Human papillomavirus testing and screening

Comparative assessment of test characteristics of cervical cancer screening methods for implementation in low-resource settings

Cervical cancer disproportionately affects low-resource settings. Papanicolaou, human papillomavirus (HPV), and visual inspection of cervix with acetic acid (VIA) testing, each with different characteristics, will reduce cervical cancer burden. We conducted a critical literature review using PubMed, Cochrane, WHO, and grey literature from 1994 to 2020. We examined efficacy, harms, and comparative effectiveness of screening methods by age, human immunodeficiency virus, provider characteristics, and assessed implementation challenges in low-resource settings. Comprehensive data on utility and efficacy of screening tests indicates that each screening has strengths and shortcomings but all confer acceptable performance. HPV and VIA appear more promising. Primary HPV test-and-treat, self-testing, and co-testing have been studied but data on triage plans, cost, support system, implementation and sustainability is unclear in low-resource settings. HPV testing could help target subgroups of older or higher risk women. VIA offers local capacity-building and scalability. Quality VIA technique after HPV testing is still required to guide post-screening treatments. VIA competencies decline gradually with current standard trainings. Stationary cervicography improves VIA quality but isn't scalable. Affordable smartphones eliminate this barrier, enhance training through mentorship, and advance continuing education and peer-to-peer training. Smartphone-based VIA facilitates cervical image storage for patient education, health promotion, record-keeping, follow-up care, remote expert support, and quality control to improve VIA reliability and reproducibility and reduce mis-diagnoses and burden to health systems. Rather than ranking screening methods using test characteristics alone in study or higher-resource settings, we advocate for scalable strategies that maximize reliability and access and reduce cost and human resources.

The high prevalence of HPV and HPV16 European variants in cervical and anal samples of HIV-seropositive women with normal Pap test results

Human Immunodeficiency Virus (HIV)-seropositive women are more likely to have anogenital cancer, and high risk-HPV (HR-HPV) infection is the main associated factor. Between August 2013 and December 2015, we conducted a descriptive study to determine the HPV genotypes and HPV16 variants in cervical and anal samples of HIV-seropositive women with a normal Pap test. The viral DNA was amplified by PCR using the PGMY09/11 set of primers. Reverse line blot (RLB), restriction fragment length polymorphism (RFLP) and sequencing assays were used to determine the HPV genotypes. HPV16 variants were identified by gene sequencing. We found a high frequency of HR-HPV (60.3%; 76/126) at the anogenital site among HIV-seropositive women and without association with anal intercourse. HPV16 and European variant predominated among the HR-HPV. Mixed infections with at least three different HPV types were common, particularly at the anal site. CD4+ T-cell counts below 500 cells/mm³, a HIV viral load above 50 copies/mL and an age of 18 to 35 years old were all related to HPV anal infection. Our study showed a high frequency of HR-HPV in both cervical and anal sites of women with negative cytology belonging to a risk group for the development of anogenital cancer.

The clinical performance of primary HPV screening, primary HPV screening plus cytology cotesting, and cytology alone at a tertiary care hospital

BACKGROUND

Algorithms for primary human papillomavirus (HPV) screening, primary HPV screening plus cytology cotesting, and cytology alone were evaluated previously in large cohort trials for cervical cancer detection, although the quality of cytology in those studies was controversial. To investigate whether these 3 algorithms would be applicable in routine practice at a tertiary care hospital, the authors compared their clinical performance. In addition, the prevalence of HPV genotypes was determined.

METHODS

Cervical cytology samples (n = 1000) were tested using liquid-based cytology (LBC), a nucleic acid hybridization assay, real-time polymerase chain reaction analysis, and direct HPV DNA sequencing. The clinical performance of the 3 algorithms was compared among women in different age groups (age range, 17-86 years; median age, 44.7 years).

