This article was downloaded by: [Temple University Libraries] On: 24 November 2014, At: 04:01 Publisher: Routledge Informa Ltd Registered in England and Wales Registered Number: 1072954 Registered office: Mortimer House, 37-41 Mortimer Street, London W1T 3JH, UK
Journal of American College Health Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/vach20
Management of Cervical Papillomavirus Infections: A Response Henry W. Buck MD a
a b
ACHA Task Force on Human Papillomavirus (HPV) Infection , USA
b
Gynecology Watkins Memorial Health Center University of Kansas , Lawrence, USA Published online: 09 Jul 2010.
To cite this article: Henry W. Buck MD (1990) Management of Cervical Papillomavirus Infections: A Response, Journal of American College Health, 38:6, 298-299 To link to this article: http://dx.doi.org/10.1080/07448481.1990.9936204
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http://www.tandfonline.com/page/termsand-conditions
VIEWPOINT
Downloaded by [Temple University Libraries] at 04:01 24 November 2014
Management of Cervical Papillomavirus Infections: A Response
TASK FORCE ON HUMAN PAPILLOMAVIRUS (HPV) INFECTION
Members of the ACHA Task Force on Human Papillomavirus (HPV) Infection have had an opportunity to evaluate and discuss “An Alternate View of the Management of Cervical Human Papillomavirus Infections” by Drs Grace and Patrick.’ As occurs with any effort to discuss a disease from a combined epidemiologiclcost-control point of view, the article raises many interesting and relevant questions. These kinds of questions were and continue to be considered by members of the HPV Task Force in making recommendations. Answers must be based upon a basic ‘understanding of the disease in question, combined with a current appreciation of the positive and negative aspects in both diagnosis and management. The article shows evidence of errors in understanding HPV infection, resulting in expressions of wishful thinking about diagnosis and management that have Iittle to do with the real world that faces clinicians in college health services who actually see and have to deal with increasing numbers of patients with cervical and other manifestations of HPV infection. No effort will be made to discuss individually the many problems we perceived throughout the entire article. The final paragraph, appearing to recommend “management approaches,” however, will be commented upon. It discusses “relatively innocuous lowgrade squamous intraepithelial lesions” versus “advanced cervical lesions,” recommending “the more traditional ‘treat and repeat’ approach” for the former and “more aggressive management approaches . . . for advanced cervical lesions.” Clearly, the basis for making the decision whether the patient has an “innocuous” or an ”advanced” lesion must be based upon the results of the Papanicolaou smear. The Pap smear is a
298
screening test-it does not make a diagnosis, as inferred by Drs Grace and Patrick. Even if it were diagnostic, false negatives and lack of patient compliance would make its use in follow-up of the untreated or inappropriately treated cervix risky indeed. Inappropriate treatment specifically includes the “traditional” use of antibiotics (topical, oral, or parenteral) that cannot be supported as legitimate agents for treatment of HPVICIN. A sampling of from recent gynecologic and other journals is representative of the large and growing body of literature that stands counter to the ”management approaches” suggested by Drs Grace and Patrick. Clinicians in ACHA must be advised that the recommendations made by the HPV Task Force at colloquia and in print’ are consistent with current standards of quality care. They are not aggressive in the face of the nature of HPV disease, its sequelae, the documented increasing incidence, and current sexual practices. The Task Force encourages ACHA clinicians to become proficient in all aspects of diagnosis and management of HPV disease and plans an expanded effort in education to that end. Finally, we agree that greatly increased efforts must be devoted to prevention of HPV and other STDs. The Task Force will use every avenue at its disposal to foster such efforts.
Henry W. Buck, M D Chair, ACHA Task Force on Human Papillomavirus (HPV) Infection Head of Gynecology Watkins Memorial Health Center University of Kansas, Lawrence
)ACH
REFERENCES 1. Grace TW, Patrick K. An alternate view of the management of cervical human papillomavirus infections. / Am Coll Health 1989;38(4):241-243. 2. A n d m S, Hernandez E, Miyazawa K. Paired Papanicolaou smears in the evaluation of atypical squamous cells. Obstet Gyneco/ 198974(5):747-750. 3. JonesWB, Saigo PE. The "atypical" Papanicolaou smear. CA 1986;36(4):237-243.
4. Koss LG. The Papanicolaou test for cervical cancer detection-A triumph and a tragedy. jAMA 261(5):737-743. 5. Himmelstein LR. Evaluation of inflammatory atypia-A literature review. / Reprod Med 1989;34(9):634-637. 6. Wheelock JB, Kaminski PF. Value of repeat cytology at the time of colposcopy for the evaluation of cervical intraepithelial neoplasia on Papanicolaousmears. / Reprod Med 1989;34(10):815-817. 7. Genital Human Papillomavirus Disease: Diagnosis, Management, and Prevention. Rockville, MD, American College Health Association, 1989.
