2006 consensus guidelines for the management of women with abnormal cervical screening tests. J Low Genit Tract Dis. 2007;11:201-222. [PMID: 17917566 DOI: 10.1097/lgt.0b013e3181585870]

Evaluation of any or type-specific persistence of high-risk human papillomavirus for detecting cervical precancer

High-risk human papillomavirus (HR-HPV) testing is increasingly important. We therefore examined the impact on accuracy of repeated versus one-time testing, type-specific versus pooled detection, and assay analytic sensitivity. By using a nested case-control design from the ASCUS-LSIL Triage Study, we selected women with incident cervical intraepithelial neoplasia grade 2 or grade 3 (CIN2/3; n = 325) and a random sample of women with <CIN2 as controls (n = 401). HPV DNA status was assessed using hybrid capture 2 (HC2), a pooled test for 13 HR-HPV types, and the linear array (LA) and the line blot assay (LBA), two PCR-based HPV genotyping assays, at enrollment and the 6-month follow-up visit. The relative sensitivity and specificity for different permutations of multiple measurements were compared to a single measurement using marginal regression models. We found that repeat detection of any HR-HPV (by HC2, LA, or LBA) and of type-specific persistence (by LA or LBA) were significantly more specific but less sensitive than use of a single time point measurement of any HR-HPV. Sensitivity decreased and specificity increased further when testing intervals were increased from 12 to 24 months. Including detection of borderline carcinogenic/noncarcinogenic HPV types with HR-HPV types decreased specificity for repeat measures of HPV with no impact on sensitivity. Similar patterns were observed when we used a CIN3 end point. We conclude that assay performance for detecting incident CIN2/3 was affected by which types were included, the analytic sensitivity of the assay, and the testing interval. These trade-offs need to be considered when assessing the potential overall clinical utility of repeated testing for HR-HPV DNA to identify women at risk for CIN2/3.

Human papillomavirus deoxyribonucleic acid testing in developed countries

Cervical cancer has been largely eliminated in developed countries with the implementation of cytology-based screening programmes that depend on a call-recall system, followed by colposcopy and biopsy, treatment of precancerous lesions and follow up. With the discovery that persistent infection with high-risk human papillomavirus types is necessary for the development of cervical cancer, several tests for human papillomavirus deoxyribonucleic acid have been developed that can identify women at risk. Human papillomavirus deoxyribonucleic acid testing is more sensitive and only slightly less specific than cytology for detecting cervical intraepithelial neoplasia. It is also more reproducible, with the potential for self-sampling. Human papillomavirus genotyping, messenger RNA analysis and other biomarkers can help to further stratify this group and diminish referrals to colposcopy. Initially, human papillomavirus testing was used as an adjunct to cytology for triage of borderline cases, but evidence has shown its superiority as a screening method and in the follow up of women treated for cervical intraepithelial neoplasia.

Health economics of screening for gynaecological cancers

In this chapter, we summarise findings from recent cost-effectiveness analyses of screening for cervical cancer and ovarian cancer. We begin with a brief summary of key issues that affect the cost-effectiveness of screening, including disease burden, and availability and type of screening tests. For cervical cancer, we discuss the potential effect of human papilloma virus vaccines on screening. Outstanding epidemiological and cost-effectiveness issues are included. For cervical cancer, this includes incorporating the long-term effect of treatment (including adverse birth outcomes in treated women who are of reproductive age) into cost-effectiveness models using newly available trial data to identify the best strategy for incorporating human papilloma virus tests. A second issue is the need for additional data on human papilloma virus vaccines, such as effectiveness of reduced cancer incidence and mortality, effectiveness in previously exposed women and coverage. Definitive data on these parameters will allow us to update model-based analyses to include more realistic estimates, and also potentially dramatically alter our approach to screening. For ovarian cancer, outstanding issues include confirming within the context of a trial that screening is effective for reducing mortality and incorporating tests with high specificity into screening into screening algorithms for ovarian cancer.

The clinical meaning of a cervical intraepithelial neoplasia grade 1 biopsy

OBJECTIVE

To determine whether the diagnosis of cervical intraepithelial neoplasia (CIN) grade 1 increases the risk of CIN 3 above what is observed for human papillomavirus (HPV) infection.

METHODS

Using data from the atypical squamous cells of undetermined significance (ASCUS) and low-grade squamous intraepithelial lesions (LSIL) triage study, we compared the 2-year cumulative risk of CIN 3 for women with an enrollment diagnosis of CIN 1 (n=594) (median age 23 years) compared with those with negative histology or no biopsy taken at colposcopy ("no CIN 1," n=570) (median age 24 years). Baseline cervical specimens were tested for carcinogenic HPV by a clinical HPV test and HPV genotypes by polymerase chain reaction. Logistic regression was used to calculate odds ratios (ORs) and 95% confidence intervals (CIs) as a measure of association of enrollment status, including CIN 1 compared with no CIN 1 diagnosis, with 2-year worst outcomes of CIN 3.

RESULTS

The two-year risks of CIN 3 were 10.3% (95% CI 7.9-13.0) for women with CIN 1, 7.3% (95% CI 4.6-10.9) for negative histology, and 6.4% (95% CI 3.8-9.9) for women referred to colposcopy and no biopsies were taken (P=.1). The 2-year risks of CIN 3 for women positive for HPV16, HPV18, or other carcinogenic HPV genotypes were 19.1%, 13.9%, and 5.7%, respectively, and did not differ significantly by the baseline cytology interpretation (ASCUS or LSIL). Taking HPV genotypes into account, having a CIN 1 (compared with no CIN 1) was not a risk factor for developing CIN 3 (OR 0.99, 95% CI 0.54-1.8).

CONCLUSION

A CIN 1 diagnosis does not represent a significant risk factor for CIN 3 above the risk attributed to its molecular cause, genotype-specific HPV infection.

LEVEL OF EVIDENCE

II.

Comparison of the hybrid capture 2 and cobas 4800 tests for detection of high-risk human papillomavirus in specimens collected in PreservCyt medium

Clinical cervical cytology specimens (n = 466) collected in PreservCyt (Hologic Inc.) were used to evaluate the agreement between Hybrid Capture 2 (hc2; Qiagen) and cobas 4800 (c4800; Roche Molecular Diagnostics) for the detection of high-risk human papillomavirus (HR HPV) genotype infections. The agreement between the two assays was 93.8% (kappa = 0.87; 95% confidence interval, 0.828 to 0.918), with 186 and 251 concordant positive and negative results, respectively. All 186 concordant positives were confirmed using the Linear Array (LA; Roche Molecular Diagnostics) genotyping test. Of the 29 samples with discordant results (6.2%), 18 were hc2 positive and LA verified 17 as positive for HR HPV. Eleven discordant specimens were c4800 positive, and LA confirmed 5 as positive for HR HPV. As of October 2009, practice guidelines in Alberta, Canada, recommend reflex HPV testing for women over 30 years old with atypical squamous cells of undetermined significance (ASCUS) and for women over 50 years old with low-grade squamous intraepithelial lesions (LSIL) to help prioritize those who should undergo further evaluation. In this study, agreement between hc2 and c4800 results for samples from women over 30 years old with ASCUS cytology was 92.3% (n = 13), while no samples from women over 50 years old with LSIL cytology were identified for analysis.

