Cervical high-risk human papillomavirus infection among women residing in the Gulf Cooperation Council countries: Prevalence, type-specific distribution, and correlation with cervical cytology

Prevalence of high-risk human papillomavirus genotypes and viral load correlated with squamous cell inflammation among women in Gabon

BACKGROUND

High-risk genotypes of Human Papillomavirus are responsible for 90% of cases of cervical cancer worldwide. Inflammation of squamous cells is mainly linked to HPV. In Gabon, HPV is endemic and circulates among the female population. The study aimed to determine the prevalence of HR-HPV genotypes and to investigate the correlation between squamous cell inflammation and HPV viral load in infected women in Gabon.

METHODS

The cross-sectional study was conducted at Libreville University Hospital Center (UHC) and National Public Health Laboratory from March to May 2024 among 399 women. Two cervical smears were taken. Genotype detection was carried out by multiplex fluorescence real-time PCR in the NPHL virology unit. Cytology was carried out in UHC's anatomic-pathology laboratory. Data were analyzed by SPSS software. Graphs were plotted using Microsoft Excel 2016.

RESULTS

The prevalence of Human Papillomavirus was 26.1% (95% CI: 22-30.6). The prevalence of HR-HPV genotypes was 24.8%. The most common HR-HPV genotypes were HPV-16/52/18/35/56/58/53/68. The rate of multiple HPV infections was 29.8% and 95.2% for the HR-HPV infection rate. Viral load was significantly correlated with squamous cell inflammation (r = 0.977 and P = 0.001).

CONCLUSION

HR-HPV infection remains a concern in women, however early screening is necessary for optimal monitoring and management. HR-HPV viral load is a predictive marker of squamous cell inflammation.

Low uptake of Pap test as a cervical cancer screen among Saudi women: Findings from a national survey

OBJECTIVE

The present study aimed to assess the current knowledge and uptake of Papanicolaou (Pap) tests for cervical screening among Saudi women, including barriers to undergoing the test and the availability of related services.

METHODS

A cross-sectional study was conducted using a health questionnaire administered through the Absher portal between April 1, 2019, and March 31, 2020. The questionnaire consisted of five questions and took less than 5 min to complete. Descriptive and inferential statistics were employed to analyze demographic variables, and chi-square tests were used to examine the association between these variables and Pap test uptake.

RESULTS

The questionnaire included 8194 Saudi women, with the majority from Makkah (24.40%), Riyadh (21.92%), and Eastern (14.44%) regions. Only 22.52% of respondents had ever received a Pap test, and among them, 17.48% did so based on their physician's recommendation. Private clinics accounted for 10.73% of Pap test locations, while public clinics accounted for 8.97%. The primary reasons for not undergoing the test were lack of knowledge regarding its importance (40.24%) and lack of information from physicians (16.96%). Knowledge of the Pap test as a cervical screening method was significantly associated with marital status, Saudi region, and age group.

CONCLUSIONS

This study revealed low awareness of the Pap test for cervical screening among Saudi women, particularly in younger age groups. Targeted educational initiatives are essential to increase awareness and emphasize the significance of regular screenings, especially among younger individuals, to enhance early detection and reduce the burden of cervical cancer in Saudi Arabia.

HPV infection and vaccination: a cross-sectional study of knowledge, perception, and attitude to vaccine uptake among university students in Qatar

BACKGROUND

Human Papilloma Virus (HPV) infection is a significant public health concern in the Gulf Cooperation Council countries, being widely prevalent and the main risk factor for cervical cancer. We aimed to assess knowledge and perception towards HPV, acceptability of the HPV vaccine, and HPV vaccination rates among university students in Education City, Doha, Qatar.

METHODS

This cross-sectional survey utilized proportional quota-sampling, with quotas based on university, sex, and nationality, to recruit students from seven universities between February and September 2022. The English language questionnaire requested socio-demographic information, knowledge, and attitudes about HPV infection and the vaccine. The chi-square test, Student t-test, Mann-Whitney-Wilcoxon tests and multivariable ordinal logistic regression were used to assess differences in proportion, mean, and median according to broad HPV knowledge categories.

