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Abstract
Objective:
UK colposcopy services are seeing increased workloads, a large proportion of which are follow-up appointments. The English Cervical Screening Programme HPV Special Interest Group identified five subcategories of colposcopy clinic patients who often require prolonged follow-up regimes for low-grade abnormalities. Human papillomavirus (HPV) testing has a high negative predictive value, meaning that HPV-negative women are at very low risk of underlying disease. Our objectives were to quantify the number of HPV-negative women in each study subcategory and to evaluate the number who could potentially be discharged from colposcopy on the basis of their results.
Methods:
Four colposcopy clinics prospectively identified women according to five categories over 12 months. All women underwent cytological testing and high-risk HPV (hrHPV) testing using the Hybrid Capture 2 test. Management outcomes and decisions based on a knowledge of the HPV status were recorded.
Results:
Data available on 755 women showed that 422/755 (55.9%) and 260/755 (34.4%) had persistent cervical intraepithelial neoplasia grade 1 (CIN1) (Category 1) or a minor abnormality following treatment (Category 2), respectively. In Categories 1 and 2, 51.7% and 60.2%, respectively, were hrHPV negative. The rates with biopsies of CIN2 or worse (CIN2+) across the two categories were 3/355 (0.8%) and 21/291 (7.0%) for hrHPV-negative and hrHPV-positive women, respectively.
Conclusion:
The incorporation of hrHPV testing within organized cervical screening programmes has been widely accepted. hrHPV testing for the clinical scenarios outlined in this study detects women who are hrHPV negative and therefore at low risk of underlying disease, potentially reducing anxiety and inconvenience for women and costs to colposcopy services.
... These methods are basically relying on detection of viral nucleic acids in infected samples taken from patients as HPV cannot be cultured (Table1) [14][15]. Potential clinical applications of HPV tests classified into four categories: primary screening [16][17], triage of cases with low grade cervical abnormalities [17][18] follow up after treatment of CIN [17] [19] and resolution of uncertainty [20] [18]. ...
... Since HPV testing has a high negative predictive value it can be useful to resolve the uncertainty of colposcopy results of patients entered in colposcopy referral process. Bowring et al. [20] studied 755 women over 12 months, of them two categories showed 90.3% of the resolution of uncertainties. HC2 technique was applied for HPV testing and their findings proved its ability to recognize the patients at higher risks. ...
Cervical cancer is one of the major women health problems, which is considered to be responsible for significant percentage of cancer related deaths in low and middle income countries. While Human Papilloma virus (HPV) DNA testing has an established role in cervical cancer prevention, there is a need to use other biomarkers with higher specificity and prognostic value to recognize patients at risk of progressive illness. There are evidences suggest that, direct detection of HPV messenger RNA transcripts may establish a more specific method for defining clinically important infection than viral DNA detection. Our objective was to provide an overview of the literature on specificity of HPV mRNA testing compared to DNA testing for detecting the risk evaluation of cervical intraepithelial neoplasia and invasive cervical cancer. We focused on recent clinical studies that support the application of HPV E6/E7 mRNA as a marker in advanced cervical cancer screening program. We provide overview of sample size, recruitment setting, age, HPV mRNA and HPV DNA assays for researches included in our review. The pooled review of clinical studies provided evidence that HPV mRNA might be a relevant diagnostic biomarker but additional studies need to be developed in order to make strong conclusion.
... Do we have to accept a low PPV in this context and be reassured that HPV testing in ToC has a better detection rate for CIN2+ than cytology even if there may still be occasional false negatives? For example, Bowring et al. 13 found CIN2+ in 0.8% of HPV-negative compared with 7.0% of HPV-positive women with borderline cytology after CIN treatment in a study of HPV testing to 'resolve uncertainty' published in this issue. Perhaps, however, more thought should be given to the most appropriate HPV platform in this clinical situation. ...
... These findings lead to the introduction of hr-HPV testing in the follow-up of women with an abnormal cytology who were CIN2 þ negative at the first assessment. The incorporation of hr-HPV testing in follow-up post-colposcopy can potentially reduce the colposcopy workloads (Bowring et al, 2012). ...
