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Re: Cervical Cancer Screening with ThinPrep and High Risk HPV DNAFrom: ainsron (ainsron@sbcglobal.net)Mon Apr 26 20:08:58 2004
Check out the symposium in Nov 2000 Contemporary OB/GYN. This excerpt is the most relevant to your question: Richart: Dr. Meijer, how do you apply HPV DNA testing for primary screening? Who should be screened-and when? Can we use HPV DNA alone or combined with cytology? What does it do to the false-negative rate of cytology, which is a problem for us and for the women we serve? Meijer: In 1992, I originally suggested at a WHO meeting in Brussels that we use high-risk HPV testing alone, augmenting it with a Pap smear afterwards for those who are high-risk HPV positive. But the argument that is always raised is that invariably a few high-grade HPV-negative CIN 3 lesions will provoke litigation if undetected. We countered that argument by recommending combining high-risk HPV testing with cytology. That raised the cost of screening and prompted discussion on reducing that cost. We've already discussed the practice in the Netherlands of screening women over 30 as one of two possible ways to reduce costs. Richart: And the other possibility? Meijer: Postponing screening intervals. Our data suggest that theoretically we can increase to 10 years the screening interval of a woman who is high-risk HPV negative and has a normal Pap smear. The cost of an extra high-risk HPV test is brought down through the cost reduction achieved by increasing the screening interval. Moreover it takes about 13 years to acquire cervical carcinoma from a persistent high-risk HPV infection.21 Richart: What degree of sensitivity are we talking about? Meijer: Using cytology and high-risk HPV testing, the sensitivity for picking up a high-grade lesion and cervical cancer is over 95%. So if a woman were tested only once every 10 years, employing such a regimen would be very useful. Richart: What form do you think the combination testing will take? Will it be a Pap smear plus high-risk HPV test? Or will it be liquid cytology with a high-risk Pap test? Meijer: In a recent review in the Journal of Clinical Pathology, I argued that at the moment liquid cytology is quite expensive in The Netherlands.22 Its cost is about one quarter of the maximum amount paid by insurance companies. At present, if I had to choose between liquid cytology or a high-risk HPV test, I'd choose the latter. But if the pharmaceutical companies and the doctors could negotiate a less costly screening program that combined the tests, I think that would be best for screening. Richart: The so-called unit pricing approach consists of packaging the elements and charging a single fee for the package-almost like an insurance policy-so that it's spread across the population and used population-wide. This would be useful, would it not? Meijer: By doing high-risk HPV testing-plus cytology-we detect in our screening population about 4% of women who are high-risk HPV positive and have normal smears. And as we've already published and recently updated, if you follow these 4% for 4 years, then 8% of them in fact show CIN 3. (Rozendaal L, Westerga J, van der Linden JC, et al. PCR-based high-risk HPV testing is superior to neural network based screening for predicting incident CIN III in women with normal cytology and borderline changes. J Clin Pathol. 2000;53:606-611.) Moreover by combining both tests, our false-negative rate is decreasing and early on we're picking up at-risk women who were formerly missed. (In The Netherlands we assume this represents about one quarter of the high-grade CIN lesions that were missed.) This increase in detection rate of high-grade precursor lesions is another argument in support of high-risk HPV testing combined with cytology. Ronald E. Ainsworth -----Original Message----- From: ob-gyn-l@obgyn.net [mailto:ob-gyn-l@obgyn.net] On Behalf Of Garry E. Siegel, M.D. Sent: Monday, April 26, 2004 5:26 PM To: Multiple recipients of list OB-GYN-L Subject: GYN: Cervical Cancer Screening with ThinPrep and High Risk HPV DNA Dear all: I'm stumped on finding the answer to this one, although I know that it is out there somewhere. Primary screening can be done every 3 years with liquid cytology and HPV DNA testing, at age 30 and beyond. What does one do if the pap is normal but she is HPV positive??? 29 YO P0 is in for a routine pap, and due basically to a clerical error (either we checked the wrong box on the lab form, or the lab messed up), she had: Negative liquid cytology Positive HPV high risk DNA I can't find managment for this anywhere, alhtough I find a couple of places that suggest that "guidelines need to be developed." Note againt that this was routine screening with a normal pap. Garry
-- Garry E. Siegel, M.D. Private Practice Roswell, GA
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