Accuracy of human papillomavirus testing on self-collected versus clinician-collected samples: a meta-analysis

Secondary prevention of cervical cancer

Cervical cancer affects women in their reproductive ages. Screening is an important secondary prevention strategy. The long process of carcinogenic transformation from human papillomavirus (HPV) infection to invasive cancer provides ample opportunities to detect the disease at a stage when treatment is highly effective. Suitable screening tests are cytology, visual inspection after acetic acid application and HPV detection tests. Evidence of effectiveness of the tests to reduce cervical cancer mortality and the cost-effectiveness of screening programs have been demonstrated. Cervical intraepithelial neoplasia grade 2 and grade 3 are the high-grade cervical cancer precursors and need to be treated. Treatment is safe and effective with ablative or excisional techniques. The World Health Organization recommends screening women at least once in a lifetime between 30 and 49 years of age and ensuring effective treatment of the detected abnormalities. Combination of HPV vaccination and population-based screening will be instrumental in eliminating cervical cancer.

Assessing Acceptability of Self-Sampling Kits, Prevalence, and Risk Factors for Human Papillomavirus Infection in American Indian Women

We evaluated the feasibility and acceptability of self-sampling for human papillomavirus (HPV) testing and calculated the prevalence of and risk factors for high-risk (hr) HPV infections in a community-based sample of American Indian women. To this end, we recruited 329 Hopi women aged 21-65 years to self-collect vaginal samples for hrHPV testing. Samples were tested by polymerase chain reaction for 14 hrHPV genotypes. We used Chi square tests to identify correlates of preference for clinician Pap testing versus HPV self-sampling, and age-adjusted Poisson regression to evaluate correlates of hrHPV prevalence. We found that satisfaction with HPV self-sampling was high, with 96 % of women reporting that the sample was easy to collect and 87 % reporting no discomfort. The majority (62 %) indicated that they preferred HPV self-sampling to receiving a Pap test from a clinician. Preference for Pap testing over HPV self-sampling was positively associated with adherence to Pap screening and employment outside the home. All samples evaluated were satisfactory for HPV testing, and 22 % were positive for hrHPV. HrHPV prevalence peaked in the late 20 s and declined with increasing age. HrHPV positivity was inversely associated with having children living the household. In conclusion, HPV self-sampling is feasible and acceptable to Hopi women, and could be effective in increasing rates of cervical cancer screening in Hopi communities. HrHPV prevalence was similar to estimates in the general United States population.

Mailed Human Papillomavirus Self-Collection With Papanicolaou Test Referral for Infrequently Screened Women in the United States

BACKGROUND

Testing for high-risk human papillomavirus (HPV) infection using mailed, self-collected samples is a promising approach to increase screening in women who do not attend clinic screening at recommended intervals.

METHODS

To assess this intervention among high-risk women in the United States, 429 women without a Papanicolaou (Pap) test in 4 or more years (overdue by US guidelines) were recruited from the general population. Participants aged 30 to 65 years were mailed a kit to self-collect a cervicovaginal sample at home, return the sample by mail, and receive HPV results by telephone, with referral to follow-up cytological Pap testing at a local clinic. Cervicovaginal self-samples were collected with a Viba brush, stored in Scope mouthwash, and tested by Hybrid Capture 2. Data were collected in 2010 to 2011 and analyzed in 2017.

RESULTS

Two-thirds (64%) of participants returned a self-collected sample, of whom 15% tested HPV DNA positive. Human papillomavirus self-test-positive women reported higher rates of follow-up Pap tests (82%) than did those with self-test negative results (51%). No demographic differences were found in self-test return rate or HPV positivity. High acceptability was reported in participant surveys: most women (81%) had "mostly positive" overall thoughts about the self-test, and most reported being comfortable receiving the kit in the mail (99%), returning their self-collected sample by mail (82%), and receiving their test results by telephone (97%).

CONCLUSIONS

Conducting HPV self-testing through population-based recruitment, mailed kit delivery and return by mail, and results delivery by telephone has the potential to reach a broad segment of US underscreened women.

"They Should Be Asking Us": A Qualitative Decisional Needs Assessment for Women Considering Cervical Cancer Screening

In this study, we examine from multiple perspectives, women's shared decision-making needs when considering cervical screening options: Pap testing, in-clinic human papillomavirus (HPV) testing, self-collected HPV testing, or no screening. The Ottawa Decision Support Framework guided the development of the interview schedule. We conducted semi-structured interviews with seven screen-eligible women and five health care professionals (three health care providers and two health system managers). Women did not perceive that cervical screening involves a "decision," which limited their knowledge of options, risks, and benefits. Women and health professionals emphasized how a trusted primary care provider can support women making a choice among cervical screening modalities. Having all cervical screening options recommended and funded was perceived as an important step to facilitate shared decision making. Supporting women in making preference-based decisions in cervical cancer screening may increase screening among those who do not undergo screening regularly and decrease uptake in women who are over-screened.

Safety and acceptability of human papillomavirus testing of self-collected specimens: A methodologic study of the impact of collection devices and HPV assays on sensitivity for cervical cancer and high-grade lesions

BACKGROUND

Comparative data on different self-collection methods is limited.

OBJECTIVES

To assess the impact of hrHPV testing of two self-collection devices for detection of cervical carcinoma and high-grade lesions.

STUDY DESIGN

Three hundred ten patients collected two cervicovaginal specimens using a brush (Evalyn^®Brush) and a swab (FLOQSwabs™), and filled a questionnaire at home. Then, a physician at the clinic took a cervical specimen into PreservCyt^® buffer for hrHPV testing and cytology. All specimens were tested using Anyplex™ II HPV28, Cobas^® 4800 HPV Test and Xpert^®HPV.

RESULTS

Performance comparison included 45 cervical carcinomas and 187 patients with premalignant lesions. Compared to the physician-specimen, hrHPV testing of Evalyn^®Brush showed non-inferior sensitivity for CIN3+ (relative sensitivity of Anyplex™ 0.99; Cobas^® 0.96; Xpert^®HPV 0.97) while hrHPV testing of FLOQSwabs™ showed inferior sensitivity (relative sensitivity of Anyplex™ 0.91; Cobas^® 0.92; Xpert^®HPV 0.93). Similar results were observed for invasive carcinomas albeit that FLOQSwabs™ was statistically non-inferior to the physician-specimen. Self-collection by either Evalyn^®Brush or FLOQSwabs™ was more sensitive for CIN3+ than LSIL or worse cytology. Significant decrease in sensitivity for CIN3+ were observed for FLOQSwabs™ when specimens were preprocessed for hrHPV testing after 28 days. Both devices were well accepted, but patients considered Evalyn^®Brush easier and more comfortable than FLOQSwabs™.

CONCLUSIONS

Self-collection is comparable to current screening practice for detecting cervical carcinoma and CIN3+ but device and specimen processing effects exist. Only validated procedure including collection device, hrHPV assay and specimen preparation should be used.

Overcoming barriers in HPV vaccination and screening programs

The Human Papillomavirus Prevention and Control Board brought together experts to discuss optimizing HPV vaccination and screening programs. Board members reviewed the safety profile of licensed HPV vaccines based on clinical and post-marketing data, reaching a consensus that current safety data is reassuring. Successful vaccination programs used well-coordinated communication campaigns, integrating (social) media to spread awareness. Communication of evidence supporting vaccine effectiveness had beneficial effects on the perception of the vaccine. However, anti-vaccination campaigns have threatened existing programs in many countries. Measurement and monitoring of HPV vaccine confidence over time could help understand the nature and scale of waning confidence, define issues and intervene appropriately using context-specific evidence-based strategies. Finally, a broad group of stakeholders, such as teachers, health care providers and the media should also be provided with accurate information and training to help support prevention efforts through enhanced understanding of the risks and benefits of vaccination. Similarly, while cervical cancer screening through population-based programs is highly effective, barriers to screening exist: awareness in countries with population-based screening programs, access for vulnerable populations, and access and affordability in low- and middle-income countries. Integration of primary and secondary prevention has the potential to accelerate the decrease in cervical cancer incidence.