RESULTS

For cervical intraepithelial neoplasia grade 2 or worse (CIN 2+), the sensitivity of primary HPV screening alone, cotesting, and LBC alone was 71.7%, 72.5%, and 63.8%, respectively; whereas the specificity was 87.5%, 96.5%, and 97.4%, respectively. Cotesting and LBC alone had slightly higher positive predictive values for CIN 2 + (97.8% and 98.9%, respectively) than primary HPV screening alone (91%), whereas primary HPV screening alone and cotesting demonstrated higher negative predictive values (63.6% and 62.5%, respectively) than LBC alone (43.2%). High-risk HPV types were detected in 24.3% of individuals. The most common type was HPV type 16 (HPV-16) followed by multiple HPV infections and HPV-58, HPV-52, HPV-31, HPV-35, HPV-51, HPV-39, HPV-56, HPV-33, HPV-18, HPV-59, and HPV-45.

CONCLUSIONS

Primary HPV screening alone in a tertiary care hospital demonstrated a performance that was equivalent to that of cotesting for CIN 2+, irrespective of patient age. With regard to the distribution of HPV genotypes, the nonavalent HPV vaccine would prevent approximately 60% of high-risk HPV.

Human papillomavirus detection in women with and without human immunodeficiency virus infection in Colombia

Background

HIV infection leads to a decreasing immune response, thereby facilitating the appearance of other infections, one of the most important ones being HPV. However, studies are needed for determining associations between immunodeficiency caused by HIV and/or the presence of HPV during the course of cervical lesions and their degree of malignancy. This study describes the cytological findings revealed by the Papanicolaou test, laboratory characteristics and HPV molecular profile in women with and without HIV infection.

Methods

A total of 216 HIV-positive and 1,159 HIV-negative women were invited to participate in the study; PCR was used for the molecular detection of HPV in cervical samples. Statistical analysis (such as percentages, Chi-square test and Fisher’s exact test when applicable) determined human papillomavirus (HPV) infection frequency (single and multiple) and the distribution of six types of high-risk-HPV in women with and without HIV infection. Likewise, a logistic regression model was run to evaluate the relationship between HIV-HPV infection and different risk factors.

Results

An association was found between the frequency of HPV infection and infection involving 2 or more HPV types (also known as multiple HPV infection) in HIV-positive women (69.0% and 54.2%, respectively); such frequency was greater than that found in HIV-negative women (44.3% and 22.7%, respectively). Statistically significant differences were observed between both groups (p = 0.001) regarding HPV presence (both in infection and multiple HPV infection). HPV-16 was the most prevalent type in the population being studied (p = 0.001); other viral types had variable distribution in both groups (HIV-positive and HIV-negative). HPV detection was associated with <500 cell/mm³ CD4-count (p = 0.004) and higher HIV-viral-load (p = 0.001). HPV-DNA detection, <200 cell/mm³ CD4-count (p = 0.001), and higher HIV-viral-load (p = 0.001) were associated with abnormal cytological findings.

Conclusions

The HIV-1 positive population in this study had high multiple HPV infection prevalence. The results for this population group also suggested a greater association between HPV-DNA presence and cytological findings. HPV detection, together with low CD4 count, could represent useful tools for identifying HIV-positive women at risk of developing cervical lesions.

Progress in Fourier Transform Infrared Spectroscopic Imaging Applied to Venereal Cancer Diagnosis

Fourier transform infrared imaging spectroscopy is a powerful technique that provides molecular and spatial information at the single-cell level. We report on the progress of this technology in the field of cancer research, focusing on human cervical cancer because of the inherent difficulty in grading this type of cancer and as a model for venereal cancers in dogs. Using a suite of multivariate imaging processing techniques, we demonstrate the potential of this technique to identify histologic features in the normal epithelium and cervical intraepithelial neoplasia stages I and III. We highlight the advantages and detail the barriers that need to be overcome before implementation of this technology in the clinical environment.