Background:
The follow-up after abnormal Pap smear and negative colposcopy is not clearly defined. This study aimed at investigating the role of hr-HPV testing in the management of abnormal Pap test and negative colposcopy for Cervical Intraepithelial Neoplasia grade 2 or worse (CIN2+).
Methods:
The study enroled 1029 women with abnormal screening cytology (years 2006–2010) and negative colposcopy for CIN2+, which subsequently performed a hr-HPV test. Incident CIN2+ lesions were identified through linkage with cancer registry, hospital discharge records, neoplastic pathology reports and the archive of screening programme (2006–2011).
Results:
During the follow-up, the cohort developed 133 CIN2+ lesions; only one among hr-HPV-negative women. The probability of developing CIN2+ on follow-up time was 0.44% (95% confidence interval (CI) 0.1–3.1) and 41.8% (95% CI 31.8–53.5) for hr-HPV-negative women and hr-HPV-positive women, respectively. A woman with a positive hr-HPV test had about 105 times higher probability of developing a CIN2+ lesion than a woman with a negative hr-HPV test (hazard ratio (HR)=104.5, 95% CI 14.5–755.1), adjusted for index Pap test result, age and cervix squamocolumnar junction visualisation.
Conclusion:
Our results confirm that hr-HPV testing is able to select the real group of women at risk of developing CIN2+ lesions in the follow-up of abnormal cytology and first negative colposcopy.
Objective
To provide a scientific basis for the prevention and treatment of cervical intraepithelial neoplasia grade 1 (CIN1). This study evaluated the impact of human papillomavirus (HPV) infection on the natural history of CIN1.
Methods
Electronic databases of Cochrane Library, EMBASE, PubMed, CNKI, CBM, and Wanfang were searched in April 2016. The eligibility criteria were documented by Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). We used the Newcastle-Ottawa scale (NOS) to assess study quality.
Results
Thirty-eight studies out of 3,246 identified papers were eligible for inclusion. The risk of CIN1 progression (relative risk [RR]: 3.04; 95% confidence interval [CI]: 2.41–3.83; P < 0.00001) and persistence (RR: 1.48; 95% CI: 1.17–1.87; P = 0.001) was higher in the HPV-positive group than HPV-negative group. Specifically, the risk of CIN1 progression (RR: 13.91; 95% CI: 3.46–55.90; P = 0.000) was higher among persistent high-risk HPV-positive patients and the ratio of CIN1 regression (RR: 0.65; 95% CI: 0.59–0.71; P < 0.00001) was lower in the HPV-positive group than HPV-negative group.
Conclusion
HPV infection resulted in an increased risk of CIN1 progression and decreased disease reversibility. Persistent high-risk HPV infection resulted in a further increased risk of CIN1 progression.
A 34-year-old nullipara, wishing to start a family, presented to colposcopy clinic. Her most recent cervical cytology result showed high-grade dyskaryosis. Having undergone four large loop excisions of the transformation zone during the past 6 years, this woman had no remaining vaginal cervix. In order to excise presumed high-grade cervical intraepithelial neoplasia while mitigating obstetric risk, she underwent a simple vaginal trachelectomy and isthmic cerclage. 6 months later, the patient had a negative test of cure. 7 months following surgery she became pregnant naturally. At 29 weeks she had antenatal sepsis of unknown cause, which was treated with intravenous antibiotics. She delivered by caesarean section at 37 weeks and now has a healthy child. This report will discuss the obstetric impact of colposcopic treatment, and simple vaginal trachelectomy as a fertility-sparing treatment option for women who have had multiple loop excision procedures to treat premalignant lesions.
Objective:
The aim of this study was to evaluate the effect and performance of the new algorithm in cervical cancer screening program in two years' experience of Latina (Italy). MATERIALS AND MTHODS: The female population was divided into two groups, the first group was referred to PAP test and the second one to hr-HPV test according to national guidelines.
Results:
In two years the participation mean rate increased among women aged 35-64 compared to women aged 25-34. The primary PAP test positive rate and hr-HPV test positive rate were 4.0% and 5.2%, respectively. The PAP test positive rate among hr-HPV+ women decreased from 2012 to 2013. Women with hr-HPV+/PAP+ were referred immediately to colposcopy and this rate was 1.2%. The predictive positive value for CIN2+ to colposcopy was 10.9% in 2012 and 9.1% in 2013, while the detection rate for CIN2+ was 1.6% in 2012 and 1.4% in 2013.