RESULTS

Three hundred and ninety-eight students were recruited (response rate = 82.3%), of whom 251 (63.1%) were female. Mean age was 21.7 years. Eighty-nine (22.4%, 95% CI 18.4-26.8%) students had poor knowledge about HPV, 220 (55.3%, 95% CI 50.2-60.2%) students had some awareness, and 89 (22.4%, 95% CI 18.4-26.8%) students were knowledgeable. Age, nationality, and field of study influenced the students' knowledge about HPV. Only 25 (6.3%) students had previously been vaccinated against HPV. However, 71% of the unvaccinated students reported being willing to get vaccinated if recommended by their healthcare provider.

CONCLUSIONS

Overall, 77.7% of the student population had some-to-good levels of knowledge about HPV-related infection, cancer, and vaccination. There are gaps in the student population's understanding and knowledge about HPV. Increasing knowledge can be key toward shared decision-making for HPV vaccination among eligible populations. Targeted public health campaigns and integration into childhood vaccination programs should be critical first steps, especially as most of the surveyed students had a positive outlook on getting vaccinated. Healthcare professionals should be incentivized to increase their HPV knowledge and communication skills, while policymakers can work toward easing barriers in integrating HPV vaccinations in the immunization schedule and encouraging overall HPV vaccination uptake.

Human papillomavirus prevalence and genotypes in Gulf Cooperation Council countries: A scoping review 2017-2024

Background

Cervical cancer remains a global health challenge, claiming the lives of millions annually and having a significant impact on Gulf Cooperation Council (GCC) countries. Human papillomavirus (HPV), the primary causative agent, plays a central role, with regional variations in prevalence.1 The process from HPV infection to neoplastic changes takes 5-25 years to occur, hence, knowing its prevalence in our community is vital.2.

Methods

PubMed and SCOPUS were searched to identify articles related to cervical and anogenital HPV prevalence and genotypes in Qatar, Kuwait, Bahrain, Oman, the United Arab Emirates (UAE), and the Kingdom of Saudi Arabia (KSA) published between 2017 and 2024.

Results

A total of 19 articles were included in this review. Eight studies were from KSA, four were from Kuwait, three were from the UAE, one was from Qatar, Oman, and Bahrain, and one presented data collectively from the KSA, UAE, Qatar, and Bahrain. The prevalence of HPV ranged between 4.7% and 77% in studies from the KSA, between 15% and 54.3% in studies from Kuwait, between 14.7% and 88% in studies from the UAE, was 8.1% and 31.3% in the two studies from Qatar, and was 17.8% and 20% in the studies from Oman and Bahrain, respectively. HPV 16 was the most prevalent high-risk genotype found in studies conducted in the KSA, UAE, Kuwait, and Qatar. In Oman, HPV 82 predominated. In Bahrain, the majority had other non-HPV 16/18/45 genotypes. In the UAE and Kuwait, HPV 11 was the predominant low-risk type, followed by HPV 6. In Qatar, HPV 81 was the most common low-risk type, followed by HPV 11. In Oman, HPV 54 was the most common low-risk type, followed by HPV 42.

Conclusion

There are no studies with data on HPV prevalence and genotypes among women who have been vaccinated against HPV in GCC countries.

Atypical squamous cells of undetermined significance cervical cytology in Bahrain: Reporting rates, high-risk HPV testing, and cytologic and histopathologic follow-up findings

Objective

Atypical squamous cells of undetermined significance cytology (ASC-US) is a challenging and equivocal diagnosis for pathologists in cervical Pap smears. The data on ASC-US cervical cytology in Bahrain are deficient. This study reviewed and identified the reporting rates, high-risk human papillomavirus (HPV) testing results, histopathologic follow-up findings, and the cytologic progression of patients diagnosed with ASC-US in Bahrain.

Material and Methods

A retrospective chart review was conducted on the medical records of 23,888 women who had Pap smear test results between January 2019 and March 2022 at the main referral tertiary hospital in Bahrain to identify the ASC-US cases. High-risk HPV (hrHPV) genotype was identified, and the histopathological results of the cervical biopsy was recorded. In addition, cytologic follow-up Pap smear tests conducted within 1 year of ASC-US diagnosis were tracked to monitor the progression or regression of ASC-US.

