How does new technology impact cervical cancer?
Several strides have been made when it comes to cervical cancer prevention. Research has identified high-risk human papillomaviruses (HPVs) as causal agents, a test has been developed to detect HPV infection (Digene HPV Test, Digene Corp.; Gaithersburg, MD), and a vaccine (Gardasil, Merck & Co.; Whitehouse Station, NJ) is now marketed to prevent infection of the most common types of HPV.
However, results of a new online survey of more than 1,000 women released by the National Association of Nurse Practitioners in Women's Health (NPWH) indicate more than half of women surveyed do not know that cervical cancer is preventable.1
Women need to be brought up to speed about cervical cancer prevention, as public health officials are attempting to determine how to most efficiently carry out cervical cancer screening in the era of HPV vaccination. Results of a newly published study suggest it may be time to reconsider changes in the guidelines for cervical cancer screening in the United States.2
Using mathematical models to predict the impact of various screening techniques in vaccinated and unvaccinated women, researchers conclude the addition of preadolescent vaccination to current screening approaches will yield an additional 36% reduction in cancer risk. For vaccinated and unvaccinated women, age-based screening protocols that include HPV DNA testing, used for triage of atypical squamous cells of undetermined significance in younger women and for primary screening in older women, offer improved effectiveness as compared with current screening recommendations.3
Current guidelines now recommend screening with cytology methods and using HPV DNA testing only when the results are equivocal. Using mathematical modeling, findings from the new research paper suggest it may be more cost-effective to continue screening using cervical cytology with HPV triage for women between ages 21 and 25, then switching to HPV DNA testing with cytology triage for women older than 30 years.2
For the nearly 40 million girls who are likely to be vaccinated over the next 20 years, and if the HPV vaccine proves to provide long-lasting immunity, the analysis indicates that screening after age 25 be less frequent. Current recommendations call for yearly screening with conventional cytology methods, with screening once every two to three years using liquid-based cytology methods.
As public health officials continue to determine the most cost-effective methods of cervical cancer prevention, where will the Pap smear fit in the equation? Beth Jordan, MD, medical director at the Association for Reproductive Health Professionals, sees the Pap smear as a key method for screening, particularly for more disadvantaged populations. "While new technologies are great, we can't get rid of the old ones, because they provide such an important screening tool at low cost for disadvantaged, higher-risk populations," states Jordan.
Get women up to speed
Education is a key part of preventing cervical cancer. According to the results of the NPWH survey, clinicians need to provide more information to their patients about prevention. For example, surveyed women older than age 30 — who are most at risk of developing cervical cancer — are half as likely as their younger counterparts to recall speaking to providers about HPV and its link to cervical cancer.
While 90% of women ages 30 and older said they were somewhat or very familiar with the preventive tests they need, more than half (58%) had not heard of the HPV test, and 86% did not recall providers ever talking to them about the test.
Women of all ages need to be informed of the essential facts regarding HPV and risk of cervical cancer, says Susan Wysocki, RNC, NP, FAANP, NPWH president and CEO. These facts include the following:
- Cervical cancer is preventable and caused by high-risk types of HPV.
- Most women will have HPV infection at some point.
- The virus usually is cleared by an immune response.
- Persistent HPV infection by high-risk types is the factor that increases the risk for cervical cancer.
- Infection by HPV is common, but cervical cancer is rare.
- When an HPV test is positive, it does not mean that the virus is new or that a partner has been unfaithful.
- HPV can persist in the cells for decades.
Use of the HPV vaccine is very important, says Robert Hatcher, MD, MPH, professor of gynecology and obstetrics at Emory University School of Medicine in Atlanta.
"We're now in an age when young women can get protection," says Hatcher. "The most important technology impacting cervical cancer is for all young women to get immunization."
References
- Penn, Schoen & Berland Associates for the National Association of Nurse Practitioners in Women's Health. Cervical Cancer Awareness and Knowledge Survey. Washington, DC; February 2008.
- Goldhaber-Fiebert JD, Stout NK, Salomon JA, et al. Cost-effectiveness of cervical cancer screening with human papillomavirus DNA testing and HPV-16,18 vaccination. J Natl Cancer Inst 2008; 100:308-320.
- Kiviat NB, Hawes SE, Feng Q. Screening for cervical cancer in the era of the HPV vaccine — the urgent need for both new screening guidelines and new biomarkers. J Natl Cancer Inst 2008; 100:290-291.
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