Prevalence of human papillomavirus infection in women in Benin, West Africa

BACKGROUND

Cervical cancer ranks as the first most frequent cancer among women in Benin. The major cause of cervical cancer now recognized is persistent infection of Human Papillomavirus (HPV). In Benin there is a lack of screening programs for prevention of cervical cancer and little information exists regarding HPV genotype distribution.

METHODS

Cervical cells from 725 women were examined for the presence of viral DNA by means of a polymerase chain reaction (PCR) multiplex-based assay with the amplification of a fragment of L1 region and of E6/E7 region of the HPV genome, and of abnormal cytology by Papanicolaou method. The association between HPV status and Pap test reports was evaluated. Socio-demographic and reproductive characteristics were also related.

RESULTS

A total of 18 different HPV types were identified, with a prevalence of 33.2% overall, and 52% and 26.7% among women with and without cervical lesions, respectively. Multiple HPV infections were observed in 40.2% of HPV-infected women. In the HPV-testing group, the odds ratio for the detection of abnormal cytology was 2.98 (95% CI, 1.83-4.84) for HPV positive in comparison to HPV negative women. High risk types were involved in 88% of infections, most notably HPV-59, HPV-35, HPV-16, HPV-18, HPV-58 and HPV-45. In multiple infections of women with cytological abnormalities HPV-45 predominated.

CONCLUSIONS

This study provides the first estimates of the prevalence of HPV and type-specific distribution among women from Benin and demonstrates that the epidemiology of HPV infection in Benin is different from that of other world regions. Specific area vaccinations may be needed to prevent cervical cancer and the other HPV-related diseases.

Human papillomavirus and Papanicolaou tests screening interval recommendations in the United States

OBJECTIVE

Guidelines recommend when the human papillomavirus (HPV) and Papanicolaou tests are used together (HPV co-test) for routine cervical cancer screening, screening intervals can be extended to 3 years. We assessed HPV test practices and Papanicolaou test screening interval recommendations of US providers.

STUDY DESIGN

Using a multistage probability design, we analyzed nationally representative data that were collected in 2006 through the Centers for Disease Control and Prevention's National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey.

RESULTS

Approximately 51% of providers ordered the HPV co-test; however, clinical vignettes found that <15% of providers who ordered the HPV test recommend the next Papanicolaou test in 3 years for women with concurrent normal HPV co-test results and a documented normal screening history.

CONCLUSION

Overall, annual cervical cancer screening continues to be a common recommendation, regardless of whether a screening history has been established or an HPV test has been ordered.

Gynecologic Cytology Proficiency Testing Failures: What Have We Learned?: Observations From the College of American Pathologists Gynecologic Cytology Proficiency Testing Program

Context.—In 2006, the first gynecologic cytology proficiency tests were offered by the College of American Pathologists. Four years of data are now available using field-validated slides, including conventional and liquid-based Papanicolaou tests.

Objective.—To characterize the pattern of error types that resulted in initial proficiency-test failure for cytotechnologists, primary screening pathologists, and secondary pathologists (those whose slides are prescreened by cytotechnologists).

Design.—The results of 37 029 initial College of American Pathologists Papanicolaou proficiency tests were reviewed from 4 slide-set modules: conventional, ThinPrep, SurePath, or a module containing all 3 slide types.

Results.—During this 4-year period, cytotechnologists were least likely to fail the initial test (3.4%; 614 of 18 264), followed by secondary pathologists (ie, those reviewing slides already screened by a cytotechnologist) with a failure rate of 4.2% (728 of 17 346), and primary pathologists (ie, those screening their own slides) having the highest level of failure (13.7%; 194 of 1419). Failure rates have fallen for all 3 groups over time. Pathologists are graded more stringently on proficiency tests, and more primary pathologists would have passed if they had been graded as cytotechnologists. There were no significant differences among performances using different types of slide sets. False-positive errors were common for both primary (63.9%; 124 of 194 errors) and secondary (55.6%; 405 of 728 errors) pathologists, whereas automatic failures were most common for cytotechnologists (75.7%; 465 of 614 errors).

Conclusions.—The failure rate is decreasing for all participants. The failures for primary pathologist screeners are due to false-positive responses. Primary screening cytotechnologists and secondary pathologists have automatic failures more often than do primary screening pathologists.

Assessment of knowledge and stigmatizing attitudes related to human papillomavirus among Hong Kong Chinese healthcare providers

OBJECTIVE

To assess knowledge and stigmatizing attitudes related to human papillomavirus (HPV) and HPV testing among Chinese healthcare providers in Hong Kong.

METHODS

Between May and September 2010, an anonymous self-administered questionnaire was sent to 247 doctors, nurses, and smear-taking trainees providing cervical screening in Hong Kong.

RESULTS

In total, 137 questionnaires were returned. Most participants had basic knowledge about HPV infection and HPV vaccination. Only about 33% knew that high-risk HPV does not cause genital warts, infection is most common among young women, or infected individuals might not have any identifiable sexual risk factors. Regarding HPV testing, 6 of 7 knowledge items were answered incorrectly by many participants (≥ 50%), highlighting a lack of understanding of the indications for HPV testing and the implications of a positive result. About 30% of participants agreed that individuals with HPV infection were sexually easy, responsible for their infection, or had more than 1 sexual partner. More knowledge about HPV infection predicted less stigmatizing attitudes.

CONCLUSION

Continued education on HPV and HPV testing is needed for frontline healthcare providers of screening in Hong Kong. The stigmatizing attitudes toward HPV-infected individuals warrant further exploration of the impact of HPV infection on patient care and interventions.

Comparative performance of human papillomavirus DNA testing using novel sample collection methods

To explore alternative cervical cancer screening approaches in an underserved population, we compared the performance of human papillomavirus (HPV) DNA assays in combination with different sample collection methods for primary cervical screening in the Mississippi Delta region. Three specimens were collected from women aged 26 to 65 years who were either routinely undergoing screening (n = 252) or not (n = 191): clinician-collected cervical specimens, clinician-collected cervicovaginal specimens, and self-collected cervicovaginal specimens taken at home. A novel collection device and medium were used for cervicovaginal sampling. Specimens were tested by three HPV DNA assays: hybrid capture 2 (HC2; Qiagen Corp., Gaithersburg, MD), Linear Array (LA; Roche Molecular Systems, Pleasanton, CA), and Amplicor (Roche Molecular Systems, Pleasanton, CA). Liquid-based cytology was performed on cervical specimens. We compared the overall positivity (a proxy for clinical specificity) for any carcinogenic HPV genotype and calculated the agreement across assay and specimen type using McNemar's test for differences in test positivity. Across all three assays there were no significant differences between clinician-collected and self-collected cervicovaginal specimens (P > 0.01 for all comparisons). For both cervicovaginal specimens (clinician collected and self-collected), fewer women tested positive by HC2 than by LA or Amplicor (P < 0.01 for all comparisons). HC2 had the best agreement between specimens for all assays. HC2 is likely more clinically specific, although possibly less sensitive, than either PCR test. Thus, use of HC2 on cervicovaginal specimens for screening could result in fewer referrals compared to LA and Amplicor.