Results

In this study, 259 out of 23,888 women reported to have ASC-UC cytology results with a reporting rate of 1.1%. The mean age of the ASC-US cases was 43 ± 11.6. Thirty percent of the ASC-US cases tested positive for hrHPV, and they were predominantly infected with the other hrHPV genotype (75%). When the histopathological changes of the cervix were analyzed, 82.1% had normal histopathologic findings. However, low-grade cervical intraepithelial neoplasia-1 was reported in 2 cases (7.1%), and high-grade cervical lesions (cervical intraepithelial neoplasia-2 and higher) were reported in 3 cases (10.7%). Regarding the cytologic follow-up, most of the ASC-US cases were negative for intraepithelial lesion or malignancy (NILM) (73.8%) or had persistent ASC-US (17.9%). The remaining minority of cases progressed into either low-grade squamous intraepithelial lesions (6%) or high-grade squamous intraepithelial lesions (2.4%). There was a statistically significant and relatively strong association between the cytology follow-up findings and the hrHPV test results (χ2 [2] = 8.869, P < 0.012, Cramer's V = 0.417).

Conclusion

This is the first and largest study to characterize the ASC-US cytology cases in Bahrain. The reporting rates of ASC-US fell within the worldwide reported range. Although most of the ASC-US cases regressed into NILM, ASC-US showed progression into more advanced cervical cytologic diagnoses or contributed to the malignant transformation of cervical tissue, especially in the presence of hrHPV infection which was positive in 30% of the ASC-US cases. This emphasizes the role of cotesting (combination of hrHPV genotyping and Pap smear test) and the importance of colposcopic evaluation of those women with cytologic follow-up tests at 1 year of diagnosis. Implementing these recommendations in the cervical cancer screening practice in Bahrain will help in having a better management plan for women diagnosed with ASC-US cervical cytology.

HPV Vaccine Knowledge and Hesitancy Among Health Colleges' Students at a Saudi University

Introduction

Human papillomavirus (HPV) infection is a widespread sexually transmitted infection linked to various types of cancer. Although vaccination against HPV is available, global HPV vaccination rates remain low.

Aim

This study aimed to evaluate the awareness and knowledge of the HPV vaccine and to identify predictors associated with vaccine hesitancy among health college students at King Saud University, Saudi Arabia.

Methods

A cross-sectional survey was distributed during December 2022 to students enrolled in health colleges. The survey link was randomly distributed via social media platforms and in-person interactions. The number of participants was 405 including both males and females. The data was analyzed using the Statistical Package for Social Sciences (SPSS). The correct response rate for all knowledge items was calculated, and they were stratified by gender and college. The association of vaccine hesitancy with sociodemographic characteristics was examined using logistic regression analysis.

Results

The study found that approximately half of the students (49.9%) were aware of the HPV vaccine. However, only a small percentage of students answered all to all HPV knowledge items correctly. Additionally, only a small proportion (5.2%) reported receiving the vaccine. The overall HPV vaccine hesitancy was 59.1% (43.9% for female and 75.9% for male). The most common reasons for vaccine hesitancy was not knowing enough about it. Males were two times more likely than females to believe that they did not need the HPV vaccine. The odds for HPV vaccine hesitancy were greater among males and younger age groups compared to females and older age groups.

Conclusion

This study underscores the importance of implementing university-wide interventions and educational campaigns to enhance awareness and knowledge of the HPV vaccine.

Awareness of human papillomavirus and acceptability of the vaccine among women in Palestine: is it time for policy adjustment?

Background

Progress has been made in the reduction of morbidity and mortality of cervical cancer by the implementation of human papillomavirus (HPV) vaccination programs. This study aimed to assess the awareness of Palestinian women about HPV as well as their knowledge and acceptability of the HPV vaccine and to examine the factors associated with good awareness.

Methods

This was a national cross-sectional study. Adult women were recruited from hospitals, primary healthcare centers, and public spaces in 11 Palestinian governorates using convenience sampling. A structured questionnaire was used for data collection. For each correctly answered question, one point was given. The total score was calculated and categorized into poor (0–10) and good awareness (11–21).

Results

The questionnaire was completed by 7223 women out of 8086 who were approached (response rate = 89.3%). A total of 7058 questionnaires were included in the final analysis; 4403 from the West Bank and Jerusalem (WBJ) and 2655 from the Gaza Strip. Women recruited from the Gaza Strip were younger, getting lower monthly incomes, and with fewer chronic diseases than women recruited from the WBJ.

