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The Benefit of Human Papillomavirus Testing in Predicting Cervical Cancer
It is still not clear what the definition of ‘HPV persistence’ should be. for primary screening, where HPV testing is being used adjunctively
Some studies have defined HPV persistence as the presence of with cytology. In the future it may be possible to employ type-specific
HPV-DNA-positive tests on two or more occasions, comparing it with assays (genotyping) as a follow-up to an HPV-positive cocktail result to
transient infection (those who tested positive only once).
19
The problem determine the type of high-risk HPV and which women are at highest
with this approach is that the duration of a persistent infection is variable risk of developing the disease. This may provide significant clinical
and depends on the interval between HPV tests. In most of these studies benefit since women who have HPV 16 and HPV 18 would be identified
the interval between tests ranged from two to seven years. as having an elevated risk of having or developing high-grade CIN
compared with women with other high-risk types of HPV.
A few other studies have considered ‘time to clearance’ of HPV
infection as HPV persistence.
20
Moreover, the distinction between a Serious consideration is being given to whether or not we actually
persistent and a transient infection is arbitrary and depends on both need to utilise cervical cytology for primary screening. Instead, over
the timing of samples in relation to the natural history of infection the next decade we may move to using primary HPV DNA testing
and the interval between samples. We cannot determine the length of alone as the front-line screening test and then using cytology, with
time for which a woman testing positive at her first sample was its higher specificity, as secondary screening.
infected before that sample was taken.
Furthermore, in the presence of a negative smear, HPV genotyping
Kajaer et al. showed that the odds ratio for incident high-grade lesions showing a high-risk HPV type will identify those women who require
was 24.4 (95% CI 8.4–119.0%) in the HPV-persistent group compared colposcopy as opposed to clinical follow-up. It is now time for
with women in whom it regressed.
21
Interestingly, one study showed Europe to update its cervical cancer screening guidelines and to
that the same type of HPV could re-appear.
22
This raises the valid enjoy the benefits that routine HPV testing can offer both clinicans
question of whether clearance of HPV really means complete and patients. ■
clearance or rather its maintenance in a latent undetectable state in
the basal layer of the cervical epithelium. HPV may replicate at a very
low level during this time, which would make the virus undetectable
Albert Singer is Professor of Gynaecological Research
by conventional methods. Changes in immune status could reactivate
and Professor of Molecular Pathology at University
College London, and a Consultant Gynaecologist at
the latent virus and it could be speculated that the secondary peak
the Whittington Hospital NHS Trust. He has a specialist
now seen in women in their 40s and 50s could be as a result of this
interest in gynaecological oncology, especially in
change. Larger cohort studies with long-term follow-up will help up us
relation to the cervix. He is co-founder of both the
British Society for Colposcopy and Cervical Pathology
to determine the true extent of persistent HPV infections.
(BSCCP) and the British Gynaecological Cancer Group,
which was the forerunner of the British Society for
Conclusion
Gynaecological Oncology. On an international level he is a founding member and
board member of the European Research Society for Gynaecological Infection and
We now have ample evidence to justify the incorporation of HPV
Neoplasia (EUROGIN) and was President of the 8th EUROGIN Congress in Paris in
testing in different phases of cervical cancer screening and
April 2006. He is also Past President of the BSCCP, as well as a Board member of
management. Guidelines and recommendations already exist and HPV
many other societies.
testing is used routinely for triage and post-treatment indications and
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