Suppose there were a screening test for cervical cancer that could detect potential dangers with far more sensitivity than the Pap. A test so reliable that when it was done with the Pap, you could trust the results nearly 100 percent. Sounds like all women would be getting it, right?
Well...there is such a screen - the HPV test. It's been approved by the FDA and endorsed by the American College of Obstetricians and Gynecologists (ACOG) and the American Cancer Society as an option to be done with your Pap, and yet only an estimated 15 percent of doctors are using it.
If your ob-gyn has never mentioned it, then get all the facts here and learn how to start the conversation.
What is the new HPV test?
Almost all cervical cancers are caused by prior infection with human papillomavirus, or HPV. There are more than 100 strains of HPV, about 40 of which can be spread by having sex. Some cause warts, others no symptoms at all. But some types cause cell abnormalities in the lining of the cervix that, years later, can become malignant. Two of these strains - numbers 16 and 18 - are thought to be responsible for roughly 70 percent of cervical cancer cases. The HPV test literally homes in on genetic coding that occurs in these two, plus about a dozen other high-risk strains. A negative HPV test means that no active virus could be found; a positive result, that one or more of those strains is present.
How is this different from the Pap?
The Pap is designed for visual identification (by either lab technician or computer) of any cells that look abnormal. The HPV test was originally approved by the FDA as a follow-up for women whose Pap results were ambiguous (technically called ASCUS - "atypical squamous cells of undetermined significance"), a category that may affect some three million women every year. Now it's been OK'd as a screening test for women 30 and over, to be done with the Pap and, generally, the same sample of cervical cells.
How effective is it?
Last April, two scientists from the National Cancer Institute, writing in the prestigious New England Journal of Medicine about a study of 131,746 women in India, said that "among...women between the ages of 30 and 59 years...a single HPV test performed 15 to 20 years after the median age of first sexual intercourse will detect many easily treatable, persistent infections and precancers while limiting overtreatment." One test, they wrote, "dramatically reduced the incidence of advanced cervical cancer and cervical cancer mortality."
Do you still need an annual Pap test?
Actually, since 1987, virtually every medical organization that has issued guidelines on cervical screening has endorsed the idea that after three successive "normals," a healthy, low-risk woman age 30 or over needs to be tested only every two to three years. "The tradition of annual Pap tests is just that, a tradition, and it's not backed up by science," says Debbie Saslow, Ph.D., the American Cancer Society's director of breast and gynecologic cancers. Only women considered at high risk - DES daughters, for example, or those who've had cervical cancer or precancerous lesions - need more frequent tests. (Smoking also ups your risk; if you smoke, ask about extra tests.) Even if you don't have a Pap, though, you should have regular checkups that include breast and pelvic exams, a blood pressure reading, and other tests depending on your age and medical history.
OK, but what if a yearly Pap makes you feel safer?
Trouble is, each time you're tested, you run the risk of an abnormal finding. And though there's a strong chance that any aberrant cells would be cleared by your body before your next test two or three years later, now the doctor has to "do something," which might include removing those cells. You're subject to needless procedures, not to mention a lot of anxiety about the possibility of cancer - all for a disease that likely would never have developed.
If you have an HPV test and a Pap and both are normal, what next?
You're "free," so to speak, for three years. "Even if a 40-something woman went out and got a new infection the very next day, she would be effectively setting the clock back to zero; her risk of cervical cancer wouldn't rise significantly until she was in her 60s," says Mark Schiffman, M.P.H., M.D., senior investigator at the National Cancer Institute. In other words, a double "all-clear" may finally give a woman - and her doctor - the peace of mind to break the Pap-every-year habit.
Why aren't all doctors recommending HPV testing?
Physicians may be hesitant to adopt this new technology until there's stronger evidence that it's beneficial - that it prevents illness and saves lives, says Joy Melnikow, M.D., M.P.H., director of the UC Davis Health System Center for Healthcare Policy and Research. There are also practical considerations. The HPV test is easiest to do in conjunction with so-called liquid Paps, in which "leftover" fluid provides cells to test for HPV. Although roughly 90 percent of Paps are now done this way, 10 percent of doctors still use the older slide/smear technology (which, by the way, new research shows is just as accurate); adding a second test would mean taking a second cell sample. Finally, there's the cost - about $100. Pap tests are routinely covered by insurance. Although 26 states plus the District of Columbia require private insurers to pay for cervical screening in some way, just seven - California, Maryland, New Mexico, North Carolina, Oregon, Texas, and West Virginia - specifically cover HPV testing. "Many women can't or don't want to pay for it," notes Concepcion Diaz-Arrastia, M.D., director of gynecologic oncology at Baylor College of Medicine.
Should you ask your doctor about the test?
Absolutely, says Dr. Diaz-Arrastia. You may think, 'How could I have HPV?' but in a study she supervised at the University of Texas Medical Branch at Galveston, researchers found there was a peak in active infections in women in their 50s. In one group of 167 women age 55 and over, 35 percent of those who tested positive for active HPV reported no sexual activity for five or more years. These women may have had persistent or recurrent infections; she speculates that the virus can reemerge, similar to the way shingles develops decades after a childhood bout of chicken pox.
Cervical cancer screening is in transition, from the Pap-only mode to the HPV/Pap testing combo and perhaps to HPV testing alone first, says Dr. Schiffman. Or the move may be to other techniques in development.
Meanwhile, the best way to safeguard your own health is to speak up: Ask about the new test, be open and honest about your sexual and medical history, and, if your doctor is hesitant, find out why. Habit is not a good enough reason to miss out on the reassurance that HPV testing can offer.
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Reprinted with permission of Hearst Communications, Inc.