A randomized controlled trial of subantimicrobial-dose doxycycline to prevent unscheduled bleeding with continuous oral contraceptive pill use

BACKGROUND

Unscheduled bleeding is the main side effect of continuous oral contraceptive pills (OCPs) and has been correlated with the up-regulation of matrix metalloprotineases (MMPs). The study objective was to determine if prophylactic administration of doxycycline (an MMP inhibitor at low subantimicrobial doses) would prevent unscheduled bleeding during the initiation of a continuous OCP.

STUDY DESIGN

Subjects using cyclic hormonal contraceptives (combined OCPs, patch or ring) without unscheduled bleeding were switched to continuous OCPs (20 mcg ethinyl estradiol/100 mcg levonorgestrel). They were randomized to receive daily doxycycline [sustained-release subantimicrobial dose (40 mg daily)] or placebo for the first 84 days and then observed for an additional 28 days on the continuous OCP alone. The number of bleeding/spotting days and the time in days it took to achieve amenorrhea were compared using a t test.

RESULTS

Sixty-five subjects were randomized. Although the use of doxycycline did not significantly decrease the number of mean bleeding/spotting days in the first 84 days of the study [doxycycline 14.75 (SE 2.30), placebo 17.78 (2.31), p=.36], women who received doxycycline had a significantly earlier onset of amenorrhea [mean last day of bleeding/spotting doxycycline 61.7 (7.7), placebo 85.2 (6.7), p=.03].

CONCLUSION

The coadministration of subantimicrobial-dose doxycycline during initiation of continuous OCPs results in a significant reduction in the length of time needed to achieve amenorrhea.

Low-risk human papillomavirus testing and other nonrecommended human papillomavirus testing practices among U.S. health care providers

OBJECTIVE

To assess self-reported human papillomavirus (HPV) DNA testing practices by health care providers and clinics, including nonrecommended practices such as low-risk HPV testing, HPV cotesting in women younger than age 30 years, and HPV reflex testing for high-grade abnormal Pap test results.

METHODS

We analyzed responses to a cross-sectional survey of a nationally representative sample of Papanicolaou test providers administered in conjunction with the 2006 National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey. Data analysis was performed on responses from 376 office-based health care providers and 216 outpatient clinics.

RESULTS

Overall, 75.5% (95% confidence interval [CI] 68.7-81.2%) of health care providers and 77.2% (95% CI 60.3-88.3%) of clinics reported ever using the HPV DNA test. Of health care providers who used HPV testing, 28.5% (95% CI 21.6-36.6%) used both high-risk and low-risk HPV tests. Most health care providers (59.6%, 95% CI 48.5-69.7%) and clinics (66.0%, 95% CI 48.0-80.3%) used HPV cotesting in women younger than age 30 years. A high percentage of health care providers and clinics performed reflex HPV testing after Pap test results of atypical squamous cells, cannot exclude high-grade squamous intraepithelial lesions (71.4%, 95% CI 63.5-78.3% and 62.8%, 95% CI 49.0-74.9%, respectively) and high-grade squamous intraepithelial lesions (50.7%, 95% CI 42.4-58.9% and 49.0%, 95% CI 33.1-65.2%, respectively), results for which HPV testing is not recommended.

CONCLUSION

Many health care providers reported inappropriate uses of HPV testing, which may lead to unnecessary follow-up and increased medical costs without added benefits. Interventions such as eliminating the low-risk HPV test from the U.S. market and educating health care providers and patients on appropriate indications for HPV testing are needed to discourage health care providers from such practices.

Colposcopy in special circumstances: Pregnancy, immunocompromise, including HIV and transplants, adolescence and menopause

The true value of colposcopy in pregnancy is under debate; the examination may be more difficult depending on the gestation at which a woman presents. Cervical intraepithelial neoplasia does not have an accelerated progression during pregnancy, and treatment is usually deferred until postpartum. The prevalence of cervical intraepithelial neoplasia is greater in women with immune compromise. Those with human immunodeficiency have a higher prevalence, more persistence and less regression of human papillomavirus-related infections. Cervical cancer remains an AIDS-defining illness. Women who have had renal transplants also have a higher risk of developing cervical intraepithelial neoplasia. By contrast, other chronic illnesses that require immunosuppressant therapy do not seem to show this added risk. In young women, human papillomavirus infection is common and cervical intraepithelial neoplasia is also evident, but regression of these lesions is frequent and so conservative review may be appropriate. At the menopause, colposcopy is often unsatisfactory. The use of human papillomavirus testing for triage of low-grade cytological abnormalities may benefit this age group.

Objective perspective in colposcopy

Colposcopy is a widely used diagnostic procedure, primarily in the assessment of women with abnormal cervical cytology. It is used by appropriately trained individuals using techniques that allow a full assessment of the abnormality and plan for further investigation or treatment. Certain key features are specifically looked for, and a colposcopic impression formed. Using a systematic approach to the colposcopic assessment can improve the diagnostic accuracy. In this chapter, we review various factors and meta-analyses in relation to the diagnostic performance of colposcopy. Newer technologies are being developed that will assist the clinician in assessing the colposcopic changes. Quality assurance of the training and practise of colposcopy is important to maintain appropriate management for women with cytological abnormalities.

Clinical experience with the Cervista HPV HR assay: correlation of cytology and HPV status from 56,501 specimens

Testing for high-risk (HR) human papillomavirus (HPV) is a key component of current recommendations for cervical cancer screening. Herein is described our clinical experience using Cervista HPV HR, a testing platform recently approved by the US Food and Drug Administration for clinical use. Using data from a high-volume commercial laboratory, a retrospective analysis of cytologic and Cervista HPV HR test results from 56,501 samples was performed, and an indirect comparison was made with previous experience with 53,008 samples tested using the Hybrid Capture 2 platform. Of samples analyzed using Cervista HPV HR, 1.5% were of insufficient volume for testing and 1.1% yielded an insufficient signal from the internal control to be reported. In samples with a cytological interpretation of atypical squamous cells of undetermined significance, 48.5% (95% confidence interval [CI], 47.5 to 49.5) tested positive using Cervista HPV HR, compared with 59.4% (95% CI, 58.3 to 60.5) of samples using Hybrid Capture 2. Of samples from women aged 30 years or older with a negative cytological interpretation, 5.8% (95% CI, 5.6 to 6.1) tested positive using Cervista HPV HR, compared with 5.5% (95% CI, 5.3 to 5.7) of samples using Hybrid Capture 2. When stratified by five-year age groups between 30 and 65 years, positivity rates for high-risk human papillomavirus were similar in the Cervista HPV HR and Hybrid Capture 2 populations, and were consistent with expectations established by the literature.

