Pap Cytology Research Articles

The Role of Cytology in the 21st Century: The Integration of Cells and Molecules

Objectives: Cervical cancer screening test performance has been hampered by either a lack of sensitivity in Pap cytology or a lack of specificity of human papillomavirus (HPV) testing. This is disturbing for patients and a cause of high costs for health care providers. Study Design: The identification of p16^INK4a as a specific marker for the neoplastic transformation of cervical squamous epithelial cells by HPVs allows the identification of HPV-transformed cells in cytopathology specimens. Results: When compared to molecular HPV tests for triaging minor cytologic atypia, such as atypical squamous cells of undetermined significance or low-grade squamous intraepithelial lesions, the immunochemical detection of dual p16^INK4a/Ki-67-stained cells demonstrates a significantly improved specificity with good relative sensitivity. Conclusions: HPV testing has shown earlier detection of persistent high-grade squamous intraepithelial lesions (HSIL) compared to cytology and is more effective in preventing invasive cervical cancer. The next challenge for the HPV primary screening program is to find the best method(s) for selecting, among HPV-positive women, those patients in need of immediate colposcopy because they are at a higher risk of developing a precancerous lesion. An HSIL cytology result and/or dual p16/Ki-67 staining could be the best candidates, but further randomized studies are required before these approaches can be used in routine practice.

Triaging HPV-positive women with p16/Ki-67 dual-stained cytology: Results from a sub-study nested into the ATHENA trial

ObjectivesIn addition to genotyping for HPV16/18, dual-immunostaining for p16/Ki-67 has shown promise as a triage of HPV-positive women. We assessed the performance of p16/Ki-67 dual-stained cytology for triaging HPV-positive women undergoing primary HPV screening. MethodsAll women ≥25years with valid cervical biopsy and cobas® HPV Test results from the cross-sectional phase of ATHENA who were referred to colposcopy (n=7727) were eligible for enrolment. p16/Ki-67 dual-stained cytology was retrospectively performed on residual cytologic material collected into a second liquid-based cytology vial during the ATHENA enrolment visit. The diagnostic performance of dual-stained cytology, with or without HPV16/18 genotyping, for the detection of biopsy-confirmed cervical intraepithelial neoplasia grade 3 or worse (CIN3+) was determined and compared to Pap cytology. Furthermore, the number of colposcopies required per CIN3+ detected was determined. ResultsDual-stained cytology was significantly more sensitive than Pap cytology (74.9% vs. 51.9%; p<0.0001) for triaging HPV-positive women, whereas specificity was comparable (74.1% vs. 75.0%; p=0.3198). Referral of all HPV16/18 positive women combined with dual-stained cytology triage of women positive for 12 “other” HPV genotypes provided the highest sensitivity for CIN3+ (86.8%; 95% CI: 81.9–90.8). A similar strategy but using Pap cytology for the triage of women positive for 12 “other” HPV genotypes was less sensitive (78.2%; 95% CI: 72.5–83.2; p=0.0003), but required a similar number of colposcopies per CIN3+ detected. Conclusionsp16/Ki-67 dual-stained cytology, either alone or combined with HPV16/18 genotyping, represents a promising approach as a sensitive and efficient triage for colposcopy of HPV-positive women when primary HPV screening is utilized.

Differential proteins among normal cervix cells and cervical cancer cells with HPV-16 infection, through mass spectrometry-based Proteomics (2D-DIGE) in women from Southern México.

BackgroundCervical cancer (CC) is the fourth most common cancer in women worldwide with an estimated 528,000 new cases in 2012. The same year México had an incidence of 13,960 and a mortality of 4769 cases. There are several diagnosis methods of CC; among the most frequents are the conventional Pap cytology (Pap), colposcopy, and visual inspection with acetic acid (VIA), histopathological examination, tests of imaging and detection of high-risk papilloma virus (HR-HPV) with molecular tests (PCR, hybridization, sequencing). Proteomics is a tool for the detection of new biomarkers that can be associated with clinical stage, histological type, prognosis, and/or response to treatment. In this study we performed a comparative analysis of CC cells with normal cervical cells. The proteomic analysis was carried out with the fluorescent two-dimensional electrophoresis (2D-DIGE) technique to subsequently identify differential protein profiles using Decyder Software, and the selected proteins were identified by Mass Spectrometry (MALDI-TOF).ResultsThe proteins that showed an increased expression in cervical cancer in comparison with normal cervix cells were: Mimecan, Actin from aortic smooth muscle and Lumican. While Keratin, type II cytoskeletal 5, Peroxiredoxin-1 and 14-3-3 protein sigma showed a decrease in their protein expression level in cervical cancer in comparison with normal cervix cells.ConclusionsThus, this study was successful in identifying biomarker signatures for cervical cancer, and might provide new insights into the mechanism of CC progression.

