Successfully Integrating Human Papillomavirus Testing Into Your Practice

The process of bringing human papillomavirus (HPV) testing into one's laboratory begins with education. You must educate yourself, other pathologists, and your clinicians, as all of you will face questions about laboratory policy and the clinical significance of HPV results. Your clinicians will ask about costs, turnaround time, and the laboratory rate for atypical squamous cells of undetermined significance (ASCUS). Helpful references include the American Society for Colposcopy and Cervical Pathology (ASCCP) guidelines and the ASCUS/Low-Grade Squamous Intraepithelial Lesion (LSIL) Triage Study (ALTS) publications, among others.1–5 Gauging the awareness level of your clinicians is helpful. Are they aware of and are they following the ASCCP guidelines? Knowledge of your own laboratory data is useful, specifically the ASCUS rate and ASCUS–squamous intraepithelial lesion (SIL) ratio. Ideally, if your computer system can produce individualized statistics for each clinician, this becomes a much more powerful report (Table 1). Providing this report to your clinicians will let them identify trends in test ordering and standard of care. Monitoring the data regularly will also help the laboratory identify adverse trends, such as prolonged turnaround time, specimen adequacy difficulties, or ASCUS inflation.

Discuss HPV testing with each of your clinician groups, but it may be helpful to choose a few leaders among this group when testing the waters. My experience has indicated that society guidelines and insurance coverage are the determining factors for clinicians when deciding to begin new technologies. The most important questions to discuss are as follows:

• What are the ASCCP-recommended indications for HPV testing?

• What other emerging indications exist?

• What is the expected turnaround time?

• Will insurers cover HPV testing? If not, what are patient costs?

• Will HPV testing be ordered as an automatic reflex or on a case-by-case basis?

The ability to bring HPV testing in house hinges on volume. Total gynecologic cytology volume, conversion to liquid Papanicolaou (Pap) tests (with reflex HPV ordered), laboratory ASCUS rates, and turnaround time all play a critical role in the decision-making process (Table 2). The Food and Drug Administration's 3-week expiration (from the time of collection) means that weekly or biweekly HPV testing will be necessary. There are also emerging indications (primary HPV screening and follow-up after cone biopsy) that may increase the volume to a profitable threshold. If the laboratory volume is initially too low for in-house testing, using a referral laboratory may bridge the gap until volumes increase.

The reimbursement issues that impeded conversion to liquid cytology will not affect HPV testing, because the Current Procedural Terminology (CPT) code for HPV testing has existed for years (CPT code 88621, Medicare $48.50).6 Therefore, HPV testing has not faced the gap-fill process that liquid cytology faced. There are regional variations in reimbursement coverage, but individual payer rates should be established (average reimbursement $41.74; Digene Corporation, unpublished data, 2000). Once you identify your outpatient payer mix (percent Medicare, percent Blue Cross, etc) and individual payer reimbursement rates, you can estimate your average reimbursement. It will cost between $40 and $50 per test for established in-house testing (average $37.00; Digene Corporation, unpublished data, 2001), and $50.00 to $60.00 per test to send out to a reference laboratory. If you plan to send out HPV tests but bill the patient or insurance carrier yourself, you should be aware that the American Medical Association has issued ethical guidelines that address “significant mark-ups” of client bills.7 

Based on your laboratory costs and estimated laboratory reimbursement, you can decide whether to use a reference laboratory or bring testing in house. Your ASCUS rate will also impact this determination (Table 2). For turnaround time purposes, you will probably need to run HPV testing at least once a week. Based on average costs and reimbursement rates, the minimum number of tests required for each run to be cost-effective is approximately 26 to 34 (Table 3).

It will be helpful to realize that there are pressures that may act to maintain or increase the ASCUS rate, despite The Bethesda System 2001 removing “ASCUS favor reactive” as an option.8 Theoretically, if you interpreted every case as ASCUS, your false-negative rate would be zero. Psychologically, none of us want to be wrong, and the ASCUS interpretation offers a perfect middle ground where one is never entirely wrong. Years of increased laboratory scrutiny have instilled a culture of extreme caution within many laboratories. Many pathologists are reluctant to downgrade a preliminary ASCUS interpretation by their cytotechnologist, reinforcing the use of this interpretation. As a result of these factors, the ASCUS rate may actually increase for many laboratories. Human papillomavirus testing offers an objective method with which to monitor and assess laboratory ASCUS reporting practices.