Evaluation of a new DNA test for detection of carcinogenic human papillomavirus

Using archived specimens, we evaluated a new automated real-time PCR assay (BD Diagnostics) that detects all carcinogenic human papillomaviruses (HPV) and provides HPV genotyping for seven of them, including HPV16 and HPV18, the two most carcinogenic HPV genotypes. We found comparable results with Hybrid Capture 2 (HC2) for detection of carcinogenic HPV (n = 473) and with Linear Array and Line Blot Assay (n = 371) for detection of individual HPV genotypes.

Human papillomavirus (HPV) genotypes in women with cervical precancer and cancer at Kaiser Permanente Northern California

BACKGROUND

The human papillomavirus (HPV) Persistence and Progression Cohort is a natural history study of carcinogenic HPV positive women. Here, we present the HPV genotypes found in first ∼500 cases of cervical intraepithelial neoplasia grade 3 (CIN3) or more severe disease (CIN3+) diagnosed at the study baseline.

METHODS

Women aged 30 and older were screened for cervical cancer using Pap smears and tested for carcinogenic HPV using Hybrid Capture 2 (HC2; Qiagen). We randomly selected women who tested HPV positive and were diagnosed with CIN3+ (n = 448) or without CIN3+ (

RESULTS

Among HC2-positive women, HPV16 (48.9%), HPV31 (9.2%), and HPV18 (8.5%) were the most common HPV genotypes in CIN3+. There was a decrease at older ages in the fraction of CIN3 (P(trend) = 0.006), adenocarcinoma in situ (AIS) (P(trend) = 0.08), and CIN3/AIS (P(trend) = 0.002) associated with HPV16. Compared to the other carcinogenic HPV genotypes in aggregate, HPV18 was strongly associated with CIN3+ in women with a normal Pap [odds ratio (OR) = 5.7, 95% CI = 1.2-26] but not in women with abnormal Pap (OR = 1.3, 95% CI = 0.74-2.3).

CONCLUSIONS

HPV16 is more strongly associated with cervical precancer diagnosed in younger women (vs. older women). HPV18 infections were linked to precancerous lesions that were missed by cytology.

IMPACT

The progression timeline of HPV16 differs from other carcinogenic HPV genotypes, which may impact the use of HPV16 detection in the management of HPV-positive women.

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Key Words

• pap
• cervical intraepithelial neoplasia (cin)
• cervical cancer
• human papillomavirus (hpv)
• atypical squamous cells of undetermined significance (asc-us)
• hybrid capture 2 (hc2)

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MESH Headings

• Adenocarcinoma/genetics
• Adenocarcinoma/pathology
• Adenocarcinoma/virology
• Adult
• California
• Carcinoma, Squamous Cell/genetics
• Carcinoma, Squamous Cell/pathology
• Carcinoma, Squamous Cell/virology
• Cohort Studies
• DNA, Viral/genetics
• Female
• Genotype
• Humans
• Papanicolaou Test
• Papillomaviridae/classification
• Papillomaviridae/genetics
• Papillomavirus Infections/genetics
• Papillomavirus Infections/pathology
• Papillomavirus Infections/virology
• Polymerase Chain Reaction
• Precancerous Conditions/genetics
• Precancerous Conditions/pathology
• Precancerous Conditions/virology
• Prognosis
• Risk Factors
• Uterine Cervical Neoplasms/genetics
• Uterine Cervical Neoplasms/pathology
• Uterine Cervical Neoplasms/virology
• Vaginal Smears
• Uterine Cervical Dysplasia/genetics
• Uterine Cervical Dysplasia/pathology
• Uterine Cervical Dysplasia/virology

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Grants

• R01 CA078527 NCI NIH HHS
• U01 CA078527 NCI NIH HHS
• Z01 CP010124 Intramural NIH HHS
• Z01 CP010124-12 Intramural NIH HHS

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Affiliation(s)

Philip E Castle Division of Cancer Epidemiology and Genetics, National Cancer Institute, NIH, DHHS, Bethesda, Maryland, USA.
Ruth Shaber
Brandon J LaMere
Walter Kinney
Barbara Fetterma
Nancy Poitras
Thomas Lorey
Mark Schiffman
Anne Dunne
Janae M Ostolaza
Sharod McKinney
Robert D Burk

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The accuracy of colposcopic biopsy: analyses from the placebo arm of the Gardasil clinical trials

We evaluated the overall agreement between colposcopically directed biopsies and the definitive excisional specimens within the context of three clinical trials. A total of 737 women aged 16-45 who had a cervical biopsy taken within 6 months before their definitive therapy were included. Per-protocol, colposcopists were to also obtain a representative cervical biopsy immediately before definitive therapy. Using adjudicated histological diagnoses, the initial biopsies and the same day biopsies were correlated with the surgically excised specimens. The overall agreement between the biopsies taken within 6 months of definitive therapy, and the definitive therapy diagnoses was 42% (weighted kappa = 0.34) (95% CI: 0.29-0.39). The overall underestimation of cervical intraepithelial neoplasia grade 2/3 or adenocarcinoma in situ (CIN2-3/AIS) and CIN3/AIS was 26 and 42%, respectively. When allowing for one degree of variance in the correlation, the overall agreement was 92% for CIN2-3/AIS. The overall agreement between the same day biopsy and definitive therapy specimen was 56% (weighted kappa = 0.41) (95% CI: 0.36-0.47), and the underestimation of CIN2-3/AIS was 57%. There were significant associations in the agreement between biopsies and excisional specimen diagnoses when patients were stratified by age, number of biopsies, lesion size, presence of human papillomavirus (HPV)16/18 and region. Of 178 diagnostic endocervical curettages performed, 14 (7.9%) found any HPV disease. Colposcopic accuracy improved when CIN2 and CIN3/AIS were grouped as a single predictive measure of high-grade disease. Colposcopy functioned well when allowed a one-degree difference between the biopsy and the surgical histologic interpretations, as done in clinical practice. Taking more than one biopsy improved colposcopic accuracy and could improve patient management.

Combined promoter methylation analysis of CADM1 and MAL: an objective triage tool for high-risk human papillomavirus DNA-positive women

PURPOSE

Screening women for high-grade cervical intraepithelial neoplasia or cervical cancer (CIN3(+)) by high-risk human papillomavirus (hrHPV) testing has as side-effect the detection of hrHPV-positive women without clinically relevant lesions. Here, we developed an objective assay assessing the methylation status of the promoter regions of CADM1 and MAL to triage hrHPV-positive women for CIN3(+).

EXPERIMENTAL DESIGN

In a training set (51 women with CIN3(+) and 224 without CIN2(+)), panels consisting of one to four quantitative methylation-specific PCR (qMSP) assays (CADM1-m12,CADM1-m18,MAL-m1,MAL-m2) were analyzed. Cross-validated receiver-operating characteristics (ROC) curves were constructed and the panel with highest partial cross-validated area under the curve (AUC) was used for validation in an independent set of 236 consecutive hrHPV-positive women from a screening cohort. In the validation set, the ROC curve of the panel was compared with CIN3(+) sensitivity and specificity of cytology and of cytology combined with HPV16/18 genotyping.

