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HPV testing for primary cervical cancer screening.

The Dutch POBASCAM trial aimed to determine whether the effectiveness of cervical screening improves when HPV DNA testing is added to cytological testing. 17,000 women participating in a regular cervical screening programme in the Netherlands were randomly assigned to combined cytological and HPV DNA testing or to conventional cytological testing only. After five years, combined testing was done in both groups. The number of lesions detected overall between the two groups did not differ, but the added HPV DNA testing led to earlier detection of some lesions. The implementation of HPV DNA testing led to only a moderate increase in the number of colposcopies, which should be kept as low as possible. (1) One large trial in more than 10,000 Canadian women confirmed that a test for HPV is substantially more sensitive than a standard smear (95% versus 55%), but a little less specific (94% versus 97%). All the women had both tests. (2) Another large trial, in more than 12,000 Swedish women, showed that adding an HPV test to a conventional smear test in one round of screening reduced the incidence of high-grade CIN at the next round by about 40%. The combined test picked up enduring grade III lesions earlier than a smear alone. (3)

Longer screening intervals may become safe with HPV DNA testing. A screening policy based on stand-alone HPV DNA testing is ideal, with cytological tests only for triage of positive cases. (4) But while HPV tests look good, it is far too early to abandon traditional cytology, not least until cost-effectiveness is shown and there is a rapid, simple, accurate, and affordable HPV DNA test. Furthermore, large demonstration projects will be needed to evaluate new algorithms for screening, including triage of positive HPV DNA tests with perhaps repeat testing or possibly followed by cervical cytological testing. The optimal approach will depend on the prevalence of disease, access to screening, and available resources. (5)

(1.) Bulkmans NWJ, Berkhof J, Rozendaal L, et al. Human papillomavirus DNA testing for the detection of cervical intraepithelial neoplasia grade 3 and cancer: 5-year follow-up of a randomised controlled implementation trial. Lancet 2007;370:1764-72.

(2.) Mayrand M-H, Duarte-Franco E, Rodrigues I, et al. Human papillomavirus DNA versus Papanicolaou screening tests for cervical cancer. New England Journal of Medicine 2007;357(16):1579-88.

(3.) Naucler P, Ryd W, Tomberg S, et al. Human papillomavirus and Papanicolaou tests to screen for cervical cancer. New England Journal of Medicine 2007;357(16):1589-97.

(4.) Ronco G, Segnan N. HPV testing for primary cervical screening. Lancet 2007;370:1740-42.

(5.) Ronowicz CD. Molecular screening for cervical cancer--time to give up Pap tests? New England Journal of Medicine 2007;357(16):1650.
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Title Annotation:ROUND UP: Reproductive cancers
Publication:Reproductive Health Matters
Geographic Code:4EUNE
Date:Nov 1, 2008
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