Primary HPV screening
Data from more recent studies have examined the role of HPV testing as a primary screen based upon the increased sensitivity and earlier detection of CIN 3+ compared to cervical cytology alone. Several countries including Australia and the Netherlands have adopted primary HPV screening to reduce the costs and complexities of co-testing.6 Concerns regarding poor specificity and uncertainty regarding triage of HPV-positive women, with potential overuse of diagnostic evaluation, has limited the adoption of primary HPV screening in the United States. In 2015, the ATHENA trial compared performance of primary HPV screening to cytology alone or co-testing in 42,209 women aged 25 or older. In the HPV primary screening strategy, HPV-negative women were re-screened in 3 years, HPV 16/18-positive women were triaged to colposcopy, and the presence of non-HPV16/18 oncogenic subtypes triggered reflex cytology with colposcopy for a cytology > ASCUS.
Among women aged 25 years or older, primary HPV screening detected more CIN 3+ than cytology or co-testing albeit with more colposcopies than co-testing, but a similar number of colposcopies per case of CIN 3+.6 One HPV test has been FDA-approved for women older than 25. Interim consensus guidelines from the Society of Gynecologic Oncologists, ASCCP, and other expert opinion advised that primary HPV screening using this approved platform may be considered an alternative to current cervical cancer screening strategies in women aged 25 years and older. Cytology alone and cotesting remain the options specifically recommended in current major society guidelines.
Further study is needed to optimize the detection of CIN 3+ among screen-detected HPV-positive women.7