RESULTS

In the training set, CADM1-m18 combined with MAL-m1 was the best panel (cross-validated partial AUC = 0.719). In the validation set, this panel revealed CIN3(+) sensitivities ranging from 100% (95% CI: 92.4-100) to 60.5% (95% CI: 47.1-74.6), with corresponding specificities ranging from 22.7% (95% CI: 20.2-25.2) to 83.3% (95% CI: 78.4-87.4). For cytology these were 65.8% (95% CI: 52.3-79.0) and 78.8% (95% CI: 73.7-83.1) and for cytology/HPV16/18, these were 84.2% (95% CI: 72.0-92.7) and 54.0% (95% CI: 49.2-58.7), respectively. The point estimates of both cytology and cytology/HPV16/18 were equal to the values of the ROC curve of CADM1-m18/MAL-m1.

CONCLUSIONS

We developed an objective methylation marker panel that was equally discriminatory for CIN3(+) as cytology or cytology with HPV16/18 genotyping in hrHPV-positive women. This opens the possibility for complete cervical screening by objective, nonmorphological molecular methods.

Predictors of anal dysplasia in men who have sex with men with benign cytology

PURPOSE

Anal cytology is used to screen patients for anal dysplasia. Anal pap smears are collected without direct visualization of the canal, whereas cervical cytology is obtained with direct visualization. Current screening guidelines dictate that patients with abnormal cytology are to be evaluated with high-resolution anoscopy, and patients with benign anal cytology forgo high-resolution anoscopy. We routinely perform standard anoscopy after cytology collection. We endeavored to determine whether our standard procedure would reveal findings supporting high-resolution anoscopy even with benign cytology.

METHODS

We performed a retrospective chart review of all anal cytology results from January 2008 to March 2009, identifying the patients with benign results who had undergone high-resolution anoscopy. Records were analyzed to determine the indication for high-resolution anoscopy and biopsy results.

RESULTS

We identified 2084 patients with anal cytology results, including 613 (29%) patients who had benign results and 169 (28%) patients who had undergone high-resolution anoscopy. The main reasons for high-resolution anoscopy were high risk of recurrent dysplasia based on prior high-grade squamous intraepithelial lesion with cytology done concurrently in 77 (46%), and abnormal anoscopy findings thought to be indicative of dysplasia (plaque or nodule suspicious of dysplasia, internal or external condyloma, dysplastic appearing fissure) in 92 (54%). Of subjects with abnormal anoscopy findings indicative of dysplasia, 25 (27%) had high-grade and 39 (42%) had low-grade dysplasia. Of those undergoing cytology and high-resolution anoscopy simultaneously, 14 (18%) had high-grade and 12 (16%) had low-grade dysplasia. In total, 90 (53%) of those with benign cytology who had high-resolution anoscopy had abnormal pathology, and 39 (23%) had high-grade dysplasia.

CONCLUSIONS

Men having sex with men can have significant dysplasia with benign cytology. Standard anoscopy identifies findings indicative of dysplasia that, if present, should lead to high-resolution anoscopy even with benign cytology. Standard anoscopy should become an integral part of anal dysplasia screening. Prior recent history of high-grade dysplasia should lead to high-resolution anoscopy even with benign cytology.

Common abnormal results of pap and human papillomavirus cotesting: what physicians are recommending for management

OBJECTIVE

To evaluate the association between physician and practice characteristics and adherence to management guidelines to better understand the factors associated with different screening recommendations by primary care physicians.

METHODS

We used a cross-sectional nationally representative survey of 950 primary care physicians familiar with human papillomavirus (HPV) testing to assess adherence to management guidelines by analyzing responses to two clinical vignettes of a 35-year-old woman who had Pap and HPV tests results: 1) discordant (normal Pap and positive HPV) or 2) mildly abnormal (atypical squamous cells of undetermined significance Pap and negative HPV). Analyses included multivariable logistic regression.

RESULTS

For the discordant test results, 54.3% (95% confidence interval [CI] 51-57.6%) of physicians recommended both Pap and HPV testing in 6-12 months, adhering to management guidelines. For the mildly abnormal results, only 12.2% (95% CI 10-14.7%) had a guideline-adherent recommendation of Pap testing in 12 months with no HPV test. In multivariable analyses, no significant difference among physicians' specialties was observed for the discordant results. For the mildly abnormal results, physician specialty was associated with guideline adherence in which obstetrician-gynecologists had the highest percent of adherence (19.8%) compared with family and general practitioners (9.3%) and internists (11%) (P<.001).

CONCLUSION

Even for the most common abnormal results, many physicians reported recommendations that did not adhere to current management guidelines. Evidence-based interventions are needed to improve adherence to management guidelines for the newer HPV DNA test.

Prevalência de lesões intraepiteliais em atipias de significado indeterminado em um serviço público de referência para neoplasias cervicais

OBJETIVOS: Determinar a prevalência de lesões intraepiteliais de baixo e alto grau, em mulheres com diagnóstico colpocitológico de atipias de significado indeterminado no Município de Maceió, Alagoas. Conhecer a influência da idade e dos agentes etiológicos para doenças sexualmente transmissíveis sobre o risco de desenvolvimento das lesões intraepiteliais de baixo e alto grau. MÉTODOS: Estudo transversal de prevalência em um serviço público de referência para neoplasias cervicais. Foram estudados 253 prontuários de mulheres com diagnóstico de atipias de significado indeterminado, no ano de 2007. RESULTADOS: A prevalência de lesões intraepiteliais foi a de 23,7%, sendo 26,7% de baixo grau e 73,3% de alto grau. CONCLUSÕES: A prevalência de lesões intraepiteliais de alto grau em mulheres com diagnóstico colpocitológico de atipias de significado indeterminado (ASCUS) foi de 23,7%, o aumento do risco foi diretamente proporcional ao da idade e houve maior prevalência de lesão intraepitelial de baixo grau,associada à infecção pelo Papilomavirus humano.

Risk of cervical intraepithelial neoplasia 2+ among women with a history of previous treatment for cervical intraepithelial neoplasia: ASCUS and LSIL Pap smears after treatment

OBJECTIVE

The objective of the current study was to describe outcomes among women with low-grade abnormalities on cervical cytology screening in the setting of previous excisional or ablative treatment for cervical intraepithelial neoplasia (CIN).

METHODS

Study participants were recruited into the Study to Understand Cervical Cancer Early Endpoints and Determinants. At enrollment, the patient's previous cytology results, previous colposcopic biopsy results, and previous cervical procedures were recorded. Study procedures included collection of biospecimens followed by colposcopy and biopsy. From clinical records, additional information regarding previous treatment for CIN was collected.

RESULTS

Two hundred seventy-four women had an atypical squamous cells of uncertain significance (ASCUS) referral Pap and 532 women had a low-grade squamous intraepithelial lesion (LSIL) referral Pap. For patients with an ASCUS referral Pap, previous treatment was associated with an odds ratio for CIN 2+ (45.0% vs 28.2% of untreated patients) of 2.08 (95% confidence interval = 1.05-4.13, p = .04). For patients with an LSIL referral Pap, 33.3% of those women with previous treatment had CIN 2+ compared with 16.7% of those patients enrolled with no previous treatment (odds ratio = 2.49, 95% confidence interval = 1.12-5.51, p = .03).