Downloaded by [Temple University Libraries] at 04:01 24 November 2014
LETTER TO THE EDITORS We were pleased that Paul Reith, MD, mentioned the work of the US Preventive Services Task Force in his discussion of the periodic health examination.' Our recommendations on this subject are somewhat more extensive than is suggested in his article, however, For example, the article cites only 6 task force background papers in the journal of the American Medical Association UAMA). Six additional articles*-' have since appeared in jAMA, and an anthology of over 40 background papers will soon be available! More important, these papers, the last of which was pub lished in January 1990, were used primarily as background for developing the more definitive recommendations contained in our full report. They address only a subset of the preventive services evaluated by the task force. Our final report, the Guide to Clinical ~reventiveservices,' was released in May 1989 and provides recommendations on about 170 clinical preventive services. The 500report contains scientific reviews of 60 target conditions, most of which are major health issues for the college-aged population. The book includes detailed agespecific tables that are risk-stratified to help clinicians tailor the periodic health examination to the risk profile of individual patients. The single table contained in Dr Reith's article is based primarily on the recommendations of the Canadian Task Force. It is a reasonable approach but is not entirely consistent with our clinical philosophy.
Our group was incorrectly identified in the abstract as the "Joint American" task force. Although we have done some collaborative work with the Canadians, our recommendations are not truly "binational," as is implied by Dr Reith. The "rules of evidence" developed by the Canadiansand described in his article were instrumental in the mid-1980s in helping our group shape our methodology. But our procedures for reviewing evidence and for develop ing practice guidelines haw since evolved into a more complex analytic framework, which is described in our report. Our recommendations are not identical. Finally, your readers may be interested in 1989 reports by the Canadian Task Force" and the INSURE project" that are too recent to have been cited by Dr Reith. It should also be added that our group is now establishing a new science panel to succeed the US Preventive Services Task Force. The new panel will make recommendations on preventive services not examined by the task force, and those for which new evidence or technologies have emerged. Many topics of relevance to the collegeaged population are certain to be considered. Steven H. Woolf, MD, MPH Scientific Advisor US Preventive Services Task Force REFERENCES 1. Reith P. Adapting the selective periodic health exam to a college-aged population. / Am Coll Health. 1989;38:109-113.
Health Education Credenu;rling Exam.
,
The National Commission for Health Education Credentialing, lnc, has scheduled the first examination for Certified Health Education Specialists (CHES) for Sep tember IS, 1990, in 12 cities across the nation. Anyone with at least a bachelor's degree in any field who has current or past experience in health education is eligi-
VOL 38, MAY 7990
2. Selby JV, Friedman CD. Sigmoidos copy in the periodic health examination of asymptomatic adults. IAMA. 1989;261: 594-601. 3. Harris SS, Caspersen CJ, DeFriese GH, Estes EH. Physical activity counseling for healthy adults as a primary preventive intervention in the clinical setting. jAMA. 1989;261:358&3598. 4. Woolhandler S, Pels @, Bor DH, et al. Dipstick urinalysis scmning of asympte matic adults for urinary tract disorders, I: Hematuria and m i n u r i a . /AMA. 19119; 262 1214-1 219. 5. Pels RJ, Bor DH, Woolhandler S, et al. Dipstick urinalysis screening of asymptomatic adults for urinary tract disorders, 11: Bacteriuria. IAMA. 1989;262:1220-1224. 6. Greene JC, Louis R, Wycoff SJ. Preventive dentistry, I: Dental caries. IAMA. 1989;262:3459-3463. 7. Greene JC, Louis R, WyaH SJ. Preventive dentistry, 11: Periodontal diseases. malocculsion, trauma, and oral cancer. jAMA. 199O;263421-425. 8. Goldbloom RB, Lawrence RS, eds. Prewnting Disease: Beyond the Rhetoric. New York: Springer-Verlag. In press. 9. US Preventive Services Task Force. Guide to Clinical Preventive Services: An Assessment of the Effectiveness of 169 Interventions. Baltimore, MD: Williams & Wilkins; 1989. 10. Canadian Task FoKe on the Periodic Health Examination. The periodic health examination: 1989 update. Can Med Arroc ]. 198%141:205-216. 11. Logsdon DN, Lazar0 CM, Meier RV. The feasibilii of behavioral risk reduction in primary medical care. Am j Prev Med. 1989; S249-256.
ble to take the certification exam. About 1600 persons in the United States, Puerto Rico, and 9 foreign countries are currently certified. Application deadline for the 1990 examination is June 15. For further details, call or write the National Commission for Health Education Credentialing, Inc, Professional Examination Service, 475 Riverside Drive, New York, NY 10115; telephone (212) 870-2047.
