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"Suppose there were a screening test for cervical cancer that could detect potential dangers with far more sensitivity than the Pap. A test so reliable that when it was done with the Pap, you could trust the results nearly 100 percent. Sounds like all women would be getting it, right? Well...there is such a screen \u2014 the HPV test. It&amp;#039;s been approved by the FDA and endorsed by the American College of Obstetricians and Gynecologists (ACOG) and the American Cancer Society as an option to be done with your Pap, and yet only an estimated 15 percent of doctors are using it. If your ob-gyn has never mentioned it, read on. Understanding the limits of the Pap and what the new test can do, and getting updated info on who&amp;#039;s at risk of cervical cancer, will help you start the conversation.  What is the new HPV test? Almost all cervical cancers are caused by prior infection with human papillomavirus, or HPV. There are more than 100 strains of HPV, about 40 of which can be spread by having sex. Some cause warts, others no symptoms at all. But some types cause cell abnormalities in the lining of the cervix that, years later, can become malignant. Two of these strains \u2014 numbers 16 and 18 \u2014 are thought to be responsible for roughly 70 percent of cervical cancer cases. The HPV test literally homes in on genetic coding that occurs in these two, plus about a dozen other high-risk strains. A negative HPV test means that no active virus could be found; a positive result, that one or more of those strains is present. How is this different from the Pap? The Pap is designed for visual identification (by either lab technician or computer) of any cells that look abnormal. The HPV test was originally approved by the FDA as a follow-up for women whose Pap results were ambiguous (technically called ASCUS \u2014 &amp;quot;atypical squamous cells of undetermined significance&amp;quot;), a category that may affect some three million women every year. Now it&amp;#039;s been OK&amp;#039;d as a screening test for women 30 and over, to be done with the Pap and, generally, the same sample of cervical cells.  How effective is it? Last April, two scientists from the National Cancer Institute, writing in the prestigious New England Journal of Medicine about a study of 131,746 women in India, said that &amp;quot;among...women between the ages of 30 and 59 years...a single HPV test performed 15 to 20 years after the median age of first sexual intercourse will detect many easily treatable, persistent infections and precancers while limiting overtreatment.&amp;quot; One test, they wrote, &amp;quot;dramatically reduced the incidence of advanced cervical cancer and cervical cancer mortality.&amp;quot; Why improve on the Pap? This one test has made a huge difference in the health of American women; since the Pap&amp;#039;s introduction in the 1940s, cervical cancer rates have been slashed by 70 percent, to 11,270 cases and 4,070 deaths in 2009. But the test has problems. For one, a single Pap can miss up to 50 percent of cell abnormalities (but because these changes usually occur very slowly, chances are great that an abnormality will be picked up on your next test). The Pap can also raise a false alarm when nothing&amp;#039;s really wrong: Cervical tissue undergoes surface changes all the time, and these may pop up on your Pap, then disappear on their own. No screen can ever be considered 100 percent perfect, but the Pap/HPV combo comes pretty close. Studies from the U.S. and Europe show if you have negative results on the two tests given together, you can be 99.84 percent assured you won&amp;#039;t develop cervical cancer within the next three or more years, says Alan G. Waxman, M.D., M.P.H., professor of obstetrics and gynecology at the University of New Mexico School of Medicine and lead author of the cervical-screening guidelines published by ACOG last December.  Do you still need an annual Pap test?  Actually, since 1987, virtually every medical organization that has issued guidelines on cervical screening has endorsed the idea that after three successive &amp;quot;normals,&amp;quot; a healthy, low-risk woman age 30 or over needs to be tested only every two to three years. &amp;quot;The tradition of annual Pap tests is just that, a tradition, and it&amp;#039;s not backed up by science,&amp;quot; says Debbie Saslow, Ph.D., the American Cancer Society&amp;#039;s director of breast and gynecologic cancers. Only women considered at high risk \u2014 DES daughters, for example, or those who&amp;#039;ve had cervical cancer or precancerous lesions \u2014 need more frequent tests. (Smoking also ups your risk; if you smoke, ask about extra tests.) Even if you don&amp;#039;t have a Pap, though, you should have regular checkups that include breast and pelvic exams, a blood pressure reading, and other tests depending on your age and medical history. OK, but what if a yearly Pap makes you feel safer?  