CONCLUSIONS

Patients with a history of previous treatment for CIN have a 2-fold risk of CIN 2+ at the time of colposcopy referral for ASCUS or LSIL cervical cytology.

The 2006 consensus guidelines for the management of women with abnormal cervical screening tests: challenges remain

The American Society for Colposcopy and Cervical Pathology (ASCCP) guidelines for the management of women with abnormal cervical screening test results is a powerful, evidence-based document representing an advance in the consistent treatment of women with cervical abnormalities. Nevertheless, the complexity of the guidelines is an outstanding issue, compliance with the guidelines is problematic in some areas, and there is a growing recognition of the deficiencies of colposcopy. In light of these challenges, the cytopathology community has an opportunity to play an active role in integrating data, defining risk, and recommending proper management for women screened for cervical cancer.

Informatics methods for laboratory evaluation of HPV ordering patterns with an example from a nationwide sample in the United States, 2003-2009

Background:

Laboratory data is a rich source of information that can be used to estimate adherence to physician guidelines and motivate improvement in clinical practice. Human papillomavirus (HPV) testing is an important component of cervical cancer screening programs with established screening guidelines. The purpose of this study was to develop methods to estimate concordance with published guidelines for HPV testing in order to provide clinicians and payors specific feedback about overscreening.

Methods:

This retrospective analysis of laboratory test ordering patterns evaluated 454,532 HPV tests ordered from September 2003 to October 2009 from 110 facilities and performed at ARUP laboratories. We used laboratory data including patient demographics, ordering frequency, timestamps and results to examine the proportion of HPV tests ordered on women under 21 years, ordered on women between 21 and 29 years apparently before cytological examination, repeated less than 1 year after a positive HPV result in women over 30 years, and repeated less than 3 years after a negative HPV result in women over 30 years.

Results:

The absolute number and proportion of HPV tests performed on women under 21 years declined from 20% in 2005 to 5% in October 2009. The proportion of HPV tests performed women between 21 and 29 years also declined during this period. Approximately one-third of HPV tests performed on women between 21 and 29 years arrived for HPV testing before cervical screening had presumably been completed. The most common follow-up intervals for HPV testing on women over 30 years were 6 months following a positive HPV result and 12 months following a negative HPV result. Only 6% of repeat HPV testing in women over 30 years followed a negative HPV result by 3 years or more. Approximately one-fourth of HPV tests ordered the year ending October 2009 were unnecessary based on the American Society for Colposcopy and Cervical Pathology guideline.

Conclusions:

We demonstrate simple methods to evaluate appropriate utilization of HPV testing using laboratory data. Our data illustrates that some aspects of HPV test ordering have become more consistent with guidelines over time. However, a large portion of HPV testing in the United States is unnecessary. This highlights opportunities for optimization of a rational cancer prevention strategy to reduce unnecessary screening, colposcopy and biopsies.

The age-specific relationships of abnormal cytology and human papillomavirus DNA results to the risk of cervical precancer and cancer

BACKGROUND

To estimate the relationship of human papillomavirus (HPV) detection and abnormal cytology with histologic diagnoses of cervical precancer and cancer.

METHODS

From 2003 to 2008 we examined the HPV, cytology, and diagnostic results from almost one million cervical cancer screenings done on women aged 30 and older who were members in Kaiser Permanente Northern California, a large health maintenance organization that introduced cotesting in 2003. Women were screened using conventional Pap tests and a DNA test for a pool of 13 high-risk HPV genotypes. Women with HPV-positive atypical squamous cells of undetermined significance and other abnormal cervical cytology, independent of their HPV results, routinely underwent colposcopy. Results were stratified by 5-year age groups from 30 to 64.

RESULTS

High-grade squamous intraepithelial lesions (HSIL), atypical squamous cells, cannot exclude HSIL (ASC-H), and atypical glandular cells were more strongly associated with cervical intraepithelial neoplasia grade 3 while low-grade squamous intraepithelial lesions (LSIL) and HPV-positive atypical squamous cells of undetermined significance were more strongly associated with cervical intraepithelial neoplasia grade 2 (CIN2). Cervical cancer was most commonly found in women with HSIL and atypical glandular cells cytology. Human papillomavirus-negative women with ASC-H cytology were at a reduced but significant risk of CIN2 or more severe (CIN2+) (10.6%) compared with HPV-positive women with ASC-H cytology. Human papillomavirus-negative women with LSIL were at a 4.0% risk of CIN2+, and among women 50 and older, at a 0.5% risk of CIN2+ with no cancers were diagnosed.

CONCLUSION

Human papillomavirus testing may be useful for triage for colposcopic referral for LSIL cytology in older women but not for ASC-H cytology at any age.

LEVEL OF EVIDENCE

II.

Surveillance after treatment for cervical intraepithelial neoplasia: outcomes, costs, and cost-effectiveness

OBJECTIVE

To estimate outcomes and costs of surveillance strategies after treatment for high-grade cervical intraepithelial neoplasia (CIN).

METHODS

A hypothetical cohort of women was evaluated after treatment for CIN 2 or 3 using a Markov model incorporating data from a large study of women treated for CIN, systematic reviews of test accuracy, and individual preferences. Surveillance strategies included initial conventional or liquid-based cytology, human papillomavirus testing, or colposcopy 6 months after treatment, followed by annual or triennial cytology. Estimated outcomes included CIN, cervical cancer, cervical cancer deaths, life expectancy, costs, cost per life-year, and cost per quality-adjusted life-year.

RESULTS

Conventional cytology at 6 and 12 months, followed by triennial cytology, was least costly. Compared with triennial cytology, annual cytology follow-up reduced expected cervical cancer deaths by 73% to 77% and had an average incremental cost per life-year gained of $69,000 to $81,000. For colposcopy followed by annual cytology, the incremental cost per life-year gained ranged from $70,000 to more than $1 million, depending on risk. Between-strategy differences in mean additional life expectancy per woman were less than 4 days; differences in mean incremental costs per woman were as high as $822. In the cost-utility analysis, colposcopy at 6 months followed by annual cytology had an incremental cost per quality-adjusted life-year of less than $5,500. Human papillomavirus testing or liquid-based cytology added little to no improvement to life-expectancy with higher costs.

CONCLUSION

Annual conventional cytology surveillance reduced cervical cancers and cancer deaths compared with triennial cytology. For high risk of recurrence, a strategy of colposcopy at 6 months increased life expectancy and quality-adjusted life expectancy. Human papillomavirus testing and liquid-based cytology increased costs, but not effectiveness, compared with traditional approaches.

Cost-effectiveness of using human papillomavirus 16/18 genotype triage in cervical cancer screening

OBJECTIVE

Testing for human papillomavirus (HPV) 16 and 18 genotypes, which are known to cause approximately 65-70% of invasive cervical cancer cases, may allow clinicians to identify women at highest risk for underlying cervical intraepithelial neoplasia missed by Pap cytology. Our objective was to determine the cost-effectiveness of adding HPV-16 and 18 genotype triage to current cervical cancer screening strategies in the United States.

