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Abstract
Primary cervical cancer screening through HPV DNA testing is currently being recommended by major guidelines worldwide for all women aged 30 to 65 years.
While management of high grade cervical lesions histologically confirmed is well standardized, there is still considerable confusion regarding the management of an HPV positive result. Cervical cytology should be performed in all these cases, but some Authors recommend genotyping for HPV 16/18 first, while others recommend dual-staining with p16/Ki-67 first, in an effort to reduce referral to colposcopy.
The main problem employing HPV testing based strategies in cervical cancer screening is the fact that both positive and negative HPV results are often misinterpreted or overestimated. An HPV positive, cytology negative woman, should repeat both tests after one year interval. Actually, patients too often tend to undergo immediate colposcopic examination, increasing health care costs and patients’ anxiety, without benefit and potentially resulting in overtreatments.
Not rarely clinicians start treating HPV infections detected with molecular tests with surgery, laser, cryotherapy, interferon, 5-florouracil. Then multiple preventive, diagnostic, and therapeutic activities are initiated, both in women and their partners, with strict follow up programs, more tests and more interventions. What many health professionals actually do is test women under 30 years of age; re-screen every 1–2 years; test for low risk HPV types; test anal, vulvar, penile, oral sites; test male partners; test to screen for sexually transmitted infections. All these indications are not recommended and may lead to wrong decisions, with well documented but poorly recognized ill effects.
Screening policies designed to achieve an optimal cost-effectiveness ratio are being misinterpreted and have been declined into daily clinical practice, with unmeasurable downstream consequences.
Concerns on sexual relationships are frequently reported, even after having provided detailed explanations. Besides, there is no urge to detect too early lesions that have a very slow progression rate, and might have been detected with repeat cytology a couple of years later.
Both doctors’ attitudes and women’s expectations are difficult to meet with the widespread utilization of different molecular tests not applied consistently according to shared recommendations. The economic, social, and psychological impact of HPV screening seems to have outweighed presumed benefits: the risks are a waste of resources, raise in costs and anxiety, and underrecognition of true disease.
Objectives To assess emotional, relational, and sexual aspects in women screened for cervical cancer through HPV DNA testing, and to document whether clinicians are willing to respect guidelines recommendations on HPV testing.
Method We analyzed data from a survey regarding more than 400 gynaecologists in Italy to assess knowledge, attitudes and practice among gynecologists. To test women’s reactions we also conducted an observational, prospective, quantitative, case-control study: a group of 90 HPV DNA positive women were interviewed and compared with 61 controls (women with unknown HPV status), through specific questionnaires provided to each patient.
Results After a negative HPV result, 26.5% of gynecologists recommend repeating HPV testing within 1–3 years instead of 5. Testing the male sexual partner is being recommended by 45.1% of specialists dealing with patients with low-grade cervical cytology and a positive HPV result. Women who tested HPV positive experienced negative psychosocial responses even in the presence of a normal cytological smear and a normal colposcopy. Questionnaires revealed various degrees of anxiety, fear, anger, shame, regret, overestimation of cancer risk, concerns about loss of reproductive functions, concerns about negative reactions from friends, family, or sexual partners, concerns about partner infidelity, as well as changes in physical intimacy activities or sexual refusal. Many women felt urgent need for treatment. Answers may be grouped into four categories: – Grief of the discovery: why is this happening to me? – Couple: symbol of marital infidelity – Family: weight of prejudice – Everyday life: abiding memory.
Conclusions A high proportion of gynaecologists participating in the survey, reported inappropriate uses of HPV testing. This may lead to unnecessary follow-up and potential overtreatment. As a consequence, in Italy many women are undergoing unnecessary tests, raising medical costs and anxiety both in women and their families. Not rarely cervical excision procedures are being performed for low grade lesions in young women, instead of waiting for spontaneous regression. Women who tested HPV positive experienced different psychological reactions, ranging from anxiety and fear to severe depression, isolation and sexual refusal. HPV testing can have important social and psychological effects on women and can potentially damage their wellbeing particularly when used outside an organized prevention program. HPV positivity may also cause a prolonged psychosocial burden on women even after having had the necessary follow-up for their cervical abnormalities and having provided adequate explanations.