The Role of Affordable, Point-of-Care Technologies for Cancer Care in Low- and Middle-Income Countries: A Review and Commentary

As the burden of non-communicable diseases such as cancer continues to rise in low- and middle-income countries (LMICs), it is essential to identify and invest in promising solutions for cancer control and treatment. Point-of-care technologies (POCTs) have played critical roles in curbing infectious disease epidemics in both high- and low-income settings, and their successes can serve as a model for transforming cancer care in LMICs, where access to traditional clinical resources is often limited. The versatility, cost-effectiveness, and simplicity of POCTs warrant attention for their potential to revolutionize cancer detection, diagnosis, and treatment. This paper reviews the landscape of affordable POCTs for cancer care in LMICs with a focus on imaging tools, in vitro diagnostics, and treatment technologies and aspires to encourage innovation and further investment in this space.

Candidate biomarkers in the cervical vaginal fluid for the (self-)diagnosis of cervical precancer

Purpose

Despite improvement in vaccines against human papilloma virus (HPV), the causative agent of cervical cancer, screening women for cervical precancer will remain indispensable in the coming 30–40 years. A simple test that could be performed at home or at a doctor’s practice and that informs the woman whether she is at risk would significantly help make a broader group of patients who aware that they need medical treatment. Cervical vaginal fluid (CVF) is a body fluid that is very well suited for such a test.

Methods

Narrative review of cervical (pre)cancer candidate biomarkers from cervicovaginal fluid, is based on a detailed review of the literature. We will also discuss the possibilities that these biomarkers create for the development of a self-test or point-of-care test for cervical (pre)cancer.

Results

Several DNA, DNA methylation, miRNA, and protein biomarkers were identified in the cervical vaginal fluid; however, not all of these biomarkers are suited for development of a simple diagnostic assay.

Conclusions

Proteins, especially alpha-actinin-4, are most suited for development of a simple assay for cervical (pre)cancer. Accuracy of the test could further be improved by combination of several proteins or by combination with a new type of biomarker, e.g., originating from the cervicovaginal microbiome or metabolome.

Barriers to HPV self-sampling and cytology among low-income indigenous women in rural areas of a middle-income setting: a qualitative study

Background

Data is needed about barriers to self-collection of Human Papillomavirus (HPV) samples and cytology among low-income, disadvantaged women living in rural areas of lower-income countries as these women are at increased risk of cervical cancer mortality.

Methods

Individual interviews (n = 29), focus groups (n = 7, 5–11 participants) and discussion groups (n = 2, 18–25 participants) were organized with women from three indigenous ethnic groups residing in rural areas in Mexico, after they were provided with free, self-sampled HPV tests. These groups are low-income, underserved by healthcare and have historically been on the receiving end of racism and social exclusion. Descriptive, qualitative content analysis was done, including two cycles of coding.

Results

Interview and focus/discussion group data indicate women had limited understanding of HPV’s role in cervical cancer etiology. They identified HPV’s existence, that cytology detects cervical cancer, the need for regular testing and that cervical cancer is sexually transmitted. Organizational barriers to clinic-based cytology included irregular supplies of disposable speculums, distance to clinics and lack of clear communication by healthcare personnel. Women considered self-collected HPV-testing easy, less embarrassing and less painful than cytology, an opportunity for self-care and most felt they understood how to take a self-sample after a 20-min explanation. Some women feared hurting themselves when taking the self-sample or that they would take the sample incorrectly, which they worried would make the test useless. Attending HPV-testing in groups facilitated use by allowing women to discuss their doubts and fears before doing self-collection of the sample or to ask other women who were the first to do the self-sampling what the experience had been like (whether it hurt and how easy it was). Lack of indoor bathrooms was a barrier to doing HPV self-sampling at home, when those homes were resource-poor (one-room dwellings).

Conclusions

Low-income, indigenous Mexican women residing in rural, underserved areas identified their need for cervical cancer screening but encountered multiple barriers to cytology-based screening. They found a number of advantages of HPV self-sampled tests. Employing self-collected HPV-testing instead of cytology could resolve some but not all gender-related, organizational or technical quality-of-care issues within cervical cancer detection and control programs.

Electronic supplementary material

The online version of this article (10.1186/s12885-017-3723-5) contains supplementary material, which is available to authorized users.

Evaluation of the Clinical Performance of the HPV-Risk Assay Using the VALGENT-3 Panel

Human papillomavirus (HPV) testing is increasingly being incorporated into cervical cancer screening. The Validation of HPV Genotyping Tests (VALGENT) is a framework designed to evaluate the clinical performance of various HPV tests relative to that of the validated and accepted comparator test in a formalized and uniform manner. The aim of this study was to evaluate the clinical performance of the HPV-Risk assay with samples from the VALGENT-3 panel and to compare its performance to that of the clinically validated Hybrid Capture 2 assay (HC2). The VALGENT-3 panel comprises 1,300 consecutive samples from women participating in routine cervical cancer screening and is enriched with 300 samples from women with abnormal cytology. DNA was extracted from original ThinPrep PreservCyt medium aliquots, and HPV testing was performed using the HPV-Risk assay by investigators blind to the clinical data. HPV prevalence was analyzed, and the clinical performance of the HPV-Risk assay for the detection of cervical intraepithelial neoplasia grade 3 or worse (CIN3+) and CIN2 or worse (CIN2+) relative to the performance of HC2 was assessed. The sensitivity of the HPV-Risk assay for the detection of CIN3+ was similar to that of HC2 (relative sensitivity, 1.00; 95% confidence interval [CI], 0.95 to 1.05; P = 1.000), but the specificity of the HPV-Risk assay was significantly higher than that of HC2 (relative specificity, 1.02; 95% CI, 1.01 to 1.04; P < 0.001). For the detection of CIN2+, similar results were obtained, with the relative sensitivity being 0.98 (95% CI, 0.93 to 1.02; P = 0.257) and the relative specificity being 1.02 (95% CI, 1.01 to 1.03; P < 0.001). The performance of the HPV-Risk assay for the detection of CIN3+ and CIN2+ was noninferior to that of HC2, with all P values being ≤0.006. In conclusion, the HPV-Risk assay demonstrated noninferiority to the clinically validated HC2 by the use of samples from the VALGENT-3 panel for test validation and comparison.

Optimizing secondary prevention of cervical cancer: Recent advances and future challenges

Although human papillomavirus (HPV) vaccines offer enormous promise for the ultimate control and possible elimination of cervical cancer, barriers to uptake and coverage of the vaccine both in high- and low/middle-income settings mean that advances in secondary prevention continue to be essential to prevent unnecessary deaths and suffering from cervical cancer for decades to come. While cytology (the Pap smear) has reduced cervical cancer incidence and prevalence in jurisdictions where it has been systematically implemented in population-based programs-mainly in high-income settings-limitations inherent to this method, and to program delivery, leave many women still vulnerable to cervical cancer. Recent evidence has confirmed that screening based on HPV testing prevents more invasive cervical cancer and precancerous lesions, and offers innovative options such as self-collection of specimens to improve screening uptake broadly. In this paper, we review key advances, future opportunities, and ongoing challenges for secondary prevention of cervical cancer using HPV-based testing.

Secondary Prevention of Cervical Cancer: ASCO Resource-Stratified Clinical Practice Guideline

PURPOSE

To provide resource-stratified, evidence-based recommendations on the secondary prevention of cervical cancer globally.

METHODS

ASCO convened a multidisciplinary, multinational panel of oncology, primary care, epidemiology, health economic, cancer control, public health, and patient advocacy experts to produce recommendations reflecting four resource-tiered settings. A review of existing guidelines, a formal consensus-based process, and a modified ADAPTE process to adapt existing guidelines were conducted. Other experts participated in formal consensus.

RESULTS

Seven existing guidelines were identified and reviewed, and adapted recommendations form the evidence base. Four systematic reviews plus cost-effectiveness analyses provided indirect evidence to inform consensus, which resulted in ≥ 75% agreement.

RECOMMENDATIONS

Human papillomavirus (HPV) DNA testing is recommended in all resource settings; visual inspection with acetic acid may be used in basic settings. Recommended age ranges and frequencies by setting are as follows: maximal: ages 25 to 65, every 5 years; enhanced: ages 30 to 65, if two consecutive negative tests at 5-year intervals, then every 10 years; limited: ages 30 to 49, every 10 years; and basic: ages 30 to 49, one to three times per lifetime. For basic settings, visual assessment is recommended as triage; in other settings, genotyping and/or cytology are recommended. For basic settings, treatment is recommended if abnormal triage results are present; in other settings, colposcopy is recommended for abnormal triage results. For basic settings, treatment options are cryotherapy or loop electrosurgical excision procedure; for other settings, loop electrosurgical excision procedure (or ablation) is recommended. Twelve-month post-treatment follow-up is recommended in all settings. Women who are HIV positive should be screened with HPV testing after diagnosis and screened twice as many times per lifetime as the general population. Screening is recommended at 6 weeks postpartum in basic settings; in other settings, screening is recommended at 6 months. In basic settings without mass screening, infrastructure for HPV testing, diagnosis, and treatment should be developed.Additional information can be found at www.asco.org/rs-cervical-cancer-secondary-prev-guideline and www.asco.org/guidelineswiki.It is the view of of ASCO that health care providers and health care system decision makers should be guided by the recommendations for the highest stratum of resources available. The guideline is intended to complement, but not replace, local guidelines.

