance, depending on the cytology result. Those with low-risk HPV can also be followed up, whereas those with high-risk genotypes need a more aggressive approach. Combining HPV testing with cytology increase the sensitivity of the test but also results in more unnecessary colposcopies as the specificity gets lower.^[3]

Widespread vaccination against high-risk genotypes is expected to lower cervical cancer rates. Incorporation of HPV testing into screening algorithms is expected to detect more intraepithelial neoplasias and cancers but also to increase the need for colposcopies and biopsies. Because CIN 3 and cancer are rare, cost/benefit analysis should also be used to identify the best screening algorithm.

Message

HPV types 16 and 18 are responsible for 70% of cervical cancers. Screening for HPV allows an individualized approach to patients with cytologic abnormalities. Vaccination of HPV-negative women is expected to further lower the incidence of cervical cancer.

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