HPV Testing Under Fire: Remember Dr. Castle's Lack of Context

HPV testing can help detect cervical cancer and cervical precancer. HPV infections are both common, and for the most part, not serious as most women rapidly clear their viral infection. According to current testing and an article by Schiffman and Wentzensen in Obstetrics and Gynecology in 2010, about half of infections no longer apparent within about 6 months and more than 90% unapparent by a few years.

We have discussed much about the pap smear and the HPV tests that have arrived to be done in conjunction with the pap smear. A number of HPV tests are available. When to test and what test to use is a complex topic. A new concern for gynos about these tests has arrived.  Dr. Philip Castle, a brilliant researcher in the area of HPV disease and a member of the American Society for clinical pathology has accused physicians of abusing HPV DNA testing in fairly large numbers in a recent editorial. He bases his conclusions on looking at what tests are being ordered in a survey type research paper, and while this editorial was written for physicians about the testing we have available, some women, if aware of these comments may be worried regarding tests they have had in the past.

The majority of tests are done appropriately, for good reason, and it's important to understand a bit more about the subject of the testing. But while Dr. Castle fires away at the abuse, we might have cause to fire back the lack of context. Castle is not a physician, but a PhD doctor. He has not taken care of patients, performed pap smears nor surgeries. He has no knowledge of what the individual management context of these "abusive" tests might have been. One concern is that an inappropriate test can lead to inappropriate or expensive treatments or other tests. But from the article Dr. Castle is siting he has no way of knowing what treatments were or then are rendered to patients getting these tests. He doesn't know why some of these "non-standard" tests were run, and it's a serious subject we need to gab about. He slings the Hippocratic oath at the physicians 'abusing' tests saying 'first do not harm,' a harsh and perhaps warranted admonishment,  and unlike the eloquent debaters of our day, doesn't provide any counter points or mitigating factors that may be reasons that these non-standard uses of the tests may still be used in a minority of individual cases. Since "Dr" Castle goes on to say that we should shift fee for service over to payment for performance system for physicians, I say, for the public health commentators, we should shift a leap to conclusions to a hold off until we have gold standard proof of the money saving that is apparently the most important end point of his article. And a snap shot of only the tests doesn't summarize the cost analysis of these patients, nor is it the primary concern of each patient physician interaction. As an individual patient who may have had an HPV test recently it may leave you feeling nervous about that test, on the other hand, if you haven't had the test, it may be important to have one, and a study like this cannot really bear that out.

To step back and think about this topic I think I would say that in the area of gynecology that we think of as the most stable, the most cataclysmic changes have been taking place. That would be our pap smear. Well understood, well performed, well participated in, but yet, improvements have been necessary, for many reasons. The pap smear was invented decades before the HPV epidemic. And a technology that protected American Women from cervical cancer: colposcopy and then treatment with excision procedures, has come under attack as being too aggressive. So we have gradually introduced guidelines that allow us to begin pap smears later, to introduce HPV testing, to modify the HPV testing, and thus many women today are treated with the safe expectant management that is both healthy for the body and not too risky in terms of allowing disease to progress past the point of treatment success. But if you have been getting prior treatments, if you have had previous surgeries, if you have conditions your insurance wants to claim are still "on going" or if you have long persistence of disease, or if you suffer from a poor immune system, if you want the HPV vaccine, if you had the HPV vaccine, you may in fact have issues that an individual physician would select a tailored program of testing for. You and your gyno would have to discuss pros and cons, and as an individual who has a right to help make her own health decisions, you would have the right to help select your tests and then based on those tests select your therapies. I encourage second opinions if you are unsure of a course of action, and I encourage keeping track of all your records, as well as a serious discussion with your own gyno as to what is best for you. Your physician has that context of caring for you over time, and I'm saying that is a very good context for most patients.


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