Are you talking to women about HPV and cervical cancer screening?

Less than 20% of women say providers have discussed cancer/HPV link

As you review which talking points to cover with your next patient, are you planning to include dialogue on the link between human papillomavirus (HPV) and cervical cancer? Chances are you’re not, according to the results from a new national survey released by the Washington, DC-based Association of Reproductive Health Professionals (ARHP).

The survey results show that while 88% of women rely on their health care providers to learn about gynecological issues, only 19% say their providers have talked to them about cervical cancer and its major cause, HPV. The survey was conducted by Greenberg, Quinlan, Rosner Research of Washington, DC.

While great strides have been made in reducing the impact of cervical cancer in America, 2005 statistics from the American Cancer Society (ACS) estimate about 10,370 cases of invasive cervical cancer will be diagnosed in the United States.1 About 3,710 women will die from cervical cancer in the United States during 2005, according to the ACS.1

It is now known that some strains of HPV account for most cervical cancer cases; in the United States, HPV 16 alone accounts for more than half of all cervical cancer cases, followed by HPV 18, 31, and 45.2

"It is really surprising to me that so many women don’t know what the connection is between human papillomavirus and cervical cancer," says Beth Jordan, MD, ARHP medical director. "I think one of the key things for providers to do is to just ask: "Do you know why you’re having Pap smears? Do you know what the connection is? If not, let’s talk."

When and who to test?

In 2003, the Food and Drug Administration (FDA) approved the DNAwithPap, manufactured by Digene Corp. of Gaithersburg, MD, to help distinguish women at increased risk from those at very low risk of developing the disease. The test combines the company’s Hybrid Capture 2 High-Risk HPV DNA test with a Pap test.

The FDA approved the dual test as a primary screening option for women 30 years of age and older. The test is not intended to substitute for regular Pap screening, nor is it intended to screen women younger than 30 who have normal Pap tests, states the FDA.3

The ACS issued guidelines in 2002 calling for Pap tests beginning at age 21 or three years after a woman first has sexual intercourse.4 Until age 30, screening should be done every year with the regular Pap test or every two years using the liquid-based Pap test. After age 30, women who have had three normal Pap tests in a row can wait two or three years for their next Pap.

Women with a negative HPV test and a normal Pap smear need not be screened again for three years. Women with a positive HPV test and a normal Pap test should be retested in six months to a year, according to the ACS guidelines.

According to the ARHP survey, women age 30 and younger, who are least at risk for cervical cancer, are most knowledgeable about its cause and more likely to discuss HPV openly with their health care professionals. However, women age 30 and older are less knowledgeable about the virus, the survey results indicate. They are more likely to have persistent, high-risk forms of HPV that can lead to cervical cancer and therefore may benefit from HPV testing along with their Pap test.5

HPV testing also is appropriate for the following situations:

  • triage after a test result of atypical squamous cells of unknown origin (ASC-US);
  • triage after colposcopy does not detect precancer in women with low-grade squamous intraepithelial lesion (LSIL);
  • testing one year after known cervical intraepithelial neoplasia (CIN-1) biopsy;
  • testing the cervix after cryosurgery or a loop electrosurgical excision procedure (LEEP) to treat precancerous dysplasia;
  • HPV testing for anal lesions.6

"In our study of 338 women undergoing screening for cervical cancer, only 34% of women were aware that HPV testing was a part of the follow-up for an abnormal Pap test," says Carmen Radecki Breitkopf, PhD, assistant professor in the department of obstetrics and gynecology at the University of Texas Medical Branch in Galveston.

Check Pap knowledge

Breitkopf and her fellow researchers questioned women undergoing cervical screening at two Texas clinics to evaluate their knowledge and informational needs about Pap testing.6

Results of their study indicate that minority women and those of low socioeconomic status had poor understanding of Pap testing.7 Identifying misunderstandings and improving patient education on the most basic aspects of Pap testing may increase adherence to follow-up when abnormalities are detected, researchers conclude.7

Despite the benefits of Pap test screening, not all American women take advantage of it, according to the ACS. Between 60% and 80% of American women with newly diagnosed invasive cervical cancer have not had a Pap test in the past five years, and many of these women have never had a Pap test.8 In particular, elderly, African-American, and low-income women are less likely to have regular Pap tests, says the ACS.8

Why aren’t clinicians talking to women about cervical cancer and HPV?

"The communications gap between providers and patients related to cervical cancer and HPV is an issue that is largely due to time constraints and a reluctance to discuss a sexually transmitted infection with women," says Jordan. "But because new techniques, including improved types of diagnostic testing, now make cervical cancer a disease that can be better prevented, we’re encouraging women to discuss with their health care provider their HPV risk, get regular screenings with the Pap test and, if they are age 30 or older, ask about HPV testing as well."

References

  1. American Cancer Society. Detailed Guide: Cervical Cancer What Are the Key Statistics About Cervical Cancer? January 2005; Accessed at: www.cancer.org.
  2. Bosch FX, de Sanjose S. Chapter 1: Human papillomavirus and cervical cancer — burden and assessment of causality. J Natl Cancer Inst Monogr 2003; 3:3-13.
  3. Food and Drug Administration. FDA Approves Expanded Use of HPV Test. Bethesda; March 31, 2003. Accessed at www.fda.gov.
  4. American Cancer Society. FDA Approves New Cervical Cancer Screening Test. Atlanta; March 31, 2003. Accessed at: www.cancer.org.
  5. Association of Reproductive Health Professionals. Survey reveals women and doctors aren’t talking about HPV. Press release. June 28, 2005.
  6. Association of Reproductive Health Professionals. When is HPV DNA testing appropriate? Health & Sexuality 2005; 10:9.
  7. Breitkopf CR, Pearson HC, Breitkopf DM. Poor knowledge regarding the Pap test among low-income women undergoing routine screening. Perspect Sex Reprod Health. 2005; 37:78-84.
  8. American Cancer Society. Can Cervical Cancer Be Found Early? Accessed at: www.cancer.org.

Resource

The Association of Reproductive Health Professionals has devoted an entire issue of Health & Sexuality to the topic of cervical cancer prevention and HPV DNA testing. To download the publication, go to the ARHP web site, www.arhp.org. Click on "Healthcare Providers," "Online Publications," "Health & Sexuality Magazine," and "Cervical Cancer Prevention and HPV DNA Testing." Answers to frequently asked questions about HPV are on pp. 11-12.