FDA approved the use of HC2 for primary screening with HPV testing combined with cytology (Pap smear) for women aged 30 and above. HPV testing is very expensive. Test itself cost Rs1000 to 1500. Because HPV testing is more sensitive than cervical cytology in detecting CIN 2 and CIN 3,(precancerous lesions). Women with negative concurrent test result can be reassured by doctor that their risk of unidentified Precancerous lesion or cervical cancer is approximately 1/1000. Studies using combined HPV tests with cervical cytology have reported a negative predictive value for precancerous lesion of 99-100%.
Initiation of screening
Both American college of obstetrician and gynaecologists and American cancer society (ACOG&ACS) guidelines agree that cytological screening should be initiated 3years after the first sexual activity but no later than 21years.In France, the recommendations to start cytology screening at 25 years. For HPV testing American societies recommend not to start before the age of 30 years. Cuzik’s group proposed to use HPV alone as the primary test for women >25 years. There are no guideline issued by FOGSI, our gynaecologists association or GOI.
Screening interval
If combined cytology and HPV are used screening should be done every three years. In women >30 years with a negative cytology result with positive high risk HPV DNA test result should have both tests repeated every 6-12 months. Those with persistent high-risk HPV should undergo colposcopy regardless of the cytological results. This test of colposcopy is a routine test, available with leading gynaecologist of all metros, big hospitals and medical colleges.
When to stop screening?
Experts state that evidence is inconclusive to establish an upper age limit for cervical cancer screening.
However international cancer society guidelines recommend that if the patient had 3 or more documented technically normal cytology and had no abnormal results within the past 10 years, one can stop screening .
Particular recommendations
Immunocompromised patients, HIV positive patients, women with a former history of precancerous lesion or cervical cancer require frequent (annual or biannual) screening.
HPV VACCINATION IN PRIMARY PREVENTION OF CERVICAL CANCER
The fact that cervical cancer is caused by a viral infection raises the possibility of preventing the disease by vaccination against this known etiological agent, simulating a hepatitis B vaccination in prevention of cancer liver.
HPV vaccination would probably have different impact on cervical cancer in different countries. Industrialized countries would probably see a rapid reduction in the number of precancerous lesions detected by screening, while developing countries like India would have to wait longer to be able to see an impact on the incidence & mortality of cervical cancer.
Prophylactic HPV vaccine should be administered ideally between 9-12 years of age and a target population of 13-26 years women have to given vaccine by parenteral route . Two types of vaccines of Merk (quadrivalent) and GSK (bivalent) are expected to be available commercially in India by next year. Duration of protection of vaccinated women has shown effective immunity for 5.5 years. The role and timing of boosters is not yet defined.
In USA Merk vaccine is available for 200 dollars, GOI has to fix the prize in India. The fact remains, that it is expensive, but people must know about it and availability should be made in India..
In socio cultural scenario of this country, many parents would not be willing to spend money for vaccine against future cancer in their girl child. But seeing 80% population who seek private care will probably spend on their daughters, if they are spending for routine vaccination given in childhood. |
