In Reply Giorgi-Rossi et al take issue with my concern that primary human papillomavirus (HPV) testing might increase costs, in particular for colposcopies. They cite as evidence the European trials and note “strong evidence of a lack of difference between” primary HPV testing followed by cytology-based testing vs screening based on Papanicolaou testing. However, as I stated, these types of analyses depend on the exact protocols being studied (ie, frequency of screening as well as appropriateness of subsequent testing) as well as the actual adherence of practitioners to the designated protocol. In health systems with a universal approach to screening and comprehensive outcomes registries to monitor the adherence to the recommended protocol, the trial findings might apply. Clinical practice, however, varies tremendously across the United States; it is not known how primary HPV testing will perform in diverse practice settings until it is studied. Such factors as the available tests, the costs attributed to those tests, and the preferences of clinicians and patients are more variable in the United States than in Europe. Changes to guidelines1 before there is strong evidence about the best approach may be ill advised. Such changes may increase confusion or lead to overevaluation and treatment of transient HPV infections or inadvertent increases in cancers.
Feldman S. Cervical Cancer Screening by Human Papillomavirus Testing Followed by Cytology Triage—Reply. JAMA Intern Med. 2015;175(6):1068-1069. doi:10.1001/jamainternmed.2015.0596