Self-collected vaginal sampling for the detection of genital human papillomavirus (HPV) using careHPV among Ghanaian women

Background

Detection of genital HPV DNA is recommended as an important strategy for modern cervical cancer screening. Challenges include access to services, the reliance on cervical samples taken by clinicians, and patient’s preference regarding provider gender. The objective of this research was to determine the acceptability, feasibility and performance of alternative self-collected vaginal samples for HPV detection among Ghanaian women.

Methods

A comparative frequency-matched study was conducted in a systematic (1:5) sample of women attending HIV and outpatient clinics in the Cape Coast Teaching Hospital, Ghana. Participants were instructed on self-collection (SC) of vaginal samples using the careHPV brush and a clinician-collected (CC) cervical sample was obtained using a similar brush. Paired specimens were tested for HPV DNA (14 high-risk types) by careHPV assay (Qiagen) and by HPV genotyping (Anyplex II, Seegene).

Results

Overall, 194 women of mean age 44.1 years (SD ± 11.3) were enrolled and 191 paired SC and CC results were analysed. The overall HPV detection concordance was 94.2% (95%CI: 89.9–97.1), Kappa value of 0.88 (p < 0.0001), showing excellent agreement. This agreement was similar between HIV positive (93.8%) and negative (94.7%) women. Sensitivity and specificity of SC compared to CC were 92.6% (95%CI: 85.3–97.0) and 95.9% (95%CI: 89.8–98.8) respectively. The highest sensitivity was among HIV positive women (95.7%, 95%CI: 88.0–99.1) and highest specificity among HIV negative women (98.6%, 95%CI: 92.4–100). Overall, 76.3% women found SC very easy/easy to obtain, 57.7% preferred SC to CC and 61.9% felt SC would increase their likelihood to access cervical cancer screening.

Conclusions

The feasibility, acceptability and performance of SC using careHPV support the use of this alternative form of HPV screening among Ghanaian women. This could be a potential new affordable strategy to improve uptake of the national cervical cancer screening program.

Defining Optimal Triage Strategies for hrHPV Screen-Positive Women-An Evaluation of HPV 16/18 Genotyping, Cytology, and p16/Ki-67 Cytoimmunochemistry

Background: Several options for the triage of high-risk HPV screen-positive (hrHPV⁺) women were assessed.Methods: This study incorporated CIN2⁺ cases and controls, all of whom tested hrHPV⁺ and whose results of liquid-based cytology (LBC), HPV16/18 genotyping, and p16/Ki67 cytoimmunochemistry were available. Sensitivity and specificity for the CIN2⁺ of these triage tests were evaluated.Results: Absolute sensitivities of HPV 16/18 typing, LBC, and p16/Ki-67 cytoimmunochemistry for CIN2⁺ detection were 61.7%, 68.3%, and 85.0% for women with hrHPV⁺ clinician-taken samples. Respective specificities were 70.5%, 89.1%, and 76.7%. The absolute accuracy of the triage tests was similar for women with a hrHPV⁺ self-sample. P16/Ki-67 cyto-immunochemistry was significantly more sensitive than LBC although significantly less specific.Conclusions: All three single-test triage options, if positive, exceed the threshold of 20% risk at which colposcopy would be indicated. However, none of them conferred a post-test probability of CIN2⁺ <2%; which would permit routine recall. P16/Ki-67 cytoimmunochemistry on HPV16/18 negative women had a post-test probability of CIN2⁺ of 1.7% and 0.6% if also LBC negative.Impact: This is one of the few studies to directly compare the performance of triage strategies of hrHPV⁺ women, in isolation and combinations. It is the only study assessing triage strategies in women who test hrHPV⁺ in self-taken vaginal samples. A combined triage option that incorporated HPV 16/18 typing prior to p16/ki-67 cytoimmunochemistry in HPV 16/18-negative women yielded a post-test probability of CIN2⁺ of >20%, whereas women who tested negative had a probability of CIN2⁺ of <2%. Cancer Epidemiol Biomarkers Prev; 26(11); 1629-35. ©2017 AACR.

Self-administered versus provider-directed sampling in the Anishinaabek Cervical Cancer Screening Study (ACCSS): a qualitative investigation with Canadian First Nations women

BACKGROUND

While (Pap)anicolaou screening has helped to decrease cervical cancer incidence in Canada, First Nations women continue to have a higher burden and mortality relative to mainstream populations. Many First Nations women may feel uncomfortable with the invasiveness of this test, contributing to this statistic. Implemented from 2009 to 2015 in 10 Northwest Ontario First Nations communities, the Anishinaabek Cervical Cancer Screening Study (ACCSS) uniquely addressed this Indigenous health inequity through a mixed methods approach.

OBJECTIVE

Our goal was to offer an alternative test which the women could do themselves: human papillomavirus (HPV) testing based on self-sampling. We investigated whether First Nations women preferred HPV self-sampling over healthcare provider (HCP)-administered Pap screening.

METHODS

Participatory action researchinformed by the ethical space concept has guided all stages of the ACCSS. We conducted qualitative interviews with 16 HCPs and 8 focus group discussions with 69 female community members followed by a cluster-randomised controlled trial (RCT). Here, we draw on the qualitative field data and an end-of-study community update gathering to disseminate and contextualise research findings. Informant data were evaluated using thematic analysis.

RESULTS

We discuss factors influencing participants' strong preference for HPV self-sampling over physician-conducted Pap screening. Key arguments included enhanced accessibility and more personal control, less physical and emotional discomfort and fewer concerns regarding privacy of test results. For future implementation of HPV self-sampling, study participants emphasised the need for more culturally sensitive education addressed to community members of all genders, starting at school, clarifying that HPV causes cervical cancer. Further, HPV infection should be de-stigmatised by accentuating that it affects men and women alike.

CONCLUSION

Here we show that self-sampling in conjunction with community engagement and culturally sensitive education and could be a viable option for underscreened Canadian First Nations women. These informant data echo our previous RCT results.

Accuracy of self-collected human papillomavirus samples from Japanese women with abnormal cervical cytology

AIM

The aim of this study was to assess the accuracy of self-collected vaginal samples compared with physician-collected cervical samples for high-risk human papillomavirus (HPV) testing in Japanese women with abnormal cervical cytology. We also assessed the acceptability of self-collected HPV (sHPV) testing using a questionnaire.

METHODS

Women aged 20-69 years (n = 136) attending Yokohama City University Hospital because of abnormal cervical cytology between April 2014 and January 2015 were enrolled in this study. Cervical samples for conventional cytology and physician-collected HPV (pHPV) testing were obtained before colposcopic examination. After this examination, patients were asked to provide a self-sampled vaginal specimen (sHPV) at home, some time between the following day and the next week and to complete a self-sampling acceptability questionnaire.

RESULTS

The overall positive rates of HPV detection with pHPV and sHPV testing were 61.0% (83/136) and 40.4% (55/136), respectively (P < 0.001). sHPV testing had a lower sensitivity compared to pHPV for detection of cervical intraepithelial neoplasia (CIN)2 or worse (CIN2+: 59.4% vs 100%, P < 0.001; CIN3: 66.7% vs 100%, P = 0.248). There were no statistically significant differences in the sensitivity to detect CIN3 among pHPV testing, sHPV testing, and cytology. The self-collecting device had good acceptability.

CONCLUSION

sHPV testing is a possible technique with which to improve poor cervical cancer screening uptake rates in Japan; however, the sensitivity to detect CIN2+ lesions must improve before it can be a substitute for conventional cytology or pHPV testing. Further large-scale acceptability studies involving non-responders are also needed before practical application.

