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

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. So if you are hearing about these accusations, and wondering about any tests you have had, remember what a complex topic this is and be sure to look into what tests you have had and why. He bases his conclusions on looking at what tests are being ordered in a survey type research paper. Included in testing that may be inappropriate are tests that are done "routinely in women under 30" or as triage in abnormal paps worse than just ASCUS, or more than every 3 years, or if less than 12 months since a last test was positive or with routine STD screening or as HPV vaccine triage or in sexual assault workup. Remember Dr. Castle, a PhD and a MPH, has a very specific context.. But while he fires away at the abuse, we might have cause to fire back the lack of clinical context. "Dr." Castle is not a physician. He has not taken care of patients, performed pap smears nor surgeries. One might even go so far as to say he hasn't had a pap smear, but even I would say that would be going a bit far, and I only put that in as a bit of a poke to use the facebook term. Although the basic point is well taken, has no knowledge of what the individual management context of these "abusive" tests are, 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. And many women have had tests under older protocols, and now have had to, in consultation, agree to a change in management. 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 had the HPV vaccine, if you have new partners that are are worry, if you have warts that aren't resolving, 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, and that MD, and I'm saying that is a very good context for most patients.


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