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Cervical-Cancer News: Too Good to Be True?

February 7, 2008 By:
Michelle Mostovy-Eisenberg, JE Feature
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A doctor at Fox Chase examines cells on a slide

Though multiple media outlets have hailed the recent findings of a cervical-cancer study as a major advancement in the detection of the disease, local doctors are wary to embrace such news at face value.

These doctors advise patients to understand this controversial issue in its entirety before assuming that the study results, recently published in the New England Journal of Medicine, mean more than they actually do.

In its Oct. 18 issue, the journal published the findings of researchers in Canada who examined the merits of the Human Papillomavirus test as a better screening exam than the 60-year-old Papanicolaou (Pap) smear method for detecting pre-cancerous and cancerous cells of the cervix.

Headlines were similar across the media: "HPV Testing Best at Detecting Early Cervical Cancer," "New Test Bests Pap Smear" and "Twice as Effective as Pap Smear."

Since oncogenic HPV is the underlying cause of cervical cancer, it is understandable why so much interest exists in HPV testing as a screening method.

What the media reported regarding the study's results -- that the HPV test was about twice as accurate as the traditional Pap smear (nearly 95 percent compared to slightly more than 55 percent) in sensitivity in detecting cervical cancer -- is misleading, according to Dr. R. Marshall Austin, professor of pathology and the director of cytopathology at Magee-Womens Hospital of the University of Pittsburgh Medical Center.

Austin said that the Pap smear is the only proven cancer screening test in medical history that has been highly cost-effective in substantially preventing a prevalent cancer. He noted that other recent studies, including one that followed thousands of women who had a negative Pap and a positive HPV test over a period of 10 years, documented less than 3 percent of Pap-negative women with an initial positive HPV test who developed precancerous signs or worse over 10 years.

"Most women with a positive HPV test do not have or ever develop precancer," he said, and added that women with an HPV infection usually never develop precancerous cells. He added that articles regarding the Canadian study used "irresponsible terminology as a scare tactic" equating HPV infection with carcinogenesis, even though most women with HPV never develop significant disease.

"We're not sure what to do with the information yet," said Dr. Cynthia A. Bergman, a gynecologic oncology surgeon at Fox Chase Cancer Center, of the research study findings. "It just showed it's a viable thing to study and evaluate further in the United States."

She added that the large number of recent studies worldwide "evaluating the utility of HPV testing should lead to better recommendations about how to use the information in the very near future."

Bergman said that offering both the HPV and the Pap is not the standard recommendation. She added that currently, "the primary utility of HPV testing is to help clarify the results of Pap smear screening."

She said patients can ask for HPV testing, "but sometimes, the psychological issues associated with positive testing are more cumbersome than helpful, particularly in younger patients who often clear their infections and do not ultimately require treatment for precancerous conditions."

Much Success With Smear Test
It's estimated that 11,150 women were diagnosed with -- and 3,670 women died of -- cancer of the cervix in 2007 in the United States, according to the American Cancer Society. Cervical cancer was once the No. 1 cause of cancer death of women in the United States, but because of the introduction of the Pap smear, new cases of cervical cancer have been reduced tremendously.

But while cervical cancer is no longer as prevalent in this country, the disease is still a leading cause of death in developing nations.

The question for Dr. Larry S. Seidman, founder of Philadelphia Clinical Research LLC in Northeast Philadelphia, is: Can the Pap smear be improved even further? The test, which he called "the best test in medicine," is inexpensive, generally reliable and easy to perform, and as such, can be repeated as needed.

Pap smears can miss detecting abnormal cells, Seidman conceded, but he said that exams on a regular basis should pick up anything missed on a previous test, as cervical cancer is a fairly slow-progressing disease.

Seidman, who after more than 30 years experience as a gynecologist, now devotes his time to the clinical-research facility he established in 1996, said that if a patient is diagnosed with a high-grade HPV, it just means she is at risk for developing cervical cancer in the future. That doesn't necessarily mean she has cells that will develop into the disease; it just means further tests and observation are needed.

"Many people have HPV in their systems," he said -- anywhere from 50 percent to 80 percent of people carry the virus at some point in their lives.

It is still too early to see if the HPV test is a better screening test, said Seidman. "None of these tests are exact."

He added that he questions if an increased false-positive rate with the HPV test could result in more biopsies being performed on women.

Austin agreed, and questioned how doctors could cost-effectively follow up with the huge number of women who would periodically have a positive HPV test. He added that the HPV test being performed on every woman routinely would not only be expensive but, with the high prevalence of HPV, many colposcopies would inevitably be performed (and already are being performed) on women "who don't have anything wrong."

Using the HPV test to identify the type of HPV that a patient has is the key in cancer detection, stated Dr. Joel R. Kramer, a physician at Kramer OB/GYN Associates, which has offices in Northeast Philadelphia and Huntingdon Valley, and is affiliated with Holy Redeemer Health System. If a patient is found to have a high-risk strand -- such as strands 16 and 18, which together are responsible for about 70 percent of infections that can lead to cervical cancer -- she should be followed more closely by her doctor.

The Pap smear "dramatically reduces the incidence of cervical cancer," said Seidman. Those who aren't getting a Pap smear performed regularly -- or at all -- remain at a higher risk for developing cervical cancer, since any abnormality in cells will usually be picked up at some time.

Advances in the Pap test in recent years -- in sampling, reading the cells, classifying the cells, as well as using a liquid-based medium to read the cells -- have led to "a much better way of being able to identify abnormal cells," said Kramer.

The current recommendation from the American Cancer Society is to have an annual Pap smear beginning no later than age 21, or within three years after the introduction of sexual activity. The organization also recommends that screening should be done every year with the regular Pap test or every two years using the newer liquid-based Pap test.

"Yearly Paps and exams are important," insisted Seidman, adding that if the HPV test becomes the standard of care in a few years, the cost of the test could come down. But, for now, "we can generally depend on the Pap smear." 

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