Retrospective Analysis: 25 to 29 Year Old Females with NILM Cytology and A Positive High Risk HPV Test

Co-testing with cytology and a high-risk HPV test is recommended for women 30-65, the same recommendation is not made for women ages 25-29. The guidelines from ACOG, USPSTF, ASCP, ASCCP, and ACS for women 25-29, recommend cytology alone every three years as screening.A retrospective analysis was done at BioReference Laboratories over a 2 year period of time of samples that had NILM cytology with HPV Roche™ co-testing in patients 25 to 29. In addition, biopsy data was analyzed for a subset of these samples. From this analysis, we have concluded that cases of high-grade cervical lesions, including cervical cancers, are missed, when the Pap cytology is normal (NILM). While HPV testing is currently not recommended in 25 to 29 year olds with NILM paps, many of the patients were positive for type 16 and /or type 18 with significant disease detected on biopsy.

Management of high-risk HPV-positive women for detection of cervical (pre)cancer

ABSTRACTIntroduction: Primary HPV-testing has been shown to provide a superior detection of women at risk of cervical (pre)cancer compared to cytology-based screening. However, as most high-risk HPV infections are harmless, additional triage testing of HPV-positive women is necessary to identify those with cervical (pre)cancer. In this paper, we compare the performance, advantages and limitations of clinically relevant available triage strategies for HPV-positive women.Areas covered: Many different colposcopy triage strategies, comprising both microscopy-based and molecular (virus/host-related) markers, have been suggested: Pap cytology, p16/Ki-67 dual-stained cytology, HPV16/18 genotyping, viral DNA methylation and host cell DNA methylation. Literature search was limited to triage strategies that have achieved at least phase 2 of the five-phase framework for biomarker development and studies including large cohorts (≥100 hrHPV-positive women). Triage markers were stratified by sample type (cervical scrape, self-collected sample) and by study population (screening, non-attendee, referral).Expert commentary: At present, repeat Pap cytology and Pap cytology combined with HPV16/18 genotyping are the only triage strategies that have been robustly shown to be ready for implementation. Other strategies such as p16/Ki-67 dual-stained cytology and host cell DNA methylation analysis, with or without additional HPV16/18 genotyping, are attractive options for the near future.

P16/Ki-67 dual-stained cytology for detecting cervical (pre)cancer in a HPV-positive gynecologic outpatient population

AbstractWomen who test positive for a high-risk type of the human papillomavirus (HPV) require triage testing to identify those women with cervical intraepithelial neoplasia grade 3 or cancer (≥CIN3). Although Pap cytology is considered an attractive triage test, its applicability is hampered by its subjective nature. This study prospectively compared the clinical performance of p16/Ki-67 dual-stained cytology to that of Pap cytology, with or without HPV16/18 genotyping, in high-risk HPV-positive women visiting gynecologic outpatient clinics (n=446 and age 18–66 years). From all women, cervical scrapes (for Pap cytology, HPV16/18 genotyping, and p16/Ki-67 dual-stained cytology) and colposcopy-directed biopsies were obtained. The sensitivity of p16/Ki-67 dual-stained cytology for ≥CIN3 (93.8%) did neither differ significantly from that of Pap cytology (87.7%; ratio 1.07 and 95% confidence interval (CI): 0.97–1.18) nor from that of Pap cytology combined with HPV16/18 genotyping (95.1%; ratio 0.99 and 95% CI: 0.91–1.07). However, the specificity of p16/Ki-67 dual-stained cytology for ≥CIN3 (51.2%) was significantly higher than that of Pap cytology (44.9%; ratio 1.14 and 95% CI: 1.01–1.29) and Pap cytology combined with HPV16/18 genotyping (25.8%; ratio 1.99 and 95% CI: 1.68–2.35). After exclusion of women who had been referred because of abnormal Pap cytology, the specificity of p16/Ki-67 dual-stained cytology for ≥CIN3 (56.7%) remained the same, whereas that of Pap cytology (60.3%) increased substantially, resulting in a similar specificity of both assays (ratio 0.94 and 95% CI: 0.83–1.07) in this sub-cohort. In summary, p16/Ki-67 dual-stained cytology has a good clinical performance and is an interesting objective microscopy-based triage tool for high-risk HPV-positive women.

