A 33-year-old woman comes to the clinic for a routine health maintenance examination. She has no lower abdominal pain, vaginal bleeding, or vaginal discharge. Her past medical history is remarkable for 1 episode of uncomplicated urinary tract infection treated with a short course of antibiotics. She is currently not taking any medications. She has had 5 sexual partners in her life and has used barrier contraception the majority of the time. Her latest sexual relationship began 3 months ago. Her last cervical cancer screening examination was a Pap smear performed at the age of 23 that showed no abnormalities. She does not use tobacco, alcohol, or illicit drugs. During her visit, she requests screening for cervical cancer and appears extremely concerned as her older sister was recently diagnosed with it.
Based on the study results, which of the following testing sequences would be most effective for ruling out cervical neoplasia in this patient?

Question

A 33-year-old woman comes to the clinic for a routine health maintenance examination.  She has no lower abdominal pain, vaginal bleeding, or vaginal discharge.  Her past medical history is remarkable for 1 episode of uncomplicated urinary tract infection treated with a short course of antibiotics.  She is currently not taking any medications.  She has had 5 sexual partners in her life and has used barrier contraception the majority of the time.  Her latest sexual relationship began 3 months ago.  Her last cervical cancer screening examination was a Pap smear performed at the age of 23 that showed no abnormalities.  She does not use tobacco, alcohol, or illicit drugs.  During her visit, she requests screening for cervical cancer and appears extremely concerned as her older sister was recently diagnosed with it. 
Based on the study results, which of the following testing sequences would be most effective for ruling out cervical neoplasia in this patient?

Quizplus · Accepted Answer

Explanation: This randomized clinical trial compares cervical cancer screening by DNA testing for oncogenic human papillomavirus (HPV) to the Papanicolaou (Pap) test. Patients were randomized to receive either a Pap test first or an HPV test first; the tests were then performed sequentially during the same visit (both tests were performed for ethical reasons). Women with an abnormal Pap test result or a positive HPV test underwent colposcopy and biopsy, as did a random sample of women with negative test results. An analysis of the diagnostic utility (sensitivity and specificity) of different combinations of screening strategies was conducted. To exclude cervical neoplasia in this patient, tests with high sensitivity would be the most helpful as negative results on such tests help to rule out a diagnosis (SnNout). Sensitivity is the ability of a test to correctly identify patients with the disease. Highly sensitive tests are the most likely to detect a disease and the least likely to give false negative results. They are most appropriate for screening. Among the answer choices listed, the strategy of screening only with HPV testing followed by colposcopy and biopsy in case of a positive result (>1 pg HPV DNA/mL) had the highest sensitivity at 97.4% (Table). The HPV and Pap co-testing strategy had a sensitivity of 100%, but this is not listed as an answer choice (see Exhibit). Exhibit (Choice A) HPV screening followed by Pap triage in case of a positive HPV result had a lower sensitivity at 53.8%, so this strategy would not be ideal for screening purposes. This strategy had a high specificity (99.1%), which is helpful for confirmatory (rather than screening) tests. (Choice C) Pap screening followed by HPV triage had a sensitivity of 53.8%. (Choice D) Screening with Pap only (with positivity defined as ASCUS or worse) had a sensitivity of 56.4%. Educational objective: A negative result on a highly sensitive diagnostic test helps to rule out a diagnosis.

A 33-Year-Old Woman Comes to the Clinic for a Routine