Human papilloma virus and cervical screening

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Abstract
There are around 450,000 cases of cervical cancer per year with 300,000 deaths, making it one of the largest causes of death in women worldwide. Dramatic decreases in cervical cancer mortality rates have been seen following the introduction of screening in several industrialised countries. This is despite using a screening test (the cervical smear) that has a fairly poor sensitivity of approximately 55%. Research has centred on finding a better primary or adjunctive test. Issues of cost and acceptability also need to be addressed. It is now widely understood that virtually all cervical cancers are initiated by oncogenic high-risk type human papilloma virus infections, namely human papilloma viruses 16, 18, 30, 31, 33, and 45. The confirmed negative predictive value (99%) of a negative human papilloma virus test makes it potentially valuable in the triage of minor smear abnormalities and as post-treatment surveillance. In addition to evidence of its value in triage, there is a growing debate about its use as a primary tool in cervical screening, particularly in settings that do not currently have a structured programme. However, the psychological impact of human papilloma virus testing is less clear. Ultimately, advances in vaccination may hold the key to the eradication of cervical cancer. This article assesses the recent evidence on the place of human papilloma virus testing in three clinical settings, as a primary screening tool, in triage and as a test of cure. It also reviews the current understanding of the psychological impact of a positive human papilloma virus test.