April 9, 2009
Letters to the Editor
The New York Times
620 Eighth Avenue
New York, NY 10018
To the Editor:
“DNA Test Outperforms Pap Smear” appeared April 7, 2009 in the New York Times calling attention to a New England Journal of Medicine research article reporting the success of using human papillomavirus (HPV) testing to screen women for cervical cancer in a low resource setting. However, the Times article failed to convey (and in fact, obfuscated the fact) that the results of this study cannot be applied to countries with well-developed screening programs such as the United States
The Indian study specifically states that HPV testing does not require the same training and quality assurance that is required for the Pap test; that testing for cervical cancer using HPV testing should not begin until age 30; and in order to be economically feasible, the HPV test must cost less. In the U. S., we are blessed with well-trained, government-regulated laboratory professionals (cytotechnologists) who are schooled to detect abnormalities in a Pap test. In the U.S., we begin screening three years after a woman has become sexually active, and we use HPV testing as a reflex to an abnormal Pap test in women over 20 years old, and as an adjunct to the Pap test in women over 30 years of age. The use of different screening scenarios has resulted in detection of abnormalities in younger women with triage for treatment, and increased screening intervals in older women who are negative for HPV and have normal Pap tests. Using the current screening guidelines, cervical cancer rates in the United States are well below the rates in the Indian study reported in the NEJM.
The focal point of the April 7 Times article should have been the fact that in India, strides are finally being made to safeguard women’s health by using a cancer screening program that is appropriate for India’s resources. Too many women have died in India because of a dearth of cervical cancer screening.
The American Society of Cytopathology is a medical society devoted to the detection of disease through the evaluation of cells, including Pap tests. While the role of Pap testing may change in the United States, it will be based upon the appropriate use of tests in a country with established, successful, cervical cancer screening practices. Casting doubt on the legitimacy of Pap test screening in the United States at the present time only thwarts efforts to detect cervical cancer. Women in the U.S. should have regular Pap tests with appropriate adjunctive tests as dictated by their clinical risk factors, age, and screening history.
Ann T. Moriarty, MD
President, American Society of Cytopathology