hpv testing in national cervical ca screen when is it recomended
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7/27/2019 HPV Testing in National Cervical CA Screen When is It Recomended
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Human papillomavirus testing in the Nati onal Cervical Screening Program when is it recommended?clinical
ntrs th gnital skin thrgh micr-abrasins in
th pithlim. Th virs is cntaind within th
pithlim and ds nt cas viramia. Tpicall,
HPV ntrs th basal clls and ss th hst cll
rplicativ nzms t assmbl and rlas nw
virins frm th pprmst clls f th sqams
pithlim.3
In sm cass, assciatd with th high risk
HPV tps, th HPV gnm bcms intgratd
int th hst chrmsm. In this frm, th
infctin is mr likl t bcm prsistnt and
clllar changs ccr that ma b rcgnisd as
high grad changs n a Pap smar.
High grade squamousintraepithelial lesions
Crvical ctlg (th Pap smar) xamins
xfliatd clls frm th crvix t dtct significant
clllar changs assciatd with prsistnt HPVinfctin. Prsistnt infctin with n f th high
risk HPV tps ma b sn as high grad changs
r HSILs. Ths changs incld fatrs sch
as a dns r dbl ncls, r a high nclar-
ctplasmic rati.
High grad changs ar rprtd at a rat f
arnd 8.5 pr 1000 crvical ctlg tsts.4 This
mans that arnd 21 000 Astralian wmn
rciv a rprt f an HSIL ach ar.
Data frm Astralian labratris sggst that
wmn with HSIL ctlg rprts hav a 6289%
chanc f harbring actal high grad crvical
intrapithlial disas and a 03% chanc f
having an invasiv crvical cancr.2 Thrfr,
ndr th NHMRC gidlins wmn with a
pssibl r dfinit HSIL dtctd n crvical
ctlg shld b rfrrd fr clpscp.1
A rviw f th litratr n th natral histr
f CIN has shwn that wmn with histlgical
vidnc f CIN 2 hav a 5% chanc f prgrssin
t crvical cancr, and wmn with histlgical CIN
3 hav a 12% chanc f prgrssin.5 It is thrfr
rcmmndd that ths wmn b tratd inrdr t rdc thir risk f dvlping invasiv
sqams cll crvical cancr. Tratmnt ma b
ablativ r xcisinal.
Development of cervicalcancer
Thr ar fr main stps fr th dvlpmnt f
crvical cancr:2
infctin f th mtaplastic pithlim at th
crvical transfrmatin zn (th sqam-
clmnar nctin) with a high risk r ncgnic
tp f HPV
prsistnt infctin with an ncgnic HPV tp
prgrssin f prsistntl infctd pithlim t
pr-cancrs changs (HSILs), tpicall taking
115 ars t bcm stablishd
invasin thrgh th basmnt mmbran f th
pithlim. Invasiv crvical cancr dvlps
vr man ars. Rapid nst cancrs can ccr,
bt th ar vr rar.
Human papillomavirus testingpost-HSIL treatment
Wmn tratd fr a bips-cnfirmd HSIL shld
rtrn t thir spcialist fr rpat clpscp and
crvical ctlg 46 mnths aftr tratmnt. If
ths tsts ar satisfactr, thr is n rasn wh
th wman shld nt rtrn t hr sal gnralpractitinr fr sbsqnt Pap tsts and HPV
tsting.
Tsting fr high risk HPV tps is an imprtant
part f th managmnt f wmn wh hav
bn tratd fr HSIL. Svral stdis hav shwn
that ths wmn ar at incrasd risk f frthr
high grad disas.611 Aftr tratmnt, th vast
marit f wmn will clar thir ncgnic HPV
infctin within 24 mnths (Figure 1).1218 Th
rliabl ngativ prdictiv val f HPV tsting
allws ths wmn t rtrn t th rtin Pap
scrning intrval.
When to perform HPVtesting
Crvical ctlg and HPV tsting shld
cmmnc 12 mnths aftr tratmnt f a bips-
cnfirmd HSIL and cntin annall ntil th
wman has tstd ngativ fr bth tsts n tw
cnsctiv ccasins. At this pint th wman
can thn rtrn t rglar pplatin scrning,
accrding t th rcmmndatins fr th gnral
fmal pplatin, which is crrntl tw-arl(Table 1). Mdicar cvrs tw HPV tsts in ths
circmstancs in an nging 2 ar prid (MBS
Itm nmbr 69418).
Hman papillmavirs tsting bnd ths
rcmmndatins is nt crrntl advisd (Table 2).
If th GP is ncrtain f a patints mdical
histr, stat crvical ctlg rgistris can sall
prvid frthr infrmatin t gid sbsqnt
tsting.