Only 33 women (0.5%) displayed good awareness of HPV and its vaccine with 0.7% of women from WBJ and only 0.2% of women from the Gaza Strip. Completing post-secondary education, being employed or a student, and having a higher monthly income were associated with an increase in the likelihood of having good awareness.

Among women who had heard of HPV (n = 571, 8.1%), only 46 women (8.1%) reported familiarity with its vaccine. Women from the WBJ were more likely than women from the Gaza Strip to have heard about the HPV vaccine (0.9% vs. 0.2%). Most women agreed to receive the HPV vaccine themselves or for their daughters if it was given without cost or with a co-payment. No differences were found in the likelihood of agreeing to receive the HPV vaccine among women in the WBJ versus the Gaza Strip.

Conclusion

The overall awareness of HPV and its vaccine was extremely low. Inclusion of the HPV vaccine in the national immunization program could change this, especially as the HPV vaccine appeared to be acceptable.

High-risk human papillomavirus infection in pregnant women: a descriptive analysis of cohorts from two centers

The aim was to descriptively analyze the clinical characteristics, cytopathology, and outcomes of pregnant patients with high-risk human papillomavirus (HPV) infection. Clinical data of 151,516 female patients with high-risk HPV infection were retrospectively collected. Baseline data, cervical cytology results, histopathology, HPV types, delivery mode, and follow-up outcomes were recorded for descriptive analysis. A total of 157 patients were identified as positive for high-risk HPV. There were 32 (24.2%), 6 (4.5%), and 107 (81.1%) cases of HPV-16, HPV-18, and other types, respectively. Additionally, 12 patients showed combined infection with HPV-18 or HPV-16 and other types. Cytopathological examinations showed that the most common type was low-grade squamous intraepithelial lesion (LSIL; 104 cases, 78.8%), followed by high-grade squamous intraepithelial lesion (HSIL; 17 cases, 12.8%), atypical squamous cells of undetermined significance (10 cases, 9.6%), and cervical cancer (1 case, 0.7%). Thirty-seven patients underwent colposcopic biopsy, of whom 9 (24.3%) showed normal results, while 12 (32.4%) and 13 (35.1%) patients had LSIL and HSIL, respectively. χ² tests demonstrated that different delivery modes did not show significant difference in patients' cervical cytopathology (p>0.05). However, therapeutic methods were statistically different among patients with different cytopathological types (p<0.05). Cervical alterations in pregnancy mostly go along with high-risk HPV infection. High-risk HPV infection in pregnancy with abnormal cervical cytology should be followed closely during the pregnancy and postpartum period.

Health Care System View of Human Papilloma Virus (HPV) Vaccine Acceptability by Emirati Men

This is the most frequent sexually transmitted illness on the planet, and both men and women are equally vulnerable. HPV is associated with a broad variety of female disorders, including 99 percent of all cervical cancer cases. Specifically, the goal and contributions of this study are to determine Emirati men's opinions about the HPV vaccination, specifically whether they would use it themselves or allow their female relatives to use the vaccine. To collect the primary data, a statistical cross-sectional survey was conducted. This quantitative study was conducted using primary sources of data. A questionnaire survey with a sample size of 390 participants was used to collect data from 400 individuals. Male university students in the United Arab Emirati men have a weak grasp of HPV and are averse to vaccination (Ortashi et al., 2013). The percentage of Emirati men who accept the HPV vaccination is 37%. A total of 40.3% of the respondents opted not to participate in the survey at all. Eighty-six percent of the women surveyed had heard of cervical cancer, and one-third believed that they were at risk in the future. Twenty-five percent of those surveyed said that the HPV vaccination was safe, while 26% said it was unsafe. Respondents were just 3.1 percent vaccinated, and their family members were only 87% not vaccinated.

Epidemiology of HPV Related Malignancies

Human papillomavirus is the most common sexually transmitted infection in the world and had been linked to both anogenital and oropharyngeal cancers. It causes nearly 100% of cervical cancers and an increasing portion of oropharyngeal cancers. The geographical burden of cervical HPV infection and associated cancers is not uniform and is mainly found in low middle income countries in South America, Africa, and Asia. However, HPV-positive oropharyngeal cancer is rapidly becoming more prevalent in high middle income countries. With the development of vaccines which prevent HPV infection, the World Health Organization has designated the extirpation of HPV and its associated cancers a priority. Countries that have implemented adequate vaccine programs have shown a decrease in HPV prevalence. Understanding the epidemiology of HPV and its associated cancers is fundamental in improving vaccine programs and other health programs.

