As mentioned in my first comment on this article, I’m not convinced that universal HPV vaccination can be justified, and I’m concerned about the possibility of ‘unintended consequences’ with the use of this vaccine.
For example, Charlotte Haug raises questions about HPV vaccination, including “…another serious question that may be answered sooner: what effect will the vaccine have on the other cancer-causing strains of HPV? Nature never leaves a void, so if HPV-16 and HPV-18 are suppressed by an effective vaccine, other strains of the virus will take their place. The question is, will these strains cause cervical cancer?” (Ref: “We need to talk about HPV vaccination – seriously”. New Scientist, September 2011: http://www.newscientist.com/article/dn20928-we-need-to-talk-about-hpv-vaccination--seriously.html )
I’m particularly interested in this possibility in light of reports that “the emerging strain of the Bordetella pertussis bacterium may be evading the effects of the widely-prescribed acellular vaccine (ACV) and increasing the incidence of the potentially fatal respiratory illness…”.* (Ref: “Resistant whooping cough takes epidemic to new level: https://theconversation.edu.au/vaccine-resistant-whooping-cough-takes-epidemic-to-new-level-5959 )*
With the pertussis bacterium experience, are there any implications here for the HPV vaccines?
It’s also interesting to consider this possibility in relation to other vaccines, e.g. the measles vaccine. As I understand it vaccination with one dose of an efficacious ‘live’ measles vaccine is generally effective in the absence of maternally derived antibodies, and immunity is likely to be lifelong, so, based on current knowledge, this seems to be a useful vaccine. (Serological testing can be used to verify a response to the ‘live’ measles vaccine.)
But HPV seems to be more problematic in that there are so many types, and the vaccines only claim to cover for a few. Leaving open the possibility for things to go awry in the future?
* Also refer to comments/queries I’ve posted on the “Resistant whooping cough” thread. I also posted my comments about this on The Conversation thread “Danger, you’re at serious risk of… no, sorry, it’s all relative” https://theconversation.edu.au/danger-youre-at-serious-risk-of-no-sorry-its-all-relative-12218 where I thought they were relevant to the article, but they were deleted, much to my surprise… But I will follow up on that later. My emails to Profs Lyn Gilbert and Ruiting Lan on the pertussis/whooping cough matter can be accessed via this link: http://users.on.net/~peter.hart/Whooping_cough_enquiry.pdf )

Both Pap tests and HPV screening involve taking a smear of cervical cells. The samples are then sent for two tests - one to look for the implicated strains of HPV virus in the cells, and the other to look for abnormalities in the cells. The two results are complementary.

It seems unlikely that doing a smear would be a big money-spinner for gynaecologists - it only involves one procedure, and a vast number are done by GPs or women's health nurses on medicare anyway.

Actually there is no need for an invasive test. I know the Dutch and some other countries are offering women a self-test device to check for HPV, it was invented by Dutch gynaecologists.
The "lucrative" nature of our program...that is probably referring to our very high referral rates. I know one study by Kavanagh et al put the lifetime risk of colposcopy and biopsy after an "abnormal"pap test to be 77% here in Australia, due to serious over-screening.(almost all are false positives)
The lifetime risk of cervical cancer is 0.65% so that's huge over-detection.

If you compare our program to evidence based programs overseas, you'll see a huge difference. Since the 1960s the Finns have had a 7 pap test program, 5 yearly from 30 to 60, they have the lowest rates of cervical cancer in the world and refer far fewer women for colposcopy/biopsy. (their program produces fewer false positives) Our over-treatment rates are very high due to the screening of those under 30, 2 yearly testing and testing up to age 70. Basically, excess costs a fortune and worries and harms lots of women for no additional benefit...you may even miss cancers with inefficient excess. Not sure what we're doing here in Australia...there is absolutely no need for most women to have pap tests, they can test themselves for HPV, most women will be HPV- and they can simply re-test every 5 or 10 years.

The Dutch have the same program as the Finns, but the Health Council of the Netherlands have recommended a new program, 5 hrHPV primary triage tests (or self test) at ages 30,35,40,50 and 60 and only the roughly 5% who test HPV+ will be offered a 5 yearly pap test. Why would HPV- women wish to have a lifetime of unnecessary pap testing with a high risk of potentially harmful over-treatment?
I think more women are finding better ways of protecting themselves from this rare cancer...the self test device is available in Singapore. Once you know your HPV status, you know where you stand and whether you might benefit from a 5 yearly pap test.
Over-treatment can damage the cervix and lead to premature babies, c-sections, miscarriages etc

Our program should have been changed LONG ago, I consider it outdated,, excessive and harmful. In my opinion, for those who wish to test, evidence based testing offers better protection from cancer and the much higher risk of over-treatment.
HPV Today, Edition 24, sets out the new Dutch program.

HI, Debra

What is the nature of this self-test device, and its accuracy and reliability? Who checks technique and reading of results?

