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Denecke A, Emar D, Hillemanns P, Ramachandran D, Brüning B, Jentschke M. Diagnostic cervical excision in patients with HPV positivity, cytological abnormalities- and preoperative cervical stenosis. BMC Womens Health 2024; 24:411. [PMID: 39026222 PMCID: PMC11264674 DOI: 10.1186/s12905-024-03195-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2024] [Accepted: 06/10/2024] [Indexed: 07/20/2024] Open
Abstract
AIM There is currently no protocol for classifying patients with HPV persistence and preoperative stenosis of the cervical canal. This has a significant impact on cytology results, colposcopy results and the possibility of obtaining reliable cervical histology outcomes. Our analysis clearly shows that colposcopy and cytology underestimate the histological results in patients with limited visibility due to the presence of a type 3 transformation zone (TZ). Our analysis revealed a significant discrepancy between the colposcopy and cytology results and the histological outcomes. Insufficient colposcopy led to the underdiagnosis of dysplastic lesions in patients with a type 3 TZ and cervical stenosis. In the case of repeated cytological abnormalities and inadequate colposcopy examination, it is crucial to perform a diagnostic conization to exclude high-grade dysplastic changes and cervical carcinoma. METHODS We conducted a retrospective analysis of 1,021 conizations performed in tertiary care hospital in Wolfsburg, Germany between 2014 and 2020. Of these surgical procedures, 89 were diagnostic conizations. In our analysis, we defined diagnostic conization as a procedure performed when there is HPV persistence and repeated cytologic abnormalities in combination with a type 3 TZ, and when it is not possible to retrieve a relevant cervical histology sample. RESULTS In this period, 8.7% of all conizations were diagnostic excisions. We found histological abnormalities in 48 of 89 patients (53.9%). The histological examination of the excised cone revealed high-grade cervical intraepithelial neoplasia (CIN/HSIL) in 9 patients (10.1%) and CIN 2+ (HSIL) in 23 out of the 89 patients (25.8%). Two cases of early-stage cervical carcinoma (FIGO IA1 and FIGO IA2) were confirmed (2.3%). CONCLUSION Patients with cervical stenosis, high-risk HPV persistence and repeated cytological abnormalities are at high risk of undetected high-grade cervical dysplasia. Histologic confirmation must be ensured in this patient consultation and this can be achieved by performing diagnostic excisions.
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Affiliation(s)
- Agnieszka Denecke
- Department of Obstetrics and Gynaecology, Hannover Medical School, Hannover, Germany.
| | - Duaa Emar
- Department of Obstetrics and Gynaecology, Klinikum Wolfsburg, Wolfsburg, Germany
| | - Peter Hillemanns
- Department of Obstetrics and Gynaecology, Hannover Medical School, Hannover, Germany
| | - Dhanya Ramachandran
- Department of Obstetrics and Gynaecology, Hannover Medical School, Hannover, Germany
| | - Bianca Brüning
- Sociology Department, Leibniz University, Hannover, Germany
| | - Matthias Jentschke
- Department of Obstetrics and Gynaecology, Hannover Medical School, Hannover, Germany
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Ang JX, Lee WY, Tay SK. Clinical efficacy of primary human papillomavirus (HPV) screening with partial genotyping for HPV-16 and HPV-18 subtypes in women from 25 years old. ANNALS OF THE ACADEMY OF MEDICINE, SINGAPORE 2023; 52:259-267. [PMID: 38904523 DOI: 10.47102/annals-acadmedsg.2022471] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/22/2024]
Abstract
Introduction Cervical screening programmes differ in the age of women recommended for primary human papillomavirus (HPV) testing. This study aims to determine the clinical efficacy and impact of 14-high-risk HPV DNA testing for women from 25 years old. Method This was a retrospective analysis of data collected prospectively from women 25 years or older who attended hospital-based gynaecology clinics for cervical screening. Women with history of cervical neoplasia or abnormal cytology were excluded. High-risk HPV DNA testing with partial genotyping for HPV-16 and HPV-18 were performed on cobas 4800 System (Roche Diagnostics International AG, Rotkreuz, Switzerland). Women tested positive for the 12 other high-risk HPV subtypes (HPV-12 other) had a reflex cytology test. Positive screening included positive for HPV-16 and/or HPV-18, HPV-12 other with cytology abnormalities equal to or greater than atypical squamous cells of undetermined significance, and repeated positive HPV at 12 months. HPV detection and colposcopy referral rates, and detection of high-grade neoplasia were determined. Results Of 10,967 women studied, 822 (7.50%) were HPV DNA positive. The overall discharge rate to routine screening according to screening protocol was 93.1%. Colposcopy referral rate was 4.4%. The screening detected 41 cervical intraepithelial neoplasia grade 2+ (CIN2+) (0.37%) and 31 (0.28%) CIN3+. The number of colposcopies needed per case of CIN2+ was 9.5, similar for women below and above 30 years old. The number of colposcopies needed per case of CIN3+ for HPV-16 positivity was 8.5, compared to 17.0 for other categories (P=0.040). Colposcopy efficacy was similar for HPV-18 and HPV-12 other positivity with abnormal cytology. Conclusion Taking CIN2+ detection and colposcopy referral rate as endpoints, HPV testing in Singapore can be extended to include women from 25 years old.
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Affiliation(s)
- Joella Xiaohong Ang
- Department of Obstetrics and Gynaecology, Singapore General Hospital, Singapore
| | - Wai Yen Lee
- Department of Obstetrics and Gynaecology, Singapore General Hospital, Singapore
| | - Sun Kuie Tay
- Department of Obstetrics and Gynaecology, Singapore General Hospital, Singapore
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Characterization and clinical management of abnormal cytology findings in pregnant women: a retrospective analysis. Arch Gynecol Obstet 2022; 306:2017-2026. [PMID: 35976386 DOI: 10.1007/s00404-022-06699-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Accepted: 07/03/2022] [Indexed: 11/26/2022]
Abstract
PURPOSE The diagnosis of cervical intraepithelial neoplasia during pregnancy poses a great challenge to the treating clinician and the patient. According to the current guidelines, watchful waiting during pregnancy can be justified. Only in cases of invasion, immediate treatment may be indicated. However, few data are available on the management of cervical dysplasia during pregnancy. Further research is important for counselling affected women. METHODS Data of pregnant patients with suspected cervical dysplasia who presented to the University Women's Hospital Tübingen between 2008 and 2018 were evaluated retrospectively. Colposcopic, cytologic, and histologic assessment was performed for diagnosis. Data on remission, persistence and progression of disease based on histologic and cytologic assessment and the mode of delivery were correlated. RESULTS 142 patients were enrolled. Cytology at first presentation was PAPIII (-p/-g) in 7.0%, PAPIIID (IIID1/IIID2) in 38.7%, PAPIVa (-p/-g) in 50.0%, PAPIVb (-p) in 2.8%, and PAPV (-p) in 1.4%. All cases with suspected invasion were recorded at the initial presentation. Complete histological or cytological remission was observed in 24.4%, partial remission in 10.4%, persistence in 56.3%, and progression in 8.9%. In two cases (1.5%) progression to squamous cell carcinoma occurred. CONCLUSIONS Watchful waiting for cervical intraepithelial neoplasia during pregnancy seems to be sufficient and oncologically safe. It is important to exclude invasion during pregnancy, to perform frequent colposcopic, cytologic and histologic examinations and to ensure a postpartum follow-up examination to initiate the treatment of high-grade lesions. Spontaneous delivery seems to be safe in patients with cervical dysplasia, Caesarean section is not indicated.
