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When It Comes To Cervical Cancer, Two Tests Are Better -- And Cheaper -- Than One

The argument has never been to test or not to test. The question is whether to co-test. With these two extraordinary studies, any doubts have been put to rest.
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It is right that we constantly should be testing our assumptions about what keeps us healthy and what puts us at risk. New ideas and evidence that challenge current behaviors must be taken into consideration. But "new" isn't necessarily better, and many of our current practices - despite alternatives that by their very newness might seem better - remain the best option for care.

This is especially relevant now as OB-GYNs from around the country recently convened at the American Congress of Obstetricians and Gynecologists (ACOG) annual meeting to debate the latest topics related to cervical cancer screening. Powerful new research related to cervical cancer backs up longstanding practices and recommendations, despite newer approaches that have gained some support. The truth is, however, these newer approaches just do not hold up under scrutiny, and may in fact be putting many women at risk.

An issue is the effectiveness and efficiency of what's known as co-testing - that is, the Pap test plus HPV (human papillomavirus infection) test for cervical cancer screening, versus screening with the HPV test used alone, which has gained some currency.

While our evolving understanding of the disease includes the role of HPV, some strains of which can cause cervical cancer, we also know the rate of cervical cancer, which had been a leading cause of death among women, has fallen by more than 70 percent since the Pap test became standard practice in the 1950s. So any practice that eliminates the Pap from the equation must prove its case before it becomes the norm.

Separate new research studies continue to add to our understanding of the benefits of co-testing, not only to women's health, but to the healthcare system as it tries to rein in costs, without equally convincing studies offering support for HPV testing alone.

Results published last year in the peer-reviewed Cancer Cytopathology journal from the American Cancer Society found that nearly one in five women with cervical cancer could be missed by screening with HPV alone. That's because HPV tests identify the presence of the virus that causes most cervical cancers - but they do not identify the cancer itself. Pap tests identify abnormalities in the cervix caused by HPV infection that could indicate the presence of cancer or pre-cancerous cellular changes - a crucial distinction that can be the difference between detection that's early or detection that's too late.

With data from more than 8.6 million women between 30 and 65 screened and 250,000 biopsy results, the study is believed to be the largest most comprehensive real-world study to compare all three cervical cancer screening strategies: Pap alone, HPV alone and Pap plus HPV together.

On their own, these conclusions, co-authored by researchers from the University of Pittsburgh Medical Center, are a compelling argument for co-testing. But another remarkable modeling study, one in which I was involved, not only offers more support for co-testing as a benefit to women, but takes into account the cost of co-testing versus HPV alone with surprising results.

The second study, published in the Journal of Women's Health, used a model based on a hypothetical cohort of women receiving cervical cancer screening every three years, and then projected the results to the 78.9 million 30- to 70-year-old women in the U.S. The model predicted that screening with Pap plus HPV together, versus testing with HPV alone, could prevent nearly 150,000 invasive cervical cancer cases and save more than 100,000 lives of women ages 30 to 70 over the next 40 years.

Moreover, the model predicted that co-testing would result in approximately $4 billion in healthcare cost savings over 40 years, a particularly notable figure for U.S. healthcare payers and women's health policy advocates seeking cervical cancer screening that provides both superior clinical and economic value.

In case you're wondering how two tests can cost less to the system than one, the explanation is simple. HPV testing alone results in more false positives, which often lead to additional tests and increased cost (not to mention more stress on those being tested repeatedly and, in many cases, needlessly). The use of Pap and HPV together can lead to earlier detection of abnormalities and subsequent treatment, resulting in cost savings.

The argument has never been to test or not to test. The question is whether to co-test. With these two extraordinary studies, any doubts have been put to rest. Co-testing ensures physicians' best opportunity for early detection and patients' best chance for a long life.

Dr. Juan Felix is chief, OB-GYN pathology, LAC+USC Women's and Children's Hospital at the University of Southern California. He was the lead author of Clinical-Economic Modeling Analysis of Human Papillomavirus (HPV) Co-Testing With Genotyping Versus Primary HPV Testing for Cervical Cancer Screening, in conjunction with Truven Health Analytics, Cambridge, Mass.

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