{"id":1256,"date":"2017-02-20T15:05:16","date_gmt":"2017-02-20T15:05:16","guid":{"rendered":"https:\/\/blogs.bmj.com\/sti\/?p=1256"},"modified":"2017-02-20T15:09:22","modified_gmt":"2017-02-20T15:09:22","slug":"what-is-the-future-of-cervical-screening-in-the-era-of-hpv-vaccination","status":"publish","type":"post","link":"https:\/\/blogs.bmj.com\/sti\/2017\/02\/20\/what-is-the-future-of-cervical-screening-in-the-era-of-hpv-vaccination\/","title":{"rendered":"What is the future of cervical screening in the era of HPV vaccination?"},"content":{"rendered":"<p>With the introduction of HPV child vaccination programmes, there will have to be a shift from cytology to HPV testing as the main technology involved in primary cervical screening, say the contributors to an on-coming special issue of <em>Preventive Medicine<\/em> (<a href=\"http:\/\/www.sciencedirect.com\/science\/article\/pii\/S0091743516303851\">Tota &amp; Ratnam I<\/a>) (T&amp;R).<em>\u00a0<\/em>Why?\u00a0 Well, first, because of the inevitable decline in the <em>positive predictive value<\/em> of the test\u00a0(i.e. proportion of positive results that are true positives)\u00a0that comes with\u00a0declining prevalence of HPV\u00a0sequelae.\u00a0 This is an important consideration given the reality of the\u00a0potential &#8216;harm&#8217; resulting from\u00a0false positive diagnoses.\u00a0 But it is\u00a0also necessary to take into account the impact on diagnosis (which, of course, in the case of cytology,\u00a0takes place through the judgment of fallible human cytotechnologists) of the ever-dwindling\u00a0proportion of abnormalities\u00a0&#8211; an\u00a0effect well described by\u00a0T&amp;R as a\u00a0reduced \u2018signal-to-noise ratio\u2019.\u00a0 This, our authors argue, will inevitably\u00a0lead to \u2018fatigue\u2019.<\/p>\n<p>Yet the transition to HPV primary screening is very much to be welcomed, it seems.\u00a0 <a href=\"http:\/\/www.sciencedirect.com\/science\/article\/pii\/S0091743516303851\">Tota &amp; Ratnam I<\/a> comprehensively review recent trials \u2013 in Canada, US and Europe \u2013 which all demonstrate that primary HPV screening (in combination with various \u2018triage\u2019 regimes for positive cases) offers more security, even at more distant testing intervals, than a cytology-based regime.\u00a0 Also one that is less prone to human error,\u00a0more cost-effective, as well as capable (unlike cytology) of being adapted to \u2018self-testing\u2019 regimes that could allow wider access (especially in limited resource settings).<\/p>\n<p>Another paper in this on-coming special issue reviews\u00a0trials (Canadian HPV FOCAL, and Montreal-based VASCAR) testing different \u2018triage\u2019 regimes (<a href=\"http:\/\/www.sciencedirect.com\/science\/article\/pii\/S0091743516303863\">Tota &amp; Ratnam II<\/a>).\u00a0 These involve cytology, with or without HPV genotyping.\u00a0\u00a0Genotyping allows the discrimination of different levels of risk according to HPV genotype, giving health services the option of a differentiated approach to\u00a0more or less &#8216;high risk&#8217;\u00a0strains\u00a0(i.e.\u00a0retesting after a year, referral to cytology, or to colposcopy). Whether or not genotyping is included in the regime, the combination of primary HPV screening in combination with triage seems to offer a much more reliable test than cytology \u2013 at the possible cost of some relatively minor increase in needless colposcopy referral.<\/p>\n<p>Yet cervical screening policy\u00a0must, in practice,\u00a0be informed by more than <em>epidemiological evidence<\/em> \u2013 as the editor of this special issue (<a href=\"http:\/\/www.sciencedirect.com\/science\/article\/pii\/S0091743516304315\">Schiffman<\/a>) reminds us.\u00a0 It will also depend on available resources and the willingness of a particular system to assume a degree of risk.\u00a0 The US is particularly good example.\u00a0 As <a href=\"http:\/\/ac.els-cdn.com\/S0091743516304443\/1-s2.0-S0091743516304443-main.pdf?_tid=f9ac7d7a-ef8e-11e6-a661-00000aacb361&amp;acdnat=1486730983_e03cfa563ddef3078eb7af57eba484f6\">Kinney &amp; Huh<\/a> show, in another study\u00a0in\u00a0this issue\u00a0same special issue, the very marginal increment in safety demonstrated by five-yearly co-testing over stand-alone HPV is one that US appears not to be willing to relinquish, even at considerable cost both economic and in terms of \u2018harms from screening\u2019.<\/p>\n<p>At the other extreme, of course, are the medium and limited-resource settings in which, for various reasons the aspiration to offer affordable protection through traditional forms of screening (e.g. \u00a0visual inspection with acetic acid (VIA)), may currently be delivering \u2018sub-optimal\u2019 results (see, for example, <a href=\"http:\/\/sti.bmj.com\/content\/91\/Suppl_2\/A228.3\">Sibanda &amp; Cowan (STIs)<\/a>). \u00a0(For an evaluation of HPV screening as against VIA, see <a href=\"http:\/\/sti.bmj.com\/content\/91\/Suppl_2\/A66.2\">Mitchell &amp; Ogilvie (STIs)<\/a>.)\u00a0 The special issue includes papers that consider the possibility of diverse screening algorithms in limited resource settings (<a href=\"http:\/\/www.sciencedirect.com\/science\/article\/pii\/S0091743516304327\">Maza &amp; Gage<\/a>; <a href=\"http:\/\/www.sciencedirect.com\/science\/article\/pii\/S0091743516304340\">Kuhn &amp; Denny<\/a>).\u00a0 Where there are problems of access, the self-collection of samples, which becomes a possibility with HPV primary screening may offer a more feasible alternative to clinician based approaches.\u00a0 <a href=\"http:\/\/sti.bmj.com\/content\/91\/Suppl_2\/A165.2\">Vallely &amp; Caldor (STIs)<\/a> makes the case for screening based on self-sampling using CepheidXpert. \u00a0<a href=\"http:\/\/sti.bmj.com\/content\/93\/1\/56\">Nelson &amp; Arnold (STIs)<\/a> \u00a0review 24 studies of HPV self-sampling across five continents.<\/p>\n","protected":false},"excerpt":{"rendered":"<p>With the introduction of HPV child vaccination programmes, there will have to be a shift from cytology to HPV testing as the main technology involved in primary cervical screening, say the contributors to an on-coming special issue of Preventive Medicine (Tota &amp; Ratnam I) (T&amp;R).\u00a0Why?\u00a0 Well, first, because of the inevitable decline in the positive [&#8230;]<\/p>\n<p><a class=\"btn btn-secondary understrap-read-more-link\" href=\"https:\/\/blogs.bmj.com\/sti\/2017\/02\/20\/what-is-the-future-of-cervical-screening-in-the-era-of-hpv-vaccination\/\">Read More&#8230;<\/a><\/p>\n","protected":false},"author":152,"featured_media":0,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[16498,2316,4362,4358,599],"tags":[],"class_list":["post-1256","post","type-post","status-publish","format-standard","hentry","category-cervical-screening-and-hpv","category-hpv","category-hpv-and-cancer","category-hpv-vaccination","category-screening"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v27.4 - https:\/\/yoast.com\/product\/yoast-seo-wordpress\/ -->\n<title>What is the future of cervical screening in the era of HPV vaccination? 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