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Reich O, Pickel H. 100 years of iodine testing of the cervix: A critical review and implications for the future. Eur J Obstet Gynecol Reprod Biol 2021; 261:34-40. [PMID: 33873086 DOI: 10.1016/j.ejogrb.2021.04.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Accepted: 04/11/2021] [Indexed: 11/30/2022]
Abstract
OBJECTIVES We aim to describe the history of iodine testing of the cervix and identify areas where further work is required. STUDY DESIGN We conducted a search of PubMed and Google Scholar. Full article texts were reviewed. Reference lists were screened for additional articles and books. 37 basic articles in journals including ones written in German and three basic articles in books were identified. RESULTS Glycogen staining of the ectocervical squamous epithelium with iodine goes back to Paul Ehrlich (1854-1915). Walter Schiller (1887-1960) examined nearly 200 different dyes and found that vital staining of the cervical squamous epithelium was best achieved with Lugol's iodine solution, which was indicated by Jean Guillaume Lugol (1786-1851) for disinfection of the vagina. In 1928 W. Lahm observed that the glycogen content of a squamous epithelium cell decreases as anaplasia increases. From the outset, H. Hinselmann included the iodine test in the minimum requirements for colposcopy. In 1946 H. J. Wespi first mentioned the finding of an "uncharacteristic iodine negative area." The first international colposcopic terminology from Graz in 1975 lists the "iodine light area" among the different colposcopy findings. The IFCPC nomenclatures from Rome 1990, Barcelona 2002, and Rio de Janeiro 2011 have evaluated the iodine test and classified their findings differently. A breakthrough to effective cervical cancer screening in resource-limited settings in Africa, India, and Latin America was achieved with R. Sankaranarayanan's publication on naked-eye visual inspection of the cervix after application of Lugol's iodine. CONCLUSIONS This paper is a step toward a better understanding of what we think and do today with iodine testing and what problems and upcoming tasks will arise in future.
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Affiliation(s)
- Olaf Reich
- Department of Obstetrics & Gynecology, Medical University of Graz, Austria.
| | - Hellmuth Pickel
- Department of Obstetrics & Gynecology, Medical University of Graz, Austria
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Coldman AJ, van Niekerk D, Krajden M, Smith LW, Cook D, Gondara L, Ceballos K, Quinlan DJ, Lee M, Elwood-Martin R, Gentile L, Peacock S, Stuart GCE, Franco EL, Ogilvie GS. Disease detection at the 48-month exit round of the HPV FOCAL cervical cancer screening trial in women per-protocol eligible for routine screening. Int J Cancer 2020; 146:1810-1818. [PMID: 31245842 DOI: 10.1002/ijc.32524] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2018] [Accepted: 04/18/2019] [Indexed: 11/10/2022]
Abstract
HPV FOCAL is a randomized control trial of cervical cancer screening. The intervention arm received baseline screening for high-risk human papillomavirus (HPV) and the control arm received liquid-based cytology (LBC) at baseline and 24 months. Both arms received 48-month exit HPV and LBC cotesting. Exit results are presented for per-protocol eligible (PPE) screened women. Participants were PPE at exit if they had completed all screening and recommended follow-up and had not been diagnosed with cervical intraepithelial neoplasia Grade 2 or worse (CIN2+) earlier in the trial. Subgroups were identified based upon results at earlier trial screening. There were 9,457 and 9,552 and women aged 25-65 randomized to control and intervention and 7,448 (77.8%) and 8,281 (86.7%), respectively, were PPE and screened. Exit cotest results were similar (p = 0.11) by arm for PPE and the relative rate (RR) of CIN2+ for intervention vs. control was RR = 0.83 (95% CI: 0.56-1.23). The RR for CIN2+ comparing intervention women baseline HPV negative to control women with negative cytology at baseline and at 24 months, was 0.68 (95% CI: 0.43-1.06). PPE women who had a negative or CIN1 colposcopy in earlier rounds had elevated rates (per 1,000) of CIN2+ at exit, control 31 (95% CI: 14-65) and intervention 43 (95% CI: 25-73). Among PPE women HPV negative at exit LBC cotesting identified little CIN2+, Rate = 0.3 (95% CI: 0.1-0.7). This per-protocol analysis found that screening with HPV using a 4-year interval is as safe as LBC with a 2-year screening interval. LBC screening in HPV negative women at exit identified few additional lesions.
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Affiliation(s)
| | - Dirk van Niekerk
- Cervical Cancer Screening Program, BC Cancer, Vancouver, BC, Canada
| | - Mel Krajden
- BC Centre for Disease Control, Vancouver, BC, Canada
| | - Laurie W Smith
- Cancer Control Research, BC Cancer, Vancouver, BC, Canada
| | - Darrel Cook
- BC Centre for Disease Control, Vancouver, BC, Canada
| | | | - Kathy Ceballos
- Cervical Cancer Screening Program, BC Cancer, Vancouver, BC, Canada
| | - David J Quinlan
- Department of Obstetrics and Gynecology, University of British Columbia, Vancouver, BC, Canada
| | - Marette Lee
- Department of Obstetrics and Gynecology, University of British Columbia, Vancouver, BC, Canada
| | - Ruth Elwood-Martin
- School of Public Health, University of British Columbia, Vancouver, BC, Canada
| | - Laura Gentile
- Cervical Cancer Screening Program, BC Cancer, Vancouver, BC, Canada
| | - Stuart Peacock
- Canadian Centre for Applied Research in Cancer Control, BC Cancer, Vancouver, BC, Canada
| | - Gavin C E Stuart
- Department of Obstetrics and Gynecology, University of British Columbia, Vancouver, BC, Canada
| | - Eduardo L Franco
- Division of Cancer Epidemiology, McGill University, Montreal, QC, Canada
| | - Gina S Ogilvie
- Women's Health Research Institute, Vancouver, BC, Canada
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Aarnio R, Wikström I, Gustavsson I, Gyllensten U, Olovsson M. Diagnostic excision of the cervix in women over 40 years with human papilloma virus persistency and normal cytology. Eur J Obstet Gynecol Reprod Biol X 2019; 3:100042. [PMID: 31404426 PMCID: PMC6687369 DOI: 10.1016/j.eurox.2019.100042] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2018] [Revised: 04/16/2019] [Accepted: 05/06/2019] [Indexed: 12/20/2022] Open
Abstract
Objective Persistent infection with human papillomavirus (HPV) is recognized as the main risk factor of cervical cancer. Investigation via cytology and colposcopy have lower sensitivity than HPV testing in the diagnosis of high-grade cervical intraepithelial neoplasia (CIN2+). Despite normal cytology and colposcopy findings women with persistent HPV infection have an increased risk of CIN2+. The aim of the study was to evaluate the proportion of histologically confirmed CIN2+ in women with persistent HPV infection and normal Pap smears. Study design From April 2013 until March 2016 we prospectively recruited 91 women over 40 years with persistent HPV infection without any abnormalities in cytology. Of these, 40 women attended a gynecological examination including an HPV test, Pap smear, endocervical cytology, colposcopy with biopsies and diagnostic loop electrosurgical excision procedure (LEEP). Biopsy and LEEP samples were subjected to histological examination Results CIN2+ was verified by histological examination of the LEEP sample in 6/40 (15%) of the women. All the cytological samples were normal and none of the biopsies confirmed CIN2+. Only 19/40 women still had a persistent HPV infection at the study visit. None of the 21/40 women who had cleared their HPV infection at the study visit had CIN2+ in histology of the LEEP sample. Conclusions A persistent HPV infection needs to be monitored despite normal Pap smears, since 6/40 (15%) women older than 40 years, was revealed to have an undiagnosed CIN2+ when LEEP was performed. Counseling women regarding the risk of cervical cancer and the expected effect of an eventual LEEP can help them to make an optimal informed choice.