Conclusion:
The stratification of the female population leads to a decreased inappropriate therapeutic path while the combination of hr-HPV test with PAP test in woman aged 35-64 lets obtain high levels specificity and sensitivity results.
The authors previously demonstrated that lysing samples with glacial acetic acid (GAA) before human papillomavirus (HPV) testing does not adversely affect HPV detection with the cobas 4800 HPV Test. However, the long-term impact of GAA on HPV DNA was not explored in that study, and inherent cell loss with the lysing protocol used also was observed. The current study considered the long-term effects of GAA treatment of cervical ThinPrep samples on HPV detection with the cobas 4800 HPV Test. They also modified the manufacturer's lysing procedure for ThinPrep specimens to help prevent cell loss.
Seventy-eight ThinPrep samples, including previously lysed, archived specimens, were split; then, 1 part was treated with GAA according to the manufacturer's protocol or using a modified protocol, and the other part was left untreated. All samples were tested for HPV using the cobas 4800 HPV Test. The HPV-positive/HPV-negative status of tested samples was used to determine the level of agreement between treated and untreated fractions. Performance of the modified lysing procedure was assessed relative to the manufacturer's protocol.
Positive HPV status produced 97% agreement between the GAA-treated/untreated fractions. Concordance between the GAA-treated/untreated fractions did not differ between the 2 lysing methods; however, the average percentage increases in β-globin and HPV cycle threshold values after lysing were less discernible for the modified lysing method.
GAA treatment of cervical ThinPrep specimens does not have long-term adverse effects on HPV detection with the cobas 4800 HPV Test. The manufacturer's GAA lysing procedure for ThinPrep specimens can be reliably modified for specimens that may subsequently undergo HPV testing. Cancer (Cancer Cytopathol) 2013;. © 2013 American Cancer Society.
Greater understanding of the role played by human papillomavirus ( HPV ) in the causation of disease has led to the development of an increasing number of HPV tests with different characteristics. The bewildering choice facing healthcare professionals and providers is daunting. Clearly, HPV testing is no longer simply of research interest, but can provide information that can be used for individual patient management and at the population level for cervical screening and vaccine surveillance. This review aims to provide the background to the development of HPV tests, to explain the different technologies and to discuss the challenges of the application of these optimally in the varied contexts of disease management.
Few HPV tests are approved for clinical use and it is important that clinicians understand which test can be utilized, in what circumstances, with what specimens and the meaning of the report issued. HPV testing is no longer applicable only to cervical disease, and we have suggested additional areas, such as the oropharynx, in which HPV testing services might be implemented in the near future. New tests will continue to emerge and we have identified some of the indirect measures of HPV activity, or biomarkers, that could help in the risk stratification of HPV infection and associated disease.
The challenges relating to the optimal application of the various HPV technologies are compounded by the lack of evidence regarding their performance in vaccinated populations. Currently published work, including modelling studies, has been undertaken in non‐immunized populations. We therefore end by addressing the issues regarding appropriate strategies and tests for immunized populations.
The cervical smear test, like all screening tests, is not 100% effective in detecting abnormality. In order to prevent 80-90% of invasive cancers, cervical screening requires cervical smears to be taken competently at regular intervals and correctly interpreted. With laboratories following the guidelines in this report, the NHSCSP should be able to meet the Health of the Nation target to reduce the incidence of invasive cervical cancer to less than 12 cases per 100 000 women in the UK by the year 2000.
Infection with high-risk human papillomavirus (HPV) is the main cause of high-grade cervical intraepithelial neoplasia (CIN) and cancer. It has been suggested that information about high-risk HPV type-specific infection might make cervical cancer screening more effective. Persistent HPV infection could also be a useful screening marker. We estimated the long-term risk of high-grade CIN after one-time detection of high-risk HPV DNA and after persistent infection with individual high-risk HPV types.
