Pap vs HPV检查:有做检查都比没做好


  【24drs.com】麻州波士顿大学医学院Rebecca B. Perkins医师和Elizabeth A. Stier医师在在线发表于6月10日内科医学志的文章写道,单独使用HPV筛检检查子宫颈癌,是否优于并用抹片检查(Pap),或者单独使用Pap检查?答案是这三种方式都适用。
  
  他们写道,虽然各项筛检与筛检间隔的相对好处还需要进一步讨论,仍不能忽略子宫颈癌大多发生在那些未曾做过任何筛检之妇女的事实。要强调的是,应致力于增加筛检率,以减少子宫颈癌,不论使用哪里种检查方法。
  
  美国食品药物管理局在2011年核准HPV检查;对于30岁以上妇女,以前只有使用Pap检查,或者是Pap检查结果曾经异常者的追踪检查。
  
  上市的四种HPV检查方式之一、Cobas HPV检查,是在2014年4月获得核准作为子宫颈癌的单一种筛检方式,这项检查可以从14种高风险人类乳突病毒中确认DNA,包括与70%子宫颈癌有关的第16和第18型。
  
  第16或第18型检查阳性的妇女后续应进行阴道镜检查;其它类型检测阳性者应进行Pap检查,以确认是否需要阴道镜检查。
  
  虽然HPV获得核准,但是实务上并未完全单独使用HPV检测,有部份是因为Pap检查效果一样好且指引中并未建议单独使用HPV检查。
  
  Perkins医师和Stier医师写道,单独使用HPV检查的敏感性和专一性都优于单独使用Pap检查。单独使用HPV检查(不论是Cobas或其它市售的HPV检查)可侦测95%的癌前病变,而单独使用Pap检查仅可侦测40%-70%;专一性则分别是HPV检查94%、Pap检查 97% 。
  
  他们写道,并用检查侦测率高于单独一种 — 是单独使用Pap的两倍、比单独使用HPV检查高12% -16%。现行指引建议的筛检间隔是,并用筛检为5年、单独使用Pap筛检是3年。
  
  指引并未提到单独使用HPV筛检之间隔,最新版的子宫颈癌筛检指引发表于它核准上市前的2012年,是由美国预防服务工作小组版本与美国癌症协会、美国阴道镜与子宫病理协会、美国临床病理协会的版本汇整。妇产科协会、美国阴道镜与子宫病理协会所召集的小组倾向发表载有使用新检查方式的暂行指引。
  
  Perkins医师和Stier医师写道,在无筛检指引时间表之下,无法确认HPV检查的总花费,但是在其它各方面看来,三种方法不相上下。Pap和HPV检查都需要扩张器检查和相同的采集技术,所以病患的检查过程是一样的。
  
  他们结论表示,单独使用HPV检查至少等同于单独使用Pap检查,对于30岁以上妇女每3年检查一次。较年轻妇女的初次HPV检查会有较高的伪阳性比率。它被核准用于25岁以上妇女,以及短暂HPV感染但未引起子宫颈病变的30岁以下妇女。他们写道,对于降低子宫颈癌比率,增加任何检测的覆盖率和增加HPV疫苗的覆盖率,比选择哪里种检查方式更重要。
  
  资料来源:http://www.24drs.com/professional/list/content.asp?x_idno=7092&x_classno=0&x_chkdelpoint=Y
  

Pap vs HPV Testing: Any Screening Is Better Than None

By Beth Skwarecki
Medscape Medical News

Does a standalone HPV screening test for cervical cancer carry any benefit over cotesting with a Papanicolaou (Pap) test or a Pap test alone? All 3 approaches are adequate for testing, Rebecca B. Perkins, MD, and Elizabeth A. Stier, MD, from Boston University School of Medicine, Massachusetts, write in an article published online June 10 in the Annals of Internal Medicine.

"Although the relative merits of screening tests and screening intervals warrant additional discussion, we cannot lose sight of the fact that most cervical cancer occurs in women who have not had any recent screening," they write. They emphasize that efforts to decrease cervical cancer should focus on increasing screening rates, regardless of which test is used.

The US Food and Drug Administration approved HPV testing in 2011; it was originally used alongside Pap testing for women aged 30 years and older and as a follow-up test for younger women who have an abnormal Pap test result.

The Cobas HPV test, 1 of 4 HPV tests on the market, was approved in April 2014 as a standalone screening test for cervical cancer. The test can recognize DNA from 14 high-risk types of the human papillomavirus, including types 16 and 18, which are responsible for 70% of cervical cancers.

Women who test positive for types 16 or 18 should then have a colposcopy; those who test positive for the other types should have a Pap test to determine whether a colposcopy is needed.

Despite its approval, providers are not entirely sold on using the HPV test alone, in part because Pap tests work so well and because recommendations have not yet been written to guide the use of HPV-only tests.

The HPV-only test has both higher sensitivity and specificity than a Pap test alone, write Dr. Perkins and Dr. Stier. "A single screening with HPV testing (either Cobas or other commercially available HPV test) detects 95% of precancerous lesions, compared with 40% to 70% for Pap testing alone; the corresponding specificities are 94% for HPV testing and 97% for Pap testing," they note.

Cotesting detects more disease than either test alone, they write — twice as many cases as a Pap alone, or 12% to 16% more than HPV testing alone. Current guidelines recommend screening intervals of 5 years for cotesting or 3 years for Pap testing alone.

Guidelines do not yet exist for how often to screen with the HPV-only test. The most recent cervical cancer screening guidelines were published before its approval, in 2012: a set from the US Preventive Services Task Force and a similar set of guidelines issued jointly by the American Cancer Society, the American Society for Colposcopy and Cervical Pathology, and the American Society for Clinical Pathology. A panel convened by the Society of Gynecologic Oncology and the American Society for Colposcopy and Cervical Pathology intends to publish interim guidelines on the use of the new test.

The overall cost of the HPV test cannot be determined without a screening schedule, Dr. Perkins and Dr. Stier write, but by other metrics, the 3 approaches are similar. Both Pap and HPV tests require speculum examination and identical collection techniques, so the patient experience is the same for both.

HPV testing alone "is at least equal to Pap testing alone," they conclude, in women aged 30 years and older who are screened every 3 years. Primary HPV testing would have higher false-positive rates in younger women. It is approved for women aged 25 years and older, and women younger 30 years frequently have transient HPV infections that do not cause cervical dysplasia. Increasing coverage with any screening test, and increasing coverage of the HPV vaccine, they write, are more important than the choice of test in efforts to decrease rates of cervical cancer.

The study was supported by an American Cancer Society Mentored Research Scholar Grant. Dr. Stier reports receiving grants from the National Institutes of Health/National Cancer Institute outside the work. Dr. Perkins has disclosed no relevant financial relationships.

Ann Intern Med. Published online June 9, 2014.

    
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