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Affiliation(s)
- Riina Aarnio
- Department of Women's and Children's Health, Uppsala University, SE-751 85 Uppsala, Sweden
- Corresponding author at: Uppsala University, SE-751 85 Uppsala, Sweden.
| | - Ingrid Wikström
- Department of Women's and Children's Health, Uppsala University, SE-751 85 Uppsala, Sweden
| | - Inger Gustavsson
- Department of Immunology, Genetics and Pathology, Biomedical Center, SciLifeLab Uppsala, Box 815, Uppsala University, SE-75108 Uppsala, Sweden
| | - Ulf Gyllensten
- Department of Immunology, Genetics and Pathology, Biomedical Center, SciLifeLab Uppsala, Box 815, Uppsala University, SE-75108 Uppsala, Sweden
| | - Matts Olovsson
- Department of Women's and Children's Health, Uppsala University, SE-751 85 Uppsala, Sweden
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Horn J, Denecke A, Luyten A, Rothe B, Reinecke-Lüthge A, Mikolajczyk R, Petry KU. Reduction of cervical cancer incidence within a primary HPV screening pilot project (WOLPHSCREEN) in Wolfsburg, Germany. Br J Cancer 2019; 120:1015-1022. [PMID: 30988395 PMCID: PMC6734660 DOI: 10.1038/s41416-019-0453-2] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2018] [Revised: 03/27/2019] [Accepted: 03/29/2019] [Indexed: 11/18/2022] Open
Abstract
Background Randomised controlled trials showed human papillomavirus (HPV)-based screening leads to a significant reduction in cervical cancer incidence compared with cytology-based screening only. Methods Non-hysterectomised participants ≥30 years underwent co-testing with Papanicolaou (Pap) smear and HR-HPV testing (Hybrid Capture 2; HC2). Women with normal findings had their next screening round after 5 years, and HC2+ and Pap abnormal cases were immediately referred for colposcopy, while cases with discordant findings had repeat testing after 12 months with referral to colposcopy in cases with persistent positive findings. Results Twenty-six thousand six hundred and twenty-four women were recruited between February 2006 and December 2016. Two hundred and seventy-four CIN3+ cases were diagnosed (270 HPV+, 4 HPV−), including 31 invasive cervical cancers (29 HPV+, 2 HPV−). No CIN3+ was detected in HPV− women with abnormal cytology. We observed a significant decline in the 5-year incidence of CIN3+ (from 0.96% [95% CI 0.85–1.09%] to 0.16% [95% CI 0.10–0.25%]; p < 0.0001) and cervical cancer (from 0.10% [95% CI 0.07%–0.15%] to 0.025% [95% CI 0.01–0.08%]; p = 0.01) between the first and subsequent rounds. Approximately 90% (246/274) of CIN3+ cases were diagnosed at first colposcopy. Conclusions The decline in disease rates with 5-yearly co-testing seems mainly attributable to HPV testing since no CIN3+ occurred in HPV−/Pap+ women.
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Affiliation(s)
- Johannes Horn
- Institute for Medical Epidemiology, Biometrics, and Informatics, Martin-Luther-University Halle-Wittenberg, Halle, Germany
| | - Agnieszka Denecke
- Department of Obstetrics and Gynecology, Klinikum Wolfsburg, Wolfsburg, Germany
| | | | - Beate Rothe
- Central Laboratory, Klinikum Wolfsburg, Wolfsburg, Germany
| | | | - Rafael Mikolajczyk
- Institute for Medical Epidemiology, Biometrics, and Informatics, Martin-Luther-University Halle-Wittenberg, Halle, Germany.,German Centre for Infection Research, Site Braunschweig-Hannover, Germany
| | - Karl Ulrich Petry
- Department of Obstetrics and Gynecology, Klinikum Wolfsburg, Wolfsburg, Germany.
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Vourlaki I, Balas C, Livanos G, Vardoulakis M, Giakos G, Zervakis M. Bootstrap clustering approaches for organization of data: Application in improving grade separability in cervical neoplasia. Biomed Signal Process Control 2019. [DOI: 10.1016/j.bspc.2018.12.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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Hilal Z, Tempfer CB, Rezniczek GA. Treatment of Cervical Dysplasia by Clinicians Who Perform Colposcopy in German-speaking Countries - a Questionnaire-based Study. Geburtshilfe Frauenheilkd 2019; 79:189-197. [PMID: 30792549 PMCID: PMC6379162 DOI: 10.1055/a-0828-7831] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2018] [Revised: 01/01/2019] [Accepted: 01/03/2019] [Indexed: 11/08/2022] Open
Abstract
Introduction In connection with the reorganisation of cervical carcinoma screening, the importance of colposcopy as an integral part of the planned series of clarification testing will greatly increase. Quality standards for performing the colposcopic examination should therefore be defined in detail. A precondition for this is surveying the current standard in clinical practice. The objective of this study was to evaluate the current practice of colposcopy and conisation in Germany by means of a questionnaire aimed at gynaecologists who perform colposcopies in order to document the actual therapeutic standard of treatment of cervical dysplasia. Materials and Methods Gynaecologists were invited via e-mail or during events to participate in a web-based survey. The questionnaire contained 38 questions on management before, during and after the examination as well as questions on the technical implementation of colposcopy and conisation. Results From February 2018 to April 2018, 961 e-mails were sent. A response was received in 197 cases (response rate 20.5%). Responses were received for another 40 questionnaires during events (response rate approx. 80%). After taking the inclusion criteria into account, 160 questionnaires were evaluated. The majority of those surveyed take an average of 2 cervical biopsies (67.3%) and nearly all of those surveyed (94.5%) do not use any local anaesthetic. As a standard method for removing cervical precancerous cells, most of the physicians surveyed perform a loop excision with the electrosurgical loop (91.2%) under colposcopic visualisation (61.2%) under general anaesthesia (92.5%). Postoperative bleeding prophylaxis by means of tamponade is performed only in 27.6% of all cases. Conclusion A differential colposcopy with two colposcopically targeted biopsies and treatment with the electrosurgical loop are the methods most frequently used by clinicians who perform colposcopy in Germany. A uniform procedure should be defined in detail within the scope of directives or guidelines.