A cohort of 8656 women from the general population of Denmark was examined twice, 2 years apart (first study examination: May 15, 1991, to January 31, 1993; second study examination: October 1, 1993, to January 31, 1995). The women underwent a gynecological examination and cervical cytology and had swabs taken for HPV DNA analysis by the Hybrid Capture 2 and line probe assays. The women were followed up through the nationwide Danish Pathology Data Bank for cervical neoplasia for up to 13.4 years. The absolute risk of developing cervical lesions before a given time was estimated as a function of time.
For women with normal cytological findings who were concurrently HPV16 DNA positive at the second examination, the estimated probability of developing CIN grade 3 (CIN3) or worse within 12 years of follow-up was 26.7% (95% confidence interval [CI] = 21.1% to 31.8%). The corresponding risks among those infected with HPV18 was 19.1% (95% CI = 10.4% to 27.3%), with HPV31 was 14.3% (95% CI = 9.1% to 19.4%), and with HPV33 was 14.9% (95% CI = 7.9% to 21.1%). The absolute risk of CIN3 or worse after infection with high-risk HPV types other than HPV16, HPV18, HPV31, or HPV33 was 6.0% (95% CI = 3.8% to 8.3%). The estimated absolute risk for CIN3 or cancer within 12 years of the second examination among women who were HPV16 DNA positive at both examinations was 47.4% (95% CI = 34.9% to 57.5%); by contrast, the risk of CIN3 or worse following a negative Hybrid Capture 2 test was 3.0% (95% CI = 2.5% to 3.5%).
HPV16, HPV18, HPV31, and HPV33 infection and especially HPV16 persistence were associated with high absolute risks for progression to high-grade cervical lesions. The results indicate the potential value of genotyping in cervical cancer screening. Given that HPV DNA-negative women retained their low risk of CIN3 or worse for many years, frequent screening of these women may be unnecessary.
We present data on the use of the Hybrid Capture 2 (HC2) test for the detection of high-risk human papillomavirus (HR HPV) with different thresholds for positivity within a primary screening setting and as a method of triage for low-grade cytology. In the ARTISTIC population-based trial, 18,386 women were screened by cytology and for HPV. Cervical intraepithelial neoplasia lesions of grade two and higher (CIN2+ lesions) were identified for 453 women within 30 months of an abnormal baseline sample. When a relative light unit/cutoff (RLU/Co) ratio of > or = 1 was used as the threshold for considering an HC2 result positive, 15.6% of results were positive, and the proportion of CIN2+ lesions in this group was 14.7%. The relative sensitivity for CIN2+ lesion detection was 93.4%. When an RLU/Co ratio of > or = 2 was used as the threshold, there was a 2.5% reduction in positivity, with an increase in the proportion of CIN2+ lesions detected. The relative sensitivity decreased slightly, to 90.3%. Among women with low-grade cytology, HPV prevalences were 43.7% and 40.3% at RLU/Co ratios of > or = 1 and > or = 2, respectively. The proportions of CIN2+ lesions detected were 17.3% and 18.0%, with relative sensitivities of 87.7% at an RLU/Co ratio of > or = 1 and 84.2% at an RLU/Co ratio of > or = 2. At an RLU/Co ratio of > or = 1, 68.3% of HC2-positive results were confirmed by the Roche line blot assay, compared to 77.2% of those at an RLU/Co ratio of > or = 2. Fewer HC2-positive results were confirmed for 35- to 64-year-olds (50.3% at an RLU/Co ratio of > or = 1 and 63.2% at an RLU/Co ratio of > 2) than for 20- to 34-year-olds (78.7% at an RLU/Co ratio of > or = 1 and 83.7% at an RLU/Co ratio of > 2). If the HC2 test is used for routine screening as an initial test or as a method of triage for low-grade cytology, we would suggest increasing the threshold for positivity from the RLU/Co ratio of > or = 1, recommended by the manufacturer, to an RLU/Co ratio of > or = 2, since this study has shown that a beneficial balance between relative sensitivity and the proportion of CIN2+ lesions detected is achieved at this threshold.
