hpv testing in national cervical ca screen when is it recomended

7/27/2019 HPV Testing in National Cervical CA Screen When is It Recomended

1/4


2/4

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

464Rprintd frm AuSTRALIAN FAMILy PHySICIAN VoL. 42, No. 6, juNe 2013


3/4

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)

Rprintd frm AuSTRALIAN FAMILy PHySICIAN VoL. 42, No. 6, juNe 2013 465


4/4

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.

19. Mitchll H. Th ndcrvical cmpnnt f Papsmars. Lttr. Md j Ast 1994;161:396.

20. Natinal Crvical Scrning Prgram. Minimmnatinal standards fr fllw-p and rmindr; prt-cls fr ctlg rgistrs. Dcmbr 2010. Availablat www.cancrscrning.gv.a/intrnt/scrning/

pblishing.nsf/Cntnt/ctlg-rgistrs [Accssd7 jn 2013].

466Rprintd frm AuSTRALIAN FAMILy PHySICIAN VoL. 42, No. 6, juNe 2013

hpv testing in national cervical ca screen when is it recomended

Documents