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Affiliation(s)
- Ziad Hilal
- ZYDOLAB, Institut für klinische Zytologie und Immunzytochemie, Dortmund, Germany
| | - Clemens B. Tempfer
- Klinik für Frauenheilkunde und Geburtshilfe, Marien Hospital Herne, Universitätsklinikum der Ruhr-Universität Bochum, Herne, Germany
| | - Günther A. Rezniczek
- Klinik für Frauenheilkunde und Geburtshilfe, Marien Hospital Herne, Universitätsklinikum der Ruhr-Universität Bochum, Herne, Germany
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Curry SJ, Krist AH, Owens DK, Barry MJ, Caughey AB, Davidson KW, Doubeni CA, Epling JW, Kemper AR, Kubik M, Landefeld CS, Mangione CM, Phipps MG, Silverstein M, Simon MA, Tseng CW, Wong JB. Screening for Cervical Cancer: US Preventive Services Task Force Recommendation Statement. JAMA 2018; 320:674-686. [PMID: 30140884 DOI: 10.1001/jama.2018.10897] [Citation(s) in RCA: 709] [Impact Index Per Article: 118.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
IMPORTANCE The number of deaths from cervical cancer in the United States has decreased substantially since the implementation of widespread cervical cancer screening and has declined from 2.8 to 2.3 deaths per 100 000 women from 2000 to 2015. OBJECTIVE To update the US Preventive Services Task Force (USPSTF) 2012 recommendation on screening for cervical cancer. EVIDENCE REVIEW The USPSTF reviewed the evidence on screening for cervical cancer, with a focus on clinical trials and cohort studies that evaluated screening with high-risk human papillomavirus (hrHPV) testing alone or hrHPV and cytology together (cotesting) compared with cervical cytology alone. The USPSTF also commissioned a decision analysis model to evaluate the age at which to begin and end screening, the optimal interval for screening, the effectiveness of different screening strategies, and related benefits and harms of different screening strategies. FINDINGS Screening with cervical cytology alone, primary hrHPV testing alone, or cotesting can detect high-grade precancerous cervical lesions and cervical cancer. Screening women aged 21 to 65 years substantially reduces cervical cancer incidence and mortality. The harms of screening for cervical cancer in women aged 30 to 65 years are moderate. The USPSTF concludes with high certainty that the benefits of screening every 3 years with cytology alone in women aged 21 to 29 years substantially outweigh the harms. The USPSTF concludes with high certainty that the benefits of screening every 3 years with cytology alone, every 5 years with hrHPV testing alone, or every 5 years with both tests (cotesting) in women aged 30 to 65 years outweigh the harms. Screening women older than 65 years who have had adequate prior screening and women younger than 21 years does not provide significant benefit. Screening women who have had a hysterectomy with removal of the cervix for indications other than a high-grade precancerous lesion or cervical cancer provides no benefit. The USPSTF concludes with moderate to high certainty that screening women older than 65 years who have had adequate prior screening and are not otherwise at high risk for cervical cancer, screening women younger than 21 years, and screening women who have had a hysterectomy with removal of the cervix for indications other than a high-grade precancerous lesion or cervical cancer does not result in a positive net benefit. CONCLUSIONS AND RECOMMENDATION The USPSTF recommends screening for cervical cancer every 3 years with cervical cytology alone in women aged 21 to 29 years. (A recommendation) The USPSTF recommends screening every 3 years with cervical cytology alone, every 5 years with hrHPV testing alone, or every 5 years with hrHPV testing in combination with cytology (cotesting) in women aged 30 to 65 years. (A recommendation) The USPSTF recommends against screening for cervical cancer in women younger than 21 years. (D recommendation) The USPSTF recommends against screening for cervical cancer in women older than 65 years who have had adequate prior screening and are not otherwise at high risk for cervical cancer. (D recommendation) The USPSTF recommends against screening for cervical cancer in women who have had a hysterectomy with removal of the cervix and do not have a history of a high-grade precancerous lesion or cervical cancer. (D recommendation).
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Affiliation(s)
| | | | - Alex H Krist
- Fairfax Family Practice Residency, Fairfax, Virginia
- Virginia Commonwealth University, Richmond
| | - Douglas K Owens
- Veterans Affairs Palo Alto Health Care System, Palo Alto, California
- Stanford University, Stanford, California
| | | | | | | | | | | | | | | | | | | | | | | | | | - Chien-Wen Tseng
- University of Hawaii, Honolulu
- Pacific Health Research and Education Institute, Honolulu, Hawaii
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Melnikow J, Henderson JT, Burda BU, Senger CA, Durbin S, Weyrich MS. Screening for Cervical Cancer With High-Risk Human Papillomavirus Testing: Updated Evidence Report and Systematic Review for the US Preventive Services Task Force. JAMA 2018; 320:687-705. [PMID: 30140883 DOI: 10.1001/jama.2018.10400] [Citation(s) in RCA: 152] [Impact Index Per Article: 25.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
IMPORTANCE Cervical cancer can be prevented with detection and treatment of precancerous cell changes caused primarily by high-risk types of human papillomavirus (hrHPV), the causative agents in more than 90% of cervical cancers. OBJECTIVE To systematically review benefits and harms of cervical cancer screening for hrHPV to inform the US Preventive Services Task Force. DATA SOURCES MEDLINE, PubMed, PsycINFO, and the Cochrane Collaboration Registry of Controlled Trials from January 2011 through February 15, 2017; surveillance through May 25, 2018. STUDY SELECTION Randomized clinical trials (RCTs) and cohort studies comparing primary hrHPV screening alone or hrHPV cotesting (both hrHPV testing and cytology) with cytology (Papanicolaou [Pap] test) screening alone. DATA EXTRACTION AND SYNTHESIS Two investigators independently reviewed abstracts and full-text articles and quality rated included studies; data were qualitatively synthesized. MAIN OUTCOMES AND MEASURES Invasive cervical cancer; cervical intraepithelial neoplasia (CIN); false-positive, colposcopy, and biopsy rates; psychological harms. RESULTS Eight RCTs (n = 410 556), 5 cohort studies (n = 402 615), and 1 individual participant data (IPD) meta-analysis (n = 176 464) were included. Trials were heterogeneous for screening interval, number of rounds, and protocol. For primary hrHPV screening, evidence was consistent across 4 trials demonstrating increased detection of CIN 3 or worse (CIN 3+) in round 1 (relative risk [RR] range, 1.61 [95% CI, 1.09-2.37] to 7.46 [95% CI, 1.02-54.66]). Among 4 hrHPV cotesting trials, first-round CIN 3+ detection was not significantly different between screening groups; RRs for cumulative CIN 3+ detection over 2 screening rounds ranged from 0.91 to 1.13. In first-round screening, false-positive rates for primary hrHPV screening ranged from 6.6% to 7.4%, compared with 2.6% to 6.5% for cytology. For cotesting, false-positives ranged from 5.8% to 19.9% in the first round of screening, compared with 2.6% to 10.9% for cytology. First-round colposcopy rates were also higher, ranging 1.2% to 7.9% for primary hrHPV testing, compared with 1.1% to 3.1% for cytology alone; colposcopy rates for cotesting ranged from 6.8% to 10.9%, compared with 3.3% to 5.2% for cytology alone. The IPD meta-analysis of data from 4 cotesting trials and 1 primary hrHPV screening trial found lower risk of invasive cervical cancer with any hrHPV screening compared with cytology alone (pooled RR, 0.60 [95% CI, 0.40-0.89]). CONCLUSIONS AND RELEVANCE Primary hrHPV screening detected higher rates of CIN 3+ at first-round screening compared with cytology. Cotesting trials did not show initial increased CIN 3+ detection. Both hrHPV screening strategies had higher false-positive and colposcopy rates than cytology, which could lead to more treatments with potential harms.
