HPV testing up, but communication gap remains

When Dwight Im, MD, tells women they have tested positive for the human papillomavirus, some get very angry. They blame their partners and question their fidelity. Sometimes, they report feeling ashamed. Other times, they become fearful because of the increased risk of cervical cancer associated with the virus. He tries to alleviate their anxieties, but, like many physicians who are testing more patients for HPV, he's not quite sure what to say.

"It's hard," said Dr. Im, co-director of the gynecologic oncology center at Mercy Medical Center in Baltimore.

HPV testing has become more commonplace, but women's health experts are beginning to recognize that the increase in the test's frequency has outpaced many physicians' ability to communicate what it means.

"When you tell a patient she has an abnormal Pap smear, that's one thing," said Dr. Im. "If you tell her she has an STD, that's a whole other issue."

The September/October CA: A Cancer Journal for Clinicians featured a review article and accompanying editorial exploring these communication challenges. The authors highlighted the need for better patient education, preferably before a physician orders the test, and the development of shared decision-making tools to address patients' lack of knowledge.

"The gap is substantial," said Diane Harper, MD, MPH, an associate professor of obstetrics-gynecology and community and family medicine at Dartmouth Medical School in Hanover, N.H., who authored the accompanying editorial. "For people to have absolutely no idea of what it is or where it comes from is something that we have to work on as a physician community."

The challenges, however, are significant. It's still not clear in all situations exactly what testing positive or negative for HPV really means in conjunction with the various other Pap smear results.

The test diagnoses an STD, albeit an unusual one in that it is highly contagious, almost ubiquitous, and has a long latency period. As a result, a positive finding can have all of the STD-associated stigma while having very different characteristics from any other known STD.

A difficult task

"It's a very difficult concept to get across to patients, and it's even a very fuzzy concept to physicians involved," said Kevin Ault, MD, associate professor of obstetrics-gynecology and epidemiology at the University of Iowa in Iowa City.

HPV also has lower name recognition than the majority of STDs.

Several studies have found that fewer than a third of patients have ever heard of it. Among those who had, most significantly overestimated the related cancer risk.

The conclusion, then, is that many women have little knowledge of the virus to begin with, and physicians have their work cut out for them.

The information they need to communicate is also complex, and time is limited.

"It's a long 20- to 30-minute conversation any time it comes up, but you have to make the time, if you're going to offer the test," said Dr. Ault.

Experts also warn that the gap must be dealt with, because a lack of knowledge can lead to fear, which is also linked to patients failing to return for results or future testing.

"If women actually understand what is happening to them, they take charge of it," said Dr. Harper. "With their knowledge of HPV, they are able to then know what they need for further care, and they come back."