MAY 2006

GOING BEYOND THE PAP: WHO SHOULD GET THE NEW SCREENINGS NOW AVAILABLE


By Adelaide G. Nardone, MD
Medical Advisor to the Vagisil Women’s Health CenterSM (VWHC)

Most women are aware of the Pap test or "Pap smear," which is used to detect changes in the cells of the cervix that can indicate the presence of cervical cancer. This relatively simple test allows for early detection of cell changes, which makes treatment possible and, often, very successful. The success of early detection has made the Pap test an integral tool in the reduction of cervical cancer deaths in the United States. However, cervical cancer still remains a common gynecologic cancer around the world: each year, half a million women are diagnosed with the cancer and close to 250,000 die from it. And, while the Pap has been the first line of defense, there are now new screenings and procedures that can take the Pap a step further.

HPV: Cervical Cancer Culprit:
Cervical cancer is now known to be caused by the human papilloma virus (HPV), one of the most common sexually transmitted infections: today as many as 80 percent of women will be exposed to it at some point in their lives. HPV typically has no symptoms, and more often than not, particularly in younger women, the virus goes away on its own, causing no damage to the woman. (Many people are unaware they even have HPV.) While there are more than 100 strains of HPV, strains HPV 16 and 18 are the cause of most cervical cancers. If the disease is caught early on, it is easily treated; however, if it progresses to an advanced stage, it is painful and much more difficult to treat.

Cervical Cancer Testing:
Up until recently, a standard Pap test was done during a women’s annual gynecological exam to screen for cellular changes. If there were abnormal results, women were often referred for further evaluation, either with repeat Pap tests or to undergo a colposcopy, in which a doctor looks at the cervix directly through a microscope (with possible biopsies taken and analyzed).

About a decade ago, the liquid Pap test was introduced and has become fairly standard, replacing the original Pap (most insurance companies now pay for the liquid Pap test). This test has significantly improved the quality of Pap smears making the interpretation of them considerably more accurate: in this decade alone, the incidence of cervical cancer has decreased by 24 percent. With the liquid Pap test, a cytobrush is used to obtain a sampling of microscopic cells from the woman’s cervix. The brush is then placed into a vial that contains a liquid medium and swished around to dislodge the cells into the fluid. The vial is sent to the lab and spun in a process that separates the cervical cells, and filters them out. The cells are then placed under a microscope and evaluated. The remaining fluid is saved for further analysis and HPV DNA testing, if her Pap reveals abnormal cells. If no "high risk" HPV is found with this "reflex" DNA test, then the woman does not need additional procedures, such as colposcopy. Her physician may recommend that the Pap test be repeated in six to 12 months.

Since most women under 30 often "clear" the HPV virus with no intervention, the HPV DNA testing is not routinely done with the Pap test annually in this age group. However, routine HPV DNA testing in combination with the Pap is now FDA approved and recommended by the American College of Obstetricians & Gynecologists (ACOG), as well as the American Cancer Society and other professional groups, for women 30 and over.

New Testing Guidelines:
New cervical cancer screening guidelines from ACOG have been modified to suit this new technology and the understanding of how HPV "acts" in women of different ages. Some of the highlights of the guidelines include:

1. Pap (cytology) screening is begun three years after the onset of sexual activity or by age 21.
2. Annual Pap screening alone for all women less than 30 years of age. If abnormalities are found from the cytology, then HPV DNA testing is done.
3. For women 30 and older who have had three consecutive negative screening results (and no other risk factors), the screening may be extended to every two to three years.

HPV Vaccination on the Horizon: A vaccine that protects against the high-risk strains of HPV will soon be available. Since it is shown to be most effective when given before the onset of sexual activity (and thus potential exposure to HPV), initially, it will likely be given to young girls ages 9 to 12, though the final guidelines haven’t been finalized in terms of age. Injected into the body, the vaccine tricks the immune system so that if the real virus is contracted, it renders it neutralized. The vaccine will not protect against all strains of HPV (primarily 16 and 18), is not itself infectious and is well tolerated.

If all this sounds confusing, it doesn’t have to be: your gynecologist will advise you as to the appropriate Pap screening interval that applies to you based on your age and risk factors. So, the most important thing is to continue to have an annual gynecological exam, be open and honest with your healthcare provider and ask questions. An informed patient is my best kind of patient.