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Affiliation(s)
- Joy Melnikow
- University of California, Davis, Center for Healthcare Policy and Research, Sacramento
| | - Jillian T Henderson
- Kaiser Permanente Research Affiliates Evidence-based Practice Center, Center for Health Research, Kaiser Permanente, Portland, Oregon
| | - Brittany U Burda
- Kaiser Permanente Research Affiliates Evidence-based Practice Center, Center for Health Research, Kaiser Permanente, Portland, Oregon
| | - Caitlyn A Senger
- Kaiser Permanente Research Affiliates Evidence-based Practice Center, Center for Health Research, Kaiser Permanente, Portland, Oregon
| | - Shauna Durbin
- University of California, Davis, Center for Healthcare Policy and Research, Sacramento
| | - Meghan S Weyrich
- University of California, Davis, Center for Healthcare Policy and Research, Sacramento
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Petry KU, Horn J, Luyten A, Mikolajczyk RT. Punch biopsies shorten time to clearance of high-risk human papillomavirus infections of the uterine cervix. BMC Cancer 2018; 18:318. [PMID: 29566658 PMCID: PMC5865384 DOI: 10.1186/s12885-018-4225-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2017] [Accepted: 03/14/2018] [Indexed: 11/10/2022] Open
Abstract
Background The primary objective was to determine human papilloma virus (HPV) clearance rate after cervical biopsy among women with persistent high-risk HPV infection compared with spontaneous HPV clearance rate in the absence of biopsy. Methods We collected data from a dedicated screening program of women aged 30–70 years old. Inclusion criteria for the baseline non-interventional cohort were a positive HPV test (hybrid capture 2, HC2) and normal cytology. In the baseline cohort women were followed with approximately yearly HPV-tests and cytology until HPV regressed (one negative HPV test) or interventions in the form of diagnostic biopsies or therapy. Women who had a diagnostic biopsy were included in the biopsy cohort and followed until HPV regression or therapy. Observed HPV regression rates and time to HPV regression were compared between baseline and biopsy cohorts. For the comparison, we used Fisher’s exact test for the HPV regression rates and interval-censored, accelerated failure time model for time to HPV regression. Results Among the 1079 women included in the baseline cohort, 499 (46.3%) had HPV clearance and 475 were referred for colposcopy with biopsy. The biopsy cohort comprised all women who were not treated and had at least one HC2 test after biopsy (201/475; 42.3%). Of those, 138 (68.7%) experienced HPV regression. In the biopsy cohort, time to clearance of HPV infection was approximately halved (0.46, 95% CI 0.38–0.56) compared with the baseline cohort. This result was robust in a wide range of sensitivity analyses. Conclusions A higher proportion of women cleared their HPV infection, and time to HPV clearance was shorter in the biopsy cohort than in the baseline cohort. It is reassuring for clinicians to know that conservative management of patients with HPV persistency is successful when colposcopy with biopsies excludes high-grade disease.
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Affiliation(s)
- K U Petry
- Department of Obstetrics and Gynecology, Klinikum Wolfsburg, Wolfsburg, Germany.
| | - J Horn
- Institute for Medical Epidemiology, Biometrics, and Informatics, Martin-Luther-University Halle-Wittenberg, Halle, Germany
| | - A Luyten
- Department of Obstetrics and Gynecology, Klinikum Wolfsburg, Wolfsburg, Germany
| | - R T Mikolajczyk
- Institute for Medical Epidemiology, Biometrics, and Informatics, Martin-Luther-University Halle-Wittenberg, Halle, Germany.,Hannover Medical School, Hannover, Germany.,German Centre for Infection Research/ Site Braunschweig-Hannover, Braunschweig, Germany
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Schiffman M, Yu K, Zuna R, Terence Dunn S, Zhang H, Walker J, Gold M, Hyun N, Rydzak G, Katki HA, Wentzensen N. Proof-of-principle study of a novel cervical screening and triage strategy: Computer-analyzed cytology to decide which HPV-positive women are likely to have ≥CIN2. Int J Cancer 2016; 140:718-725. [PMID: 27696414 DOI: 10.1002/ijc.30456] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2016] [Revised: 08/02/2016] [Accepted: 09/07/2016] [Indexed: 11/07/2022]
Abstract
A challenge in implementation of sensitive HPV-based screening is limiting unnecessary referrals to colposcopic biopsy. We combined two commonly recommended triage methods: partial HPV typing and "reflex" cytology, evaluating the possibility of automated cytology. This investigation was based on 1,178 exfoliated cervical specimens collected during the enrollment phase of The Study to Understand Cervical Cancer Early Endpoints and Determinants (SUCCEED, Oklahoma City, OK). We chose a colposcopy clinic population to maximize number of outcomes, for this proof-of-principle cross-sectional study. Residual aliquots of PreservCyt were HPV-typed using Linear Array (LA, Roche Molecular Systems, Pleasanton, CA). High-risk HPV typing data and cytologic results (conventional and automated) were used jointly to predict risk of histologically defined ≥CIN2. We developed a novel computer algorithm that uses the same optical scanning features that are generated by the FocalPoint Slide Profiler (BD, Burlington, NC). We used the Least Absolute Shrinkage and Selection Operator (LASSO) method to build the prediction model based on a training dataset (n = 600). In the validation set (n = 578), for triage of all HPV-positive women, a cytologic threshold of ≥ASC-US had a sensitivity of 0.94, and specificity of 0.30, in this colposcopy clinic setting. When we chose a threshold for the severity score (generated by the computer algorithm) that had an equal specificity of 0.30, the sensitivity was 0.91. Automated cytology also matched ≥ASC-US when partial HPV typing was added to the triage strategy, and when we re-defined cases as ≥CIN3. If this strategy works in a prospective screening setting, a totally automated screening and triage technology might be possible.
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Affiliation(s)
- Mark Schiffman
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Bethesda, MD
| | - Kai Yu
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Bethesda, MD
| | - Rosemary Zuna
- Oklahoma University Health Sciences Center, Oklahoma City, OK
| | | | - Han Zhang
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Bethesda, MD
| | - Joan Walker
- Oklahoma State Department of Health, Oklahoma City, OK
| | | | - Noorie Hyun
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Bethesda, MD
| | - Greg Rydzak
- Information Management Services, Calverton, MD
| | - Hormuzd A Katki
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Bethesda, MD
| | - Nicolas Wentzensen
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Bethesda, MD
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Huh WK, Ault KA, Chelmow D, Davey DD, Goulart RA, Garcia FA, Kinney WK, Massad LS, Mayeaux EJ, Saslow D, Schiffman M, Wentzensen N, Lawson HW, Einstein MH. Use of primary high-risk human papillomavirus testing for cervical cancer screening: interim clinical guidance. J Low Genit Tract Dis 2016; 19:91-6. [PMID: 25574659 DOI: 10.1097/lgt.0000000000000103] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
In 2011, the American Cancer Society, the American Society for Colposcopy and Cervical Pathology, and the American Society for Clinical Pathology updated screening guidelines for the early detection of cervical cancer and its precursors. Recommended screening strategies were cytology or cotesting (cytology in combination with high-risk HPV (hrHPV) testing). These guidelines also addressed the use of hrHPV testing alone as a primary screening approach, which was not recommended for use at that time. There is now a growing body of evidence for screening with primary hrHPV testing, including a prospective US-based registration study. Thirteen experts including representatives from the Society of Gynecologic Oncology, American Society for Colposcopy and Cervical Pathology, American College of Obstetricians and Gynecologists, American Cancer Society, American Society of Cytopathology, College of American Pathologists, and the American Society for Clinical Pathology, convened to provide interim guidance for primary hrHPV screening. This guidance panel was specifically triggered by an application to the FDA for a currently marketed HPV test to be labeled for the additional indication of primary cervical cancer screening. Guidance was based on literature review and review of data from the FDA registration study, supplemented by expert opinion. This document aims to provide information for health care providers who are interested in primary hrHPV testing and an overview of the potential advantages and disadvantages of this strategy for screening as well as to highlight areas in need of further investigation.
