NYT Examines Debate Over Replacing Pap Smears With HPV Tests For Cervical Cancer Screenings

Main Category: Cervical Cancer / HPV Vaccine
Article Date: 08 Apr 2009 - 0:00 PDT

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The New York Times on Tuesday examined the debate among reproductive health experts over whether a new DNA test for human papillomavirus should replace Pap smears as the primary method for screening for cervical cancer. There are about 150 strains of HPV, and although more than 90% of HPV cases clear up without treatment within two years, some strains of the virus can lead to cervical cancer, the Times reports. In the U.S., Pap smears -- which involve a laboratory test of a cervical swab to screen for abnormal cells -- have been highly effective in reducing cervical cancer deaths. However, in developing countries, Pap smears have been unsuccessful "because there are too few trained pathologists" and because women oftentimes cannot return to clinics to receive test results or treatments. Some countries have adopted "visualization" testing, which involves a vinegar swab of the cervix and inspection with a flashlight to look for changes that indicate precancerous lesions.

Some gynecologists say a new study that found that a single screening with the HPV test was more effective than all other methods at preventing cervical cancer and death supports abandoning Pap smears in favor of the HPV test, both in developed and undeveloped countries. Paul Blumenthal, a professor of gynecology at Stanford Medical School who was not involved in the study, called the research a "nail in the coffin" for the Pap smear, which he said will "soon be of mainly historical interest." However, opinions on the value of Pap smears vary "depending on which expert is asked," the Times reports. Some scientists say that women ages 30 and older could forgo annual Pap smears and be screened for HPV every three, five or even 10 years. Renegaswamy Sankaranarayanan of the World Health Organization's International Agency for Research on Cancer in France and the lead author of the new study said the findings show that with the HPV test, doctors could begin "screening women at 30 and do it once every 10 years," including in the U.S. However, Debbie Salsow, director of gynecologic cancer for the American Cancer Society, said this recommendation would "[a]bsolutely" not be applicable in the U.S., because a "negative test would mean a woman's chances of developing cancer are small, but not zero," although she added that screening every five years might be more acceptable. ACS and the American College of Obstetricians and Gynecologists since 1987 have recommended that women in the U.S. undergo Pap smears every three years after initial negative ones. The groups in 2002 recommended HPV tests as well, and "evidence is mounting that the Pap smear can be dropped," according to the Times. Salsow said, "We're totally overscreening, but when you've been telling everyone for 40 years to get an annual Pap smear, it's hard to change."

Many factors will determine whether HPV screening will replace Pap smears, and the considerations vary greatly from the U.S. and other western countries to developing countries with limited financial resources, the Times reports. Cost is a major factor in developing countries, where cervical cancer is responsible for more than 250,000 deaths a year, compared with less than 4,000 deaths in the U.S. The company Qiagen, which produces a DNA test for HPV with financing from The Bill and Melinda Gates Foundation, has developed a $5 version of the test and could continue to lower the price with enough demand. Mark Schiffman of the National Cancer Institute, who wrote an accompanying editorial to the new study, said, "The U.S. has high resources and low risk-tolerance," whereas countries like India with low average incomes are forced to tolerate risk. Jan Agosti, who oversees cervical cancer screening in developing countries through the Gates Foundation, said Qiagen's new $5 test requires only batteries, does not need water or refrigeration, and takes less than three hours. She said the test could provide an acceptable option for women in some countries who are "shyer about pelvic exams," adding that the test functions "acceptably well" on vaginal swabs that women can do themselves (McNeil, New York Times, 4/7).

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