hpv screening alone recommended by FDA subcommittee

NY times reports unanimous vote by FDA subcommittee to replace pap smears with HPV testing alone. prior to this being a new policy, has to be approved by FDA (which almost always happens),
though many providers may not use this test alone unless approved by professional societies. the initial test would be done at age 25. for full article: http://www.nytimes.com/2014/03/13/health/an-fda-panel-recommends-a-possible-replacement-for-the-pap-test.html?_r=0 

of note, 

    --approx cost (in houstin texas): $50 for pap, $150 for HPV

    --only one of the hpv tests, the one by roche (not the most common one done), is approved

    --the current guidelines (pap age 21-30 q3yrs, then combo pap/HPV after age 30 q5yrs), have consciously postponed hpv screening til age 30 because in younger sexually active women, these infections most often regress spontaneously and, if picked up
by screening, could lead unnecessarily to more invasive followup procedures (eg culposcopy and maybe more).

will append a prior email/blog below, sent out last year.

geoff

An article this week in the lancet found at that HPV-based
cervical cancer screening was better than cytology-based methods (see hpv based screening
for cervical cancer lancet 2013 in dropbox, or http://dx.doi.org/10.1016/S0140-6736(13)62028-0).  They looked at four randomized trials in Europe, with 176,000
women aged 20-64 assigned to HPV-based screening (in 3 of these studies it was combination cytology plus HPV)
versus cytology screening alone.  Women were followed on average of 6.5 years to assess the development of invasive cervical carcinoma, with a screening interval of 3 years for those with a negative result.  107 invasive cervical cancers were found.  Although
there was not any difference in the first 2-1/2 years of followup, thereafter it was found that HPV-based screening provided 60-70% greater protection against invasive cervical carcinoma
as compared with cytology. their finding was even more significant in women in the 30-34 age range, an unanticipated result. They felt their data supported HPV screening from age 30
with screening intervals of at least every 5 years. 

 

Results from this study reinforce the decision at our Health Center (as per ACOG and USPSTF)
to screen every 5 years for women aged 30 or older with HPV-based screening.  However, as recommended, we do the combination of cytology with HPV screening.
 the study authors do raise the issue "because cotesting leads to many unnecessary colposcopy procedures, stand-alone HPV testing also seems recommendable". so, maybe we should be doing
only HPV testing in women over the age of 30??

 

this article also raises peripherally the issue of cervical cancer screening in a woman who
has never been sexually active, or continued cervical screening on patients who have had negative prior HPV screening and are no longer sexually active (the subtext here is: cervical
cancer is basically a sexually transmitted disease caused by certain specific strains of HPV).  i personally do not perform cervical cancer screening in women who have never been sexually
active (the issue here, though, is to be certain that the woman really has not been sexually active). for women who have had adequate negative screens (eg, normal HPV screens twice
in the preceding 10 years), and have not been in a sexual relationship for several years and with a very
high probability of not getting into one (as with many of our patients from some different cultural backgrounds), it seems reasonable to me to stop screening. (and, not so surprisingly, when i ask if they would like a vaginal exam, the answer is almost always
a resounding “no”). this is not the recommendation of ACOG or USPSTF, but seems to make sense based on the information at hand.