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Affiliation(s)
- Warner K Huh
- 1University of Alabama at Birmingham, Birmingham, AL, USA; 2University of Kansas Medical Center, Kansas City, KS, USA; 3Virginia Commonwealth University Medical Center, Richmond, VA, USA; 4University of Central Florida, Orlando, FL, USA; 5New England Pathology Associates, Springfield, MA, USA; 6Pima County Health Department, Tucson, AZ, USA; 7Kaiser Permanente, Sacramento, CA, USA; 8Washington University School of Medicine, St. Louis, MO, USA; 9University of South Carolina School of Medicine, Columbia, SC, USA; 10American Cancer Society, Atlanta, GA, USA; 11National Cancer Institute, Bethesda, MD, USA; 12American Society of Colposcopy and Cervical Pathology, Frederick, MD, USA; and 13Albert Einstein College of Medicine, Bronx, NY, USA
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van Baars R, van der Marel J, Snijders PJF, Rodriquez-Manfredi A, ter Harmsel B, van den Munckhof HAM, Ordi J, del Pino M, van de Sandt MM, Wentzensen N, Meijer CJLM, Quint WGV. CADM1 and MAL methylation status in cervical scrapes is representative of the most severe underlying lesion in women with multiple cervical biopsies. Int J Cancer 2015. [PMID: 26219541 DOI: 10.1002/ijc.29706] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Recent studies have shown that CADM1/MAL methylation levels in cervical scrapes increase with severity and duration of the underlying cervical intraepithelial neoplasia (CIN) lesion. Multiple lesions of different histological grades and duration are frequently present on the cervix. To gain more insight into the possible epigenetic heterogeneity and its consequences for the methylation status in cervical scrapes, we performed an exploratory study of CADM1/MAL methylation in different grades of CIN lesions present in women with multiple cervical biopsies. CADM1-M18 and MAL-M1 methylation was assessed using a standardised, multiplex, quantitative methylation specific PCR on 178 biopsies with various grades of CIN in 65 women, and in their corresponding cervical scrapes. CADM1/MAL methylation positivity increased with disease severity, from 5.5% in normal biopsies to 63.3% and 100% in biopsies with CIN3 and cervical cancer, respectively. In the majority (8/9) of women where besides a CIN2/3 lesion a biopsy from normal cervical tissue was present, the CIN2/3 biopsy was CADM1/MAL methylation positive and the normal biopsy was CADM1/MAL methylation negative. A good concordance (78%) was found between CADM1/MAL methylation results on the scrapes and the biopsy with the worst diagnosis, particularly between samples of women with CIN3 and cervical cancer (92% and 100% concordance, respectively). Thus, in women with multiple cervical biopsies, CADM1/MAL methylation increases with severity of the lesion and is lesion-specific. CADM1/MAL methylation status in cervical scrapes appears to be representative of the worst underlying lesion, particularly for CIN3 and cervical cancer.
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Affiliation(s)
| | | | - Peter J F Snijders
- Department of Pathology, VU University Medical Center, Amsterdam, The Netherlands
| | | | | | | | - Jaume Ordi
- Department of Pathology, CRESIB (Centre De Recerca En Salut Internacional De Barcelona)-Hospital Clinic, Faculty of Medicine-University of Barcelona, Barcelona, Spain
| | - Marta del Pino
- Department of Obstetrics and Gynaecology, Hospital Clínic, Barcelona, Spain
| | | | - N Wentzensen
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, MD
| | - Chris J L M Meijer
- Department of Pathology, VU University Medical Center, Amsterdam, The Netherlands
| | - Wim G V Quint
- DDL Diagnostic Laboratory, Rijswijk, The Netherlands
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Long-Term Clinical Outcome after Treatment for High-Grade Cervical Lesions: A Retrospective Monoinstitutional Cohort Study. BIOMED RESEARCH INTERNATIONAL 2015; 2015:984528. [PMID: 26180819 PMCID: PMC4477134 DOI: 10.1155/2015/984528] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/08/2014] [Revised: 12/05/2014] [Accepted: 03/10/2015] [Indexed: 01/28/2023]
Abstract
Background. The aim of this retrospective observational study of women treated for cervical intraepithelial neoplasia grade 2 or worse (CIN2+) was to assess the long-term risk of residual/recurrent high-grade CIN. Materials and Methods. We evaluated 760 women treated by loop electrosurgical excision procedure (684) or conization (76) between 2000 and 2009, and followed up to June 30, 2014 (median follow-up 6.7 years, range 4–14). Visits every 6 months for the first year after treatment and yearly for up to the following 10 years included cytology, colposcopy when indicated, and HPV testing (search and typing). Results. CIN2+ or vaginal intraepithelial neoplasia grade 2 or worse (VAIN2+) was detected in 67 cases (8.8%), 39 at first follow-up and 28 after one/more negative visits. The risk of CIN2+ was higher in case of positive margins (odds ratio (OR) 8.04, 95% CI 4.31–15.0), type 3 transformation zone (OR for CIN3 27.7, 95% CI 2.07–36.9), CIN3+ excision (OR 6.02, 95% CI 1.73–20.9), and positive high-risk HPV test at first follow-up (OR for HPV16: 20.6, 95% CI 6.8–62.6; OR for other hrHPV types: 18.3, 95% CI 5.9–57.0). Conclusion. Residual/recurrent high-grade CIN occurred in <9% cases, and the risk was associated with transformation zone type, lesion grade, margins status, and hrHPV test result at 6–12 months of follow-up.
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Zhao J, Zhang X, Chen R, Zhao YQ, Wang TT, He S, Qiao YL. Performance of the R-way Colposcopic Evaluation System in Cervical Cancer Screening. Asian Pac J Cancer Prev 2015; 16:4223-8. [PMID: 26028077 DOI: 10.7314/apjcp.2015.16.10.4223] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
OBJECTIVE To investigate the diagnostic value of the R-way colposcopic evaluation system (R-way system) in cervical cancer screening. MATERIALS AND METHODS Between August 2013 and August 2014, a total of 1,059 cases referred to colposcopy in Peking University First Hospital were studied using both the R-way system and conventional colposcopy. Our study evaluated and compared the diagnostic ability of the two methods in detecting high-grade lesions and cervical cancer (hereinafter called CIN2+). Evaluation indicators including sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), Youden index and the area under the curve (AUC) of the receiver operating characteristic (ROC) were calculated. RESULTS The R-way system had a slightly lower specificity (94.5%) than conventional colposcopy (96.0%) for CIN2+ detection (P=0.181). However, the sensitivity (77.8%) was significantly higher than with the conventional colposcopic method (46.6%) (χ2=64.351, P<0.001). In addition, the AUC of the ROC for CIN2+ detection using the R-way system (0.839) was larger than that with conventional colposcopy (0.731) (Z=4.348, P<0.001). If preliminary result had been drawn from cervical exfoliated cytology before colposcopy referral, combination of the R-way system with cytology could increase the sensitivity to 93.9% for CIN2+ detection (excluding ASCUS\LSIL), confirmed by multipoint biopsy or ECC. CONCLUSIONS The diagnostic value of the R-way evaluation system is higher than that of conventional colposcopic evaluation in cervical cancer screening. Moreover, taking the ease of use and standardized quality control management into account, the R-way system is highly preferable.