High-risk human papillomavirus detection in self-sampling compared to physician-taken smear in a responder population of the Dutch cervical screening: Results of the VERA study

In 2017 the cervical cancer screening program in The Netherlands will be revised. Cervical smears will primarily be tested for the presence of high-risk human papillomavirus (hrHPV) instead of cytology, and vaginal self-sampling will be offered to non-responders. This includes a potential risk that part of the women who would otherwise opt for a cervical smear will wait for self-sampling. However, self-sampling for hrHPV in a responder population has never been studied yet. The aim of this study was to investigate the applicability and accuracy of self-sampling in detecting hrHPV in a screening responder population. A total of 2049 women, aged 30-60years, participating in the screening program in The Netherlands were included from April 2013 to May 2015. After they had their cervical smear taken, women self-collected a cervicovaginal sample with a brush-based device, the Evalyn Brush. Both the cervical smear and self-sample specimen were tested with the COBAS 4800 HPV platform. The hrHPV prevalence was 8.0% (95% CI 6.9-9.2) among the physician-taken samples, and 10.0% (95% CI 8.7-11.3) among the self-samples. There was 96.8% (95% CI 96.0-97.5) concordance of hrHPV prevalence between self-samples and physician-taken samples. Women in our study evaluated self-sampling as convenient (97.1%), user-friendly (98.5%), and 62.8% preferred self-sampling over a physician-taken sampling for the next screening round. In conclusion, self-sampling showed high concordance with physician-taken sampling for hrHPV detection in a responder screening population and highly acceptable to women. Implementation of HPV-self-sampling for the responder population as a primary screening tool may be considered.

Accuracy of self-collected vaginal dry swabs using the Xpert human papillomavirus assay

BACKGROUND

Polymerase chain reaction-based Xpert human papillomavirus (HPV) assay is a rapid test that detects high-risk HPV (hrHPV) infection. This point-of-care test is usually performed by collecting a cervical specimen in a vial of PreservCyt® transport medium. We compared HPV test positivity and accuracy between self-collected sample with a dry swab (s-DRY) versus physician-collected cervical sampling using a broom like brush and immediate immersion in PreservCyt (dr-WET).

METHODS

In this cross-sectional study, we recruited 150 women ≥ 18 years old attending the colposcopy clinic in the University Hospital of Geneva. Each participant first self-collected a vaginal sample using a dry swab and then the physician collected a cervical specimen in PreservCyt. HPV analysis was performed with Xpert. Part of the PreservCyt-collected sample was used for hrHPV detection with the cobas® HPV test. HPV test positivity and performance of the two collection methods was compared.

RESULTS

HPV positivity was 49.1% for s-DRY, 41.8% for dr-WET and 46.2% for cobas. Good agreement was found between s-DRY and dr-WET samples (kappa±Standard error (SE) = 0.64±0.09,), particularly for low-grade squamous intraepithelial lesions (LSIL+) (kappa±SE = 0.80±0.17). Excellent agreement was found between the two samples for HPV16 detection in general (kappa±SE = 0.91±0.09) and among LSIL+ lesions (kappa±SE = 1.00±0.17). Sensitivities and specificities were, respectively, 84.2% and 47.1%(s-DRY), 73.1% and 58.7%. (dr-WET) and 77.8% and 45.7% (cobas) for CIN2+ detection. The median delay between sampling and HPV analysis was 7 days for the Xpert HPV assay and 19 days for cobas. There were 36 (24.0%) invalid results among s-DRY samples and 4 (2.7%) among dr-WET (p = 0.001). Invalid results happened due to the long interval between collection and analysis.

CONCLUSION

Self-collected vaginal dry swabs are a valid alternative to collecting cervical samples in PreservCyt solution for HPV testing with the Xpert HPV assay.

IMPACT

HPV self-collection with dry cotton swabs might assist in the implementation of an effective screening strategy in developing countries.

TRIAL REGISTRATION

International Standard Randomized Controlled Trial Number Registry ISRCTN83050913.

Prevalence of Human Papillomavirus in Self-Taken Samples from Screening Nonattenders

The Copenhagen Self-Sampling Initiative (CSi) has shown how human papillomavirus (HPV)-based self-sampling can be used to increase screening participation among 23,632 nonattenders in the Capital Region of Denmark. In this study, we describe HPV prevalence and genotype frequency in 4,824 self-samples as determined by three HPV assays (the CLART, Onclarity, and Hybrid Capture 2 [HC2] assays) and compare the results with those for physician-taken follow-up samples. The HPV self-sample findings were also compared to the findings for a reference population of 3,347 routinely screened women from the Horizon study, which had been undertaken in the same screening laboratory. Nonattenders had an HPV prevalence of 11.3% as determined by the CLART assay, which was lower than that for women from the Horizon study (18.5%). One-third of the CSi women who tested HPV positive by self-sampling tested HPV negative on the physician-taken follow-up sample. The CLART and Onclarity assays agreed on 64% (95% confidence interval [CI], 60 to 68%) of the HPV-positive self-taken samples. When the HC2 assay results were added into a three-way comparison, the level of agreement decreased to 27% (95% CI, 24 to 29%). Our findings suggest that further validation of HPV assays on self-taken samples is needed for optimal HPV detection and correct clinical management of HPV-positive women.

Comparative analysis of vaginal microbiota sampling using 16S rRNA gene analysis

BACKGROUND

Molecular methods such as next-generation sequencing are actively being employed to characterize the vaginal microbiota in health and disease. Previous studies have focused on characterizing the biological variation in the microbiota, and less is known about how factors related to sampling contribute to the results. Our aim was to investigate the impact of a sampling device and anatomical sampling site on the quantitative and qualitative outcomes relevant for vaginal microbiota research. We sampled 10 Finnish women representing diverse clinical characteristics with flocked swabs, the Evalyn® self-sampling device, sterile plastic spatulas and a cervical brush that were used to collect samples from fornix, vaginal wall and cervix. Samples were compared on DNA and protein yield, bacterial load, and microbiota diversity and species composition based on Illumina MiSeq sequencing of the 16S rRNA gene. We quantified the relative contributions of sampling variables versus intrinsic variables in the overall microbiota variation, and evaluated the microbiota profiles using several commonly employed metrics such as alpha and beta diversity as well as abundance of major bacterial genera and species.

RESULTS

The total DNA yield was strongly dependent on the sampling device and to a lesser extent on the anatomical site of sampling. The sampling strategy did not affect the protein yield or the bacterial load. All tested sampling methods produced highly comparable microbiota profiles based on MiSeq sequencing. The sampling method explained only 2% (p-value = 0.89) of the overall microbiota variation, markedly surpassed by intrinsic factors such as clinical status (microscopy for bacterial vaginosis 53%, p = 0.0001), bleeding (19%, p = 0.0001), and the variation between subjects (11%, p-value 0.0001).

CONCLUSIONS

The results indicate that different sampling strategies yield comparable vaginal microbiota composition and diversity. Hence, past and future vaginal microbiota studies employing different sampling strategies should be comparable in the absence of other technical confounders. The Evalyn® self-sampling device performed equally well compared to samples taken by a clinician, and hence offers a good-quality microbiota sample without the need for a gynecological examination. The amount of collected sample as well as the DNA and protein yield varied across the sampling techniques, which may have practical implications for study design.

Does lack of resources impair access to breast and cervical cancer screening in Japan?

Objectives

To assess the impact of the quantity of resources for breast and cervical cancer screening on the participation rates in screening in clinical settings in municipalities, as well as to clarify whether lack of resources impairs access to cancer screening in Japan.

Methods

Of the 1,746 municipalities in 2010, 1,443 (82.6%) and 1,469 (84.1%) were included in the analyses for breast and cervical cancer screening, respectively. In order to estimate the effects of the number of mammography units and of gynecologists on the participation rates in breast and cervical cancer screening in clinical settings, multiple regression analyses were performed using the interaction term for urban municipalities.

Results

The average participation rate in screening in clinical settings was 6.01% for breast cancer, and was 8.93% for cervical cancer. The marginal effect of the number of mammography units per 1,000 women was significantly positive in urban municipalities (8.20 percent point). The marginal effect of the number of gynecologists per 1,000 women was significantly positive in all municipalities (2.54 percent point) and rural municipalities (3.68 percent point).

Conclusions

Lack of mammography units in urban areas and of gynecologists particularly in rural areas impaired access to breast and cervical cancer screening. Strategies are required that quickly improve access for the residents and increase their participation rates in cancer screening.