Human Papillomavirus Infection and Cervical Dysplasia in a Subset of Arab American Women

Background: With limited health data on Arab Americans (AAs), we sought to describe the health-seeking behaviors, prevalence of abnormal cervical cytology and high-risk human papillomavirus (HPV) serotypes, and the relationship with socioeconomic factors among a subset of AA women. Methods: Retrospective observational cohort study of women undergoing routine cancer screening at the Arab-American Center for Economic and Social Services clinic. Data collected included demographics, tobacco use, gross monthly income, prior Papanicolaou (Pap) smear history, and results of cervical cytology and high-risk HPV testing. Results: Of 430 women, 74 (17%) reported that they had never had a Pap smear. Three hundred eighty-eight (90%) women had cervical cytology interpreted as "negative for intraepithelial lesion," the remaining 42 (10%) women had abnormal results. Thirteen (3%) women reported prior abnormal Pap smear, which was significantly associated with additional abnormal Pap smear on multivariable analyses (odds ratio 65.46; 95% confidence interval [CI] 17.01-338.62; p < 0.001). One hundred twenty-five (29%) women were tested for high-risk HPV serotypes; 106 (91%) had negative results, 4 (3%) were positive for HPV-16, 7 (6%) were positive for other high-risk serotypes, and 8 results were not recorded. A negative HPV screen was significantly associated with a negative Pap smear (Fisher's exact test p = 0.006). There was no significant association between abnormal cervical cytology and evaluated socioeconomic factors. Conclusions: Additional population based-studies to determine cervical dysplasia/cancer and HPV prevalence in women of Middle Eastern descent are needed.

Cervical cancer: Automation of Pap test screening

BACKGROUND

Cervical cancer progresses slowly, increasing the chance of early detection of pre-neoplastic lesions via Pap exam test and subsequently preventing deaths. However, the exam presents both false-negatives and false-positives results. Therefore, automatic methods (AMs) of reading the Pap test have been used to improve the quality control of the exam. We performed a literature review to evaluate the feasibility of implementing AMs in laboratories.

METHODS

This work reviewed scientific publications regarding automated cytology from the last 15 years. The terms used were "Papanicolaou test" and "Automated cytology screening" in Portuguese, English, and Spanish, in the three scientific databases (SCIELO, PUBMED, MEDLINE).

RESULTS

Of the resulting 787 articles, 34 were selected for a complete review, including three AMs: ThinPrep Imaging System, FocalPoint GS Imaging System and CytoProcessor. In total, 1 317 148 cytopathological slides were evaluated automatically, with 1 308 028 (99.3%) liquid-based cytology slides and 9120 (0.7%) conventional cytology smears. The AM diagnostic performances were statistically equal to or better than those of the manual method. AM use increased the detection of cellular abnormalities and reduced false-negatives. The average sample rejection rate was ≤3.5%.

CONCLUSION

AMs are relevant in quality control during the analytical phase of cervical cancer screening. This technology eliminates slide-handling steps and reduces the sample space, allowing professionals to focus on diagnostic interpretation while maintaining high-level care, which can reduce false-negatives. Further studies with conventional cytology are needed. The use of AM is still not so widespread in cytopathology laboratories.

Interpreting a Diagnosis of Atypical Squamous Cells of Undetermined Significance in Cervical Cytology and its Association with Human Papillomavirus: A retrospective analysis of 180 cases in Kuwait

Objectives

Atypical squamous cells of undetermined significance (ASC-US) represent a diagnostic challenge during cervical cytology. This study aimed to review and identify high-risk human papillomavirus (HR-HPV) genotypes among previously diagnosed ASC-US cases in Kuwait.

Methods

This retrospective study analysed 180 cases diagnosed as ASC-US between June 2017 and May 2018 at the Mubarak Al-Kabeer Hospital, Kuwait. Cervical specimens were assayed to determine the presence of HR-HPV DNA; subsequently, positive cases underwent genotyping and were categorised into three groups (HPV 16, HPV 18/45 and other HR-HPV types).