Th frqnc f psitiv HPV tsts fllwing
tratmnt fr a high grad lsin is high in th
first 12 mnths aftr tratmnt, bt diminishs
significantl aftr 12 mnths, as shwn in Figure 1.
Figure 1 als dmnstrats th imprtanc f nttsting t sn aftr tratmnt.
If HPV tsting is prfrmd tsid th NHMRC
gidlins, pathlg labratris will sall
charg abt $60100.
How to perform HPV testing
HPV tsting is sall prfrmd b taking a swab
r brsh sampl frm th ndcrvix aftr crvical
ctlg has bn takn. This is thn placd in
a transprt tb (prvidd b r labratr) fr
tsting. Th rsrcs listd at th nd f this
articl prvid frthr dtails n sampl cllctin.
If a liqid basd sampl is bing cllctd fr
thr rasns, HPV tsting can b dn n this
sampl.
Diffrnt mthds fr tsting fr ncgnic
HPV tps ar availabl; chck with r labratr
fr thir rqirmnts. It is xtrml imprtant t
mak sr that th tst ffrd has bn clinicall
validatd.
Th rslt shld b availabl at th sam tim
as th crvical ctlg rprt.
Clinical scenarios
Jenna, 57 years of age, had treatment for a
biopsy-confirmed HSIL in 1989. Since then
she has returned conscientiously every 12
months for a Pap test as she was originally
told to do. Her smear results have been
negative since treatment. What will your
practice be when you next see her for her
annual Pap test?
0
10
20
30
40
50
3 months 12 months 24 months
Per
centofHPVp
ositive
tests
Post-HSIL treatment intervals
Figure 1. HPV infection rates by time
since HSIL treatment
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7/27/2019 HPV Testing in National Cervical CA Screen When is It Recomended
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clinicaHuman papillomavirus testing in the N ational Cervical Screening Program when is it recommended?
smears have been negative, including
a Pap test and HPV test 12 months ago.
Today you take another Pap smear and
an HPV test. The HPV test is negative,
the Pap smear is also negative but has no
endocervical cells present.
on rviwing r rcrds fr Sall, nt that
hav statd that saw th crvical s clarl
and wr abl t insrt bth th ctbrsh
and th swab/brsh fr th HPV tst int it. If this
is th cas, th Pap smar ds nt hav t b
rpatd. W knw that abt 12% f wmn vr
th ag f 60 ars hav a transfrmatin zn
that is prsmabl highr than th lngth f th
ctbrsh.19 It is nt rcmmndd that th brsh is
vr insrtd sch that th lwr bristls cannt b
sn. Sall can nw rtrn t tw-arl scrning
ntil th ag f 70 ars, at which pint, shld hr
intrvning smars cntin t b ngativ, shcan cas having Pap tsts.
Lesley, 38 years of age, had a high grade
cervical lesion treated just under 2 years
ago. She had her first Pap test and HPV
test 12 months post-treatment: both tests
were negative. She knows she has come in
a little early for her repeat test (11 months
after the last tests), but she is about to go
overseas for 6 months and is keen to have
the tests done before she goes. What will
you do?
Th first Pap tst and HPV DNA tsts mst b
n arlir than 12 mnths aftr th high grad
histlg rslt, bt th tim btwn frthr tsts
and an prcding tst f ach tp (smar, HPV
DNA) has t b at last 10 mnths.20 Thrfr
it is qit clinicall accptabl t rpat Lsls
tsts at this tim rathr than hav hr wait ntil h
rtrn frm vrsas.
Summary
oncgnic HPV tsting is a rliabl and xtrml
snsitiv tst that is Mdicar rbatabl whn sdin th managmnt f wmn wh hav vr had a
histlgicall-cnfirmd HSIL tratd. Th apprpriat
s f tsting fr th high risk, ncgnic, HPV tps
is a valabl tl, as th vast marit f wmn in
ths circmstancs will bcm ngativ fr ths
ncgnic tps. This will nt nl b rassring
fr ths wmn, bt will bring thm back int th
rtin crvical scrning intrval.
or challng is t ncrag its s.
likl xplanatin fr this is that hr bd is still
claring th virs. This prcss can tak a cpl f
ars. Sh nds a rpat Pap tst and HPV tsting
in 12 mnths.