METHODS

We developed a lifetime Markov model to assess the cost-effectiveness of the following cervical cancer screening algorithms: (1) liquid-based cytology (LBC), (2) LBC+HPV triage, (3) HPV+LBC triage, (4) co-screening, (5) co-screening+HPV genotyping, and (6) HPV only+HPV genotyping. Costs were estimated from a payer perspective in 2007 U.S. dollars. Outcome measures included lifetime risk of cervical cancer, quality-adjusted life years saved (QALYs), and incremental cost-effectiveness ratios (ICERs).

RESULTS

In our model, the use of HPV genotyping strategies prevented 51-73 deaths per 100,000 women screened compared to screening using LBC followed by HPV triage and 4-26 deaths compared to co-screening with LBC and high-risk HPV. Use of HPV genotyping to triage all high-risk HPV-positive women every three years had an ICER of $34,074 per QALY compared to HPV and LBC co-screening. HPV genotyping with co-screening was the most effective strategy and had an ICER of $33,807 per QALY compared to HPV genotyping for all high-risk HPV-positive women.

CONCLUSION

The addition of HPV-16 and -18 genotype triage to HPV and LBC co-screening was a cost-effective screening strategy in the United States.

Comparison of measurements of human papillomavirus persistence for postcolposcopic surveillance for cervical precancerous lesions

OBJECTIVE

Following guidelines, women evaluated by colposcopy, but not found to have a precancerous lesion, could be tested again at 12 months for carcinogenic human papillomavirus (HPV). Compared with pooled-probe testing, measuring HPV genotype-specific persistence might better predict subsequent grade 3 cervical intraepithelial neoplasia (CIN3).

METHODS

For women enrolled in the immediate colposcopy arm of the Atypical squamous cells of undetermined significance (ASCUS) and Low-grade squamous intraepithelial lesion (LSIL) Triage Study (ALTS), who underwent enrollment colposcopy but were without prevalently detected CIN2 or worse (CIN2+; n = 671), we compared 1-year HPV persistence, as measured by a pooled HPV genotype test (hybrid capture 2; hc2) versus a research PCR HPV genotyping test (line blot assay; LBA) as predictors of "missed prevalent" or possibly incident CIN3 diagnosed between 12 and 24 months.

RESULTS

Thirty-two (4.8%) women were diagnosed with subsequent CIN3. Testing repeatedly hc2-positive (hc2+) was more common (49.0%) than genotype-specific persistence as detected by LBA (30.3%, P < 0.01). Although absolute risks of CIN3 following repeat hc2+ or genotype-specific persistence were similar (8.8% versus 8.4%, P = 0.86), repeat hc2+ was more sensitive for identifying CIN3 than genotype-specific persistence (90.6% versus 53.1%, P < 0.01). Among 329 women repeatedly hc2+, women with persistent HPV16 were at higher risk of CIN3 than non-HPV16-persistent women (23.1% versus 7.0%, P < 0.01).

CONCLUSIONS

For postcolposcopy management, 1-year HPV persistence as measured by hc2 would recall more women but was more sensitive and similarly predictive for CIN3 in the following year than detection of genotype-specific persistence by LBA.

IMPACT

Although find little utility for measuring type-specific persistence, testing for persistent HPV16 might be clinically useful.

Quantitative DNA methylation analysis detects cervical intraepithelial neoplasms type 3 and worse

BACKGROUND

DNA methylation may be used a potential biomarker for detecting cervical cancer. The authors of this report used quantitative methylation analysis of 4 genes in a full spectrum of cervical lesions to test its potential clinical application.

METHODS

This hospital-based, retrospective, case-control study was conducted in 185 patients and included patients who had a normal uterine cervix (n = 53), cervical intraepithelial neoplasm type 1 (CIN1) (n = 37), CIN2 (n = 22), CIN3 (n = 24), carcinoma in situ (CIS) (n = 22), squamous cell carcinoma (SCC, n = 20), and adenocarcinoma (AC) (n = 7). Methylation levels of the genes sex-determining region Y, box 1 (SOX1); paired box gene 1 (PAX1); LIM homeobox transcription factor 1α (LMX1A), and NK6 transcription factor-related locus 1 (NKX6-1) were determined by using real-time methylation-specific polymerase chain reaction (PCR) amplification. Cutoff values of the percentage of methylation reference (PMR) for different diagnoses were determined to test the sensitivity and specificity and to generate receiver operating characteristic (ROC) curves. Two-sided Mann-Whitney U tests were used to test differences in PMR between groups.

RESULTS

The PMRs of the 4 genes were significantly higher in CIN3 and worse (CIN3+) lesions than the PMRs in specimens of normal cervix and CIN1 or CIN2 (P < .001). ROC curve analysis demonstrated that the sensitivity, specificity, and accuracy for detecting CIN3+ lesions were 0.88, 0.82, and 0.95, respectively, for SOX1; 0.78, 0.91, and 0.89, respectively, for PAX1; 0.77, 0.88, and 0.90, respectively, for LMX1A; and 0.93, 0.97, and 0.97, respectively, for NKX6-1.

CONCLUSIONS

The current results indicated that quantitative PCR-based testing for DNA methylation of 4 genes holds great promise for cervical cancer screening and warrants further population-based studies using standardized DNA methylation testing.

A weakly positive human papillomavirus Hybrid Capture II result correlates with a significantly lower risk of cervical intraepithelial neoplasia 2,3 after atypical squamous cells of undetermined significance cytology

OBJECTIVE

The Hybrid Capture II assay (hc2; QIAGEN, Inc) for high-risk human papillomavirus (hrHPV) is an in vitro nucleic acid hybridization assay using chemiluminescence for the qualitative detection of hrHPV DNA in cervical samples. Results are reported as a ratio of relative light units (RLUs) to a cutoff value based on a positive control. Specimens with RLU ratios of 1.0 or higher are scored positive for hrHPV. We tested the hypothesis that hrHPV positives with low-positive RLU ratios (1-10) had a lower prevalence of cervical intraepithelial neoplasia 2,3 (CIN 2,3) on histologic follow-up.

MATERIALS AND METHODS

Relative light unit ratios for 388 consecutive hrHPV-positive cervical cytologic specimens interpreted as atypical squamous cells of undetermined significance (ASCUS) were reviewed. Individual RLU ratios were compared with outcome histologic diagnosis in cases with colposcopic follow-up and tissue sampling (biopsy and/or endocervical curettage; n = 236).

RESULTS

Of 236 cases with histologic follow-up, 63 had RLU ratios in the range of 1 to 10; of these, 53 (84.1%) were negative for CIN, 7 (11.1%) had CIN 1, 1 (1.6%) had CIN of uncertain grade, and 2 (3.2%) had CIN 2,3. The difference in CIN 2,3 outcome between RLU ratios of 1 to 10 (3.2%) versus over 10 (17.3%) was significant (p =.0047). The difference in prevalence of CIN 1 was not significant (p =.67).

