Critical Values - January 2009 - (Page 28) Volume 2 • Issue 1 • January 2009 Not So Fast: Pap to Remain Screening Centerpiece for Foreseeable Future Austin By R. Marshall Austin, MD, PhD Q. How will the HPV vaccine affect cervical cancer screening? A. The new HPV vaccine looks promising. Nevertheless, “the proof of the pudding is in the eating,” and that means long-term field experience. The vaccine has not been fieldtested for long, and it has not been documented that it prevents invasive cervical cancer. Therefore, many questions about safety and efficacy will be answered much more clearly with longer time in the field. Recall the old adage: “Be neither the first to adopt the new nor the last to give up the old.” Even the vaccine manufacturers acknowledge that women who are vaccinated will still have to be screened. No responsible body of opinion says that women who get vaccinated will not need to be screened. Furthermore, there are reliable data showing that when the Pap test and the HPV test are done together, this powerful combination test has both very high sensitivity for detecting underlying possible disease as well as specific information (mainly from the Pap test) about the likely character of underlying disease. Thus, combination testing, either HPV reflex testing after Atypical Cells of Undetermined Significance (ASCUS) Pap results or the routine co-testing that has been approved for women older than 30 years, represents a powerful test. I’m quite positive about women electing to get these combination tests; however, neither test is perfect by itself in terms of sensitivity, specificity, or negative and positive predictive value. The Pap test is an excellent and proven test, one that generations of women are comfortable and familiar with as the anchor motivating them to present themselves for regular health visits. If Pap testing is done by using new methodologies, liquid-based cytology, and computerassisted screening and in combination with the HPV test, it is a tremendous state-of-the-art test. Currently, the Pap test gives a great deal of information about what is actually going on in the patient that the HPV test does not. The Pap test can tell a physician potentially that a woman has cancer; the HPV test certainly cannot. The Pap test can tell a physician that a woman has a high-grade lesion, and the HPV test cannot. So the Pap test often gives more specific diagnostic information about what’s going on right now in the individual patient. The HPV test is an excellent complementary test because it can sometimes raise a red flag perhaps even when no cells have been recognized or sampled because of a hidden lesion, or point to a future risk of developing a significant lesion. So I see the the Pap test and the HPV test as attractive and complementary and recommend both of them. Q. How quickly do you expect widespread acceptance and adoption of the HPV vaccine? A. The best candidates for the vaccine now are girls 9 to 12 years old, so the benefits of the vaccination in that group will not be available for a decade or more. Currently available information indicates that only one-fourth of this age group in the United States has received even a single 28
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