Results

In total, ASC-US was confirmed in only 105 cases (58.3%), with the remaining cases reclassified as negative for intraepithelial lesions or malignancy (NILM; 32.2%) and epithelial cell abnormalities (ECA; 9.4%). Of these, HR-HPV DNA was present in 20 ASC-US (19%), one NILM (1.7%) and six ECA (35.3%) cases. There were 62 Kuwaiti and 43 non-Kuwaiti women with confirmed ASC-US; of these, three (4.8%), six (9.7%) and four (6.5%) Kuwaitis and one (2.3%), one (2.3%) and five (11.6%) non-Kuwaitis had HPV 16, both HPV 16 and 18/45 and other HR-HPV genotypes, respectively. Of those with HR-HPV DNA, the NILM case had the HPV 18/45 genotype, while the six ECA cases had the HPV 16 (n = 1), both HPV 16 and 18/45 (n = 1) and other HR-HPV (n = 4) genotypes.

Conclusion

Overall, HR-HPV DNA was present in 19% of ASC-US cases compared to 1.7% of NILM cases initially misdiagnosed as ASC-US. Re-review of cervical cytology diagnoses may reduce unnecessary costs associated with HR-HPV genotyping.

Type-specific Distribution of Cervical hrHPV Infection and the Association with Cytological and Histological Results in a Large Population-based Cervical Cancer Screening Program: Baseline and 3-year Longitudinal Data

Objectives: This study aimed to describe the study design, and to analyze the type-specific distribution of cervical high-risk human papillomavirus (hrHPV) infection and its association with cytological and histological results in a large population-based screening program in Buji Street, Shenzhen, China.

Methods: A total of 10,186 women aged 21-70 years were co-tested by Cobas4800 HPV assay and liquid-based cytology. Women were referred to colposcopy by virtue of being HPV16/18-positive, Other hrHPV-positive/ cytology ≥ASCUS, or HPV-negative/ cytology ≥LSIL. Three-year histological follow-up data were recorded.

Results: The overall prevalence of hrHPV infection was 11.1%; among them, the highest type was Other hrHPV (8.9%), followed by HPV16 (1.6%) and HPV18 (0.6%). Moreover, the prevalence of hrHPV and that of HPV16 increased with cytological severity (P_trend <0.001). In the baseline phase, 106 women had cervical intraepithelial neoplasia 2/3 (CIN2/3) and six had cervical cancers. During 3-year follow-up, 12 cases of CIN2/3 and no cancers were identified. For HPV16-positive women with normal cytology, the baseline risks of CIN2/3 or worse (CIN2+/CIN3+) were 15.5% (7.0-23.9%) and 4.2% (1.4-8.5%) respectively. For Other hrHPV-positive women with normal cytology, the cumulative 3-year risks of CIN2+/CIN3+ were 3.1% (1.0-5.2%) and 0.7% (0.3-2.1%) respectively. Strikingly, 75.8% (322/425) of abnormal cytology and 50.9% (29/57) HSIL cytology were attributed to Other hrHPV infection in HPV-positive women. Similarly, Other hrHPV infection led to large proportions of CIN2 (62.7%) and CIN3+ (43.9%) over 3-year follow-up.

Conclusions: The co-testing modality is a feasible, effective and safe option for cervical cancer screening in urban population. Great importance should also be attached to 'genotypes excluding HPV16/18' and separate detection of each genotype when considering screening and vaccination strategy.

Analysis of the efficacy of liquid-based cytology combined with HPV genotypes in screening cervical lesions in women of different ages

Objectives

To evaluate the value of liquid-based cell examination combined with human papillomavirus (HPV) genotypes in the detection of cervical intraepithelial neoplasia.

Methods

A total of 21,155 patients who had undergone cytology, HPV genotypes and colposcopy-guided biopsy were grouped into three groups. Sensitivity, specificity, positive predictive value, and negative predictive value of the test methods of the three groups were compared.

Results

In the age group of less than 50 years, the sensitivity of HPV genotype testing was significantly higher than that of liquid-based cytology. The specificity of liquid-based cytology was significantly higher in all age groups than that of HPV genotype testing. The positive predictive value of each test index was higher in the age group less than 30 years, and the negative predictive value was higher in the 30–50-year age groups. In different age groups, liquid-based cytology and HPV genotype combined method can improve the sensitivity of detection and negative predictive values.

Conclusions

The HPV test has higher sensitivity and negative predictive value, and the cytology method is relatively specific and less sensitive. The combined method has better sensitivity and negative predictive value.