External Affairs

HPV, Pap Tests, and Cervical Cancer: How the Media Hear the Message
By Laura Marshall

The Message

Headlines from ReutersHealth.com¹ from January 1999 through March 2000:

"Vaccine for HPV-induced tumors shows promise in mice"
"Wart virus test adds little to Pap smear diagnosis"
"Risk factors for cervical HPV infection vary by viral type"
"Chlamydia infection linked to cervical cancer"
"HPV test better than Pap test for cervical cancer screening in high-risk populations"
"Mildly abnormal Pap smears usually OK"
"Automated rescreening of negative Pap smears not cost effective" [on Jan. 28, 1999, one day after:]
"Enhanced Pap testing cost effective for infrequent screening"
"Study determines HPV testing more effective than Pap smear"² [The study was published in Br J Cancer 1999 Jul;80(9):1306-11.]

The Media
Trying to sort the wheat from the chaff in reporting on cervical cancer and human papillomavirus (HPV), anyone--patient, journalist, researcher, or clinician--could easily get confused. The messages--those we hear and those we write--seem to change continually. Is HPV the best test? Is all cervical cancer caused by HPV? Are Pap smears obsolete? Is there a better Pap test?

April 5, 2000: Kaiser Permanente offers advanced screening for cervical cancer.³ [KP press release as posted on Business Wire]

Health care is one of the most frequent topics of news stories--in print, on TV, on the radio, and particularly on the Internet. Today's "empowered" health care consumers are hungry for information about their health, their fitness, their family's illnesses and injuries.

1982: Early research publication connecting HPV and cervical cancer: "... the strength, specificity and consistency of this relationship suggest that [subclinical papillomavirus infection] may be a precursor of cervical malignancy."^{4:p. 377} [Cancer]

Feeling the need to feed that hunger for information, journalists report on clinical research, the latest studies, presentations, and conferences that contain health care news. Often, the journalists are not health care experts themselves; almost as often, however, they have at least a basic understanding of research and can and do ask appropriate questions.

1997: On cervical cancer testing: ... The Food and Drug Administration has recently approved three new automated systems that show promise of substantially improving the accuracy of Pap tests. [ThinPrep, PAPNET, AutoPap 300 QC] ...none of these systems is perfect.⁵ [FDA Consumer]

Kaiser Permanente
The internal Kaiser Permanente (KP) debate over how to increase the accuracy of Papanicolaou tests in detecting new cases of cervical cancer has paralleled and at times been influenced by an external debate. Media coverage of new technologies has ranged from thoughtful, lengthy pieces in The New Yorker on HPV testing to inquiring articles directed at insurers who refuse to include the new technologies in health care coverage. The companies that own and manufacture the tests influence this media coverage by distributing to reporters and editors press releases that quote or reference specific studies favorable to the products the companies are trying to sell. Because those press releases are often placed on the Internet without being edited--and the average consumer doesn't see or understand the difference between a press release and objective journalism--the debate is often controlled by those who get the first word.

January 1999: The Pap Test Still Best Bet, but New Technologies Show Promise of Improving Screening Outcomes⁶ [Agency for Healthcare Research and Quality]

Meanwhile, clinicians and researchers within KP debate and determine best practices--from personal observations, from reviews of the best and most recent external research, and from research conducted at our own research centers.

May 1999: For women with ASCUS Pap tests, HPV DNA testing of residual specimens collected for routine cervical cytology can help identify those who have underlying HSIL.^{7:p. 1605} [JAMA]

Should clinical decisions and practice guidelines be determined by what's reported on World News Tonight? No one would suggest that they should. But the reality is that media coverage of an issue, a drug, a type of therapy, or a new technology increases the pressure for any insurer to include that option as a covered benefit, whether or not it has been proved effective.

July 1999: WASHINGTON, DC -- New cervical cancer screening technologies are not likely to help women most in need of cervical cancer testing and could even widen the economic gap between women who get Pap smears and those who don't, argue commentators in the August issue of Obstetrics & Gynecology⁸ [ACOG news release]

Media Relations Role
In the media relations offices of every health plan, professionals who work daily with local and national media representatives have learned to expect the "Do you/will you cover it?" call whenever new research results are released on a given drug, device, or treatment (or when its maker sends out a press release touting its benefits).

When the message received is uncertain--ie, when a phone call can't be answered simply with, "Yes, we do" or "No, we don't"--a journalist's natural reaction is to wonder why the answer is complicated. This reaction isn't necessarily effrontery; if the answer isn't simple, human nature asks, "Why?" or "Why not?"

Answering these questions creates an opportunity to educate, but complexities are generally lost in a sound-bite-hungry world. Television sound bites average seven seconds each; quotes in print occupy only a sentence or two. Far more often, a complex answer to what seems a simple question (eg, "Do you or don't you ...?") makes the respondent appear uncertain or deliberately obfuscating.

Good Reporting
Stories published and questions asked by their writers can change direction abruptly--and at any given time, these directions can appear completely divergent. One reporter will call us to ask, "Why don't you allow more access to clinical trials?" minutes before another reporter asks, "Why don't you better protect your patients from being experimented on?"

Outside a newsroom, it's difficult to see that journalists are themselves hungry for information. Like most of us, they'd like the world to make sense--even though when it doesn't, it gives them job security. At the same time, journalists are rewarded for being cynical: questioning authority is part of their job descriptions and produces the best sound bites and stories.

The Debate Continues
As clinical information on health care treatments and policies fluctuates daily, so do the stories we--and patients--read every day in newspapers and on the Internet. Similarly, fluctuation is evident in our internal debate and, by extension, in our answers to the questions we are asked by journalists, by our patients, and by the public.

To External Affairs index >>