Use of immunohistochemical staining for p16 in gynecological cytology.

Use of immunohistochemical staining for p16 in gynecological cytology.

Sanger Sequencing for BRCA1 c.68_69del, BRCA1 c.5266dup and BRCA2 c.5946del Mutation Screen on Pap Smear Cytology Samples.

Three sets of polymerase chain reaction (PCR) primers were designed for heminested PCR amplification of the target DNA fragments in the human genome which include the site of BRCA1 c.68_69del, BRCA1 c.5266dup and BRCA2 c.5946del respectively, to prepare the templates for direct Sanger sequencing screen of these three founder mutations. With a robust PCR mixture, crude proteinase K digestate of the fixed cervicovaginal cells in the liquid-based Papanicolaou (Pap) cytology specimens can be used as the sample for target DNA amplification without pre-PCR DNA extraction, purification and quantitation. The post-PCR products can be used directly as the sequencing templates without further purification or quantitation. By simplifying the frontend procedures for template preparation, the cost for screening these three founder mutations can be reduced to about US $200 per test when performed in conjunction with human papillomavirus (HPV) assays now routinely ordered for cervical cancer prevention. With this projected price structure, selective patients in a high-risk population can be tested and each provided with a set of DNA sequencing electropherograms to document the absence or presence of these founder mutations in her genome to help assess inherited susceptibility to breast and ovarian cancer in this era of precision molecular personalized medicine.

Dual p16/Ki-67 immunocytochemical stain in cervical smears: A triage comparison with HPV testing, and also with biopsy double immunolabelling (dil) for benign/low grade lesions

Testing for high risk human papilloma virus (HPV) subtypes has been incorporated to triage cervical smears with low grade (LG) squamous abnormalities, atypical squamous cells of uncertain significance (ASCUS) and low grade dysplasia (LGD), as many patients with these findings have infection without any accompanying high grade dysplasia (HGD). Addition of a dual p16/Ki-67 immunocytochemical stain (CINtecPLUS) potentially assists prediction of any HG lesion, thereby avoiding unnecessary colposcopy.Comparison of sensitivity and specificity for detection of biopsy-proven HGD was made between the 3 modalities of Pap cytology, CINtecPLUS, and HPV testing in a total of 102 smears. CINtecPLUS was found to be the most sensitive method (93.8%) and more specific (76.3%) than HPV testing (21.1%). The most specific method was Pap cytology (89.5%).Comparison of sensitivity and specificity for detection of HGD was made between the 3 modalities of CINtecPLUS, p16 alone, and DIL, in a total of 38 Pap-diagnosed cases of benign/LG lesions. The most sensitive was CINtecPLUS (91.7%), but with a specificity intermediate between DIL (88.5%) and p16 alone (65.4%).Comparison of 7 CINtecPLUS +ve cases with DIL disclosed 2 totally discrepant cases, with confirmed –ve biopsies. Of 6 CINtecPLUS –ve cases, one totally and 5 partly discrepant cases were all LGD.In conclusion, no single investigational modality demonstrated a clearly superior performance. Testing for high risk human papilloma virus (HPV) subtypes has been incorporated to triage cervical smears with low grade (LG) squamous abnormalities, atypical squamous cells of uncertain significance (ASCUS) and low grade dysplasia (LGD), as many patients with these findings have infection without any accompanying high grade dysplasia (HGD). Addition of a dual p16/Ki-67 immunocytochemical stain (CINtecPLUS) potentially assists prediction of any HG lesion, thereby avoiding unnecessary colposcopy. Comparison of sensitivity and specificity for detection of biopsy-proven HGD was made between the 3 modalities of Pap cytology, CINtecPLUS, and HPV testing in a total of 102 smears. CINtecPLUS was found to be the most sensitive method (93.8%) and more specific (76.3%) than HPV testing (21.1%). The most specific method was Pap cytology (89.5%). Comparison of sensitivity and specificity for detection of HGD was made between the 3 modalities of CINtecPLUS, p16 alone, and DIL, in a total of 38 Pap-diagnosed cases of benign/LG lesions. The most sensitive was CINtecPLUS (91.7%), but with a specificity intermediate between DIL (88.5%) and p16 alone (65.4%). Comparison of 7 CINtecPLUS +ve cases with DIL disclosed 2 totally discrepant cases, with confirmed –ve biopsies. Of 6 CINtecPLUS –ve cases, one totally and 5 partly discrepant cases were all LGD. In conclusion, no single investigational modality demonstrated a clearly superior performance.