Trouble is, each time you&amp;#039;re tested, you run the risk of an abnormal finding. And though there&amp;#039;s a strong chance that any aberrant cells would be cleared by your body before your next test two or three years later, now the doctor has to &amp;quot;do something,&amp;quot; which might include removing those cells. You&amp;#039;re subject to needless procedures, not to mention a lot of anxiety about the possibility of cancer \u2014 all for a disease that likely would never have developed. If you have an HPV test and a Pap and both are normal, what next? You&amp;#039;re &amp;quot;free,&amp;quot; so to speak, for three years. &amp;quot;Even if a 40-something woman went out and got a new infection the very next day, she would be effectively setting the clock back to zero; her risk of cervical cancer wouldn&amp;#039;t rise significantly until she was in her 60s,&amp;quot; says Mark Schiffman, M.P.H., M.D., senior investigator at the National Cancer Institute. In other words, a double &amp;quot;all-clear&amp;quot; may finally give a woman \u2014 and her doctor \u2014 the peace of mind to break the Pap-every-year habit.  What if your Pap is fine, but your HPV test is positive?  First, it doesn&amp;#039;t mean that you definitely have cancer or will get cancer. But what&amp;#039;s next depends on whom you ask. Some experts recommend, if possible, following up with the more specific HPV 16/18 test, approved last year, to check if the two most worrisome forms of the virus are present (this test is not yet widely available). If that test is positive, your doctor will almost certainly advise a colposcopy, a procedure in which the cervix is viewed directly through a tube-like microscope and, if necessary, tissue samples are removed. But most experts advise retesting in a year and, if those tests are positive, then doing a colposcopy, says Karen Smith-McCune, M.D., associate professor of obstetrics and gynecology at the University of California, San Francisco Helen Diller Family Comprehensive Cancer Center. However, not all women are comfortable with this wait-and-see approach. &amp;quot;I am getting a lot of self-referrals from women who are really frightened because they tested positive for HPV and don&amp;#039;t want to wait even a few weeks for additional test results,&amp;quot; says Dr. Smith-McCune.  What about the other way around \u2014 your HPV test comes back clear, but your Pap is questionable?  The standard advice \u2014 come back for an additional set of tests in a year \u2014 may not be what a worried woman wants to hear, but it&amp;#039;s the overwhelming consensus among experts. Most mild abnormalities will clear on their own; also, there are guidelines to help doctors decide which cell changes need further examining with a colposcopy and biopsy. &amp;quot;The majority of women who die from cervical cancer in the U.S. either have never been screened or haven&amp;#039;t been screened in five years or more,&amp;quot; says Dr. Saslow. Why aren&amp;#039;t all doctors recommending HPV testing?  Physicians may be hesitant to adopt this new technology until there&amp;#039;s stronger evidence that it&amp;#039;s beneficial \u2014 that it prevents illness and saves lives, says Joy Melnikow, M.D., M.P.H., director of the UC Davis Health System Center for Healthcare Policy and Research. There are also practical considerations. The HPV test is easiest to do in conjunction with so-called liquid Paps, in which &amp;quot;leftover&amp;quot; fluid provides cells to test for HPV. Although roughly 90 percent of Paps are now done this way, 10 percent of doctors still use the older slide/smear technology (which, by the way, new research shows is just as accurate); adding a second test would mean taking a second cell sample. Finally, there&amp;#039;s the cost \u2014 about $100. Pap tests are routinely covered by insurance. Although 26 states plus the District of Columbia require private insurers to pay for cervical screening in some way, just seven \u2014 California, Maryland, New Mexico, North Carolina, Oregon, Texas, and West Virginia \u2014 specifically cover HPV testing. &amp;quot;Many women can&amp;#039;t or don&amp;#039;t want to pay for it,&amp;quot; notes Concepcion Diaz-Arrastia, M.D., director of gynecologic oncology at Baylor College of Medicine.  Should you ask your doctor about the test?  Absolutely, says Dr. Diaz-Arrastia. You may think, &amp;#039;How could I have HPV?&amp;#039; but in a study she supervised at the University of Texas Medical Branch at Galveston, researchers found there was a peak in active infections in women in their 50s. In one group of 167 women age 55 and over, 35 percent of those who tested positive for active HPV reported no sexual activity for five or more years. These women may have had persistent or recurrent infections; she speculates that the virus can reemerge, similar to the way shingles develops decades after a childhood bout of chicken pox.  Cervical cancer screening is in transition, from the Pap-only mode to the HPV/Pap testing combo and perhaps to HPV testing alone first, says Dr. Schiffman. Or the move may be to other techniques in development.  Meanwhile, the best way to safeguard your own health is to speak up: Ask about the new test, be open and honest about your sexual and medical history, and, if your doctor is hesitant, find out why. Habit is not a good enough reason to miss out on the reassurance that HPV testing can offer. "^^<http://www.w3.org/2001/XMLSchema#string>
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