Are Doctors Using the HPV Test Appropriately?
By Rachel Walden — June 27, 2011
The current issue of Obstetrics and Gynecology includes a paper that examines how doctors are making use of HPV tests, including whether they are using them appropriately to assess women’s cervical cancer risk.
HPV tests are sometimes done as part of pelvic exams because of the connection between HPV and cervical cancer. Guidelines generally recommend screening for high-risk forms of HPV be done in women over age 30, and in women with abnormal pap results. HPV screening is not recommended in women 21 years old and younger because younger women are likely to get and fight off the virus without any resulting health problems.
An earlier article in a less high-profile journal, Journal of Pathology Informatics, reported similar concerns after reviewing data on HPV tests ordered from 2003-2009. Those authors found that while tests on younger women had declined, but about one in four tests were inappropriate according to the American Society for Colposcopy and Cervical Pathology guidelines.
For the current study, the authors used CDC survey data on what providers do for cervical cancer screening, including their use of HPV tests. They compared those responses to guidelines from the American Cancer Society, the American College of Obstetricians and Gynecologists, and the American Society for Colposcopy and Cervical Pathology to find out whether the providers were inappropriately testing.
Almost 60 percent of providers reported using HPV tests for “cotesting” in women younger than 30, meaning that the test was done as part of routine screening along with the pap, a use that is not recommended in that age group. For women under 30, “a positive HPV test more likely signifies a transient HPV infection that will resolve spontaneously without needing further intervention.” With a positive test result, however, these women are likely to undergo additional unnecessary testing or treatment.
Survey takers also reported doing HPV tests because women asked for them in order to know their HPV status, and explain that because HPV is so common, such screening should not be done outside of cervical cancer screening. It does not appear that providers were asked whether they talk with the patients in these cases about why an HPV test might not be useful for their care, but are encouraged to do so by the authors.
The authors also found that 31 percent of office-based health care providers and 25 percent of hospital clinics reported testing for low-risk forms of HPV which are not considered relevant to cervical cancer screening. They put it quite bluntly: “There is simply no role for low-risk HPV testing in cervical cancer screening nor any other clinical scenarios to justify its use.” Almost 13 percent of survey takers reported not being aware that there was a difference between the high and low risk tests.
They go on to write:
The continued use of low-risk HPV testing by health care providers in the United States may be driven by a combination of financial gain, test marketing, and health care provider confusion on the difference between the low-risk and high-risk tests. Eliminating the availability of the low-risk HPV test, which has no clinical indications, should be considered…
Both the study and editorial authors mention the need to address payment for the unnecessary tests, such as the additional costs/reimbursement received for adding a low-risk test to the more useful high-risk test.
In an accompanying editorial, Abuses in Human Papillomavirus DNA Testing, Dr. Phillip Castle writes about the negative effects of undergoing unnecessary testing, including anxiety, distress, and a decreased sense of sexual well-being, unnecessary procedures such as colposcopies, and the costs of extra tests and procedures. He asks:
Who is to blame, clinicians, laboratories, or the manufacturer? I suggest that they all share in the blame—the clinicians order it, the laboratories provide it, and the manufacturer makes it (ie, the low-risk HPV test). Unfortunately, it is the patient who has to live with the consequences of payment or copayments and being labeled as HPV-positive.
I just wanted to also point out that those cervical procedures effect how her cervix dilates in labor, thus contributing to a rising cesarean rate.
With regards to Dr. Castle’s statements about the ‘negative effects of undergoing unnecessary testing’, this is a societal problem, not the problem of the doctors attempting to determine if women need HPV treatment. There’s no question that STD testing has a negative social stigma when in actuality it should be recognized as a positive and socially conscious thing to do.
Well, I would disagree that unnecessary testing generally is just a societal problem – there is a cost problem which can be a real issue for women. For many tests, such as in the mammography debate, there are pain, cost, and stress concerns related to invasive follow-up procedures that may not have been necessary. In the case of the HPV testing, in some cases the test may be for low risk strains or an exposure that will clear on its own, rather than something that can or should be acted on clinically. I agree though that there should be less stigma about STI testing.
Another reason why we as patients must ask our providers a lot of questions. Do your homework, ask why, how much and how often do I need such tests? I found this helpful in shaping my questions: http://whatstherealcost.org/video.php?post=five-questions