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Affiliation(s)
- Jian Zhao
- Department of Gynaecology and Obstetrics, Peking University First Hospital, Peking University Health Science Center, Peking University, Beijing, China E-mail :
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18
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Use of primary high-risk human papillomavirus testing for cervical cancer screening: Interim clinical guidance. Gynecol Oncol 2015; 136:178-82. [DOI: 10.1016/j.ygyno.2014.12.022] [Citation(s) in RCA: 316] [Impact Index Per Article: 35.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2014] [Revised: 12/15/2014] [Accepted: 12/15/2014] [Indexed: 11/22/2022]
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Use of Primary High-Risk Human Papillomavirus Testing for Cervical Cancer Screening. Obstet Gynecol 2015; 125:330-337. [DOI: 10.1097/aog.0000000000000669] [Citation(s) in RCA: 154] [Impact Index Per Article: 17.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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20
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Tian X, Chen D, Zhang R, Zhou J, Peng X, Yang X, Zhang X, Zheng Z. Quantitative survey of multiple CpGs from 5 genes identifies CpG methylation panel discriminating between high- and low-grade cervical intraepithelial neoplasia. Clin Epigenetics 2015; 7:4. [PMID: 25699113 PMCID: PMC4334603 DOI: 10.1186/s13148-014-0037-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2014] [Accepted: 12/16/2014] [Indexed: 12/14/2022] Open
Abstract
Background Studies of methylation biomarkers for cervical cancer often involved only few randomly selected CpGs per candidate gene analyzed by methylation-specific PCR-based methods, with often inconsistent results from different laboratories. We evaluated the role of different CpGs from multiple genes as methylation biomarkers for high-grade cervical intraepithelial neoplasia (CIN). Results We applied a mass spectrometry-based platform to survey the quantitative methylation levels of 34 CpG units from SOX1, PAX1, NKX6-1, LMX1A, and ONECUT1 genes in 100 cervical formalin-fixed paraffin-embedded (FFPE) tissues. We then used nonparametric statistics and Random Forest algorithm to rank significant CpG methylations and support vector machine with 10-fold cross validation and 200 times bootstrap resampling to build a predictive model separating CIN II/III from CIN I/normal subjects. We found only select CpG units showed significant differences in methylation between CIN II/III and CIN I/normal groups, while mean methylation levels per gene were similar between the two groups for each gene except PAX1. An optimal classification model involving five CpG units from SOX1, PAX1, NKX6-1, and LMX1A achieved 81.2% specificity, 80.4% sensitivity, and 80.8% accuracy. Conclusions Our study suggested that during CIN development, the methylation of CpGs within CpG islands is not uniform, with varying degrees of significance as biomarkers. Our study emphasizes the importance of not only methylated marker genes but also specific CpGs for identifying high-grade CINs. The 5-CpG classification model provides a promising biomarker panel for the early detection of cervical cancer. Electronic supplementary material The online version of this article (doi:10.1186/s13148-014-0037-1) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Xiaoyi Tian
- Department of Biochemistry and Molecular Biology, Institute of Basic Medical Sciences, Chinese Academy of Medical Sciences and School of Basic Medicine, Peking Union Medical College, No. 5 Dong Dan San Tiao, Beijing, 100005 China
| | - Di Chen
- Department of Pathology, Aerospace Central Hospital, No. 15 Yuquan Road, Beijing, 100049 China
| | - Ran Zhang
- Department of Biochemistry and Molecular Biology, Institute of Basic Medical Sciences, Chinese Academy of Medical Sciences and School of Basic Medicine, Peking Union Medical College, No. 5 Dong Dan San Tiao, Beijing, 100005 China
| | - Jun Zhou
- Department of Biochemistry and Molecular Biology, Institute of Basic Medical Sciences, Chinese Academy of Medical Sciences and School of Basic Medicine, Peking Union Medical College, No. 5 Dong Dan San Tiao, Beijing, 100005 China
| | - Xiaozhong Peng
- Department of Biochemistry and Molecular Biology, Institute of Basic Medical Sciences, Chinese Academy of Medical Sciences and School of Basic Medicine, Peking Union Medical College, No. 5 Dong Dan San Tiao, Beijing, 100005 China
| | - Xiaolin Yang
- Department of Biomedical Engineering, Institute of Basic Medical Sciences, Chinese Academy of Medical Sciences and School of Basic Medicine, Peking Union Medical College, No. 5 Dong Dan San Tiao, Beijing, 100005 China
| | - Xiuru Zhang
- Department of Pathology, Beijing Tiantan Hospital Affiliated with Capital Medical University, No. 6 Tiantan Xili, Beijing, 100050 China
| | - Zhi Zheng
- Department of Biochemistry and Molecular Biology, Institute of Basic Medical Sciences, Chinese Academy of Medical Sciences and School of Basic Medicine, Peking Union Medical College, No. 5 Dong Dan San Tiao, Beijing, 100005 China
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Clinical relevance of objectifying colposcopy. Arch Gynecol Obstet 2014; 291:907-15. [DOI: 10.1007/s00404-014-3518-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2014] [Accepted: 10/07/2014] [Indexed: 10/24/2022]
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Petry KU, Wörmann B, Schneider A. Benefits and risks of cervical cancer screening. Oncol Res Treat 2014; 37 Suppl 3:48-57. [PMID: 25195832 DOI: 10.1159/000365059] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- Karl U Petry
- Frauenklinik, Klinikum Wolfsburg, Wolfsburg, Germany
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Spinillo A, Gardella B, Chiesa A, Cesari S, Alberizzi P, Silini EM. Diagnostic accuracy of colposcopy in relation to human papillomavirus genotypes and multiple infection. Gynecol Oncol 2014; 134:527-33. [PMID: 25026638 DOI: 10.1016/j.ygyno.2014.07.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2014] [Revised: 07/04/2014] [Accepted: 07/06/2014] [Indexed: 11/30/2022]
Abstract
OBJECTIVE The aim of this study is to evaluate the diagnostic accuracy of colposcopy for cervical intraepithelial neoplasia grade 3 or worse (CIN3+) in relation to the detection of human papillomavirus (HPV) type 16 and multiple HPV infection. METHODS A cohort study of 2526 subjects attending a colposcopic service because of cytological abnormalities. HPV genotypes were identified using the INNO-LIPA genotyping system. RESULTS The final colposcopic/pathological diagnoses were as follows: 1282 (50.8%) negative, 709 (28.1%) CIN1, 169 (6.7%) CIN2, 318 (12.6%) CIN3 and 48 (1.9%) invasive cervical cancer, respectively. Among women with ASCUS/LSIL, assuming any colposcopic abnormality as a cut-off, there were no significant differences in the sensitivities (83.8%, 95% CI=76-89.6 as compared to 84.1%, 95% CI=73.2-91.1, p=0.9) and ROC curves (0.61, 95% CI=0.58-0.65 as compared to 0.59, 95% CI=0.54-0.64, p=0.5) in the detection of CIN3+ lesions between subjects with single and multiple high-risk infection, and between subjects infected by HPV16 (83.1%, 95% CI=73.7-89.7, ROC=0.59, 95% CI=0.54-063) or other high-risk HPVs (84.7%, 95% CI=75.6-90.8, ROC=0.62, 95% CI=0.58-0.66, p=0.8 and p=0.6 compared to HPV16). After correction for confounders, the odds ratios of CIN3+ associated with any abnormal colposcopic findings were 2.47 (95%CI=1.44-4.23, p=0.001) among HPV16 positive, 3.34 (95% CI=2.16-5.42, p<0.001) among other high-risk HPVs and 1.3 (95% CI=0.72-2.48, p=0.36) among subjects with negative/low-risk HPVs. CONCLUSION In routine clinical practice, multiple infection or HPV16 positivity did not affect colposcopic accuracy in the diagnosis of CIN3+ lesions. The sensitivity of colposcopy was poor among subjects who were uninfected or infected by low-risk HPV genotypes.
