Recent Studies Regarding HPV and Cervical Cancer: Questions and Answers
Background
Cervical infections due to a group of about 15 oncogenic, or cancer-causing,
human papillomavirus (HPV) types cause virtually all cervical cancers. They
also are the cause of their immediate precursor, cervical intraepithelial
neoplasia grade 3 (CIN3), a precancerous condition. Overall, about 10 percent
of women at any one time have an oncogenic HPV infection, and they are more
common in young women than in older women. Most cervical infections by even
oncogenic HPV types go away on their own and do not cause cancer. In some
women, oncogenic HPV infections persist and can progress over several years to
CIN3, and may even progress to invasive cervical cancer. Most women, however do
not progress to the precancer stage. Cervical cancer itself is extremely rare
in the United States; there are about 11,000 new cases diagnosed and about
4,000 related deaths reported annually.
Understanding Pap Smears and Other Cervical Cancer Screening and Management
Techniques
1. What is a Pap smear? What is a colposcopy?
A Pap smear is a procedure in which cells are scraped from the cervix (the
lower, narrow end of the uterus that serves as a channel between the uterus and
the vagina) and examined under a microscope. A Pap smear is used to detect
cancer and cellular changes that may lead to cancer, as well as non-cancerous
conditions like infection or inflammation.
A colposcopy is a procedure in which the vagina and cervix are examined using a
lighted magnifying instrument called a colposcope. The vagina and cervix may be
biopsied during a colposcopy so that tissue samples can be examined under a
microscope for abnormal cells. A colposcopy may be prescribed if a Pap smear
detects certain abnormal cellular conditions.
2. What is human papillomavirus (HPV)?
There are more than 100 types of human papillomaviruses (HPV). HPV is one of
the most common sexually transmitted diseases (STDs), and more than 30 of the
different types of HPV can be transmitted through sexual contact. While some
types of HPV may cause warts to appear around the genitals, HPV infections also
may occur without any obvious symptoms.
The U.S. Food and Drug Administration (FDA) has approved the use of a test for
HPV as a screening tool for cervical cancer in conjunction with a Pap smear or
cytology. Oncogenic HPV DNA testing (or "triage") for patients with ASCUS has
proven to be a useful alternative to referring patients for immediate
colposcopy to detect CIN3 and cancer (greater or equal to CIN3). A 2004
conference of the International Agency for Research on Cancer concluded that
there was sufficient evidence that HPV DNA testing could be used as a primary
screening test in women age 30 and older.
3. Why are HPV16 and HPV18 important?
Of the types of HPV that increase risk for certain types of cancer, HPV16 is
the most common among women in the general population. Large case studies have
shown that approximately 50 percent of women with CIN3 or cervical cancer are
infected with HPV16. Additional research suggests that 60 percent to 70 percent
of cervical cancer cases worldwide are caused by either HPV16 or HPV18.
Virtually all remaining cases of cervical cancer are caused by other oncogenic
HPV types.
4. What are ASCUS and LSIL?
ASCUS and LSIL are acronyms for two mild abnormalities detected by Pap tests.
ASCUS stands for "Atypical Squamous Cells of Undetermined Significance", and
LSIL stands for "Low-grade Squamous Intraepithelial Lesion".
A diagnosis of ASCUS means that the nature of the abnormality is uncertain or
equivocal. A diagnosis of LSIL means that there is a more definite, but still
mild, abnormality.
Study Findings
5. What were the goals of the ALTS and the Portland Kaiser Permanente studies?
The National Cancer Institute (NCI) organized and funded ALTS (the ASCUS/LSIL
Triage Study for Cervical Cancer) to help resolve the controversy over what
physicians and women should do about ASCUS (equivocal) and LSIL (mildly
abnormal) Pap test results*. Most of these abnormalities will go away without
treatment, but some may lead to a precancerous condition or cancer. This
analysis of the ALTS data provided the opportunity for researchers to determine
whether women with equivocal Pap smear results, who also tested positive for
HPV16, had a greater risk for CIN3 or cervical cancer than women with equivocal
Pap smear results who tested positive for other oncogenic types of HPV.
The Portland study was designed to examine the natural history of HPV infection
and cervical neoplasia (abnormal and uncontrolled cell growth)**. Additionally,
this study allowed analysis of whether testing specifically for HPV16 and
HPV18, in addition to overall testing for all HPV oncogenic types, might help
identify women at particularly high risk for CIN3 or cervical cancer.
6. What were the results of these studies?
In their analysis of ALTS data, Castle et al. found that 542 women in the study
group developed CIN3 or cervical cancer. Those who tested positive for HPV16
had 38 times the risk for CIN3 or cervical cancer than women in the study who
were HPV negative. Women who tested positive for other oncogenic HPV types had
seven times the risk for these conditions than women who tested HPV negative.
The authors concluded that patients with a positive HPV16 diagnosis may require
more aggressive management than those who test positive for another oncogenic
HPV type or who are HPV negative.
