Pap vs HPV檢查:有做檢查都比沒做好


  【24drs.com】麻州波士頓大學醫學院Rebecca B. Perkins醫師和Elizabeth A. Stier醫師在線上發表於6月10日內科醫學誌的文章寫道,單獨使用HPV篩檢檢查子宮頸癌,是否優於併用抹片檢查(Pap),或者單獨使用Pap檢查?答案是這三種方式都適用。
  
  他們寫道,雖然各項篩檢與篩檢間隔的相對好處還需要進一步討論,仍不能忽略子宮頸癌大多發生在那些未曾做過任何篩檢之婦女的事實。要強調的是,應致力於增加篩檢率,以減少子宮頸癌,不論使用哪種檢查方法。
  
  美國食品藥物管理局在2011年核准HPV檢查;對於30歲以上婦女,以前只有使用Pap檢查,或者是Pap檢查結果曾經異常者的追蹤檢查。
  
  上市的四種HPV檢查方式之一、Cobas HPV檢查,是在2014年4月獲得核准作為子宮頸癌的單一種篩檢方式,這項檢查可以從14種高風險人類乳突病毒中確認DNA,包括與70%子宮頸癌有關的第16和第18型。
  
  第16或第18型檢查陽性的婦女後續應進行陰道鏡檢查;其他類型檢測陽性者應進行Pap檢查,以確認是否需要陰道鏡檢查。
  
  雖然HPV獲得核准,但是實務上並未完全單獨使用HPV檢測,有部份是因為Pap檢查效果一樣好且指引中並未建議單獨使用HPV檢查。
  
  Perkins醫師和Stier醫師寫道,單獨使用HPV檢查的敏感性和專一性都優於單獨使用Pap檢查。單獨使用HPV檢查(不論是Cobas或其他市售的HPV檢查)可偵測95%的癌前病變,而單獨使用Pap檢查僅可偵測40%-70%;專一性則分別是HPV檢查94%、Pap檢查 97% 。
  
  他們寫道,併用檢查偵測率高於單獨一種 — 是單獨使用Pap的兩倍、比單獨使用HPV檢查高12% -16%。現行指引建議的篩檢間隔是,併用篩檢為5年、單獨使用Pap篩檢是3年。
  
  指引並未提到單獨使用HPV篩檢之間隔,最新版的子宮頸癌篩檢指引發表於它核准上市前的2012年,是由美國預防服務工作小組版本與美國癌症協會、美國陰道鏡與子宮病理協會、美國臨床病理協會的版本彙整。婦產科協會、美國陰道鏡與子宮病理協會所召集的小組傾向發表載有使用新檢查方式的暫行指引。
  
  Perkins醫師和Stier醫師寫道,在無篩檢指引時間表之下,無法確認HPV檢查的總花費,但是在其他各方面看來,三種方法不相上下。Pap和HPV檢查都需要擴張器檢查和相同的採集技術,所以病患的檢查過程是一樣的。
  
  他們結論表示,單獨使用HPV檢查至少等同於單獨使用Pap檢查,對於30歲以上婦女每3年檢查一次。較年輕婦女的初次HPV檢查會有較高的偽陽性比率。它被核准用於25歲以上婦女,以及短暫HPV感染但未引起子宮頸病變的30歲以下婦女。他們寫道,對於降低子宮頸癌比率,增加任何檢測的覆蓋率和增加HPV疫苗的覆蓋率,比選擇哪種檢查方式更重要。
  
  資料來源: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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