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Affiliation(s)
- Arsenio Spinillo
- Department of Obstetrics and Gynecology, University of Pavia, IRCCS Fondazione Policlinico San Matteo, Italy.
| | - Barbara Gardella
- Department of Obstetrics and Gynecology, University of Pavia, IRCCS Fondazione Policlinico San Matteo, Italy
| | - Alessia Chiesa
- Department of Obstetrics and Gynecology, University of Pavia, IRCCS Fondazione Policlinico San Matteo, Italy
| | - Stefania Cesari
- Department of Pathology, University of Pavia, IRCCS Fondazione Policlinico San Matteo, Italy
| | - Paola Alberizzi
- Department of Pathology, University of Pavia, IRCCS Fondazione Policlinico San Matteo, Italy
| | - Enrico Maria Silini
- Department of Biomedical, Biotechnological and Translational Sciences, Unit of Surgical Pathology and Center for Molecular and Translational Oncology (COMT), University of Parma, Italy
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Luyten A, Buttmann-Schweiger N, Luyten K, Mauritz C, Reinecke-Lüthge A, Pietralla M, Meijer CJLM, Petry KU. Early detection of CIN3 and cervical cancer during long-term follow-up using HPV/Pap smear co-testing and risk-adapted follow-up in a locally organised screening programme. Int J Cancer 2014; 135:1408-16. [PMID: 24519782 DOI: 10.1002/ijc.28783] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2013] [Accepted: 01/08/2014] [Indexed: 11/07/2022]
Abstract
We evaluated compliance with human papillomavirus (HPV) testing and risk-adapted patient pathways and monitored changes in high-grade cervical disease during long-term follow-up. Women aged >30 years attending routine screening for cervical cancer were managed according to results from first-round screening tests (cytology and high-risk HPV; Hybrid Capture 2). Between February 2006 and January 2011, 19,795 of 19,947 women agreed to participate, of whom 4,067 proceeded to a second screening round 5 years after recruitment. Predefined endpoints were compliance, grade 3 cervical intraepithelial neoplasia or cancer (CIN3+), new HPV infection, HPV persistence and abnormal smears in round 2. A total of 765 of 19,795 women (3.9%) in round 1 and 41 of 4,067 (1.0%) in round 2 were referred for colposcopy. Compliance rates with colposcopy were 93.1 and 92.7%, respectively, while histological assessment was performed in 680 of 712 (95.5%) and 36 of 38 (94.7%), respectively. CIN3+ rates were 172 of 19,795 (0.87%; 95% confidence intervals: 0.7-1.0) in round 1 and 2 of 4,064 (0.05%; 95% confidence intervals: 0.006-0.2) in round 2; the difference was statistically significant (Fisher's exact test, p<0.001). After 5 years, the incidence of new HPV infection was 124 of 3,906 (3.2%) and HPV persistence was observed in 22 of 161 (13.7%). Locally organised HPV/cytology co-testing is feasible and acceptable to women. Risk-adapted management rapidly detected a high rate of prevalent CIN3+, while the subsequent long-term risk of new high-grade cervical disease was surprisingly low. It remains unclear if this phenomenon is explained by CIN3 mostly occurring early in life or by modifying the natural course of HPV infection with colposcopy and histological assessment.
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Affiliation(s)
- Alexander Luyten
- Department of Gynaecology and Obstetrics, Klinikum Wolfsburg, Wolfsburg, Germany
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van der Marel J, van Baars R, Quint WGV, Berkhof J, del Pino M, Torné A, Ordi J, Wentzensen N, Schiffman M, van de Sandt MM, Lindeman J, Jenkins D, Helmerhorst TJM, Verheijen RHM, ter Harmsel B, Alonso I. The impact of human papillomavirus genotype on colposcopic appearance: a cross-sectional analysis. BJOG 2014; 121:1117-26. [DOI: 10.1111/1471-0528.12668] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/17/2013] [Indexed: 11/29/2022]
Affiliation(s)
- J van der Marel
- Department of Research and Development; DDL Diagnostic Laboratory; Rijswijk the Netherlands
| | - R van Baars
- Department of Research and Development; DDL Diagnostic Laboratory; Rijswijk the Netherlands
| | - WGV Quint
- Department of Research and Development; DDL Diagnostic Laboratory; Rijswijk the Netherlands
| | - J Berkhof
- Department of Epidemiology and Biostatistics; VU University Medical Centre; Amsterdam the Netherlands
| | - M del Pino
- Institut Clinic of Gynecology, Obstetrics and Neonatology; Hospital Clínic-Institut d′Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS); Barcelona Spain
| | - A Torné
- Institut Clinic of Gynecology, Obstetrics and Neonatology; Hospital Clínic-Institut d′Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS); Barcelona Spain
| | - J Ordi
- Department of Pathology; CRESIB (Centre de Recerca en Salut Internacional de Barcelona)-Hospital Clínic; Barcelona Spain
| | - N Wentzensen
- Division of Cancer Epidemiology and Genetics; National Cancer Institute; Bethesda MD USA
| | - M Schiffman
- Division of Cancer Epidemiology and Genetics; National Cancer Institute; Bethesda MD USA
| | - MM van de Sandt
- Department of Research and Development; DDL Diagnostic Laboratory; Rijswijk the Netherlands
| | - J Lindeman
- Department of Research and Development; DDL Diagnostic Laboratory; Rijswijk the Netherlands
| | - D Jenkins
- Department of Research and Development; DDL Diagnostic Laboratory; Rijswijk the Netherlands
| | - TJM Helmerhorst
- Department of Obstetrics & Gynaecology; Erasmus University Medical Center; Rotterdam the Netherlands
| | - RHM Verheijen
- Division of Woman and Baby; Gynaecological Oncology; University Medical Centre Utrecht; Utrecht the Netherlands
| | - B ter Harmsel
- Department of Obstetrics and Gynaecology; Reinier de Graaf Groep; Delft the Netherlands
- Department of Gynaecology; Roosevelt Kliniek; Leiden the Netherlands
| | - I Alonso
- Institut Clinic of Gynecology, Obstetrics and Neonatology; Hospital Clínic-Institut d′Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS); Barcelona Spain
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27
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Petry KU, Rinnau F, Böhmer G, Hollwitz B, Luyten A, Buttmann N, Brünger M, Iftner T. Annual Papanicolaou screening for 5 years among human papillomavirus-negative women. BMC Cancer 2013; 13:379. [PMID: 23937771 PMCID: PMC3751119 DOI: 10.1186/1471-2407-13-379] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2013] [Accepted: 08/01/2013] [Indexed: 11/17/2022] Open
Abstract
Background Primary human papilloma virus (HPV) screening is more effective than cytology in reducing the risk of cervical cancer, but screening intervals should be extended in HPV-negative women. However, some Markov models predicted that long intervals are associated with an excess risk of cervical cancer. The aim of this analysis was to estimate the real-life risks and benefits of annual Papanicolaou (Pap) screening in HPV-negative women with normal cytology. Methods Women with negative Hybrid Capture 2 (HC2) results and normal cytology at the time of inclusion in the Hannover HPV screening trial underwent annual Pap smears for 5 years. A subgroup was randomly selected for retesting with cytology, HC2, and colposcopy 60–68 months after recruitment. Results Of 4236 women included, 3406 had at least one Pap smear, but only 1185 attended all five annual screening visits. The proportion of women with at least one abnormal smear was 14.4% in 60 months. The probability of abnormal smears increased continuously over time. No case of ≥ CIN2+ was observed during 5 years. Of 605 women selected for subgroup analysis, 292 agreed to be retested (48.3%). The rate of high-risk HPV at 60–68 months was 3.0% (9/296). Conclusions The long-term risk of high-grade neoplasia after an initial negative HC2 test and normal cytology result was low, while the rate of false-positive abnormal Pap smears was significant and increased constantly over time. Pap smear screening of HPV-negative women more frequently than every 5 years could be potentially harmful and seems to be of little clinical value.
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Affiliation(s)
- Karl Ulrich Petry
- Zentrum für Frauenheilkunde, Medizinische Hochschule Hannover (MHH), Carl-Neuberg-Street 1, 30625 Hannover, Germany.
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