Classical molecular tests using urine samples as a potential screening tool for human papillomavirus detection in human immunodeficiency virus-infected women

Human papillomavirus (HPV) is the main risk factor associated with the development of cervical cancer (CC); however, there are other factors, such as immunosuppression caused by the human immunodeficiency virus (HIV), that favor progression of the illness. This study was thus aimed at evaluating the functionality of classical PCR-based molecular tests for the generic identification of HPV DNA (GP5+/GP6+, MY09/MY11, and pU1M/2R primers, individually or in combination) using cervical and urine samples from 194 HIV-positive women. Infected samples were tested with type-specific primers for six high-risk types (HPV-16, -18, -31, -33, -45, and -58) and two low-risk types (HPV-6 and -11). HPV infection prevalence rates were 70.1% for the cervical samples and 63.9% for the urine samples. HPV-16 was the most prevalent viral type in the cervical and urine samples, with higher rates of multiple infections than single infections detected in such samples. HPV DNA detection by PCR (mainly with the pU1M/2R primer set) in urine samples was positively associated with abnormal cytological findings (atypical squamous cells of undetermined significance/squamous intraepithelial lesions [ASCUS/SIL]). It was determined that the operative characteristics for detection of cytological abnormalities were similar for cervical and urine samples. This suggested using PCR for the detection of HPV DNA in urine samples as a potential screening strategy for CC prevention in future prevention and control programs along with currently implemented strategies for reducing the impact of the disease, i.e., urine samples are economical, are easy to collect, have wide acceptability among women, and have operative characteristics similar to those of cervical samples.

Screening for Cervical Cancer in Low-Resource Settings in 2011

Context.—Cervical cancer remains the most common malignancy in women living in low- and middle-income countries, despite the decline of the disease in countries where cervical cytology screening programs have been implemented.

Objectives.—To review the current incidence of cervical cancer in low-resource countries, the availability and types of screening programs, and the treatment options.

Data Sources.—Literature review through PubMed, Internet search, and personal communication.

Conclusions.—Although data are incomplete, available figures confirm that the rate of cervical cancer deaths and the availability of cervical cancer screening programs are inversely proportional and vary, in general, by the wealth of the nation. Despite the success of cervical cytology screening, many major health care organizations have abandoned screening by cytology in favor of direct visualization methods with immediate treatment of lesions by cryotherapy provided by trained, nonmedical personnel.

Prevalence of high-risk human papillomavirus infections in healthy Saudi women attending gynecologic clinics in the western region of Saudi Arabia

BACKGROUND AND OBJECTIVES

Infection with human papillomavirus (HPV) is the major cause of cervical cancer. There is little published data on the prevalence of HPV infection among Saudi women. The aim of this study was to determine the prevalence of HPV in a group of women in the western region of Saudi Arabia.

DESIGN AND SETTING

A prospective study of Saudi women seeking gynecologic care at King Abdulaziz University Hospital from March 2010 to January 2011.

PATIENTS AND METHODS

Four hundred eighty-five Saudi women of different age groups attending gynecology clinic were tested for high-risk HPV DNA. HPV DNA was detected in cervical scrapes using Hybrid Capture 2 (HC2) high-risk HPV DNA test. The prevalence of HPV DNA positivity in different age groups was calculated.

RESULTS

Out of the 485 specimens, 27 (5.6%) were positive for the high-risk HPV. The highest percentage was among women aged 60 years and older. Patients in the age group 40-49 years were more likely to accept HPV testing with a total of 188 patients.

CONCLUSION

The prevalence of HPV in this group of Saudi women is similar to what was reported in some Arab countries and lower than that reported in developed countries. This information could be used to help in establishing a primary screening program using HPV DNA testing in Saudi Arabia.

HPV DNA and Pap smear test results in cases with and without cervical pathology

OBJECTIVE

The aim of the study was to determine the HPV prevalance and its relation to Pap smear, colposcopy and colposcopy directed biopsy in our region of Eskisehir, Turkey.