First-void urine: A potential biomarker source for triage of high-risk human papillomavirus infected women

Great interest has been directed towards the use of first-void urine as a liquid biopsy for high-risk human papillomavirus DNA testing. Despite the high correlations established between urinary and cervical infections, human papillomavirus testing is unable to distinguish between productive and transforming high-risk infections that have the tendency to progress to cervical cancer. Thus far, investigations have been primarily confined to the identification of biomarkers for triage of high-risk human papillomavirus-positive women in cervicovaginal specimens and tissue biopsies. This paper reviews urinary biomarkers for cervical cancer and triage of high-risk human papillomavirus infections and elaborates on the opportunities and challenges that have emerged regarding the use of first-void urine as a liquid biopsy for the analysis of both morphological- (conventional cytology and novel immunohistochemical techniques) and molecular-based (HPV16/18 genotyping, host/viral gene methylation, RNA, and proteins) biomarkers. A literature search was performed in PubMed and Web of Science for studies investigating the use of urine as a biomarker source for cervical cancer screening. Five studies were identified reporting on biomarkers that are still in preclinical exploratory or clinical assay development phases and on assessments of non-invasive (urine) samples. Although large-scale validation studies are still needed, we conclude that methylation of both host and viral genes in urine has been proven feasible for use as a molecular cervical cancer triage and screening biomarker in phase two studies. This is especially promising and underscores our hypothesis that human papillomavirus DNA and candidate human and viral biomarkers are washed away with the initial, first-void urine, together with exfoliated cells, debris and impurities that line the urethra opening. Similar to the limitations of self-collected cervicovaginal samples, first-void urine will likely not fulfil the high-quality cellularity standards required for morphological biomarkers. Molecular biomarkers will likely overcome this issue to yield high-throughput, objective, and reproducible results. When using proper sampling, transport, storage, preanalytical biomarker concentration techniques, and clinically validated assays, first-void urine is expected to be a valuable source of molecular biomarkers for cervical cancer screening. Furthermore, as first-void urine can be easily and non-invasively collected, it is a highly preferred technique among women and offers the ability to test both primary high-risk human papillomavirus and biomarkers in the same sample. In addition, the use of first-void urine confers opportunities to reduce loss-to follow-up and non-adherence to screening subjects.

Self-collected cervicovaginal sampling for site-of-care primary HPV-based cervical cancer screening: a pilot study in a rural underserved Greek population

In the present pilot study, the feasibility of a site-of-care cervicovaginal self-sampling methodology for HPV-based screening was tested in 346 women residing in underserved rural areas of Northern Greece. These women provided self-collected cervicovaginal sample along with a study questionnaire. Following molecular testing, using the cobas^® HPV Test, Roche^®, HPV positive women, were referred to colposcopy and upon abnormal findings, to biopsy and treatment. Participation rate was 100%. Regular pap-test examination was reported for 17.1%. Among hrHPV testing, 11.9% were positive and colposcopy/biopsy revealed 2 CIN3 cases. Non-compliance was the most prevalent reason for no previous attendance. Most women reported non-difficulty and non-discomfort in self-sampling (77.6% and 82.4%, respectively). They would choose self-sampling over clinician-sampling (86.2%), and should self-sampling being available, they would test themselves more regularly (92.3%). In conclusion, self-sampling is feasible and well-accepted for HPV-based screening, and could increase population coverage in underserved areas, helping towards successful prevention.

Vaginal self-sampling as a diagnosis tool in low-income countries and potential applications for exploring the infectious causes of miscarriage

Gynecological health is a challenge in low-income countries. Personal opposition to perineal examination has been overcome by the use of vaginal self-sampling. Here, we review the use of this procedure notably in low-income countries and the main infectious causes of miscarriage. Vaginal self-sampling was mainly used for human papillomavirus detection but also to detect microorganisms causing sexually transmitted infections or bacterial vaginosis. 58 studies have been performed in low-resource countries, mainly studies performed to detect human papillomavirus in urban and peri-urban areas and demonstrating excellent acceptability. Several infectious causes of miscarriage could be tested using self-vaginal samples. In the future, such strategies coupled with a rapid-identification point-of-care method could allow the development of screening and treatment programs in rural areas in low-resource countries.

A pilot study of community-based self-sampling for HPV testing among non-attenders of cervical cancer screening programs in El Salvador

OBJECTIVE

To establish the feasibility and acceptability of home-based HPV self-sampling among women who did not attend screening appointments in rural El Salvador.

METHODS

In a cross-sectional study, data were collected from May 2015 to January 2016 among 60 women aged 30-59 years who were not pregnant, provided informed consent, had not been screened in 2 years, had no history of pre-cancer treatment, and did not attend a scheduled HPV screening. Participants completed questionnaires and received educational information before being given an opportunity to self-sample with the Hybrid Capture 2 High Risk HPV DNA Test.

RESULTS

Self-sampling was accepted by 41 (68%) participants. Almost all women chose to self-sample because the process was easy (40/41, 98%), could be performed at home (40/41, 98%), and saved time (38/41, 93%), and because they felt less embarrassed (33/41, 80%). The most common reason for declining the test was not wanting to be screened (8/19, 42%). The prevalence of high-risk HPV types among women who accepted self-sampling was 17% (7/41).

CONCLUSION

For most women, community-based self-sampling was an acceptable way to participate in a cervical cancer screening program. In low-resource countries, incorporating community-based self-sampling into screening programs might improve coverage of high-risk women.

Cervical cancer screening in a low-resource setting: a pilot study on an HPV-based screen-and-treat approach

Cervical cancer (CC) is the leading cause of cancer‐related death among women in sub‐Saharan Africa, primarily because of limited access to effective screening and preventive treatment. Our aim was to assess the feasibility of a human papillomavirus (HPV)‐based CC screen‐and‐treat approach in a low‐resource context. We recruited 1012 women aged 30–49 years through a CC screening campaign conducted in the District Hospital of Dschang, Cameroon. Participants performed HPV self‐sampling, which was tested for high‐risk HPV (HR‐HPV) DNA using the point‐of‐care Xpert HPV assay. All HPV‐positive women were invited for visual inspection with acetic acid and Lugol's iodine (VIA/VILI) to exclude CC or enable triage. A cervical sample for histological analysis was also collected. Women positive for HPV 16/18/45 and for other HR‐HPV with pathological VIA/VILI were selected to undergo treatment with thermocoagulation. The HPV prevalence in the study population was 18.5% (n = 187); of these cases, 20 (10.6%), 42 (22.3%) and 140 (74.9%) were positive for HPV16, HPV18/45 and other HR‐HPV types, respectively. Overall, 107/185 (57.8%) VIA/VILI examinations were classified as pathological and 78 (42.2%) as normal. Women positive for HPV16/18/45 were 4.2 times more likely to harbor cervical intraepithelial neoplasia grade 2 or worse (CIN2+) than those with other HPV types. The specificity of HPV 16/18/45 genotypes for detection of high‐grade lesions among HR‐HPV positive women was higher than that of VIA/VILI in all age groups. The sensitivity and specificity of VIA/VILI in detecting CIN2+ among HPV positive women were 80% and 44%, respectively. Overall, 110/121 screen‐positive women (90.9%) were eligible for, and were treated with, thermocoagulation. An HPV‐based screen‐and‐treat approach is feasible in a low‐resource context and may contribute to improving the effectiveness of CC prevention programs. Immediate thermocoagulation treatment for women who are HPV16‐ and/or HPV18/45‐positive is a practical approach for the treatment of CIN2+. The combination of HPV‐testing and VIA/VILI for CC screening might reduce overtreatment.

[Health agents' perspective on the incorporation of self-collected samples in HPV screening programs]

The objective of this study was to analyze health agents' perception of self-collecting of samples for HPV testing among women and the degree of agreement by the agents to incorporate this approach into their daily tasks. A self-administered questionnaire was applied to 127/191 health agents that participated in the EMA Project (Proyecto Evaluación Modalidad Autotoma) in the province of Jujuy, Argentina, in 2012-2013. The health agents with and without the experience of offering self-collected sampling expressed a high degree of agreement towards adoption of the strategy (78.7%), given its potential to prevent cervical cancer and its contribution to health care for the women under their coverage. However, the health agents identified the extra work and problems linking to the formal health system as the main barriers to offering this modality in the future. The study found that self-collecting of samples is a practice that can be adopted by health agents in the province of Jujuy, but that it should be accompanied by support measures from the formal health system.