Primary HPV genotyping with reflex Pap cytology for cervical cancer screening

Primary HPV genotyping with reflex Pap cytology for cervical cancer screening

Cytomorphology of vaginal pap smears-A spectrum of lesions in a tertiary hospital

Background: Pap test is an important and easy diagnostic tool to detect any abnormalities on vaginal cytology. It is routinely done in women of reproductive age group. In addition to detecting cellular and epithelial abnormalities; certain infections, rare entities including neoplastic and non-neoplastic conditions can also be identified. Aims and Objectives: 1. To study the spectrum of abnormalities on vaginal pap cytology as per The Bethesda System (TBS) 2001.2. To study the utility of pap smears in early diagnosis of premalignant lesions. Materials and Methods: This prospective study was conducted in Dr. B.R. Ambedkar Medical College, Bangalore where routine pap smears referred from the Obstetrics and Gynaecology Department were studied. Important clinical data like vaginal discharge, inter menstrual bleed, post–coital bleed and lower pain abdomen were collected. Pap smears were analysed, interpreted and categorised based on TBS2001. Importance of detecting premalignant lesions were highlighted in our study. Results: 525 pap smears were interpreted in a 2 year prospective study out of which 400 cases were analysed after excluding 125 unsatisfactory case. The age range was 18-78 yrs (mean age of 48 yrs). 120 (30%) cases of nonspecific inflammation were identified. Specific infectious etiologies included 186 (46.5%) cases range including most common candida and Bacterial vaginosis to 2 rare infections, one case each of filariasis and granulomatous cervicitis. Significant number(82 cases) of premalignant conditions were diagnosed. 12 malignancies-10 SCC and 2Adenocarcinomas were reported. Conclusions: Certain rare infectious entities were detected in our study which pose challenge due to infrequent occurance in our daily practice. Close follow- up and histological examination are necessary in premaligant lesions to avoid spread and untimely death of the patient. Thus emphasising effective utility of this simple and cost-effective tool. Keywords: Vaginal p

Clinical Performance of Cervista HPV HR and HC2 Co-testing with SurePath Pap Cytology

Clinical Performance of Cervista HPV HR and HC2 Co-testing with SurePath Pap Cytology

Efficacy of HPV Testing in Predicting CIN2+ in Women with an Unsatisfactory Pap Cytology Result

Efficacy of HPV Testing in Predicting CIN2+ in Women with an Unsatisfactory Pap Cytology Result

The Sensitivity of Pap Cytology and HPV Testing to Detect Cervical Cancer: Prior Testing Results in 178 Patients with Invasive Cervical Cancer at a Large General Hospital in China

The Sensitivity of Pap Cytology and HPV Testing to Detect Cervical Cancer: Prior Testing Results in 178 Patients with Invasive Cervical Cancer at a Large General Hospital in China

Risk of Human Papillomavirus (HPV) Infection and Cervical Neoplasia after Pregnancy.

BackgroundParity is well established as a risk factor for cervical cancer. It is not clear, however, how pregnancy influences the natural history of HPV infection and cervical neoplasia. Our objective was to study the risk of HPV infection and cervical squamous intraepithelial lesions (SIL) after pregnancy.MethodsWe used the Ludwig-McGill cohort study which includes 2462 women recruited in Sao Paulo, Brazil in 1993–97 and followed for up to 10 years. Cellular specimens were collected every 4–6 months for Pap cytology and HPV detection and genotyping by a polymerase chain reaction protocol. Study nurses recorded pregnancy occurrence during follow-up. HPV and Pap results from pregnant women were available before and after, but not during pregnancy. The associations between pregnancy and post-partum HPV infection/SIL were studied using generalized estimating equation models with logistic link. Adjusted odds ratios (OR) were estimated with empirical adjustment for confounding.ResultsWe recorded 122 women with a history of pregnancy during follow-up. Of these, 29 reintegrated the cohort study after delivery. No association between HPV and pregnancy was found. A single SIL case (high grade SIL) occurred post-partum. Likewise, there was no association between pregnancy and risk of low grade SIL or any-grade SIL at the next visit (adjusted OR = 0.84, 95 % CI: 0.46-15.33) after controlling for confounders.ConclusionsNo associations were found between pregnancy and HPV or LSIL. The single observed case of HSIL post-partum was more than would be expected based on the rate of these abnormalities among non-pregnant women. As this association was found with only one case, caution is required in the interpretation of these results.