Martha, 43 years of age, presents to you for
a Pap test. She has recently moved from
interstate. She recalls that around 1998 she
had a smear that showed some abnormal
cells, and that she had treatment for these
at that time. She has no idea what the
biopsy actually showed. She has had two or
three smears since then, which she believes
were negative. What should you do?
yr stat crvical ctlg rgistr will b abl
t prvid th tlphn nmbr fr thr stat
crvical ctlg rgistris. It is cnfirmd that
in Ma 1997, Martha had a crvical bips that
shwd a mild dsplasia (CIN 1); sh has had thr
smars sinc thn, all f which hav bn ngativ.
As Martha did nt hav a bips-cnfirmd
high grad lsin sh is nt ligibl fr Mdicar
rbatabl HPV tsting. Bfr th NHMRC
gidlins (2005), lw grad (CIN 1; mild dsplasia)lsins wr ftn tratd. Tda st nd t
d a Pap smar n Martha and rmind hr f th
imprtanc f rglar rtin crvical scrning.
Sally, 66 years of age, has a past history of
a biopsy-confirmed high grade lesion when
she was aged 36 years (in 1983). She has
presented reasonably regularly over the
years, and apart from a low grade smear
(possible HPV) in 1993, all her other annual
y can xplain t jnna that thr is nw a
rliabl tst t chck fr th prsnc f th HPV
tps that can cas crvical cancr. It is a vr
snsitiv and accrat tst. Th vast marit f
wmn, xplain t hr, clar this virs within a
ar r tw f tratmnt. If, vn aftr sch a lng
tim, this is fnd t b th cas with hr, n tw
cnsctiv ccasins 12 mnths apart, sh will
b abl t rtrn t 2-arl instad f annal Pap
tsts. In ths circmstancs, th tst is ligibl fr
th Mdicar rbat.
Emily, 28 years of age, is seeing you 6
months after she was reviewed by her
gynaecologist post-treatment of a high
grade cervical lesion (CIN 2) 12 months
ago. The letter from the gynaecologist
assures you that the Pap smear and
colposcopy at 6 months were both normal.
Emily is new to your practice and has a
few questions about HPV that she feels
have not been adequately answered.
y xplain t emil that th crrntrcmmndatin is that sh hav a Pap tst and
an HPV tst (t chck fr viral claranc) vr
12 mnths ntil sh has a ngativ Pap tst
and a ngativ HPV tst n ar, fllwd b
a ngativ Pap tst and a ngativ HPV tst th
fllwing ar. Aftr that sh can rtrn t th
tw-arl intrval.
Th rslts shw a ngativ Pap smar and a
psitiv HPV tst. y can tll emil that th mst
Table 1. HPV testing recommendations post-HSIL treatment
Time since treatment Cervical cytology Coloposcopy HPV testing
46 months
12 months
24 months
Continue cervical cytology and HPV testing every 12 months until these tests areboth negative on two consecutive occasions
The Medicare rebate for HPV testing in these circumstances covers two HPV tests inan ongoing 24 month period (item number 69418)
Table 2. Current NHMRC guidelines for when HPV testing is not
recommended1
Less than 12 months after treatment of a high grade cervical lesion
As a screening test
As a triage tool for women with low grade squamous intra-epithelial cervical lesions(unless this is part of the follow up post-treatment of an HSIL)
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Human papillomavirus testing in the Nati onal Cervical Screening Program when is it recommended?clinical
Resources TakingaPaptest:instructionalDVD.Producedby
Victrian Ctlg Srvic and Mlbrn Sxal
Halth Cntr, and spprtd b PapScrn
Victria. This DVD dmnstrats hw t tak an
HPV tst (as wll as hw t tak a Pap smar).
It is availabl fr f charg frm VCS Pathlg
b calling 03 9250 0300. It can als b watchd
nlin at www.mshc.rg.a. G t halth pr-fssinals thn vids
Cervixsamplingcard.ThisA4-sizedlaminated
card shws pictrs f diffrnt crvics, and
dscribs th rcmmndd tchniqs and
instrmnts that shld b sd whn taking a
Pap tst. It als dscribs tsting fr HPV sing
th Hbrid Captr brsh. Th card is fr f
charg and is availabl frm PapScrn Victria
at www.papscrn.rg.a
HPV:Aguideforpractitioners.ThisA4-sized
laminatd sht has a chck-list fr xplaining
HPV t patints, as wll as th answrs t man
cmmn qstins patints ask. It als givssm backgrnd n HPV fr mdical practitin-
rs, xplains th prps f HPV tsting, tlins
HPV tsting pst-HSIL tratmnt, and prvids
cmmn scnaris with diffring rslts fr
patints wh hav bn tratd fr an HSIL
lsin. It is fr f charg frm PapScrn
Victria at www.papscrn.rg.a.