MATERIAL AND METHODS

A total of 615 women who applied to the outpatient clinic between December 2009 and December 2010 constituted our study population. All patients underwent pelvic examination and Pap smear sampling. Patients who had pathological cervical appearance or Pap smear results of ASCUS, AGUS, LSIL or HSIL were referred to colposcopy. Cervical samples for HPV DNA were taken from the patients before Pap smear sampling during the routine examination or before the colposcopic evaluation.

RESULTS

Twenty six of 615 patients (4%) were HPV positive. Of these 26 patients, 12 were positive for HPV type 16, 3 for type 18, 3 for type 51, 2 for type 6, 1 for type 52, 1 for type 33, 1 for type 16 and type 31, 1 for type 6 and 52, 1 for type 56 and 90, 1 for type 39 and 66. In 4 patients with cervical cancer, and in 3 of 4 CIN III cases both HPV DNA and Pap smear were positive. In the Pap smear examination of 615 patients, cytology revealed 35 ASCUS (5.6%) 4 AGUS (0.6%), 2 CIN I (0.3%) results who were negative for HPV DNA. These patients with abnormal cytology (n=41) underwent colposcopy directed biopsy, there were 3 CIN I and 1 CIN III and all the other cervical biopsy results of these patients were benign (inflammation, chronic cervicitis).

CONCLUSION

HPV positivity in our hospital setting is low which is compatible with other studies in Turkey. In positive HPV cases there is a good correlation between HPV type and positive cervical biopsy results.

Comparison of human papillomavirus testing and cytology for cervical cancer screening in a primary health care setting in the Democratic Republic of the Congo

OBJECTIVES

We compared the screening performance of conventional Pap cytology and two human papillomavirus (HPV) DNA assays, the original Hybrid Capture 2 (HC2) and an expanded version that tests for 4 additional HPV types (HC2+4; Qiagen Corporation), in the detection of cervical neoplasia among unscreened women in a primary care setting in a suburb of Kinshasa, Democratic Republic of the Congo.

METHODS

All women 30 years or older residing in the area were invited to participate, and 1528 were evaluated by Pap cytology and the two HPV assays, conducted at a European and US reference laboratory, respectively, followed by colposcopy. Cervical biopsies were obtained from all women with abnormal colposcopy and from 290 randomly chosen women with normal colposcopy (to correct for verification bias).

RESULTS

Using a relative light unit of 1 as the cutoff for positivity, 169 and 168 (11%) women tested positive using HC2 and HC2+4, respectively. HC2 and HC2+4 were in agreement in 98.6% of cases (Kappa=0.94; 95% confidence interval: 0.91-0.96). Both assays were sensitive (~83%) and specific (~91%) for the detection of cervical intraepithelial neoplasia-2 or worse disease. Irrespective of the cutoff point used to define positivity, Pap cytology was both less sensitive and more specific than HC2 or HC2+4. For instance, cytology was 63% sensitive and 97% specific when a cutoff point of low-grade squamous intraepithelial lesions or worse was used.

CONCLUSIONS

Among unscreened women, HC2 and HC2+4 had similar screening accuracy for cervical neoplasia, and both were more sensitive but less specific than Pap cytology.

A quantum dots and superparamagnetic nanoparticle-based method for the detection of HPV DNA

BACKGROUND

The recent advance in nanomaterial research field prompts the development of diagnostics of infectious diseases greatly. Many nanomaterials have been developed and applied to molecular diagnostics in labs. At present, the diagnostic test of human papillomavirus (HPV) relies exclusively on molecular test. Hereon, we report a rapid and facile quantum dots (QDs) and superparamagnetic nanoparticle-based hybridization assay for the detection of (HPV) 16 infections which combines the merits of superparamagnetic nanoparticles and QDs and wholly differs from a conventional hybridization assay at that the reaction occurs at homogeneous solution, and total time for detection is no more than 1 h.

METHODS

The probes were labeled with superparamagnetic nanoparticles and QDs. Sixty cervical swab samples were used to perform a hybridization assay with these probes, and the results were compared with type-specific polymerase chain reaction (PCR) method.