I think you'll find studies comparing the senstitvity and specificity of self HPV tests to HPV test taken by doctors as well as comparisons to pap tests.
For example "Accuracy and cost-effectiveness of cervical cancer screening by high-risk human papillomavirus DNA testing of self-collected vaginal samples." by Balasubramanian et al in the Journal of Lower Genital Tract Diseases.
"Compared to cytology-based screening, high-risk HPV DNA testing of self-collected vaginal samples was more sensitive (68%, 95%CI=58%-78% versus 85%, 95%CI=76%-94%) but less specific (89%, 95%CI=86%-91% versus 73%, 95%CI=67%-79%). A strategy of high-risk HPV DNA testing of self-collected vaginal samples followed by cytology triage of HPV positive women, was comparably sensitive (75%, 95%CI=64%-86%) and specific (88%, 95%CI=85%-92%) to cytology-based screening. In-home self-collection for high-risk HPV DNA detection followed by in-clinic cytology triage had a slightly lower lifetime cost and a slightly higher quality-adjusted life expectancy than did cytology-based screening (ICER of triennial screening compared to no screening was $9,871/QALY and $12,878/QALY, respectively)."

Thanks, Mary

The trade-off with a test that is more sensitive (picks up more possible cases) but is less specific (more of the positive results are false-positives) is that more people then need to go on to further testing for confirmation.

One paper I read suggested that self-testing for vaginal HPV might be preferable to lack of screening in communities where routine pap smears are not accessed.

I'm not sure whether the same argument applies in our society, where there is easy access and direct reminders. It seems that a single examination, with cervical smear taken for cytology and concurrent HPV testing, gives a more specific answer and allows for more focussed follow-up.

I'm not convinced that the management of abnormal cervial cytology is a "money-spinner". I suspect that action based on an abnormal smear relates more to risk tolerance vs risk aversion (in both heath practitioner and patient) than profit.

If you were managing women with abnormal pap smears, what approach would you use to decide when to take further action?

Sue, The Delphi Screener is the self-test device invented by Dutch gynaecologists.
The Delphi Bioscience site can provide more information.
Studies have shown it's very reliable and as I mentioned, it's already being used in the Netherlands and elsewhere. I think many women would prefer the option of self-testing.

The important point: HPV primary triage testing (and self-testing) used properly, in "an evidence based" program, (like the new Dutch program) takes most women out of pap testing and harms way. (false positives and over-treatment)
Why would any woman want to have a lifetime of unnecessary pap testing with the risk of over-treatment? And we're talking about roughly 95% of women aged 30 to 60.
Doing pap AND HPV tests on all women aged 30+ is being done in the States - it's expensive, unnecessary and leads to the most over-investigation. The Dutch will not do pap tests on HPV- women. Only about 5% of women aged 30 to 60 are HPV+ and at risk, these are the only women who will be offered a 5 yearly pap test. (until they clear the virus)
HPV primary testing is not recommended for those under 30 as about 40% would test positive, almost all have transient and harmless infections that will clear in a year or so. The Dutch don't do pap or HPV testing on those under 30.

The Finnish program that dates back to the 1960s also excludes those under 30...for very good reason.
"No country in the world has shown a reduction in the incidence and mortality of cervical cancer in those under 30, regardless of cervical screening. Many countries do not test those under 30" from "Cervical Screening" in Australian Doctor, July 2006 by Assoc Professor Margaret Davy and Dr Shorne. It's not just unnecessary testing we're talking about, but young women produce the most false positives, so testing leads to over-investigation and potentially harmful over-treatment. (with anxiety, fear, pain etc)

I'll do what I've done for decades...get to real information and make an informed decision.
Australian women are still being told they should have 2 yearly pap testing from 18-20 (some start even younger) and that HPV primary testing is not available as HPV is common, there is no cure and it clears on it's own in most cases.
I consider this very bad medical advice and the statement on HPV primary testing is true, but with one glaring omission...knowing your HPV status provides you with important information...HPV+ and you might consider a 5 yearly pap test, HPV- and you're not currently at risk and might choose to test for HPV again in 5 or 10 years time. (or self test)

Debra, re your comment that only 5% of women aged 30 to 60 years are HPV+ and at risk”. Have you got a reference for that?
I was also interested in your comments: “HPV primary testing is not recommended for those under 30 as about 40% would test positive, almost all have transient and harmless infections that will clear in a year or so” and “but young women produce the most false positives, so testing leads to over-investigation and potentially harmful over-treatment”.
Debra, what is your opinion of HPV vaccination, i.e. vaccinating all girls and boys with 3 shots of HPV vaccine?

Hi, Debra

The manufacturer's site confirms what I discussed above "High-risk HPV testing is 5-8% less specific than cytology and there is a need to find a strategy that increases the specificity of the high-risk HPV DNA testing while maintaining its high sensitivity."

Lower specificity means that there will be more false positives.

The site says that they are working on this. It certainly seems promising for when the specificity can be brought up to the level of cytology.

I agree with you, and the article, that young women are at very low risk of cervical cancer. Self-testing seems promising, but not yet ready to replace pap smears.

Sue,

"Lower specificity means that there will be more false positives."

But a LOT less than with population pap testing...false positives and over-treatment are a BIG problem with our program. If used properly, confining HPV primary testing to women aged 30 to 60, only about 5% will be HPV+ and offered pap tests. About 95% of women aged 30 to 60 will avoid unnecessary pap testing and the risk of over-treatment. Surely the vast majority of women deserve some consideration, they cannot benefit from pap testing.

Self-testing is already being offered to Dutch and other women. I believe this option should be made available to Australian women. I know some women are already testing while they're overseas. A woman no longer sexually active and aged say 50 or 60 will be told here she needs 2 yearly pap testing until she's 70...when in fact, she could simply be tested for HPV and if negative could forget further testing. (and reassess the matter if she takes a new partner)
Sweeping all women into population pap testing and serious over-screening is in my opinion, beyond unfair.