A cluster randomized trial of strategies to increase uptake amongst young women invited for their first cervical screen: The STRATEGIC trial

Objectives

To measure the feasibility and effectiveness of interventions to increase cervical screening uptake amongst young women.

Methods

A two-phase cluster randomized trial conducted in general practices in the NHS Cervical Screening Programme. In Phase 1, women in practices randomized to intervention due for their first invitation to cervical screening received a pre-invitation leaflet and, separately, access to online booking. In Phase 2, non-attenders at six months were randomized to one of: vaginal self-sample kits sent unrequested or offered; timed appointments; nurse navigator; or the choice between nurse navigator or self-sample kits. Primary outcome was uplift in intervention vs. control practices, at 3 and 12 months post invitation.

Results

Phase 1 randomized 20,879 women. Neither pre-invitation leaflet nor online booking increased screening uptake by three months (18.8% pre-invitation leaflet vs. 19.2% control and 17.8% online booking vs. 17.2% control). Uptake was higher amongst human papillomavirus vaccinees at three months (OR 2.07, 95% CI 1.69–2.53, p < 0.001). Phase 2 randomized 10,126 non-attenders, with 32–34 clusters for each intervention and 100 clusters as controls. Sending self-sample kits increased uptake at 12 months (OR 1.51, 95% CI 1.20–1.91, p = 0.001), as did timed appointments (OR 1.41, 95% CI 1.14–1.74, p = 0.001). The offer of a nurse navigator, a self-sample kits on request, and choice between timed appointments and nurse navigator were ineffective.

Conclusions

Amongst non-attenders, self-sample kits sent and timed appointments achieved an uplift in screening over the short term; longer term impact is less certain. Prior human papillomavirus vaccination was associated with increased screening uptake.

Eurogin 2016 Roadmap: how HPV knowledge is changing screening practice

Human papillomaviruses (HPVs) are the necessary cause of most cervical cancers, a large proportion of other anogenital cancers, and a subset of oropharyngeal cancers. The knowledge about HPV has led to development of novel HPV-based prevention strategies with important impact on clinical and public health practice. Two complementary reviews have been prepared following the 2015 Eurogin Conference to evaluate how knowledge about HPV is changing practice in HPV infection and disease control through vaccination and screening. This review focuses on screening for cervical and anal cancers in increasingly vaccinated populations. The introduction of HPV vaccines a decade ago has led to reductions in HPV infections and early cancer precursors in countries with wide vaccination coverage. Despite the high efficacy of HPV vaccines, cervical cancer screening will remain important for many decades. Many healthcare systems are considering switching to primary HPV screening, which has higher sensitivity for cervical precancers and allows extending screening intervals. We describe different approaches to implementing HPV-based screening efforts in different healthcare systems with a focus in high-income countries. While the population prevalence for other anogenital cancers is too low for population-based screening, anal cancer incidence is very high in HIV-infected men who have sex with men, warranting consideration of early detection approaches. We summarize the current evidence on HPV-based prevention of anal cancers and highlight important evidence gaps.

HPV-based cervical cancer screening- facts, fiction, and misperceptions

Several randomized trials have demonstrated that HPV-based cervical cancer screening is more effective than cytology-based screening. A pooled analysis of long-term follow-up data from these trials has shown reduced cervical cancer mortality in women screened with HPV compared to cytology. As a consequence, many health systems are currently transitioning to HPV-based screening programs. However, there are several controversies that influence whether and how HPV-based cervical cancer screening is implemented in different settings. Here, we discuss the most important controversies surrounding cervical cancer screening using primary HPV testing in light of published data from clinical trials and large observational studies. Overall, there is strong and uniform evidence for the efficacy of HPV-based screening, and little evidence for the usefulness of adding cytology to primary screening. However, there is currently limited data on optimal triage strategies for HPV-positive women, a critical component of an HPV-based screening program. There will likely be multiple choices for integrated screening programs and implementation may differ depending on risk perception, healthcare funds, assay costs, and available infrastructure, among other factors, in different settings. A particular challenge is the integration of screening and vaccination programs, since increasingly vaccinated populations will have a continuous decrease of cervical cancer risk.

Introduction of molecular HPV testing as the primary technology in cervical cancer screening: Acting on evidence to change the current paradigm

Since being introduced in the 1940s, cervical cytology - despite its limitations - has had unequivocal success in reducing cervical cancer burden in many countries. However, we now know that infection with human papillomavirus (HPV) is a necessary cause of cervical cancer and there is overwhelming evidence from large-scale clinical trials, feasibility studies and real-world experience that supports the introduction of molecular testing for HPV as the primary technology in cervical cancer screening (i.e., "HPV primary screening"). While questions remain about the most appropriate age groups for screening, screening interval and triage approach, these should not be considered barriers to implementation. Many countries are in various stages of adopting HPV primary screening, whereas others have not taken any major steps towards introduction of this approach. As a group of clinical experts and researchers in cervical cancer prevention from across Canada, we have jointly authored this comprehensive examination of the evidence to implement HPV primary screening. Our intention is to create a common understanding among policy makers, agencies, clinicians, researchers and other stakeholders about the evidence concerning HPV primary screening to catalyze the adoption of this improved approach to cervical cancer prevention. With the first cohort of vaccinated girls now turning 21, the age when routine screening typically begins, there is increased urgency to introduce HPV primary screening, whose performance may be less adversely affected compared with cervical cytology as a consequence of reduced lesion prevalence post-vaccination.

Self-sampling to improve cervical cancer screening coverage in Switzerland: a randomised controlled trial

BACKGROUND

The aim of this study is to evaluate whether self-sampling can increase screening attendance of women who do not attend regular screening in Switzerland.

METHODS

Participants were proactively recruited in Geneva between September 2011 and November 2015. Women (25-69 years) who had not undergone CC screening in the last 3 years were considered eligible. Through a 1 : 1 ratio randomisation, enrolled participants were invited to either undergo liquid-based cytology, which was performed by a health-care provider (control group, CG) or to take a self-sample for HPV-testing, which was mailed to their home (intervention group, IG).

RESULTS

A total of 331 and 336 women were randomised in the CG and in the IG, respectively. Overall, 7.3% (95% CI: 4.9-10.6) women in the CG and 5.7% (95% CI: 3.6-8.7) women in the IG did not undergo the initial screening (P=0.400). There were 1.95% (95% CI: 0.8-4.3) women in the CG and 5.05% (95% CI: 3.1-8.1) women in the IG with a positive screen who did not attend triage and colposcopy (P=0.036).

CONCLUSIONS

The participation in CC screening in women offered self-sampling was not higher than among those offered specimen collection by a clinician. Compliance with further follow-up for women with a positive HPV test on the self-sample requires further attention.

Understanding Transgender Men's Experiences with and Preferences for Cervical Cancer Screening: A Rapid Assessment Survey

PURPOSE

Transgender men are less likely than cisgender women to receive cervical cancer screening. The purpose of the current study was to understand experiences with and preferences for cervical cancer screening among transgender men.

METHODS

Ninety-one transgender men ages 21-63 completed the survey. The survey evaluated experiences with and preferences for screening, including opinions regarding human papillomavirus (HPV) self-sampling as a primary cervical cancer screening.

RESULTS

Half (50.5%) of participants did not have Pap smear screening within the past 3 years. The majority (57.1%) of participants preferred HPV self-sampling over provider-collected Pap smear screening. Participants who reported discrimination were more likely to prefer HPV self-sampling (odds ratio = 3.29, 95% confidence interval 1.38-7.84, P = 0.007).

CONCLUSION

Primary HPV testing via HPV self-sampling may improve cervical cancer screening uptake among transgender men. Future work should pilot this innovative cervical cancer screening method within this population.

Clinician and Patient Acceptability of Self-Collected Human Papillomavirus Testing for Cervical Cancer Screening

BACKGROUND

To evaluate clinician and patient attitudes toward home self-collected human papillomavirus (HPV) testing for cervical cancer screening.

METHODS

Women aged 21-65 years were recruited for a randomized trial comparing home self-collected HPV testing to standard clinician-collected Pap screening. Participants were surveyed about their attitudes toward self-collected HPV testing. Clinicians performing cervical cancer screening in University of Washington medical clinics were also surveyed to determine their acceptability of self-collected HPV testing.