Colposcopic examination frequently includes important (and sometimes severe) psychological reactions in the patients, here discussed in the context of different pathologies detected by this diagnostic technique and cervical screening in general. For many women, the most important of these psychological reactions, anxiety, starts with the first invitation to screening, i.e., well before any colposcopy is planned. Self-evidently, these reactions are aggravated by the detection of abnormal PAP smears that necessitates further examinations. The author discusses the different options, how these reactions can be alleviated by different interventions and expert counseling. All these activities should aim at reducing anxiety in women attending colposcopy, which is an important part of the current state-of-art colposcopic practice.
To determine the risk of incident high-grade cervical intraepithelial neoplasia (CIN) in human papillomavirus (HPV) -positive women with low-grade cytological abnormalities who had a satisfactory normal colposcopy.
A retrospective follow-up study within the NHS HPV/LBC pilot studies.
The NHS Cervical Screening Programme in England.
A total of 1063 HPV-positive women with borderline or mild dyskaryosis who were negative at colposcopy from three sites within the NHS HPV/liquid-based cytology (LBC) pilot studies.
HPV triage took place in 2001/02. In 2009 all information on additional management on HPV-positive/colposcopy-negative women was requested. The rate of disease following a negative colposcopy was calculated, and survival analysis was used to determine whether the grade of referral cytology impacted on risk of subsequent disease. Results were compared with those in women from the same population who had not been HPV triaged.
Incident CIN2 or worse during follow up.
Of 1063 eligible women 965 had documented follow up. The cumulative rate of CIN2+ at 3 years in these women was 4.4% (95% CI 4.0-7.0%); the median time from normal colposcopy to final result was 27 months. There was no significant increase in the risk of future disease associated with age or initial cytology result.
The rate of subsequent high-grade CIN among colposcopically negative triaged women was sufficiently low to justify return to routine recall.
More than ever, clinicians need regularly updated reviews given the continuously increasing amount of new information regarding innovative cervical cancer prevention methods.
A summary is given from recently published meta-analyses on three possible clinical applications of human papillomavirus (HPV)-DNA testing: triage of women with equivocal or low-grade cytological abnormalities; prediction of the therapeutic outcome after treatment of cervical intraepithelial neoplasia (CIN) lesions, and last not but not least, primary screening for cervical cancer and pre-cancer.
Consistent evidence is available indicating that HPV-triage with the Hybrid Capture-2 assay (HC2) is more accurate (significantly higher sensitivity, similar specificity) than repeat cytology to triage women with equivocal Pap smear results. When triaging women with low-grade squamous intraepithelial lesions (LSIL), a reflex HC2 test does not show a significantly higher sensitivity, but a significantly lower specificity compared to a repeat Pap smear. After treatment of cervical lesions, HPV testing easily detects (with higher sensitivity and not lower specificity) residual or recurrent CIN than follow-up cytology. Primary screening with HC2 generally detects 23% (95% confidence interval, CI: 13-23%) more CIN-2, CIN-3, or cancer compared to cytology at cut-off atypical squamous cells of undetermined significance (ASCUS) or LSIL, but is 6% (95% CI: 4-8%) less specific. By combined HPV and cytology screening, a further 4% (95% CI: 3-5%) more CIN-3 lesions can be identified but at the expense of a 7% (95% CI: 5-9%) loss in specificity, in comparison with isolated HC2 screening.
Sufficient evidence exists to recommend HPV testing in triage of women with atypical cytology and in surveillance after treatment of CIN lesions. In the United States, recently reviewed knowledge has resulted in the approval of combined cytology and HC2 primary screening in women older than 30 years. However, in Europe, cytology-based screening still remains the standard screening method. The European screening policy will be reviewed based on the longitudinal results of randomised population trials which are currently underway.
Colposcopy has been shown to be associated with high levels of anxiety, even higher than anxiety levels in women before surgery and similar to the anxiety levels in women following an abnormal screening test for fetal abnormalities. High levels of anxiety before and during colposcopy can have psychological consequences including pain, discomfort and failure to return for follow-up. This review examined interventions aimed at reducing such anxiety. Anxiety associated with colposcopic examination appears to be reduced by a variety of interventions including playing music during colposcopy, videos giving information about colposcopy and viewing the procedure on a TV monitor (video colposcopy).