The Pap smear, an annual test that checks for cervical cancer in women, is considered one of the most effective screening tools ever developed. Since the implementation of Pap smears in the 1940s, the number of women who have died as a result of cervical cancer in the United States has steadily declined, even as the disease continues to be the number one killer of women in many developing countries. Now, a test for human papillomavirus (HPV), the primary cause of cervical cancer, is showing promise of being an even more effective means of early detection, yet HPV testing in Memphis is vastly underutilized.

 

Each year, 11,000 women in the U.S. are diagnosed with cervical cancer and more than 3,800 die as the result of a disease that is largely preventable. Cervical cancer is caused by HPV, one of the most common sexually transmitted diseases in the U.S. However, HPV infection does not lead to cervical cancer in most women because the body's immune system fights off the infection.

 

The HPV screen uses the same cell sample that is gathered during a Pap smear. Both screens look for abnormal cervical-cell changes, an early warning sign of cancer. "We know that 99 percent of cervical cancer is due to HPV but not all HPV is responsible for cancer," noted Joseph Santoso, MD, a professor and director of GYN Oncology at University of Tennessee Health Science Center (UTHSC) and the West Clinic. The test looks for 15 high-risk HPV types, including strains 16 and 18, responsible for 70 percent of all cervical cancers.

 

First approved in 2000 by the FDA for women with abnormal Pap results, the HPV screen is now approved for use in most women over the age of 30. As studies are showing, the screen is a powerful tool for early detection of cervical cancer. A Canadian study published in the New England Journal of Medicine in October 2007 found that the Pap identified only 55 percent of high-grade cervical lesions, compared with 95 percent for the HPV DNA test, which screens for 13 potential cancer-causing strains.

If performing an HPV test would let a woman know the existence of the high-risk HPV virus and alert her physician to retest the following year, why are private practice physicians in Memphis not providing the test more routinely? There are several factors. Consumer education is one piece of the puzzle. Women need to know the exam is available and covered by most insurance providers.

 

Another piece is physician practice. Many doctors rely on the Pap smear because it's long been the gold standard and it is how they were trained to look for cervical cancer. "They're getting conflicting results on the effectiveness of the HPV test," said Santoso. "What do the results mean and how do we take action? When the patient comes in and asks 'is the test normal or abnormal?' then you've just opened a Pandora's Box. It's not that simple anymore."

 

Guidelines have been in a state of flux over the past several years as more research has come to the fore regarding HPV testing. Consensus guidelines by the American Society for Colposcopy and Cervical Pathology recommended that "women be screened with a combination of Pap/HPV test to improve the sensitivity of screening. Women who are found to have negative Paps but positive HPV tests should be followed in a year with another combination test, with coloposcopy, and possible treatment only if the Pap test becomes abnormal or the HPV infection persists."   

 

If both tests come back negative, then ASCCP guidelines say the patient can wait three years before being retested. But doctors express concern that during that interval, women might not be as diligent about seeing their OB-GYN for annual pelvic and breast exams, as well as general well-woman care. "Some doctors feel uncomfortable telling patients to only test every three years. They're afraid they won't see the patient in the meantime and not catch a problem early on," said Lynda Gioia-Flynt, an OB-GYN and assistant professor with UTHSC.

 

"As a practicing nurse, I would rather have the test to pick up the strain than not at all," said Beth Cahill, executive director of the National Women's Health Resource Center (NWHRC). "It's another step we can take to identify HPV, so why not have that done?" The NWHRC has partnered with QIAGEN, the makers of digene HPV test, in a marketing campaign to get the word out about the importance of HPV testing.  

 

Cahill also points out another consideration, the changing demographics of women. Most women 40 and older didn't become sexually active until college. "Now, girls are having sex at a younger age," said Cahill, "so they need to have an annual exam (once they turn 30)," because the likelihood of having HPV is higher with the more sexual partners you have. The test is recommended after age 30 because at that life stage most women are in more stable relationships and therefore at less risk for contracting HPV. 

 

Advancing cervical cancer prevention has been a goal of Women in Government (WIG), a nonprofit, bipartisan group of women state legislators. In 2004, WIG launched the Challenge to Eliminate Cervical Cancer Campaign, an effort to educate legislators about cervical cancer and prevention policies. At that time, each state was assessed to determine what types of legislation and public health policy were in place to lower cervical cancer rates. According to their report, 30 states received a grade of Good or Very Good for their efforts. In 2009, that figure climbed to 40 states, yet Tennessee continues to lag behind remaining among 10 states nationally to receive the lowest grade of Fair.

 

While doctors have access to the HPV test, many local OB-GYNs are still more reliant on Pap smears which leave women at risk, particularly women of color. According to information on the NWHRC's Web site, "African-American women are 30 percent more likely to develop cervical cancer and twice as likely to die from it as Caucasian women. In addition, Hispanic women are twice as likely to develop cervical cancer, with three percent of all cancer deaths in Hispanics due to cervical cancer."

 

"The test results and understanding what they mean is still being understood. But it's better to have the test than not, even though interpreting the results is still a work in progress," said Santoso. "Pap smear guidelines have changed multiple times because information on HPV is relatively new within the last decade. We might eventually do only screens using HPV tests and not Paps, as they do more studies to see what the test is catching and what it is missing with this screening."