Two efficacious prophylactic vaccines against infections with human papillomavirus (HPV) types 16 and 18 have become available since 2006. Universal pre-exposure HPV vaccination has the potential to reduce the incidence of cervical cancer by up to 75%. Vaccination is also expected to have an impact on the rate of cervical cytological abnormalities and of diagnostic and treatment procedures required to manage women with such precancerous lesions. The traditional paradigm of Pap cytology screening may not be a suitable complementary preventive strategy in the era of HPV vaccination. Once the cohorts of young women who are being vaccinated reach the age of screening the prevalence of Pap smear-detectable abnormalities will decrease substantially, which will ultimately affect the positive predictive value of cytology and decrease its cost-effectiveness. It is now widely accepted that testing cervical exfoliated cells for DNA of high oncogenic risk HPVs is a much more sensitive screening tool than cytology to detect high grade cervical lesions and cervical cancer. Cytologic or HPV-typing triage of HPV-positive women can reveal cases that should undergo colposcopic examination and biopsy and will largely obviate the concerns related to false-positives. With the improved sensitivity to detect existing lesions and the more “upstream” focus on cervical carcinogenesis this strategy could be implemented via longer screening intervals than are currently possible with cytology alone, and thus be cost-saving especially after HPV testing is deployed as a screening tool. However, it is in the post-vaccination era when the cohorts of women vaccinated in their teens enter screening age that this approach may prove most valuable by permitting a surveillance system that can serve two roles simultaneously: monitoring duration of vaccine protection (with HPV typing for those who are positive) and screening for cervical cancer. The author will present the arguments for an integrated approach that involve the two prevention strategies against this disease: HPV vaccination and molecular testing in cervical cancer screening.
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