Cervical cancer risk for women undergoing concurrent testing for human papillomavirus and cervical cytology: A population-based study in routine clinical practice

Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, DHHS, Bethesda, MD 20882, USA.
The Lancet Oncology (Impact Factor: 24.69). 07/2011; 12(7):663-72. DOI: 10.1016/S1470-2045(11)70145-0
Source: PubMed


Concurrent testing for human papillomavirus (HPV) and cervical cytology (co-testing) is an approved alternative to cytology alone in women aged 30 years and older. We aimed to assess the safety in routine clinical practice of 3-year screening intervals for women testing negative for HPV with normal cytology and to assess if co-testing can identify women at high risk of cervical cancer or cervical intraepithelial neoplasia grade 3 (CIN3) or worse over 5 years.
We assessed the 5-year cumulative incidence, starting in 2003-05, of cervical cancer and CIN3 or worse for 331,818 women aged 30 years and older who enrolled in co-testing at Kaiser Permanente Northern California (Berkeley, CA, USA) and had adequate enrolment co-test results. Follow-up continued until Dec 31, 2009. We defined cumulative incidence to include prevalence at enrolment and incidence after enrolment. Prevalence at enrolment was defined as the ratio of women diagnosed with each outcome on the biopsy visit immediately after their enrolment screening visit to the total enrolled women. At screening visits only HPV test and Pap smear samples were collected, and at biopsy visits colposcopically directed biopsies were taken. To estimate post-enrolment incidence, we used Weibull survival models.
In 315,061 women negative by HPV testing, the 5-year cumulative incidence of cancer was 3.8 per 100,000 women per year, slightly higher than for the 306,969 who were both negative by HPV and Pap testing (3.2 per 100,000), and half the cancer risk of the 319,177 who were negative by Pap testing (7.5 per 100,000). 313,465 (99.5%) women negative by HPV testing had either normal cytology or equivocal abnormalities. Abnormal cytology greatly increased cumulative incidence of CIN3 or worse over 5 years for the 16,757 positive by HPV testing (12.1%vs 5.9%; p<0.0001). By contrast, although statistically significant, abnormal cytology did not increase 5-year risk of CIN3 or worse for women negative by HPV testing to a substantial level (0.86%vs 0.16%; p=0.004). 12,208 (73%) of the women positive by HPV testing had no cytological abnormality, and these women had 258 (35%) of 747 CIN3 or adenocarcinoma in situ, [corrected] 25 (29%) of 87 cancers, and 17 (63%) of 27 adenocarcinomas.
For women aged 30 years and older in routine clinical practice who are negative by co-testing (both HPV and cytology), 3-year screening intervals were safe because a single negative test for HPV was sufficient to reassure against cervical cancer over 5 years. Incorporating HPV testing with cytology also resulted in earlier identification of women at high risk of cervical cancer, especially adenocarcinoma. Testing for HPV without adjunctive cytology might be sufficiently sensitive for primary screening for cervical cancer.
Intramural Research Program of the US National Cancer Institute/NIH/DHHS, and the American Cancer Society.

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    • "Primary hrHPV-based cervical cancer screening is an important scientific and clinical advance because it offers better reassurance of low cancer risk compared to cytology-only cervical cancer screening conducted at the same interval [11]. The effectiveness and safety of HPV-based primary cervical cancer screening has been assessed in large-scale randomized clinical trials performed in several European countries, Canada, and India1213141516171819202122232425 and in screening cohorts with longitudinal follow-up data from Europe and the United States2627282930313233343536373839. According to their results, hrHPV testing as a stand-alone test or in combination with cytology (co-testing) increases the sensitivity for detecting women with underlying cervical intraepithelial neoplasia (CIN) grade 2 or worse (CIN2+) and grade 3 or worse (CIN3+), provides better and longer protection against invasive cervical cancer, and reduces cervical cancer mortality compared to cytology testing alone [12,13,15,18,19,26,32,33,40,41]. "
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    • "Second, we incorporated the findings from our work to better reflect the accuracy of colposcopy (Cantor et al, 2008). Third, if a woman had a Papanicolaou smear result of atypical squamous cells of undetermined significance (ASC-US) and a normal colposcopy result, we assumed that two additional follow-up visits over a 1-year period would also be required (Centers for Disease Control and Prevention, 2011; Katki et al, 2011). Fourth, the sensitivity and specificity for all screening and diagnostic tests were updated based on recently published studies (Goldie et al, 2004; Guillaud et al, 2006; Garner, 2014). "
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