Human Papillomavirus Infection and Cervical Cytology in Women Screened for Cervical Cancer in the United States, 2003–2005

; Elizabeth R. Unger, MD, PhD; Judith Shlay, MD, MSPH; Tracie McClain, MD; Beth Weaver, MD; Peter Kerndt, MD; Jonathan Zenilman, MD; Michael Hagensee, MD, PhD; Cristen J. Suhr, MPH, CHES; and Hillard Weinstock, MD, MPH

1 April 2008 | Volume 148 Issue 7 | Pages 493-500

Background: Millions of women in the United States receive cervical screening in sexually transmitted disease (STD), family planning, and primary care clinical settings.

Objective: To inform current cervical screening programs.

Design: Measurement of abnormal Papanicolaou (Pap) tests and high-risk human papillomavirus (HPV) infection among demographically diverse women who received routine cervical screening from January 2003 to December 2005 in the United States.

Setting: 26 STD, family planning, and primary care clinics in 6 U.S. cities.

Patients: 9657 women age 14 to 65 years receiving routine cervical screening.

Measurements: Pap test results and high-risk HPV prevalence by Hybrid Capture 2 assay (Digene, Gaithersburg, Maryland).

Results: Among 9657 patients, overall high-risk HPV prevalence by Hybrid Capture 2 testing was 23% (95% CI, 22% to 24%). Prevalence was highest among women age 14 to 19 years (35% [CI, 32% to 38%]) and lowest among women age 50 to 65 years (6% [CI, 4% to 8%]). Prevalence by clinic type (adjusted for age and city) ranged from 26% (CI, 24% to 29%) in STD clinics to 17% (CI, 16% to 20%) in primary care clinics. Women younger than 30 years of age whose Pap test showed atypical squamous cells of undetermined significance had a high-risk HPV prevalence of 53%; women 30 years of age or older with normal Pap tests had a 9% prevalence. Values did not vary substantially by clinic type.

Limitation: Hybrid Capture 2 and Pap testing were noncentralized, and consent was required for enrollment.

Conclusion: High-risk HPV was widespread among women receiving cervical screening in the United States. Many women 30 years of age or older with normal Pap tests would need follow-up if Hybrid Capture 2 testing is added to cytology screening.

Editors' Notes Context Some cervical cancer screening programs use reflex testing, performing tests for high-risk human papillomavirus (HPV) only after abnormal Papanicolaou (Pap) tests to guide colposcopy decisions. Others perform both tests in women 30 years of age or older (co-testing) and repeat testing if either result is abnormal. Lack of data limits analysis of the usefulness of different screening strategies. Contribution The Pap and high-risk HPV tests in 9657 women in 26 sexually transmitted disease, family planning, and primary care outpatient clinics from 2003 to 2005 showed that 23% were positive for high-risk HPV. Among women older than 30 years with normal Pap tests, 9% tested positive for high-risk HPV. Implication These data suggest that many women older than 30 years with normal Pap tests would require additional follow-up in programs that co-test with HPV testing and cytology. —The Editors

 

Author and Article Information

From the Centers for Disease Control and Prevention, Atlanta, Georgia; University of Washington, Seattle, Washington; Massachusetts Department of Public Health, Boston, Massachusetts; Denver Public Health, Denver, Colorado; County of Los Angeles Department of Health Services, Los Angeles, California; Johns Hopkins University School of Medicine, Baltimore, Maryland; and Louisiana State University Health Sciences Center, New Orleans, Louisiana.

Acknowledgment: The authors thank Donna Felsenstein, Julie M. Freedman, Karen Gacicia, Rick Intres, Cindy Miller, Sheila Hart Nelson, Asuncion "Susie" Rivera, Laura Smock, Silvia Vernaza, Akhila Balasubramanian, Tara McPartland, Jim Braxton, Alicia Edwards, Rob Nelson, Ashley Sardella, David Swan, Ruth Ann Tucker, Akbar Zaidi, Mona Saraiya, Mark Foster, Xinyue Hou, Rebecca Rothbard, Julie Subiadur, Bita Amani, Kim Burtle, Sara R. Germann, Peter He, Evelyn Kim, Maxine Liggins, Lizzeth Romero, Nandini Sodhi, Angela H. Shin, Nicole D. Vick, Susan Walker, Sharon Webb, Evette Youssef, and the HSS project staff for their contributions toward the preparation of the manuscript. The authors dedicate this work to the memory of Dr. Sylvie Ratelle, whose scientific acumen, leadership, dedication to the field of STD prevention, and kind spirit were vital to the HSS project.

Potential Financial Conflicts of Interest: Consultancies: B. Weaver (Merck), M. Hagensee (Merck). Honoraria: B. Weaver (Merck). Grants received: L.A. Koutsky (Merck).

Reproducible Research Statement: Study protocol: Available on request from Dr. Datta (e-mail, ddatta{at}cdc.gov). Statistical code: Contact Dr. Datta (e-mail ddatta{at}cdc.gov) regarding availability. Data set: Contact Dr. Datta (e-mail, ddatta{at}cdc.gov) regarding availability.

Requests for Single Reprints: S. Deblina Datta, MD, Centers for Disease Control and Prevention, 1600 Clifton Road, MS E-02, Atlanta, GA 30333; e-mail, ddatta{at}cdc.gov.

Current Author Addresses: Drs. Datta, Unger, and Weinstock and Ms. Suhr: Centers for Disease Control and Prevention, 1600 Clifton Road, Atlanta, GA 30333.

Drs. Koutsky and Weaver: University of Washington, 1914 North 34th Street, Suite 300, Seattle, WA 98103.

Dr. Shlay: Denver Public Health, 605 Bannock Street, Denver, CO 80204.

Drs. McClain, Kerndt, and Zenilman: County of Los Angeles Department of Health Services, STD Program, 2615 South Grand Avenue, Room 500, Los Angeles, CA 90007.

Dr. Hagensee: Louisiana State University Health Sciences Center, 190 Perdido Street, New Orleans, LA 70112.

Author Contributions: Conception and design: S.D. Datta, L.A. Koutsky, E.R. Unger, J. Shlay, T. McClain, B. Weaver, P. Kerndt, J. Zenilman, M. Hagensee, H. Weinstock.

Analysis and interpretation of the data: S.D. Datta, L.A. Koutsky, E.R. Unger, J. Shlay, T. McClain, P. Kerndt, J. Zenilman, C.J. Suhr.

Drafting of the article: S.D. Datta, L.A. Koutsky, E.R. Unger.

Critical revision of the article for important intellectual content: S.D. Datta, L.A. Koutsky, E.R. Unger, J. Shlay, T. McClain, B. Weaver, P. Kerndt, J. Zenilman, M. Hagensee, H. Weinstock.

Final approval of the article: S.D. Datta, L.A. Koutsky, E.R. Unger, J. Shlay, T. McClain, B. Weaver, P. Kerndt, J. Zenilman, H. Weinstock.

Provision of study materials or patients: S.D. Datta, L.A. Koutsky, J. Shlay, T. McClain, B. Weaver, J. Zanilman, M. Hagensee.

Statistical expertise: S.D. Datta, L.A. Koutsky.

Obtaining of funding: L.A. Koutsky, J. Shlay, B. Weaver, P. Kerndt, H. Weinstock.

Administrative, technical, or logistic support: L.A. Koutsky, E.R. Unger, T. McClain, B. Weaver, P. Kerndt, C.J. Suhr.

Collection and assembly of data: J. Zenilman.

Deceased.

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