The clinician must order the HPV test. The following options are possible:

• the cytology requisition form can have an option for reflex HPV testing (eg, liquid Pap reflex, monolayer with reflex testing);

• standing orders can be given for automatic HPV testing on all ASCUS cases (must be resigned by clinician annually); and

• if HPV testing is not ordered, ASCUS results can be reported along with an educational note or clinician “alert” on the usefulness and availability of HPV testing.

This last option is an opportunity for education, increasing awareness and conversion to reflex HPV ordering practices. If not ordered as a reflex test or standing order, our laboratory faxes a requisition that must be signed and faxed back to the laboratory. If written orders are not received, it is necessary to document verbal consent each time. When your Laboratory Directory of Services is updated, this new test option can be listed as the “preferred method” for cervical cancer screening. A standing order template form can also be included in the Directory of Services. If you have space on the requisition form, it may be helpful to include options for HPV only and for additional molecular tests, such as Chlamydia, gonorrhea, and herpes. The availability of these additional and more sensitive molecular tests will simplify office ordering procedures and paperwork.

Your clinicians will need to hear about the importance of adequate specimen collection. While sampling has always been important, it is now more important than ever, since cytology and HPV testing will now come from a single sample, along with other additional molecular tests. If a nurse practitioner collects the cervical cytology specimen, spend time reviewing the proper collection procedure. It may be beneficial to let the MD clinician “overhear” this conversation. Identify the office staff responsible for rinsing the spatula and brush, often a nurse assistant, and make sure they understand the importance of adequate rinsing.

If additional testing is ordered, it will be performed on residual fluid in the vial, so additional collection is not necessary. If your laboratory allows for molecular testing (without ordering cytology), the clinician's office can streamline their requisition forms and specimen collection bottles (in other words, only your laboratory's requisition forms and liquid Pap bottles will be stocked in the clinician's office).

Specimen collection requirements for the Cytyc ThinPrep are 2 mL for the high-risk panel (HC2), 1 mL for gonorrhea, and 1 mL for Chlamydia.

Training the office clerical staff is also critical. Identify who fills out the test requisition form. Oftentimes, secretarial staff, nurses, and nurse assistants complete critical information on the requisition form. All office staff will need to know which test(s) to order, as well as the importance of completing insurance information and clinical history (routine screen vs follow-up/high risk). If the physician's office does not use correct clinical information or International Classification of Diseases (ICD-9) codes, the tests may not be covered by insurers. With multiple tests being ordered from a single requisition form and specimen bottle, the burden of an insurance claim rejection is greater (Cytology + MD Review + HPV + Gonorrhea + Chlamydia = ∼$450).

The Clinical Laboratory Improvement Act (CLIA) allows cytotechnologists to perform high-complexity testing; however, some states (eg, Tennessee, Florida, New York) have regulations preventing cytotechnologists from performing molecular testing. Molecular testing procedures are tedious and time-consuming. In our laboratory, possessing the “right temperament,” has proven to be the most critical determinant in who is trained for HPV testing. Whether a medical technologist or a cytotechnologist performs HPV testing, it will impact staffing, turnaround time, laboratory workflow, and costs (Table 4). Since HPV testing is only performed 1 day per week, our laboratory has trained 2 cytotechnologists. Personnel training is done at Digene corporate headquarters (Gaithersburg, Md) and is followed by on-site laboratory training.

The cytology laboratory is a high-complexity laboratory and therefore is qualified to perform molecular testing. Whether additional fees or certification are necessary will depend on testing volume and may vary by state. The Centers for Medicare and Medicaid Services now requires notification of new testing practices prior to beginning testing.

The Bethesda System 2001 recommends an integrated report, rather than separate reports.7 The advantages of an integrated report are consolidation of data within the cytology informatics system and simplicity for the clinician and office staff. An integrated report usually means that the specimens are co-collected from 1 vial, sent to the same laboratory on 1 requisition, and reported on 1 report. Several approaches or reporting models can be employed, however, 2 of which are listed here.

