VANCOUVER, B.C. — A large survey of U.S. clinicians in nine specialties identified clinically important gaps in their knowledge of human papillomavirus and found that many don't test for HPV in the recommended ways.
Several analyses of the survey results by investigators at the Centers for Disease Control and Prevention were reported in separate poster presentations at the 22nd International Papillomavirus Conference.
Only 35% of 4,305 clinicians surveyed were aware that recent scientific evidence shows that most HPV infections clear without medical intervention, reported Crystal M. Freeman, Ph.D., of Battelle Centers for Public Health Research and Evaluation of Seattle, which conducted the survey studies with the CDC. Knowledge of anogenital warts also appeared to be inadequate. Only 38% of respondents knew that anogenital warts do not increase the risk of cancer at the same sites where the warts are located, and only 47% knew that genital HPV types usually associated with external anogenital warts are not the same HPV types associated with cervical dysplasia and cancer.
Respondents included 464 ob.gyns., 1,107 primary care physicians (family or general physicians, internists, or adolescent medicine physicians), 966 specialists (dermatologists or urologists), 624 certified nurse-midwives, and 1,144 midlevel providers (nurse-practitioners or physician assistants).
A higher proportion of ob.gyns. (67%) knew that HPV infections may clear without medical intervention, compared with primary care physicians (31%), specialists (14%), midlevel providers (30%), or nurse-midwives (43%).
Nearly all respondents knew, however, that HPV infection is common (89%), that most people with HPV lack signs or symptoms of infection (95%), and that HPV infection increases the risk of cervical cancer (98%). They also showed high rates of knowledge that HPV infection causes anogenital warts (90%) and that treating warts or cervical dysplasia does not eliminate HPV infection (91%).
A second analysis of results related to HPV testing found that a minority uses HPV tests—35% of general internists, 33% of adolescent medicine physicians, and 57% of family or general physicians, Nidhi Jain, M.D., of the CDC in Atlanta reported at the conference, sponsored by the University of California, San Francisco. By comparison, 93% of ob.gyns. said they use HPV tests, as did 89% of certified nurse-midwives, 63% of nurse-practitioners, 56% of physician assistants, 10% of urologists, and 5% of dermatologists.
Among the 2,980 clinicians who use HPV tests, many test in ways not recommended by national guidelines, the survey found. The HPV test is approved to help manage patients with Pap results showing atypical squamous cells of undetermined significance (ASC-US), and 98% of the 2,980 respondents use it for that purpose.
The HPV test also is used by 91% of clinicians in patients with higher-grade Pap abnormalities, which is an off-label use of the test.
The second approved use of the HPV test is as an adjunct to Pap testing for cervical screening in women older than 30. Clinicians were equally likely to use HPV testing in women older or younger than 30 years, regardless of the guidelines.
A significant minority of clinicians also tested for HPV in men, patients with other sexually transmitted diseases, and patients with anogenital warts—all indications outside current guidelines. Ob.gyns. and nurse-midwives were the most likely to do an HPV test following an ASC-US Pap result, compared with other clinicians, Kathleen Irwin, M.D., of the CDC reported in a third poster on the survey.
Only 28% usually sought patient consent when doing an HPV test after an abnormal Pap result. Nearly half (48%) said they tell patients they are ordering an HPV test, and 58% usually explain the purpose of the HPV test as it relates to the Pap smear.