RESPONSE: Re: Comparison of Three Management Strategies for Patients With Atypical Squamous Cells of Undetermined Significance: Baseline Results From a Randomized Trial

Abstract

Both letters raise important points regarding the utility of HPV testing as a triage modality following an ASCUS cytology result. Harris correctly points out that there is an inevitable trade-off between specificity and sensitivity. The tests and test thresholds used in medical practice for follow-up and/or treatment of cervical abnormalities depend not only on available technology, but also on prevailing management paradigms, medicolegal issues, economic factors, and societal expectations. In the United States, sensitivity has generally been emphasized over specificity and other issues in the context of cervical cancer screening. In our recent publication (1) comparing management strategies for women with ASCUS, we reported the sensitivity for detecting CIN3 and the percentage of women referred to colposcopy (as a proxy for specificity) for HPV DNA testing performed using an analytical threshold of 1 pg/mL and for repeat cytology at several cutpoints. We were careful not to suggest that our results establish a new “standard of care.” Rather, it is the purview of the relevant medical organizations to develop guidelines for medical practice based on the available data. In fact, a conference is already planned for September 2001 under the aegis of the American Society for Colposcopy and Cervical Pathology to develop evidence-based “Consensus Guidelines for the Management of Cytological Abnormalities and Cervical Cancer Precursors.” In the future, when longitudinal data from our study become available, we will consider the cost-effectiveness and patient acceptance of the different management strategies in ALTS to further inform development of practice guidelines. We also agree with Strickler and Shah that population characteristics may affect the utility of HPV testing as a strategy for triage of ASCUS cytology. A detailed analysis of age and other factors on the performance of both cytology and HPV testing is the subject of a forthcoming ALTS publication.