299
Journal of American College Health Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/vach20
Management of Cervical Papillomavirus Infections: A Response Henry W. Buck MD a
a b
ACHA Task Force on Human Papillomavirus (HPV) Infection , USA
b
Gynecology Watkins Memorial Health Center University of Kansas , Lawrence, USA Published online: 09 Jul 2010.
To cite this article: Henry W. Buck MD (1990) Management of Cervical Papillomavirus Infections: A Response, Journal of American College Health, 38:6, 298-299 To link to this article: http://dx.doi.org/10.1080/07448481.1990.9936204
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http://www.tandfonline.com/page/termsand-conditions
VIEWPOINT
Downloaded by [Temple University Libraries] at 04:01 24 November 2014
Management of Cervical Papillomavirus Infections: A Response
TASK FORCE ON HUMAN PAPILLOMAVIRUS (HPV) INFECTION
Members of the ACHA Task Force on Human Papillomavirus (HPV) Infection have had an opportunity to evaluate and discuss “An Alternate View of the Management of Cervical Human Papillomavirus Infections” by Drs Grace and Patrick.’ As occurs with any effort to discuss a disease from a combined epidemiologiclcost-control point of view, the article raises many interesting and relevant questions. These kinds of questions were and continue to be considered by members of the HPV Task Force in making recommendations. Answers must be based upon a basic ‘understanding of the disease in question, combined with a current appreciation of the positive and negative aspects in both diagnosis and management. The article shows evidence of errors in understanding HPV infection, resulting in expressions of wishful thinking about diagnosis and management that have Iittle to do with the real world that faces clinicians in college health services who actually see and have to deal with increasing numbers of patients with cervical and other manifestations of HPV infection. No effort will be made to discuss individually the many problems we perceived throughout the entire article. The final paragraph, appearing to recommend “management approaches,” however, will be commented upon. It discusses “relatively innocuous lowgrade squamous intraepithelial lesions” versus “advanced cervical lesions,” recommending “the more traditional ‘treat and repeat’ approach” for the former and “more aggressive management approaches . . . for advanced cervical lesions.” Clearly, the basis for making the decision whether the patient has an “innocuous” or an ”advanced” lesion must be based upon the results of the Papanicolaou smear. The Pap smear is a
298
screening test-it does not make a diagnosis, as inferred by Drs Grace and Patrick. Even if it were diagnostic, false negatives and lack of patient compliance would make its use in follow-up of the untreated or inappropriately treated cervix risky indeed. Inappropriate treatment specifically includes the “traditional” use of antibiotics (topical, oral, or parenteral) that cannot be supported as legitimate agents for treatment of HPVICIN. A sampling of from recent gynecologic and other journals is representative of the large and growing body of literature that stands counter to the ”management approaches” suggested by Drs Grace and Patrick. Clinicians in ACHA must be advised that the recommendations made by the HPV Task Force at colloquia and in print’ are consistent with current standards of quality care. They are not aggressive in the face of the nature of HPV disease, its sequelae, the documented increasing incidence, and current sexual practices. The Task Force encourages ACHA clinicians to become proficient in all aspects of diagnosis and management of HPV disease and plans an expanded effort in education to that end. Finally, we agree that greatly increased efforts must be devoted to prevention of HPV and other STDs. The Task Force will use every avenue at its disposal to foster such efforts.
Henry W. Buck, M D Chair, ACHA Task Force on Human Papillomavirus (HPV) Infection Head of Gynecology Watkins Memorial Health Center University of Kansas, Lawrence
)ACH
REFERENCES 1. Grace TW, Patrick K. An alternate view of the management of cervical human papillomavirus infections. / Am Coll Health 1989;38(4):241-243. 2. A n d m S, Hernandez E, Miyazawa K. Paired Papanicolaou smears in the evaluation of atypical squamous cells. Obstet Gyneco/ 198974(5):747-750. 3. JonesWB, Saigo PE. The "atypical" Papanicolaou smear. CA 1986;36(4):237-243.
4. Koss LG. The Papanicolaou test for cervical cancer detection-A triumph and a tragedy. jAMA 261(5):737-743. 5. Himmelstein LR. Evaluation of inflammatory atypia-A literature review. / Reprod Med 1989;34(9):634-637. 6. Wheelock JB, Kaminski PF. Value of repeat cytology at the time of colposcopy for the evaluation of cervical intraepithelial neoplasia on Papanicolaousmears. / Reprod Med 1989;34(10):815-817. 7. Genital Human Papillomavirus Disease: Diagnosis, Management, and Prevention. Rockville, MD, American College Health Association, 1989.
