On hearing that your Pap smear or HPV test is positive, you need to avoid any angry confrontations with your doctor! The ancient Greeks were known to kill the messenger who brought bad news. True, your doctor may be giving you some upsetting news; but, he/she did not cause your situation! Calm down! If you blew up at your doctor because of this news, send him/her a note of apology. He/she is there to HELP you. [how you caught your HPV]

First of all, in today's litigeous climate, the medical system MUST be almost overly sensitive to any Pap smear finding which seems (is visually interpreted) "not quite right"..."a little unusual"..."atypical"..."not quite normal"..."abnormal". That is, there is a shade of gray between "normal" and "abnormal". In the 1970s, that gray zone was considered trivial and was diagnosed as "class II Pap, probable inflammatory change". Today, if there is any finding which is not strictly "typical" (that is, it is "atypical"), then a decision is made to either (1) "follow" the patient or (2) reflexly determine...using residual lquid specimen from that Pap smear sample...the "HPV status" by doing an HPV test (there are a number of different ways to test).

Less than 5% of women infected with HPV who receive no medical intervention ultimately develop cervical cancer³. A high percentage of women under 30 who get HPV have body systems which can clear the virus within about 2 years.

There are more than 100 virotypes of HPV & approximately 50 of these commonly infect the urogenital tract³. Since cancer of the uterine cervix is so strongly associated with HPV, there is a developing view that there are total-system efficiencies and cost savings if the HPV-test status can be known in women with a "not normal" (ASCUS, ASC-US, or SAUS or AGUS) Pap smear report (or HPV high-risk clinical situation). In an average practice, about 5-6% (some give a national average of 3%²) of Pap cases are "not normal'. So, many of our doctors want us to "reflexly" test for at least the high risk group of HPV. As a rule (and theoretically...theory being that HPV causes all squamous cancers of the cervix), cases with a precancerous Pap or biopsy diagnosis of "dysplasia" will be already be HPV-test positive (therefore no need to test). But, low and high risk HPV-test groups can be HPV-test negative if there is only a very small area of cervix dysplasia...such a small area not providing sufficient HPV-virus-containing cells (in the Pap sample) to trigger a positive test result. And, there may actually be some cases of cervical dysplasia in which HPV is never demonstrated.

Liquid-based Pap smear specimens (SurePath [AutoCyte] or ThinPrep) have set up a situation where the HPV test can be done out of the residual specimen, thereby saving the patient another office visit. The HPV testing might be ordered regardless of the Pap smear result if the physician and patient consider that there is an elevated risk that she harbors HPV. Otherwise, the HPV test may be reflexly performed if the Pap smear interpretation is in that borderline zone referred to as ASCUS/SAUS/AGUS. Reflex HPV testing is considered advantageous for triage of these cases in women aged 20 or older⁸. Currently, the ratio of ASCUS cases that turn out to be any degree of SIL (squamous intra-epithelial lesion) is about 1.7-1.9.

Stated conservatively, about 50,000,000 Pap smears are performed each year in the USA, and about 4% are interpreted as ASCUS/SAUS (2,000,000 cases per year).

Initial 2001 findings¹ from the National Cancer Institute's ALTS review (ASCUS/LGSIL Triage Study) showed that the hc2 method reflex testing of about a third of 3488 participating patients found that HPV molecular testing was 96.3% sensitive for detecting CIN III or higher. [go to NCI and drop ALTS into the site search engine] And, it could alternately be said that high risk HPV negativity gives 99.5% certainty that the patient does not have HGSIL or worse.

The American Society of Colposcopy and Cervical Pathology (ASCCP) met 9/2001 & has published recommendations relative to ALTS in the 24 April, 2002, issue of JAMA⁴ recommending that atypical squamous cells be divided into (a) those that are ASC-US and (b) those that are ASC-H (ASC, cannot exclude high-grade dysplasia) & that cases be followed up for clarification of significance of each case by one of 3 methods:

1. repeat Pap smear in 4-6 months & to colposcopy & biopsy if dysplasia detected & repeat at a second interval if first was non-dysplastic...for ASC-US only.
2. proceed to colposcopy and biopsy...for ASC-H, ASC-US, LGSIL, HGSIL, and AGUS (atypical glandular).
3. HPV testing triage...for ASC-US only (...see publications area of Dr. Bolick's site

1. continue to use 2001 Bethesda terminolgy.
2. use a two-tiered grade for histology: low grade (CIN1) & hi-grade (CIN2-3).
3. attempt to two-tier grade in ECC specimens.
4. follow CIN1 for up to 2 years without treatment.
5. in adolescents, separate CIN2 & CIN3 if you can...CIN2 is initially followed conservatively.