CONCLUSIONS

An RLU ratio of 10 or less was associated with a significantly lower prevalence of CIN 2,3 on biopsy outcome after a Pap test result of ASCUS. The much lower prevalence of underlying CIN 2,3 in patients who are weakly HPV-positive may justify modification of the management algorithm for this subset of women with ASCUS.

Detection of TERC amplification in cervical epithelial cells for the diagnosis of high-grade cervical lesions and invasive cancer: a multicenter study in China

Because the activation of telomerase is a relatively early event in the progression of cervical carcinogenesis, the expression of the human telomerase RNA gene, TERC, has the potential to serve as a biomarker for both the diagnosis and prognosis of cervical neoplasias. In total, 83 research centers participated in the study, and 7786 patients were enrolled. TERC amplification was detected using a dual-color fluorescence in situ hybridization (FISH) probe set, and these results were compared with cytological and histological results, testing for high-risk human papillomavirus (HPV) DNA (n = 2316 for the HPV DNA test), as well as patient age. TERC amplification was found to be increased in more advanced cases of cervical carcinogenesis. Moreover, a Youden's index value and the area under the receiver operating characteristic (ROC) curve were also calculated for samples with TERC amplification and found to be higher than the same values calculated for both cytology and high-risk HPV analyses of the same samples. With regard to cytological ASCUS and LSIL findings, the combination of HPV + TERC testing showed the potential to provide effective triaging to detect CIN2(+). Therefore, TERC amplification represents a valuable genetic biomarker, which in combination with an evaluation of cytology or HPV testing, can achieve higher sensitivity and specificity in distinguishing high-grade cervical lesions and invasive cancers from low-grade lesions compared with conventional methods.

Special commentary: patient safety and the next generation of HPV DNA tests

Human papillomavirus (HPV) testing is more sensitive for the detection of cervical precancer and cancer than cervical cytology. The increased sensitivity of HPV testing and cytology combined ("cotesting") compared to cytology alone permitted professional societies to recommend 3-year screening intervals among the cotest-negative results. However, there is an increasing recognition that both clinical sensitivity and specificity of cervical cancer screening are important to patient safety and must be considered in the context of using current and future HPV DNA tests. Exquisite analytic sensitivity for HPV does not increase clinical sensitivity of an HPV test but does result in excessive test positivity and decreased clinical specificity. A recent US Food and Drug Administration (FDA)-approved HPV test, Cervista (Hologic, Bedford, MA), demonstrated excessive test positivity-2 to 4 times more positive than the other FDA-approved HPV test-from its premarketing approval trial. The poor specificity of Cervista raises questions about the safety and applicability of using this test in routine cervical cancer screening. These data provide a didactic example of the potential dangers of mistaking excellent analytic sensitivity and even clinical sensitivity for good clinical performance.

Detection of oncogenic human papillomavirus impacts anal screening guidelines in men who have sex with men

PURPOSE

It has been shown that testing for oncogenic human papillomavirus (HPV+) improves the sensitivity of cytologic diagnosis of atypical cells of undetermined significance in the cervix and anus, reducing the number of patients requiring colposcopy or high-resolution anoscopy. Some recommend that men who have sex with men with any abnormal cytology undergo high-resolution anoscopy. We endeavored to determine whether HPV testing could predict future high-grade dysplasia (high-grade squamous intraepithelial lesions) and modify screening internals.

METHODS

This investigation was conducted via a retrospective chart review of subjects with atypical cells of undetermined significance anal cytology, high-resolution anoscopy, and HPV testing. Records were abstracted for prior and subsequent screenings.

RESULTS

Four hundred men who have sex with men (285 HIV-) underwent 2224 screenings. Of 224 subjects monitored for >2 years, the hazard ratio for developing high-grade dysplasia was 77% less for men who have sex with men who never had oncogenic HPV (HPV-) vs those who stayed HPV+ (P < .013). The hazard ratio for high-grade dysplasia in those who were HPV- vs those who became HPV- was not different. Risk of high-grade dysplasia was 28% within 6 months of becoming HPV+. The 3-year high-grade dysplasia risk was 15% and 54% for HPV- vs HPV+ subjects (P = .0006). Frequency of high-grade dysplasia in subjects who remained HPV- with predominantly atypical cells of undetermined significance cytology for 1, 2, or 3 years was 2%, 0% and 0% and was 17%, 0%, and 0% in HIV+ subjects. Kaplan-Meier analysis for HIV- subjects with HPV- predominantly atypical cells of undetermined significance cytology for 1 year showed <5% incidence of high-grade dysplasia at 4 years.

CONCLUSIONS

Change in HPV status can predict the risk of high-grade dysplasia. Subjects with predominantly HPV- atypical cells of undetermined significance cytology for 2 years have a decreased risk of high-grade dysplasia. HPV testing when screening for anal dysplasia could alter screening parameters.

Cervical dysplasia in pregnancy: a multi-institutional evaluation

OBJECTIVE

This study was undertaken to identify the prognostic indicators associated with postpartum regression of cervical dysplasia diagnosed in pregnancy.

STUDY DESIGN

A retrospective cohort study of pregnant women referred for colposcopy from 2004-2007 at four academic centers.

RESULTS

One thousand seventy-nine patients were identified. Colposcopic impression by cervical cytology is detailed later in the text. Of patients who underwent biopsy, results correlated with or were less severe than colposcopic impression in 83% with CIN 1 and 56% with CIN 2/3. Fifty-seven percent had follow-up postpartum, with 61% reverting to normal. Resolution of cervical dysplasia was inversely associated with smoking (P = .002). No progression to cancer occurred during pregnancy.

CONCLUSION

Colposcopic impression in pregnancy correlated with cervical biopsy results and postpartum colposcopic findings when performed by expert colposcopists. A high proportion of cervical dysplasia regressed postpartum. Cervical biopsies in pregnancy may not be necessary unless invasive cancer is suspected.

Loop Electrosurgical Excisional Procedure (LEEP) Done for Discrepancy: Does the Time from HGSIL Affect Pathologic Grade of CIN in LEEP Specimen?

Objective. When pathologic discrepancy arises between high-grade cytology on Papanicolaou (Pap) smear and low-grade histology on cervical biopsy, Loop Electrosurgical Excisional Procedure (LEEP) is one management alternative. Our objective was to determine whether the time from initial HGSIL Pap to LEEP affects the pathologic grade of the LEEP specimen. Study Design. We performed a retrospective case-control study identifying LEEPs performed for discrepancy over a 10-year period (1997-2007). 121 subjects were separated into two groups based on LEEP pathology (</=CIN 1 and CIN 2,3) and compared using chi(2). Results. Of the 121 LEEP specimens, 67 (55.4%) had CIN 2,3. CIN 2,3 was more often discovered when LEEP was performed within 3 months of the HGSIL Pap smear versus after 5 months (55.2% versus 16.4%, P = .096). Conclusion. Women undergoing LEEP for discrepancy >5 months from their HGSIL Pap demonstrated a trend toward less CIN 2,3 on LEEP pathology.