AuthorStlla Hl BA(Hns), MBBS, FAChSHM, is Snir
Liaisn Phsician, Victrian Ctlg Srvic,
Mlbrn, Victria. [email protected].
Cmpting intrsts: Nn.
Prvnanc and pr rviw: Nt cmmissind;
xtrnall pr rviwd.
References1. Natinal Halth and Mdical Rsarch Cncil.
Scrning t prvnt crvical cancr. Gidlinsfr th managmnt f asmptmatic wmnwith scrn dtctd abnrmalitis. Canbrra:NHMRC, 2005.
2. Schiffman M, Castl Pe, jrnima j, Rdrgz AC,Wachldr S. Hman papillmavirs and crvicalcancr. Lanct 2007;370:890907.
3. Strn PL, Kitchnr HC, ditrs. Vaccins fr thprvntin f crvical cancr. oxfrd onclg Librar.oxfrd univrsit Prss, 2008.
4. Astralian Institt f Halth and Wlfar. Crvicalscrning in Astralia 20092010. Cancr sris n67. Cat n. CAT 63. Canbrra: AIHW, 2012.
5. ostr AG. Natral histr f crvical intrapithlialnplasia: a critical rviw. Intrnatinal jrnal fGnaclgical Pathlg 1993b;12:18692.
6. Pttrssn F, Malkr B. Invasiv carcinma f thtrin crvix fllwing diagnsis and tratmnt f insit carcinma. Rcrd linkag std with a natinalcancr rgistr. Radithr oncl 1989;16:11520.
7. Lvi F, Randimbisn L, La Vcchia and Francschi S.Incidnc f invasiv cancrs fllwing carcinma insit f th crvix. Br j Cancr 1996;74:13213.
8. Sttr WP, d Barrs Lps A, Fltchr A, t al.Invasiv crvical cancr aftr cnsrvativ thrap frcrvical intrapithlial nplasia. Lanct 1997;349:97880.
9. Nagai y, Mahama T, Asat T, Kanazawa K.Prsistnc f hman papillmavirs infctin aftrthraptic cnizatin fr CIN 3: is it an alarm frdisas rcrrnc? Gnacl oncl 2000;79:2949.
10. Vikki M, Pkkala e, Hakama M. Risk f crvical cancr
sbsqnt t a psitiv scrning ctlg; fllw-p std in Finland. Acta obstt Gncl Scand2000;79:5769.
11. Mitchll H, Hcking j. Inflncs n risk f rcr-rnt high grad crvical abnrmalit. Int j GnaclCancr 2002;12:72834.
12. Kcra e, Slitz G, Czrwnka K, BritnckrG, Ldltr S, Rinthallr A. Is high-risk hmanpapillmavirs infctin assciatd with crvicalintrapithlial nplasia liminatd aftr cnisatinb larg-lp xcisin f th transfrmatin zn? erj obstt Gncl Rprd Bil 2001;100:726.
13. Nbbnhis MA, Mir Cj, van dn Brl Aj, tal. Additin f high-risk HPV tsting imprvs thcrrnt gidlins n fllw-p aftr tratmntfr crvical intrapithlial nplasia. Br j Cancr
2001b;84:796801.14. Paraskvaidis e, Klipls G, Alamans y,
Malam-Mitsi V, Llis eD, Kitchnr HC. Hmanpapillmavirs tsting and th tcm tratmntfr crvical intrapithlial nplasia. obstt Gncl2001;98(5 Pt 1):8336.
15. Bar-Am A, Gamz R, Lvin I, Fainar o, Niv j, AlmgB. Fllw-p cmbind ctlg and hman papil-lmavirs tsting fr patints pst-cn bips:rslts f lng-trm fllw-p. Gnacl oncl2003;91:14953.
16. Dbarg VH, Cllint P, Vinatir D, t al. Valf hman papillmavirs tsting aftr cnisatinb lp lctrsrgical xcisin fr high gradsqams intrapithlial lsins. Gnacl oncl2003;90:58792.
17. Zilinski GD, Rzndaal L, Vrhrst Fj, t al. HPVtsting can rdc th nmbr f fllw-p visits inwmn tratd fr crvical intrapithlial nplasiagrad 3. Gnacl oncl 2003;9:6773.
18. Cha Angl, Lin Chn-Ta, Hsh Swi, t al.usflnss f hman papillmavirs tsting inth fllw-p f patints with high grad crvicalintrapithlial nplasia aftr cnizatin. Am j obsttGncl 2004;190:104651.
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pblishing.nsf/Cntnt/ctlg-rgistrs [Accssd7 jn 2013].
466Rprintd frm AuSTRALIAN FAMILy PHySICIAN VoL. 42, No. 6, juNe 2013