Cervical Cytology Reporting Rates from China's Largest College of American Pathologists-Certified Laboratory with a Focus on Squamous Cell Carcinoma Cytology and Its Histopathological Follow-Up Results

Objective: No organized cervical screening programs or national cervical cytology quality control standards currently exist in China. This study reported cervical cytology performance in China's largest independent laboratory with accreditation from the College of American Pathologists. Design: Results from over 2 million Papanicolaou (Pap) tests by the KingMed Diagnostics Laboratory were categorized according to The Bethesda System (TBS) from 2007 and 2014. Pap reports and histopathologic follow-up results of squamous cell carcinomas (SCC) were analyzed. Results: Data on 676,445 conventional Pap smears (CPS) and 1,696,284 liquid-based cytology (LBC) specimens were available. Abnormality rates reported were significantly higher with LBC than with CPS in all TBS categories (p < 0.001). A total of 800 SCC cytology reports were identified, representing a laboratory SCC reporting rate of 0.0337%. The SCC reporting rate with LBC (0.0457%) was significantly higher than the reporting rate with CPS. Histopathologic invasive cervical carcinoma and cervical intraepithelial neoplasia 2/3 were diagnosed in 80.7 and 17.6% of the 119 patients with SCC Pap cytology. Conclusions: Reporting rates for most TBS categories from this CAP-accredited laboratory in China were within the CAP benchmark ranges except for low atypical glandular cell and unsatisfactory case rates. Histological follow-up results in patients with SCC cytology reports demonstrate very high specificity of SCC Pap cytology.

P16/Ki-67 Dual Stain Cytology for Detection of Cervical Precancer in HPV-Positive Women.

Human papillomavirus (HPV)-based cervical cancer screening requires triage markers to decide who should be referred to colposcopy. p16/Ki-67 dual stain cytology has been proposed as a biomarker for cervical precancers. We evaluated the dual stain in a large population of HPV-positive women. One thousand five hundred and nine HPV-positive women screened with HPV/cytology cotesting at Kaiser Permanente California were enrolled into a prospective observational study in 2012. Dual stain cytology was performed on residual Surepath material, and slides were evaluated for dual stain-positive cells. Disease endpoints were ascertained from the clinical database at KPNC. We evaluated the clinical performance of the assay among all HPV-positive women and among HPV-positive, cytology-negative women. We used internal benchmarks for clinical management to evaluate the clinical relevance of the dual stain assay. We evaluated sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of the dual stain compared with Pap cytology. All statistical tests were two-sided. The dual stain had lower positivity (45.9%) compared with cytology at an ASC-US threshold (53.4%). For detection of CIN2+, the dual stain had similar sensitivity (83.4% vs 76.6%, P = .1), and statistically higher specificity (58.9% vs 49.6%, P < .001), PPV (21.0% vs 16.6%, P < .001), and NPV (96.4% vs 94.2%, P = .01) compared with cytology. Similar patterns were observed for CIN3+. Women with a positive test had high enough risk for referral to colposcopy, while the risk for women with negative tests was below a one-year return threshold based on current US management guidelines. Dual stain cytology showed good risk stratification for all HPV-positive women and for HPV-positive women with normal cytology. Additional follow-up is needed to determine how long dual stain negative women remain at low risk of precancer.

HPV DNA testing with cytology triage in cervical cancer screening: Influence of revealing HPV infection status.