RESULTS

Over half (59.1%) of the 1,769 women surveyed preferred self-collected HPV testing to clinician-collected tests. Reasons most often cited were convenience or time saving (82.7%), and avoiding embarrassment or discomfort associated with pelvic exam (38.1%). Women who did not prefer self-collected HPV testing reported greater faith in clinician-collected samples (56.7%) or a desire for a clinic visit to address other issues (42.4%). One hundred eighteen (49.6%) of 238 physicians and midlevel providers surveyed completed the survey. The majority (78.0%) reported that they would recommend a self-collected HPV test if the test had qualities such as high sensitivity and cost effectiveness. Provider concerns mirrored those of patients, namely ensuring adequate sample collection and the opportunity to address other health concerns.

CONCLUSION

Patients and clinicians are supportive of self-collected HPV testing. However, concerns regarding adequacy of samples that are self collected and the desire to see a provider in a clinic setting for other health needs highlight areas that need to be addressed if self collection proves to be a viable option for cervical cancer screening.

Recent advances in understanding and preventing human papillomavirus-related disease

High-risk human papillomaviruses (hrHPV) are responsible for anogenital and oropharyngeal cancers, which together account for at least 5% of cancers worldwide. Industrialised nations have benefitted from highly effective screening for the prevention of cervical cancer in recent decades, yet this vital intervention remains inaccessible to millions of women in low- and middle-income countries (LMICs), who bear the greatest burden of HPV disease. While there is an urgent need to increase investment in basic health infrastructure and rollout of prophylactic vaccination, there are now unprecedented opportunities to exploit recent scientific and technological advances in screening and treatment of pre-invasive hrHPV lesions and to adapt them for delivery at scale in resource-limited settings. In addition, non-surgical approaches to the treatment of cervical intraepithelial neoplasia and other hrHPV lesions are showing encouraging results in clinical trials of therapeutic vaccines and antiviral agents. Finally, the use of next-generation sequencing to characterise the vaginal microbial environment is beginning to shed light on host factors that may influence the natural history of HPV infections. In this article, we focus on recent advances in these areas and discuss their potential for impact on HPV disease.

Methylation analysis and HPV genotyping of self-collected cervical samples from women not responding to screening invitation and review of the literature

Aim of the study

To assess the feasibility of partial HPV genotyping and methylation analysis of CADM1, MAL, and miR124-2 genes as triage tests in assaying self-collected cervical samples positive for high-risk HPV on primary screening, and to review the literature regarding host cellular gene methylation analysis of self-collected cervical samples.

Material and methods

Women residing in North-East Italy who had failed to respond to the invitation to participate in an organized population-based program were invited to provide a self-sample. Their stored baseline (self-collected) and follow-up (clinician-collected) cervical samples were included in the study. DNA was extracted from HPV-positive (Qiagen’s Hybrid Capture 2, HC2) samples. Partial genotyping with separate detection of HPV types 16 and 18 was performed with a hybrid capture-based method and a quantitative PCR assay. Methylation was assayed with a quantitative methylation-specific PCR.

Results

High-risk HPV infection was detected in 48% of baseline and 71% of follow-up HC2-positive samples. Methylation was demonstrated respectively in 15% and 23.5% of baseline and follow-up samples and chiefly involved a single gene (miR124-2). Invalid quantitative PCR results were recorded in 5% of self-collected samples. The specificity of miR124-1, MAL, and CADM1 methylation was 84%, 94%, and 98%, respectively, and the specificity of the three markers combined was 84%. Sensitivity was not estimated due to the lack of CIN2+ samples. The systematic review showed that different methylation assays yield different accuracy values.

Conclusion

Self-collected samples are suitable for methylation assays included in reflex triage testing. The reproducibility and accuracy of the methylation tests described in the literature should be improved.

Improving Prognostic Accuracy in Subjects at Clinical High Risk for Psychosis: Systematic Review of Predictive Models and Meta-analytical Sequential Testing Simulation

Discriminating subjects at clinical high risk (CHR) for psychosis who will develop psychosis from those who will not is a prerequisite for preventive treatments. However, it is not yet possible to make any personalized prediction of psychosis onset relying only on the initial clinical baseline assessment. Here, we first present a systematic review of prognostic accuracy parameters of predictive modeling studies using clinical, biological, neurocognitive, environmental, and combinations of predictors. In a second step, we performed statistical simulations to test different probabilistic sequential 3-stage testing strategies aimed at improving prognostic accuracy on top of the clinical baseline assessment. The systematic review revealed that the best environmental predictive model yielded a modest positive predictive value (PPV) (63%). Conversely, the best predictive models in other domains (clinical, biological, neurocognitive, and combined models) yielded PPVs of above 82%. Using only data from validated models, 3-stage simulations showed that the highest PPV was achieved by sequentially using a combined (clinical + electroencephalography), then structural magnetic resonance imaging and then a blood markers model. Specifically, PPV was estimated to be 98% (number needed to treat, NNT = 2) for an individual with 3 positive sequential tests, 71%-82% (NNT = 3) with 2 positive tests, 12%-21% (NNT = 11-18) with 1 positive test, and 1% (NNT = 219) for an individual with no positive tests. This work suggests that sequentially testing CHR subjects with predictive models across multiple domains may substantially improve psychosis prediction following the initial CHR assessment. Multistage sequential testing may allow individual risk stratification of CHR individuals and optimize the prediction of psychosis.

Offering self-sampling to cervical screening non-attenders in primary care

Objectives To assess the feasibility and acceptability of offering self-sampling for Human Papillomavirus (HPV) testing to cervical screening non-attenders when they consult primary care for any reason. Methods In a pilot implementation study, six general practices in London, UK, offered self-sampling kits during consultation to women aged 25-64 who were at least six months overdue for cervical screening (no cytology test recorded in the past 3.5 years if aged 25-49, or 5.5 years if aged 50-64). Eligible women were identified using an automated real-time search (during consultation) of the general practice electronic medical record system. Women collected samples either in clinic or at home (dry flocked swabs analysed using Roche Cobas®4800). Results Of approximately 5000 eligible women, 3131 consulted primary care between January and December 2014 (mean recruitment period 9.5 months). Of these, 21% (652) were offered kits, 14% (443) accepted, and 9% (292) returned a self-sample. The proportion of eligible women offered kits varied considerably among practices (11-36%). Sample return rates increased with kit offered rates ( r = 0.8, p = 0.04). Of 39 HPV positive women 85% (33) attended follow-up, including two with invasive cancers (stage 2A1 and 1A1). Conclusions Offering self-sampling to cervical screening non-attenders opportunistically in primary care is feasible. Return rates could be increased if more women were offered kits. A large trial is needed to identify how self-sampling is best integrated into the national screening programme, and to identify determinants of uptake.

Differential HPV16 variant distribution in squamous cell carcinoma, adenocarcinoma and adenosquamous cell carcinoma

Human Papillomavirus 16 (HPV16) causes 70% of invasive cervical cancers (ICC) worldwide. Interaction between HPV16 genetic diversity, host genetics and target tissue largely determine the chances to trigger carcinogenesis. We have analyzed the differential prevalence of viral variants in 233 HPV16-monoinfected squamous (SCC), glandular (ADC) and mixed (ADSC) ICCs from four continents, assessing the contribution of geographical origin and cancer histology. We have further quantified the contribution of viral variants and cancer histology to differences in age at tumor diagnosis. The model fitted to the data explained 97% of the total variance: the largest explanatory factors were differential abundance among HPV16 variants (78%) and their interaction with cancer histology (9.2%) and geography (10.1%). HPV16_A1-3 variants were more prevalent in SCC while HPV16_D variants were increased in glandular ICCs. We confirm further a non-random geographical structure of the viral variants distribution. ADCs were diagnosed at younger ages than SCCs, independently of the viral variant triggering carcinogenesis. HPV16 variants are differentially associated with histological ICCs types, and ADCs are systematically diagnosed in younger women. Our results have implications for the implementation of cervical cancer screening algorithms, to ensure proper early detection of elusive ADCs.