Our lab (as of 14 Oct. 2001) utilizes the SurePath (AutoCyte) liquid-based Pap sample processor (which we consider superior to ThinPrep). Our pathology group signed, on 11 Oct. 2001,  the commitment to obtain and utilize the AutoPap (FocalPoint)  artificial intelligence computer image analysis screener which is applied to all of our Pap cases...followed by manual rescreening of all cases by our cytotechnologists. Our cytotechnologist-and-pathologist team has parallel data to show that their detection performance is equally good whether working with cytopreps made by old-style conventional methods or the liquid based SurePath (AutoCyte) method. With that manual team plus supplementary computer screening, we intend to find all of the "abnormals" displayed/contained on the cytoprep slides. That will insure maximum detection of ASCUS/SAUS/AGUS or cancer. Then we  will send cases for HPV testing as indicated/requested (individually or by standing order) by the physician. The ALTS thought in 2003 that HPV-only primary cervical screening was reasonable for women over 30⁶.

Prior to 1 Feb. 2003 (when we began our own in-house testing), we sent liquid Pap samples to Molecular Pathology Laboratory in Maryville, Tenn. for the Digene (Digene Corp. maintains an HPV web site) Hybrid Capture 2 (hc2) signal-amplification DNA cocktail assays (CPT code 87621). Lexington Medical Center currently performs this Digene test in-house:

• low risk panel: HPV 6, 11, 42, 43, and 44

• high risk (oncogenic) panel: HPV 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, and 68 (the five that are bolded account for 80% of cases of cervical dysplasias and cancers³)...with 16 & 18 being by far the most important⁸.

If biopsies of various types need testing for HPV, we currently send them to PhenoPath Laboratories in Seattle, Washington for their preferred method using the Enzo DNA probe cocktail assays (about a $175 charge direct to patient): HPV 6, 11, 16, 18, 31, and 33.[S-01-11199].

There are PCR DNA-amplification test methods. There is an in situ hybridization (ISH) technique (2001) on the horizon (Kreatech for HPV 1, 2, 6, 11, 16, 18, 31, 33). Now it is here (2003).

Ventanna has come out (3/2003) with a slide-based chromogenic in-situ hybridization (CISH) assay (INFORM HPV) that produces a permanent-record slide for viewing under the microscope: HPV-low 6, 11, 42, 43, 44; HPV-high 16, 18, 31, 33, 35, 45, 51, 52, 56, 58, 59, 68, and 70. Our lab checked this system out between Nov. '03 and Feb. '04. [HPV testing methods comparison]

Billing:

1. CPT-4 code: 87621 if Digene hi-risk only (one panel); 87621 x2 if both high and low risk panels done.
2. ICD-9 codes:

Pap smear topic list & links page within this website

References:

1. CAP Today May 2001
2. Baunoch DA, In Search of a Paradigm, Advance for Administrators of the Laboratory, page 69, 1 May 2001.
3. Qureshi MN, et. al. Role of HPV DNA Testing in Predicting Cervical Intraepithelial Lesions: Comparison of HC HPV and ISH HPV, Diagnostic Cytopathology 29(3):149-155, September 2003.
4. Wright TC, et. al., JAMA 287:2120-2129, 2002.
5. Volk EE & Wilbur DC, CAP Today, January 2004.
6. Moriarty AT, Q&A of CAP TODAY, July 2004 p. 142 (referring to ASCCP in Arch. Path. & Lab Med 127:959-968, 2003).
7. Wright TC & Cox JT, "Clinical Uses of Human Papillomavirus (HPV) DNA Testing", a booklet by ASCCP, 2004 (EBS's office).
8. CAP Today November 2007...ASCCP 2006 Consensus Guidelines.

(posted Oct. 2001; latest addition 14 August 2008)