This model is less labor intensive and consists of the result plus a probabilistic statement of an underlying carcinoma intraepithelial neoplasia (CIN) 2 or 3.

• Interpretation: ASCUS with detection of high-risk oncogenic HPV DNA.

Note.—These findings are associated with a 10% to 20% risk of underlying CIN 2 or higher lesion.1 

This model requires multiple steps and reevaluations before a final interpretation is issued that reflects both cytomorphology and the HPV status.

• Interpretation: LSIL.

Note.—The preliminary cytologic interpretation is ASCUS. High-risk oncogenic DNA has been detected. In combination, these results are most consistent with a diagnosis of LSIL.

Armed with the HPV results and the initial impression, one can re-review the cytology and make a final interpretation. The HPV data give you immediate feedback, which can be used for self-education and improving case triage. An initial ASCUS interpretation may be unchanged, downgraded, or upgraded. The final report will include a revised interpretation with the HPV results. This method is more labor intensive but provides a polished report, which some clinicians prefer.

At the end of the day, incorporating HPV testing into one's practice is a difficult task with ongoing challenges. There are Food and Drug Administration–approved indications for its use, treatment algorithms based on its results, concerns about false-negative and false-positive results, ASCUS inflation concerns, and regulatory issues, just to name a few. An HPV gatekeeper can oversee the deployment of this test and help ensure appropriate clinical utilization. The gatekeeper may play a more important role in large laboratories or large groups, but can serve many functions in any situation.

The functions of the gatekeeper include the following:

1. Education: Educating cytotechnologists, pathologists, and clinicians about the proper indications and clinical implications. This task includes controlling against overuse with morphologic LSILs and high-grade intraepithelial lesions and against use of the low-risk HPV panel.

2. Control against ASCUS inflation within the laboratory by giving direct feedback and education to cytotechnologists and other pathologists.

3. Review the patient history to ensure that HPV testing is not repeated too frequently and that it follows the ASCCP guidelines.

4. Risk reduction: Reevaluation of the cytology material prior to issuing an integrated report may help guard against false-negative HPV results. Establishing an equivocal result threshold (0.75–1.5 RLU/CO [relative light units/average calibrator value]) will help identify potential false-positive and false-negative HPV results.

5. Future indications: The gatekeeper can also identify glandular lesions that may benefit from HPV triage (eg, endocervical lesions).

6. Laboratory workflow management: The decision on when to run the plates of HPV tests is a balance between turnaround time and cost-effectiveness. In many laboratories, this decision will also involve availability of cytotechnologists and medical technologists.

Cases labeled ASCUS generally yield a 40% to 50% HPV-positive rate, based on ALTS data. If your HPV-positive rate is significantly lower, your laboratory may be overdiagnosing ASCUS. A higher rate may indicate the potential for underreporting ASCUS and missing some cases of SIL. Although CLIA only requires cytohistologic correlation for SIL+ cases, correlating ASCUS cases provides many quality improvement benefits. Not all ASCUS/HPV-positive cytologies will have biopsy-proven abnormalities; however, you should be prepared to explain why your results differ significantly from expectations.

It is easiest to perform HPV testing in or near the cytology laboratory. Therefore, specimen bottles should be stored in close proximity to the laboratory and in some standardized method (eg, according to their accession day). The specimen vials expire after 3 weeks,9 which places an emphasis on turnaround time, the ability to identify and pull bottles quickly, and proper disposal of expired vials.

Will you send all ASCUS cases for HPV testing, or will you use a gatekeeper? Since your ASCUS rate can be manipulated, insurance carriers may begin monitoring to guard against overuse. (It may be important to document your ASCUS rate prior to implementing HPV testing, as a defense against overuse or test bundling.)

If additional sexually transmitted disease testing is ordered or offered, it may be helpful to mark the specimen bottles and requisition forms at the time of accessioning for ease of identification.

Your laboratory procedure manual should include HPV testing procedures, as well as the methods used for triaging ASCUS cases and reporting results.

If your laboratory performs HPV testing, your next CAP inspection should include a molecular laboratory checklist (Section 12, CAP checklist).10 

Proficiency testing is now available for HPV testing.