Downloaded by [Temple University Libraries] at 04:01 24 November 2014
LETTER TO THE EDITORS We were pleased that Paul Reith, MD, mentioned the work of the US Preventive Services Task Force in his discussion of the periodic health examination.' Our recommendations on this subject are somewhat more extensive than is suggested in his article, however, For example, the article cites only 6 task force background papers in the journal of the American Medical Association UAMA). Six additional articles*-' have since appeared in jAMA, and an anthology of over 40 background papers will soon be available! More important, these papers, the last of which was pub lished in January 1990, were used primarily as background for developing the more definitive recommendations contained in our full report. They address only a subset of the preventive services evaluated by the task force. Our final report, the Guide to Clinical ~reventiveservices,' was released in May 1989 and provides recommendations on about 170 clinical preventive services. The 500report contains scientific reviews of 60 target conditions, most of which are major health issues for the college-aged population. The book includes detailed agespecific tables that are risk-stratified to help clinicians tailor the periodic health examination to the risk profile of individual patients. The single table contained in Dr Reith's article is based primarily on the recommendations of the Canadian Task Force. It is a reasonable approach but is not entirely consistent with our clinical philosophy.
Our group was incorrectly identified in the abstract as the "Joint American" task force. Although we have done some collaborative work with the Canadians, our recommendations are not truly "binational," as is implied by Dr Reith. The "rules of evidence" developed by the Canadiansand described in his article were instrumental in the mid-1980s in helping our group shape our methodology. But our procedures for reviewing evidence and for develop ing practice guidelines haw since evolved into a more complex analytic framework, which is described in our report. Our recommendations are not identical. Finally, your readers may be interested in 1989 reports by the Canadian Task Force" and the INSURE project" that are too recent to have been cited by Dr Reith. It should also be added that our group is now establishing a new science panel to succeed the US Preventive Services Task Force. The new panel will make recommendations on preventive services not examined by the task force, and those for which new evidence or technologies have emerged. Many topics of relevance to the collegeaged population are certain to be considered. Steven H. Woolf, MD, MPH Scientific Advisor US Preventive Services Task Force REFERENCES 1. Reith P. Adapting the selective periodic health exam to a college-aged population. / Am Coll Health. 1989;38:109-113.
Health Education Credenu;rling Exam.
,
The National Commission for Health Education Credentialing, lnc, has scheduled the first examination for Certified Health Education Specialists (CHES) for Sep tember IS, 1990, in 12 cities across the nation. Anyone with at least a bachelor's degree in any field who has current or past experience in health education is eligi-
VOL 38, MAY 7990
2. Selby JV, Friedman CD. Sigmoidos copy in the periodic health examination of asymptomatic adults. IAMA. 1989;261: 594-601. 3. Harris SS, Caspersen CJ, DeFriese GH, Estes EH. Physical activity counseling for healthy adults as a primary preventive intervention in the clinical setting. jAMA. 1989;261:358&3598. 4. Woolhandler S, Pels @, Bor DH, et al. Dipstick urinalysis scmning of asympte matic adults for urinary tract disorders, I: Hematuria and m i n u r i a . /AMA. 19119; 262 1214-1 219. 5. Pels RJ, Bor DH, Woolhandler S, et al. Dipstick urinalysis screening of asymptomatic adults for urinary tract disorders, 11: Bacteriuria. IAMA. 1989;262:1220-1224. 6. Greene JC, Louis R, Wycoff SJ. Preventive dentistry, I: Dental caries. IAMA. 1989;262:3459-3463. 7. Greene JC, Louis R, WyaH SJ. Preventive dentistry, 11: Periodontal diseases. malocculsion, trauma, and oral cancer. jAMA. 199O;263421-425. 8. Goldbloom RB, Lawrence RS, eds. Prewnting Disease: Beyond the Rhetoric. New York: Springer-Verlag. In press. 9. US Preventive Services Task Force. Guide to Clinical Preventive Services: An Assessment of the Effectiveness of 169 Interventions. Baltimore, MD: Williams & Wilkins; 1989. 10. Canadian Task FoKe on the Periodic Health Examination. The periodic health examination: 1989 update. Can Med Arroc ]. 198%141:205-216. 11. Logsdon DN, Lazar0 CM, Meier RV. The feasibilii of behavioral risk reduction in primary medical care. Am j Prev Med. 1989; S249-256.
ble to take the certification exam. About 1600 persons in the United States, Puerto Rico, and 9 foreign countries are currently certified. Application deadline for the 1990 examination is June 15. For further details, call or write the National Commission for Health Education Credentialing, Inc, Professional Examination Service, 475 Riverside Drive, New York, NY 10115; telephone (212) 870-2047.
299
