[The authors respond:]
We wish to respond to the thoughtful comments by Howlett and colleagues and Burn to our commentary.1 We agree with Burn that cervical cancer risk among young women is very low. However, the finding of an LSIL smear in a young woman is a very common byproduct of existing cervical cancer screening guidelines. What we proposed is in line with the new knowledge concerning the relative performance of Pap cytology and oncogenic HPV testing and, contrary to what Howlett and colleagues suggest, it is based on a thorough review of the evidence by the American Society for Colposcopy and Cervical Pathology that included Canadian experts.2 HPV testing has substantially greater sensitivity than cytology and it targets a period in the natural history of cervical neoplasia that is „upstream” from the appearance of cytological abnormalities, which provides a better margin of safety if the result is negative. Cytological follow-up every 6 months has been the management standard in Canada, but immediate colposcopy also occurs frequently. We recommended using HPV testing because it would lead to fewer visits to the primary care provider. We further reasoned that with less than three years since first vaginal intercourse it would be highly unlikely that an HPV infection once established would have led to a high grade lesion.
There are no Canadian guidelines yet that appropriately take into account HPV testing. The Pan-Canadian Forum on Cervical Cancer Prevention and Control3 has provided a fast-track opportunity to generate such evidence in the context of our country's screening programmes. In the meantime, however, we believe that the algorithms we proposed are a scientifically and clinically cogent management option.
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