Human papillomavirus self-sampling for screening nonattenders: Opt-in pilot implementation with electronic communication platforms

In organized cervical screening programs, typically 25% of the invited women do not attend. The Copenhagen Self‐sampling Initiative (CSi) aimed to gain experiences on participation among screening nonattenders in the Capital Region of Denmark. Here, we report on the effectiveness of different communication platforms used in the pilot with suggestions for strategies prior to a full‐implementation. Moreover, an innovative approach using self‐sampling brushes with unique radio frequency identification chips allowed for unprecedented levels patient identification safety. Nonattenders from the capital region of Denmark were identified via the organized national invitation module. Screening history was obtained via the nationwide pathology registry. Twenty‐four thousand women were invited, and as an alternative to the regular communication platforms (letter and phone), women could request a home test via a mobile‐friendly webpage. Instruction material and video‐animation in several languages were made available online. Chi‐square test was used to test differences. Out of all invited, 31.7% requested a home test, and 20% returned it to the laboratory. In addition, 10% were screened at the physician after receiving the invitation. Stratified by screening history, long‐term unscreened women were less likely to participate than intermittently screened women (28% vs. 16%, p < 0.001). Of all contacts received, 64% (63–65) came via letter, and 31% (95CI: 30–32%) via webpage/mobile‐app. Self‐sampling was well‐accepted among nonattenders. Adopting modern technology‐based platforms into the current organized screening program would serve as a convenient communication method between health authority and citizens, allowing easy access for the citizen and reducing the work load in administrating self‐sampling approaches.

What's new?

Our implementation study is the first to evaluate opt‐in self‐sampling for 24,000 screening nonattenders, which can be basis for future routine implementation. Women could respond through a variety of communication channels (regular mail, phone and custom‐made web/mobile‐app). Our study utilized self‐sampling brushes with a novel RFID‐chip for secure patient‐identification, eliminating inconveniences for the women to fill out forms on returning the brush and loss of brushes due to missing identification.

Molecular tests potentially improving HPV screening and genotyping for cervical cancer prevention

INTRODUCTION

Human papillomavirus (HPV)-related cancers can be averted by type-specific vaccination (primary prevention) and/or through detection and ablation of precancerous cervical lesions (secondary prevention). This review presents current challenges to cervical cancer screening programs, focusing on recent molecular advances in HPV testing and potential improvements on risk stratification. Areas covered: High-risk (HR)-HPV DNA detection has been progressively incorporated into cervix cancer prevention programs based on its increased sensitivity. Advances in next-generation sequencing (NGS) are being rapidly applied to HPV typing. However, current HPV DNA tests lack specificity for identification of cervical precancer (CIN3). HPV typing methods were reviewed based on published literature, with a focus on these applications for screening and risk stratification in the emerging complex clinical scenario post-vaccine introduction. In addition, the potential for NGS technologies to increase specificity is discussed in regards to reflex testing of specimens for emerging biomarkers for cervix precancer/cancer. Expert commentary: Integrative multi-disciplinary molecular tests accurately triaging exfoliated cervical specimens will improve cervical cancer prevention programs while simplifying healthcare procedures in HPV-infected women. Hence, the concept of a 'liquid-biopsy' (i.e., 'molecular' Pap test) highly specific for early identification of cervical precancerous lesions is of critical importance in the years to come.

Evaluation of scaling-up of HPV self-collection offered by community health workers at home visits to increase screening among socially vulnerable under-screened women in Jujuy Province, Argentina

BACKGROUND

Self-collection has been proposed as a strategy to increase cervical screening coverage among hard-to-reach women. However, evaluations of the implementation of this strategy on a large scale are scarce. This paper describes the process and measurement of the scaling-up of self-collection offered by community health workers during home visits as a strategy to reach under-screened women aged 30+ with public health coverage, defined as the target women.

METHODS

We used an adaptation of the Health System Framework to analyze key drivers of scaling-up. A content analysis approach was used to collect and analyze information from different sources. The RE-AIM (Reach, Effectiveness, Adoption, Implementation, and Maintenance) model was used to evaluate the impact of the strategy.

RESULTS

HPV self-collection was scaled-up in the province of Jujuy in 2014 after a RCT (Self-collection Modality Trial, initials EMA in Spanish) was carried out locally in 2012 and demonstrated effectiveness of the strategy to increase screening uptake. Facilitators of scaling-up were the organizational capacity of the provincial health system, sustainable funding for HPV testing, and local consensus about the value of the technology. Reach: In 2014, 9% (2983/33,245) of target women were screened through self-collection in the Jujuy public health sector. Effectiveness: In 2014, 17% (n = 5657/33,245) of target women were screened with any HPV test (self-collected and clinician-collected tests) vs. 11.7% (4579/38,981) in 2013, the pre-scaling-up period (p < 0.0001).

IMPLEMENTATION

Training about the strategy was provided to 84.2% (n = 609/723) of total community health workers (CHWs). Of 414 HPV+ women, 77.5% (n = 320) had follow-up procedures. Of 113 women with positive triage, 66.4% (n = 75) had colposcopic diagnosis. Treatment was provided to 80.7% of CIN2+ women (n = 21/26). Adoption: Of trained CHWs, 69.3% (n = 422/609) had at least one woman with self-collection; 85.2% (n = 315/368) of CHWs who responded to an evaluation survey were satisfied with self-collection strategy. Maintenance: During 2015, 100.0% (723/723) CHWs were operational and 63.8% (461/723) had at least one woman with self-collection.

CONCLUSIONS

The strategy was successfully scaled-up, with a high level of adoption among CHWs, which resulted in increased screening among socially vulnerable under-screened women.

A review of screening strategies for cervical cancer in human immunodeficiency virus-positive women in sub-Saharan Africa

Cervical cancer (CC) is a leading cause of cancer-related death and a major public health issue in sub-Saharan Africa. This heavy burden parallels that of the human immunodeficiency virus (HIV) infection, which increases the risk of developing CC. Despite the progressive reduction of HIV prevalence in the past decade, the CC incidence and mortality rates in sub-Saharan Africa remain high. The heterogeneity of the distribution of the two diseases in the African continent, together with the different availability of human and material resources, stands in the way of finding an appropriate screening strategy. The lack of high-quality evidence on the prevention of CC for HIV-positive women, which is necessary for the implementation of efficient screening and treatment strategies, results in the absence of a clearly defined program, which is responsible for the low screening uptake and high mortality rates in sub-Saharan Africa. By taking advantage of the HIV-positive women's frequent access to health facilities, one way to increase the CC screening coverage rates would be by providing integrated HIV and screening services within the same infrastructure. With the increasing availability of cost-effective methods, screening is becoming more and more available to women who have limited access to health care. Moreover, the introduction of point-of-care technologies for human papillomavirus testing and the subsequent implementation of screen-and-treat strategies, by reducing the number of clinical appointments and, in the long term, the loss to follow-up rates, open up new opportunities for all women, regardless of their HIV status. The purpose of this review is to provide an insight into the different screening practices for CC in order to help define one that is adapted to the resources and necessities of HIV-positive women living in middle-to-low income countries.

Mailed HPV self-sampling for cervical cancer screening among underserved minority women: study protocol for a randomized controlled trial

Background

Underserved ethnic minority women experience significant disparities in cervical cancer incidence and mortality, mainly due to lack of cervical cancer screening. Barriers to Pap smear screening include lack of knowledge, lack of health insurance and access, and cultural beliefs regarding disease prevention. In our previous SUCCESS trial, we demonstrated that HPV self-sampling delivered by a community health worker (CHW) is efficacious in circumventing these barriers. This approach increased screening uptake relative to navigation to Pap smear screening. SUCCESS trial participants, as well as our community partners, provided feedback that women may prefer the HPV self-sampler to be delivered through the mail, such that they would not need to schedule an appointment with the CHW. Thus, our current trial aims to elucidate the efficacy of the HPV self-sampling method when delivered via mail.

Design

We are conducting a randomized controlled trial among 600 Haitian, Hispanic, and African-American women from the South Florida communities of Little Haiti, Hialeah, and South Dade. Women between the ages of 30 and 65 years who have not had a Pap smear within the past 3 years are eligible for the study. Women are recruited by CHWs and complete a structured interview to assess multilevel determinants of cervical cancer risk. Women are then randomized to receive HPV self-sampling delivered by either the CHW (group 1) or via mail (group 2). The primary outcome is completion of HPV self-sampling within 6 months post enrollment.

Discussion

Our trial is among the first to examine the efficacy of the mailed HPV self-sampling approach. If found to be efficacious, this approach may represent a cost-effective strategy for cervical cancer screening within underserved and underscreened minority groups.

Trial registration

ClinicalTrials.gov, NCT02202109. Registered on 9 July 2014.

Electronic supplementary material

The online version of this article (doi:10.1186/s13063-016-1721-6) contains supplementary material, which is available to authorized users.