iPathology

Should HPV Testing Replace Cytology for Screening for Cervical Cancer?

This week's New England Journal of Medicine (357:1579-88, 2007) reports a very important study that looks at the performance of HPV molecular testing for screening for grade 2 and 3 (i.e., high-grade) cervical intra-epithelial neoplasia. The population consisted of over 10,000 women aged 30-69 in Canada with good access to health care. Sensitivities for HPV and cytology were 94.6% and 55.4%, respectively. Specificities were 94.1% and 96.8%.

Cervical cancer screening by the use of the Pap smear has been one of the best examples of a successful cancer screening program in history. With current practice, it's common that HPV testing is used to clarify cases of ASCUS (identified by cytology/cytopathology) rather than as a primary screening technique. This study (and others) suggests that HPV testing could be a primary screening modality, although more data are needed to reach that conclusion with certainty.

From a laboratory perspective, screening programs need high sensitivity, and the difference between molecular HPV testing and cytology is striking. On the other hand, there is variation in the number of HPV types that can be detected by different molecular methods and the method used in this study may not be the most sensitive. Different assays have different sensitivities and specificities (see J Clin Micro 45:2130-7, 2007 for example). This study demonstrates that in vitro molecular testing can, in certain situations, be a viable alternative to microscopy. This last point emphasizes the need for pathologists to be closely involved with molecular pathology and its implementation in hospital laboratories or they risk being marginalized in the changing diagnostic landscape. For many cytology technicians and cytopatholgists, Pap testing (or one of its liquid counterparts) is the major professional activity of the daily workload. A widespread change from morphology to in vitro testing for HPV could pose the possibility of sudden and substantial disruptions to professional activities.

Microsoft and Health Care Software

Writing in the Wall St. Journal on October 7, 2007, Bill Gates rightly points out the significant deficiencies with the state of health care informatics and its adverse effect on the quality of patient care. What might a company like Microsoft offer to this field? I submit that Microsoft is exactly what we need to make some sense out of the mess we face in health care informatics. We need a common software product that is as ubiquitous as Word or PowerPoint. We need someone with deep pockets like Microsoft to make the initial investment, to implement standards that have been agreed upon such as HL7, and to introduce some meaningful competition into a field that needs more of a driving sense of the importance and urgent need for innovation. Microsoft has been criticized by many for lacking a spirit of innovation in its flagship products, Windows and Office, but the truth is that they work as expected for most users, and it would be difficult to imagine how global businesses could function without them. If only the same could be said of health care software. Microsoft's entry to this field is to be welcomed.