The changing landscape for cervical screening
The changing landscape for cervical screening
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宫颈筛查不断变化的格局
DOI：
--
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发表时间：
2008
影响因子：
11.4
通讯作者：
A. Farnsworth
中科院分区：
文献类型：
--
作者：
A. Farnsworth
使用传统子宫颈抹片检查进行全国性、资金充足和有组织的筛查计划已显着降低了澳大利亚宫颈癌的发病率和死亡率。随着该计划的实施，人们对宫颈癌发病机制的认识有了很大的提高，人类乳头瘤病毒 (HPV) 的某些致癌亚型已被证明是这种疾病发生的必要原因。此外，针对 15 种致癌病毒中的两种病毒的国家疫苗接种计划于 2007 年 4 月开始，并且现已可以进行 HPV 检测。此外，研究还表明，筛查宫颈样本的新技术优于传统细胞学。宫颈筛查计划如何应对部分接种疫苗的人群和这些新可用的检测？当药品福利咨询委员会评估资助 HPV 疫苗接种的价值时，它指出，目前澳大利亚筛查人群中宫颈癌的累积终生风险为 0.78%，比未筛查人群估计的 2.4% 风险大幅降低，反映出筛查计划的成功。随着筛查的持续进行，预计 12 岁女孩接种疫苗后，这一风险将进一步降至 0.38%，14 岁女孩接种疫苗后，这一风险将进一步降至 0.43%，26 岁女性接种疫苗后，这一风险将进一步降至 0.59%。 5 委员会进一步评论说，如果疫苗接种完全取代宫颈筛查，将节省成本，但宫颈癌终生风险将增加至 1.173%。因此，建议接种疫苗后必须继续进行筛查。已接种疫苗的女性的筛查间隔和筛查测试应与未接种疫苗的女性不同，并且应在未来 5-10 年内，随着疫苗接种队列的成熟，通过基于人群的研究来确定。国家 HPV 疫苗接种登记册正在建立，这对于确定适当的筛查方案至关重要。 HPV 检测已被推荐并资助为“治愈检测”，用于治疗后对高度宫颈疾病进行随访。 Digene HPV 检测在澳大利亚使用，可检测 13 种高危 HPV 亚型中的任何一种，但无法识别具体亚型。尽管有一些单独的 HPV 亚型检测方法可供使用，但这些方法价格昂贵且未广泛使用，并且在常规实践中没有针对 HPV 的血清学检测。因此，HPV 检测的使用受到限制，但考虑到其重要性，是否应该扩大其用途，用于宫颈疾病的筛查和管理？关于用HPV检测替代宫颈细胞学检测进行初筛，国外已经有很多讨论。目前，没有理由这样做，因为 HPV 检测高度敏感但不具体。它对 30 岁以下女性的作用有限，因为大型研究表明，该年龄组中约 25% 的女性致癌病毒检测呈阳性。这些女性中的绝大多数通常通过细胞介导的免疫反应或较少见的抗体反应自然清除病毒。这些受感染的女性可能不会表现出任何疾病迹象。当病毒持续存在时，女性患高度宫颈上皮内疾病和浸润性癌症的风险更大。对于要求进行疫苗接种但已经性活跃的女性，也不建议在疫苗接种前进行 HPV 检测，因为进行疫苗接种的决定不会因检测结果而改变。 HPV 检测可能在宫颈细胞学检测检测到的不确定异常的管理中发挥更大的作用。美国大型研究的数据在根据宫颈细胞学和 HPV 检测确定重大疾病的真实风险方面相当引人注目。后者在确定宫颈细胞学检测到的低度鳞状上皮内病变的意义方面比阴道镜更准确。美国建议对出现这些结果的女性进行所谓的“反射”HPV 检测。9 短期内宫颈癌筛查的另一个主要问题是是否应使用图像引导的液基细胞学样本作为首选筛查测试。液基细胞学在该国的使用长期以来一直存在争议。然而，现在有充分的证据表明，其中一种技术——ThinPrep 成像系统（Hologic，马尔堡，马萨诸塞州，美国）——优于传统细胞学。该技术减少了不满意样本的数量并检测到更多真正的异常情况。使用这项技术还可以显着提高实验室效率，这可能会克服训练有素的科学家长期短缺的问题。灵敏度的提高可能会延长筛查间隔。该技术还为 HPV 和其他微生物检测提供样本，对于接种疫苗的人群来说是理想的选择，在该人群中，筛查检测到的异常数量将会减少。尽管澳大利亚在控制宫颈癌方面拥有令人羡慕的记录，但新知识和相关技术应纳入宫颈疾病的筛查和管理中，因为它们能带来真正的好处。 HPV 检测和 ThinPrep 成像都比传统细胞学检查更昂贵，但如果与宫颈筛查计划的全面审查适当结合使用，它们可能具有成本效益。
national, well funded and organised program of screening using the conventional Pap smear has significantly reduced the incidence of and mortality from cervical cancer in Australia. While the program has been in place, there has been a great increase in knowledge of the pathogenesis of cervical cancer, with certain oncogenic subtypes of human papillomavirus (HPV) shown to be a necessary cause for development of this disease. In addition, a national program of vaccination against two of the 15 oncogenic viruses began in April 2007, and tests to detect HPV are now available. Furthermore, research showing that new technologies for screening cervical samples are superior to conventional cytology has also been published. How is the cervical screening program responding to the presence of a partially vaccinated population and these newly available tests? When the Pharmaceutical Benefits Advisory Committee assessed the value of funding HPV vaccination, it noted that the current cumulative lifetime risk of cervical cancer in Australia’s screened population is 0.78% — a substantial reduction from the estimated 2.4% risk in an unscreened population, reflecting the success of the screening program. With continued screening, this risk was predicted to further decrease to 0.38% following vaccination of 12year-old girls, 0.43% for 14-year-old girls and 0.59% for 26-year-old women.5 The Committee further commented that there would be cost savings if vaccination were to completely replace cervical screening, but the cervical cancer lifetime risk would increase to 1.173%. The recommendation therefore is that screening must continue after vaccination. The screening interval and screening test for vaccinated women should be different to those for unvaccinated women and should be