HPV tests becoming part of cervical cancer screening
■ Kaiser Permanente is the first major institution to make the practice routine; critics say the added cost could make Pap tests less accessible.
By Victoria Stagg Elliott — Posted Feb. 2, 2004
Kaiser Permanente Northern California announced in January that human papillomavirus testing would become a routine part of cervical cancer screening for women older than 30.
The hope is that the additional cost of the test will be outweighed by this result: being able to tell women who are negative on both the Pap and HPV test and that they can wait three years for their next screening. The step also would avoid colposcopies caused by the occasional false-positive.
The HMO will recommend that women who test positive for HPV continue to come in annually and receive follow-up as needed if the Pap test is also positive.
"There's concern that the women who are at the highest risk may not be detected, and the women who are at the lowest risk are still coming in dutifully every year to get their Pap smears and they probably don't need them," said Ruth Shaber, MD, director of women's health services at Kaiser Permanente Northern California. "The science and the evidence clearly shows that HPV is an excellent way of risk assessing."
But the move is controversial because of concerns about cost, counseling and maintaining women's links to the health care system.
In March 2003 the Food and Drug Administration approved a laboratory test that detects the riskiest HPV variants in cervical cells for this use. The agency previously approved the test in March 2000, but only for women with a positive Pap smear. Most medical societies now recommend that the test be an option for women, although not necessarily a standard of care. The U.S. Preventive Services Task Force says there is not enough evidence to recommend strongly either way.
"The standard right now is to use HPV testing if there is an abnormality," said Rodney Smith, MD, an obstetrician-gynecologist at Arizona Wellness Center for Women in Phoenix. "We're waiting for the studies before we use it as routine."
Why some hesitate
Many women's health specialists consider the test appropriate for some situations but worry that making it more routine will throw out of balance what has always been a very favorable cost equation. Specifically, the additional cost may put Pap smears further out of the reach of poor women or those who are uninsured.
"We may be making a good test less accessible," said Kevin Ault, MD, associate professor of obstetrics and gynecology at the University of Iowa in Iowa City. "Cervical cancer used to be the No. 1 killer of women, and now it's a disease of people who don't get screened."
Gynecologists also worry about the additional counseling that might be needed because HPV is a sexually transmitted disease -- especially for those with a history of negative Pap smears. A study in the Jan. 15 Cancer found that women overestimated the likelihood that having HPV would lead to cancer and didn't know how to interpret normal Pap smear results accompanied by an abnormal HPV test. Women also wanted information about transmission, prevention, treatment and cancer risk.
"Telling someone who always had normal Pap smears that they have this virus is definitely a challenge," said Elisabeth Wegner, MD, assistant professor at the University of Vermont College of Medicine, Burlington. "Many people are not that well-educated about HPV, and people often have the same emotional response as to hearing that they have an STD."
Physicians also were concerned about keeping women linked to health care. The Pap smear has become an annual reason to make an appointment for getting a physical exam and other health care services.
"If we had a perfect world and knew everyone would come in every three years and not extend it to four and five years, then great, but I think it's harder for people to remember if it's not every year," Dr. Wegner said. "And there's still things that women probably need, such as yearly breast and pelvic exams."
Those at Kaiser who are advocating this approach agreed that while this may be the right move for a large HMO, it may not be appropriate for other situations.
"This is definitely the right thing for us," Dr. Shaber said. "But there are many different settings where this would not be the right choice."