Summaries of Must-Read Clinical Literature, Guidelines, and FDA Actions
Thrice yearly cytologic testing may best annual cervical screenings
Key clinical point: Current ways of testing women for cervical testing may be replaced in the near future.
Major finding: Two studies challenge existing recommendations on when women should be screened for cervical cancer and explore how to manage abnormal results.
Study details: It is not cost effective to begin primary hrHPV testing prior to age 30 years, to perform hrHPV testing every 3 years, or to perform cytologic testing annually. Dual stain reduces unnecessary colposcopy referral and unnecessary cervical biopsies, and may reduce unnecessary treatment, compared with Papanicolaou cytologic testing.
Disclosures: Five authors from Sawaya et al. reported receiving grants from the National Cancer Institute and Dr. Megan J. Huchko reported receiving a grant from the University of California, San Francisco, during that study. That study was funded by a grant from the NCI. Six authors from Wentzensen et al. reported receiving grants from the NCI or being employed by the NCI or National Institutes of Health. Dr. Philip E. Castle reported receiving low-cost or free cervical screening tests from Roche, Becton Dickinson, Cepheid, and Arbor Vita Corp. The other authors from both studies reported no relevant conflicts of interest.
Sawaya GF et al. JAMA Intern Med. 2019. doi: 10.1001/jamainternmed.2019.0299; Wentzensen N et al. JAMA Intern Med. 2019. doi: 10.1001/jamainternmed.2019.0306.
Cervical cancer screening can be simplified and managed by reducing annual screening to every 3 years for women with normal cytological test results, Sarah Feldman, MD, MPH, wrote in a related editorial. There is evidence from large studies that this is possible for women with average risk of cervical cancer.
Primary human papillomavirus (HPV) screening also is an option for patients, and although there are no current guidelines, 2015 expert guidance states HPV16/18 genotyping and reflex cytologic testing should be used in cases of abnormal results. Transitioning from cytologic testing to primary HPV testing may require a period of using both tests in clinical practice, but this may raise issues with creating false positive results.
“The biggest challenge for cervical cancer screening, however, is likely not which test to use, but determining which women are at low enough risk of cervical cancer to undergo screening at less-frequent intervals,” wrote Dr. Feldman. In these cases, a better infrastructure where clinicians can access women’s prior screening results and make recommendations with decision support systems is needed.
But challenges remain. “These challenges include clinician and patient education and acceptance; access to primary HPV tests; the development of simple, easily implementable, and evidence-based management advice; and systems-based approaches to help clinicians implement optimal care.”
While women 30 years or older are likely to receive primary HPV testing as a standard of care, the risk of cervical cancer also should decrease as more children receive the HPV vaccine, concluded Dr. Feldman.
“Ultimately, once all children have received the HPV vaccination, the incidence of both cervical cancer and precancerous abnormalities should markedly diminish,” Dr. Feldman said. “Ultimately, we may hope to prevent all cervical cancer.”
Dr. Feldman is from the division of gynecologic oncology at Brigham and Women’s Hospital in Boston. Her editorial accompanied the reports by Sawaya et al. and Wentzensen et al. (JAMA Intern Med. 2019. doi: 10.1001/jamainternmed.2019.0298). She reported no relevant conflicts of interest.