determined by population-based research over the next 5–10 years, as the vaccinated cohort reaches maturity. A national HPV vaccination register is being established, which will be critical for determining the appropriate screening regimen. HPV testing is already recommended and funded as a “test of cure” for follow-up of high-grade cervical disease after treatment. The Digene HPV test is used in Australia and detects any one of 13 high-risk HPV subtypes but does not identify the specific subtypes. Although some individual HPV subtyping assays are available, these are expensive and not widely used, and no serological tests for HPV are available in routine practice. Use of the HPV test is therefore limited but, given its importance, should its use be expanded for screening and management of cervical disease? There has been much discussion overseas about replacing cervical cytology tests with HPV testing for primary screening. Currently, there is no justification for this as HPV testing is highly sensitive but not specific. It has a limited role in women under the age of 30 years, as large studies have shown that about 25% of women in this age group test positive for the oncogenic viruses. The great majority of these women clear the virus naturally, usually via a cell-mediated immune response or, less often, through an antibody response. Such infected women may not show any sign of disease. It is when the virus persists that women are at greater risk of both high-grade cervical intraepithelial disease and invasive cancer. HPV testing is also not recommended before vaccination in women who request it but are already sexually active as the decision to proceed with vaccination will not be altered by the results of the test. HPV testing may have a greater role in the management of indeterminate abnormalities detected by cervical cytology tests. Data from large United States studies are fairly compelling in assigning a true risk of significant disease based on cervical cytology and HPV testing. The latter is more accurate than colposcopy in determining the significance of low-grade squamous intraepithelial lesions detected by cervical cytology. So-called “reflex” HPV testing in women with these findings is recommended in the US.9 Another major question for cervical cancer screening in the short term is whether image-guided liquid-based cytology samples should be used as the preferred screening test. The use of liquid-based cytology in this country has long been controversial. However, there is now good evidence that one of the techniques — the ThinPrep Imaging System (Hologic, Marlborough, Mass, USA) — is superior to conventional cytology. This technique decreases the number of unsatisfactory samples and detects more true abnormalities. There are also substantial laboratory efficiencies when using this technology, which could potentially overcome the chronic shortage of trained scientists. The increased sensitivity might allow the screening interval to be lengthened. This technique also provides a sample for HPV and other microbiological testing, and is ideal for a vaccinated population in which the number of screen-detected abnormalities will decrease. Although Australia has an enviable record in the control of cervical cancer, new knowledge and associated technologies should be incorporated into screening and management of cervical disease, as they offer real benefits. Both HPV testing and ThinPrep imaging are more expensive than conventional cytology, but they could be cost-effective if used appropriately in conjunction with a comprehensive review of the cervical screening program.
影响因子：
9.8
作者：
Castle, Philip E.;Sideri, Mario;Schiffman, Mark
通讯作者：
Schiffman, Mark