Knowledge of cervical human papillomavirus (HPV) status might influence a cytotechnician's assessment of cellular abnormalities. The authors compared original cytotechnicians' Papanicolaou (Pap) readings for which HPV status was concealed with Pap rereads for which HPV status was revealed separately for 3 screening populations. Previously collected cervical Pap smears and clinical data were obtained from the Canadian Cervical Cancer Screening Trial (study A), the Democratic Republic of Congo Community-Based Screening Study (study B), and the Brazilian Investigation into Nutrition and Cervical Cancer Prevention (study C). Smears were reread with knowledge of HPV status for all HPV-positive women as well as a sample of HPV-negative women. Diagnostic performance of Pap cytology was compared between original readings and rereads. A total of 1767 Pap tests were reread. Among 915 rereads for HPV-positive women, the contrast between "revealed" and "concealed" Pap readings demonstrated revisions from negative to positive results for 109 women (cutoff was atypical squamous cells of undetermined significance or worse) and 124 women (cutoff was low-grade squamous intraepithelial lesions [LSIL] or worse). For a disease threshold of cervical intraepithelial neoplasia of grade 2 or worse, specificity significantly declined at the atypical squamous cells of undetermined significance cutoff for studies A (86.6% to 75.3%) and C (42.5% to 15.5%), and at the LSIL cutoff for study C (61.9% to 37.6%). Sensitivity remained nearly unchanged between readings, except in study C, in which reread performance was superior (91.3% vs 71.9% for the LSIL cutoff). A reduction in the diagnostic accuracy of Pap cytology was observed when revealing patients' cervical HPV status, possibly due to a heightened awareness of potential abnormalities, which led to more false-positive results.

Colonial legacy and the experience of First Nations women in cervical cancer screening: a Canadian multi-community study

Regular Papanicolaou (Pap) screening has dramatically reduced cervical cancer incidence in Canada since the 1950s. However, Indigenous women’s rates of cervical cancer remain disproportionately high, a factor which is not acknowledged in national media or in educational materials reporting Canada’s new cervical cancer screening guidelines. Here, we present findings from a cervical cancer screening initiative in Northwestern Ontario. Based on participatory action research, we worked with 10 First Nations communities in the Robinson Superior Treaty area to increase awareness of cervical cancer risk, develop culturally sensitive tools for screening and education and test the efficacy of human papillomavirus (HPV) self-sampling as an alternative to Pap cytology. We conducted 16 interviews with health care professionals and 9 focus groups with 69 women from the communities. A central theme for both health care providers (HCPs) and community members was the colonial legacy and its influence on women’s experiences of cervical cancer screening. This was evidenced by a strong sense of body shyness, including shame related to sexuality and sexually transmitted infections, concerns about confidentiality in clinical encounters and distrust or caution around HCPs. Reaffirming women’s traditional caregiving and educational roles, enhancing mother and daughter communication, improving cultural sensitivity in health care and education and adoption of HPV self-sampling to increase women’s privacy and control of the cervical cancer screening experience were endorsed. We argue that education and screening initiatives must reflect the cultural preferences of Indigenous women, empowering them to take control of their experiences of health and body in cervical cancer screening.

The sensitivity of Pap cytology and HPV testing to detect incident cervical cancer: prior testing results in 178 patients with invasive cervical cancer at a large general hospital in China

Prior screening results in women diagnosed with cervical carcinoma are only reported in the literature in small numbers. We wish to examine a larger number of prior testing results in women with cervical carcinoma from China to better understand the strengths and weaknesses of Pap (Papanicolaou) cytology and human papillomavirus (HPV) testing. In our study, 178 patients with histologically diagnosed cervical carcinoma and Pap cytology and/or HPV testing in the year prior to diagnosis were retrospectively studied. Pap cytology was performed using liquid-based preparations and HPV testing was done with mostly Hybrid Capture 2 but also included other methods. In our study, 82.0% of women were symptomatic at presentation with vaginal bleeding or abnormal vaginal discharge. HPV testing was negative in 9.8% of women in the short period before diagnosis of cervical cancer and Pap cytology had a higher rate of false negative results at 16.7%. Adenocarcinoma showed a higher negative testing rate than squamous cell carcinoma did with both cytology and HPV testing. Only 1 of 78 patients (1.3%) having both tests showed a double negative result. Negative high-risk HPV testing was noted in 2 of 9 squamous cell carcinoma patients with routine gynecological examination. Both Pap cytology and HPV testing have higher rates of prior negative results in women with cervical carcinoma. When testing is performed using both methods, the greatest number of cervical carcinomas can be detected. These results should also be considered when making screening recommendations with the understanding that HPV testing alone will miss at least a proportion of women with incident cervical carcinoma.