RESULTS

The statistic analysis suggests that there is no significant difference between these two methods. Furthermore, this method is much quicker and easier than the type-specific PCR method.

CONCLUSION

This study has successfully validated the clinical performance of our hybridization assay. The advantages in the time of detection and ease of process endow this method with great potential in clinical usage, especially mass epidemiological screening.

Cost-effectiveness of 21 alternative cervical cancer screening strategies

OBJECTIVES

The aim of this study is to assess the cost-effectiveness of 21 alternative cervical cancer screening (CCS) strategies.

METHODS

A cohort simulation model was developed to determine from a health systems perspective the cost-effectiveness of the 21 alternative CCS strategies that incorporated combinations of Papanicolaou's smear test (PAP), liquid-based cytology (LBC) or human papillomavirus deoxyribonucleic acid (HPV-DNA) testing. The model was calibrated to categorize total costs into four budgetary authorities: testing, physician, inpatient, and outpatient services. Within each category, alternative screening strategies were contrasted in terms of their cost impacts and the percent change calculated within each category. Epidemiologic data and costs were derived from administrative health databases. Estimates of test characteristics and quality-adjusted life years (QALYs) were derived from available literature.

RESULTS

Three-year screening with PAP and HPV-DNA triage testing for women older than 30 years of age (3-year PAP+HPV+PAP-age) is less costly and more effective saving $16,078 per additional QALY gained. Although there was an associated net cost decrease of 4.2% driven by a reduction in testing and physician costs of 22.1% and 18.6%, respectively, there is a cost increase of 0.8% and 27.7% in inpatient and outpatient services, respectively.

CONCLUSION

There is economic evidence to support adopting 3-year PAP+HPV+PAP-age. Budgetary resources can potentially be shifted from testing and physician services to fund the additional resource requirements for inpatient and outpatient services.

Molecular detection and genotyping of human papillomavirus in cervical carcinoma biopsies in an area of high incidence of cancer from Moroccan women

Cervical cancer is a leading cause of cancer-related deaths in developing countries, and the human papillomavirus (HPV) is linked etiologically to cervical cancer. Eighty nine cervical carcinoma biopsies collected from women visiting the Oncologic Center in Casablanca (Centre Hospitalier Universitaire Ibn Rochd, Morocco) for cervical cancer symptoms, were screened for HPV DNA by polymerase chain reaction amplification with subsequent typing by hybridization with specific oligonucleotides for HPV types 16, 18, 31, 33, 45, and 59. Using very high stringency hybridization the HPV types could be easily distinguished. After preliminary clinical sorting, 92% (82/89) of the samples were found to be HPV-positive. Among the samples infected by a single HPV, type 16 was the most frequent 36.6% (30/82) of the positive samples, followed by HPV 18; 19.5% (16/82). Double or even multiple infections by the different HPV types were also detected (35.5% of the positive samples); dual infections were the more frequent, with the following combinations of HPVs: HPV16/HPV18 (21% of the positives samples) and HPV16/HPV45 (8.5%).

Hybrid Capture II detection of oncogenic human papillomavirus: a useful tool when evaluating men who have sex with men with atypical squamous cells of undetermined significance on anal cytology

PURPOSE

In the cervix and anus, patients with atypical squamous cells of undetermined significance often do not have high-grade squamous intraepithelial lesions. In women with atypical squamous cells of undetermined significance, Hybrid-Capture II testing for oncogenic high-risk human papillomavirus is performed and those without high-risk human papillomavirus often are observed. We endeavored to determine whether Hybrid-Capture II testing would be beneficial in men who have sex with men with atypical squamous cells of undetermined significance.

METHODS

We performed a retrospective chart review of men who have sex with men with atypical squamous cells of undetermined significance who had high-resolution anoscopy and Hybrid-Capture II.