Khan et al. found that women in the Portland study who tested positive for
HPV16 or HPV18 were diagnosed with CIN3 or cervical cancer more often than
women who tested positive for another oncogenic HPV type, or women who tested
negative for HPV. Additional analysis of women with normal Pap smear results at
study enrollment provided further evidence for the observed risk differences.
The authors concluded that screening for HPV16 and HPV18 separately from other
oncogenic HPV types may identify women at the greatest risk of CIN3 and
cervical cancer, while allowing for less aggressive management of cases of
other oncogenic HPV infections.
The authors note that an elevated risk for HPV16 also was observed in a natural
history study in Guanacaste, Costa Rica (Schiffman, Virology, 2005)***.
7. How were these studies performed?
The ALTS study compared three different management strategies for 5,060 women
with Pap tests that either showed ambiguous cytologic abnormalities (ASCUS,
3,488 women), or low-grade squamous intraepithelial lesions (LSIL, 1,572
women). The study referred one-third of the women to an immediate colposcopy,
regardless of their Pap test results; one-third to colposcopy if their initial
HPV test was positive or if their Pap test showed high-grade squamous
intraepithelilal lesions (HSIL); and one-third to colposcopy if their Pap test
showed HSIL at their enrollment in the study or during follow-up. All three
groups received additional tests every six months for two years of follow-up
and a colposcopy at the end of the trial. Women whose test results showed
cervical intraepithelial neoplasia grade 2 (CIN2) or higher received treatment
for the condition.
The Portland study examined data on 20,514 women who received routine cytologic
screening through a prepaid health plan in Oregon. Women included in this
analysis had negative, equivocal, or mildly abnormal baseline cervical Pap
smears; suitable samples for HPV testing; and type-specific HPV test results.
Study participants received regular follow-up cytology testing for up to 10
years following their enrollment. Practice guidelines at the time of the study
mandated treatment for women whose Pap smears showed CIN2 or higher, but some
physicians also treated some patients with cervical intraepithelial neoplasia
grade 1 (CIN1).
8. What were the limitations of these studies?
ALTS was a clinical trial and, consequently, the participants in the trial may
have been screened more regularly than patients in everyday clinical
management. Additionally, the women in this study were relatively young, with a
median age of 25. A population of older women might lead to different results.
Women with cellular abnormalities in the Portland study received very
aggressive treatment -- more than was mandated by clinical standards at the
time or today. Thus, results in this study may actually underestimate the risk
attributable to HPV16 and to HPV18 because of over-treatment. Additionally,
there were relatively few cases to analyze despite the study size, possibly
leading to some imprecise estimates of risk.
9. What are the next steps in this area of research?
Twenty organizations - including the American Society for Colposcopy and
Cervical Pathology (ASCCP), the American Cancer Society, and the National
Cancer Institute (NCI) - will participate in a conference in September 2005 to
discuss the use of HPV DNA testing for screening and for triage of equivocal
(ASCUS) Pap smears. One of the topics of discussion is likely to be the utility
of HPV genotype detection in screening and clinical management.
The data from these recent two studies should be confirmed in other larger
studies and in other populations, perhaps even in some of the clinical trials
that are evaluating HPV DNA tests to develop more precise estimates of risk.
Also, subsequent evaluations will need to examine this question in women who
are newly infected.
To perform HPV genotyping, a reliable, FDA-approved test to distinguish these
specific HPV types will need to be developed and validated. When FDA-approved
tests that provide genotype information become available, researchers will be
better able to identify women with persistent infection, an important risk
factor for the development of precancer and cancer. Understanding the risks
associated with a persistent HPV infection and the appropriate clinical
management of these women is critical to preventing cervical cancer.
Future research will help to demonstrate whether women who test negative for
HPV16 and HPV18 can be followed and treated less aggressively than women who
test positive for these HPV types, thereby reducing the number of clinical
visits, potential over-treatment of these women, and increasing the cost
effectiveness of such testing.
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For more information about cancer, please visit the NCI Web site at
http://www.cancer.gov or call NCI's Cancer Information Service at
1-800-4-CANCER (1-800-422-6237).
*Castle PE, Solomon D, Schiffman M, Wheeler CM for the ALTS Group. Human
papillomavirus type 16 infections and 2-year absolute risk of cervical
precancer in women with equivocal or mild cytologic abnormalities." Journal of
the National Cancer Institute, Vol 97, No. 14, July 20, 2005.
**Kahn MJ, Castle PE, Lorincz AT, Wacholder S, Sherman ME, Scott DR, Bush BB,
Glass AG, Schiffman M. The elevated 10-year risk of cervical neoplasia in women
with human papillomavirus (HPV) type 16 or 18 and the possible utility of
type-specific HPV testing in clinical practice." Journal of the National Cancer
Institute, Vol. 97, No. 14, July 20, 2005.
*** Schiffman M, Herrero R, DeSalle R, Hildesheim A, Wacholder S, Rodriguez AC,
Bratti MC, Sherman ME, Morales J, Guillen D, Alfaro M, Hutchinson M, Wright TC,
Solomon D, Zigui C, Schussler J, Castle PE, Burk RD. The carcinogenicity of
human papillomavirus types reflects viral evolution. Virology, Vol. 337, 2005.
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