August 2009
Cytopathology Programs Review

Roger B. Lane Jr., MD

Cervical cancer screening has undergone significant changes in recent years, based in large part on increasing knowledge of the natural history and epidemiology of human papillomavirus infection and cervical cancer and the accompanying widespread use of testing for HPV DNA. HPV DNA testing has proven utility in cervical cancer screening and clinical management for cervical cancer prevention in many situations. However, inappropriate testing can unnecessarily increase costs and result in overtreatment. Much effort has been put into providing guidelines for the appropriate use of HPV DNA testing, including when to use it and how to appropriately care for patients based on cervical cytology and HPV DNA testing results. This effort has resulted in the publication of various protocols and guidelines for cervical cancer screening and clinical management of women with abnormal cervical screening tests.

The Cytopathology Education and Technology Consortium, or CETC, recently developed a statement on HPV DNA test use that is intended as a concise, convenient summary of the test’s clinical indications (Statement on HPV DNA test utilization. Am J Clin Pathol. 2009; 131:768–769). The statement, by Diane Solomon, MD, et al., on behalf of the CETC, is based on published guidelines for early detection of cervical neoplasia and cancer by the American Cancer Society in 2002, interim guidance for the use of HPV DNA testing by a collection of organizations in 2004, and consensus guidelines for managing women with abnormal cervical screening tests by the American Society for Colposcopy and Cervical Pathology in 2006.

The statement contains a list of clinical situations for which HPV testing is and is not indicated. It is particularly important during this time of transformation of the field of pathology for pathologists to be able to comfortably and accurately guide clinicians in appropriate patient testing and treatment based on test results. The CETC statement provides an excellent summary of HPV testing indications that will be helpful to cytotechnologists, pathologists, and clinicians and will, it is hoped, lead to reduced inappropriate use of HPV testing.

The CETC statement is published with an accompanying commentary that provides a summary of the basic biology of HPV infections and discusses how our knowledge of the biology of HPV infections has affected cervical cancer screening and clinical management of women with screening abnormalities (Commentary on statement on HPV DNA test utilization. Am J Clin Pathol. 2009;131:770–773). The commentary, by J. Thomas Cox, MD, et al., gives examples of appropriate and inappropriate HPV testing and explains how overuse of HPV testing can potentially lead to overtreatment of many women with abnormal screening results.

For example, the commentary describes why HPV testing is not indicated for an initial ASC-US Pap test in women 20 years or younger and why HPV test results should be ignored and not used to influence patient management if HPV testing is inadvertently performed in this situation. The commentary also briefly discusses why HPV testing is not indicated for the initial triage of patients with atypical glandular cells on a Pap test and describes when HPV testing results can be used for these patients.

The CETC statement and the accompanying commentary are recommended reading for anyone involved in cervical cancer screening or in caring for women who undergo cervical cancer screening.