RESULTS

A total of 290 men were identified (mean age, 42 years), and 212 (73 percent) were HIV-negative. High-grade squamous intraepithelial lesions were found in 50 (17 percent): 23 (10 percent) who were HIV-negative and 27 (35 percent) who were HIV-positive men. High-risk human papillomavirus was found in 138 (48 percent); 91 (43 percent) of HIV-negative and 47 (60 percent) of HIV-positive men. The sensitivity, specificity, positive predictive value, and negative predictive value of atypical cells of undetermined significance cytology combined with Hybrid-Capture II were 84, 60, 30, and 95 percent, respectively. There was no significant difference between all men vs. those who were HIV-positive or HIV-negative except for the positive predictive value.

CONCLUSIONS

Hybrid-Capture II testing for high-risk human papillomavirus in men who have sex with men with atypical cells of undetermined significance and referring only those with high-risk human papillomavirus reduces the number who require high-resolution anoscopy by more than half. Five percent with high-grade squamous intraepithelial lesions would be missed.

Comparison of the Third Wave Invader human papillomavirus (HPV) assay and the digene HPV hybrid capture 2 assay for detection of high-risk HPV DNA

This study compared the clinical performance of the Digene Hybrid Capture 2 (HC2) assay to that of a prototype Third Wave Invader human papillomavirus (HPV) (IHPV) analyte-specific reagent-based assay for the detection of oncogenic or "high-risk" (HR) HPV DNA using liquid-based cytology specimens. In total, 821 ThinPrep vials were tested using both assays. In accordance with the type-specific probes contained within each test, the sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) for the IHPV assay were 95.9%, 97.6%, 97.5%, and 96.1%, respectively, and those for the HC2 assay were 98.1%, 86.2%, 87.1%, and 97.9%. Overall, the sensitivity and NPV were comparable between the assays, but the IHPV assay demonstrated a better specificity and PPV, since the IHPV assay had fewer false-positive HR HPV results. The incorporation of an internal control to evaluate the cellularity of the test material is an important feature of the IHPV assay and should reduce the risk of false-negative results due to insufficient sample collection rather than the lack of HR HPV DNA. An additional benefit of the IHPV assay was the smaller sample volume required (1 ml versus 4 ml for the HC2 assay).

Utilization of human papillomavirus testing for cervical cancer prevention in a university hospital

This study aimed to evaluate the performance and cost of using polymerase chain reaction (PCR) and hybrid capture in the detection of cervical intraepithelial neoplasia (CIN) in patients with cytological abnormalities (ASCUS/low-grade squamous intraepithelial lesion--LSIL), and the feasibility of implementing these methods in Brazil's Unified National Health System (SUS). Colposcopy gave a negative predictive value of 92.86% and efficiency of 87.8% for diagnosing CIN. The sensitivity of PCR and hybrid capture for detecting CIN was 83.33% and 66.67%, respectively, and the negative predictive value for diagnosing CIN2/CIN3 was 100% and 94.74%, respectively. The annual cost for 80 patients was lower when all patients with ASCUS/LSIL were referred for colposcopy than when HPV testing was performed and those with positive results were referred for colposcopy. Therefore, at present, it is financially unfeasible for the National Health System to implement HPV testing to screen patients with cytological abnormalities (ASCUS/LSIL). However, considering that large-scale use might make such methods cheaper, PCR should be the chosen method, since it is less expensive, more sensitive, and has a high negative predictive value.

Synthetic genes: a tool for identifying human papillomavirus genotypes by hybridization and polymerase chain reaction-based assays

Obtaining positive polymerase chain reaction (PCR) controls for human papillomavirus (HPV) diagnostic tests has been difficult because of prevalence variation in different geographic regions of each high-risk viral type. Overlapping oligonucleotides were designed for HPV-18, HPV-31, HPV-45, and HPV-58 type-specific (TS) sequences. Synthetic HPV viral genes were constructed by 2-step assembly PCR for accurately diagnosing TS HPV infection.