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Long E, Macdonald MC, Parker VL, Lyon R, Ellis K, Palmer JE. Factors associated with failed 'test of cure' in the NHS Cervical Screening Programme: A retrospective cohort study. Gynecol Oncol 2023; 179:158-163. [PMID: 37988947 DOI: 10.1016/j.ygyno.2023.10.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Revised: 10/25/2023] [Accepted: 10/27/2023] [Indexed: 11/23/2023]
Abstract
OBJECTIVE To determine predictive factors associated with failed 'test of cure' (TOC) in the NHS Cervical Screening Programme (NHSCSP). METHODS Retrospective cohort study of all patients treated by large loop excision of transformation zone (LLETZ) between 1st April 2014 and 1st April 2019. Those with no documented HPV genotype on referral, no TOC outcome, those having a hysterectomy, chemotherapy and/or radiotherapy were excluded from final analysis. RESULTS Patients referred with a singular HPV genotype of HPV 16, HPV 18, or HPV Other types (HPV O) were significantly more likely to pass TOC than those referred with multiple HPV genotypes (p < 0.0001). Those with HPV genotypes including HPV O were significantly more likely to fail TOC as compared to those with genotypes of solely HPV 16 and/or 18 (p < 0.0001). Patients aged ≥51 years were significantly more likely to fail TOC when compared to all other age groups (p < 0.0001). CONCLUSION Age >51 yrs. and infection with multiple hr-HPV types were predictors of post treatment hr-HPV persistence. Knowledge of HPV genotype both at referral, and following treatment, could allow a more individualised, and patient-centred, approach to both the management and follow up of CIN. HPV genotype should be reported as standard on all cervical screening sample results. The term HPV O should not be utilised and instead actual HPV genotype should be reported. This would enable us to optimise not only future research but would also allow future monitoring of the efficacy of vaccination programmes.
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Affiliation(s)
- Emma Long
- ST7 Obstetrics & Gynaecology, Sub-Specialty Trainee Gynaecological Oncology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Madeleine C Macdonald
- Consultant Gynaecological Oncologist, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Victoria L Parker
- NIHR Clinical Lecturer in Obstetrics and Gynaecology, Division of Clinical Medicine, School of Medicine and Population Health, University of Sheffield, Sheffield, UK.
| | - Rachel Lyon
- Clinical Nurse Specialist - Colposcopy, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Kay Ellis
- Cervical Screening Programme Lead, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK; Cervical Screening Programme Lead, North East Yorkshire Cervical Screening Centre, Gateshead, UK
| | - Julia E Palmer
- Consultant Gynaecological Oncologist, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
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Doorbar JA, Mathews CS, Denton K, Rebolj M, Brentnall AR. Supporting the implementation of new healthcare technologies by investigating generalisability of pilot studies using area-level statistics. BMC Health Serv Res 2022; 22:1412. [PMID: 36434583 PMCID: PMC9694587 DOI: 10.1186/s12913-022-08735-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Accepted: 10/25/2022] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Implementation of new technologies into national health care systems requires careful capacity planning. This is sometimes informed by data from pilot studies that implement the technology on a small scale in selected areas. A critical consideration when using implementation pilot studies for capacity planning in the wider system is generalisability. We studied the feasibility of using publicly available national statistics to determine the degree to which results from a pilot might generalise for non-pilot areas, using the English human papillomavirus (HPV) cervical screening pilot as an exemplar. METHODS From a publicly available source on population indicators in England ("Public Health Profiles"), we selected seven area-level indicators associated with cervical cancer incidence, to produce a framework for post-hoc pilot generalisability analysis. We supplemented these data by those from publicly available English Office for National Statistics modules. We compared pilot to non-pilot areas, and pilot regimens (pilot areas using the previous standard of care (cytology) vs. the new screening test (HPV)). For typical process indicators that inform real-world capacity planning in cancer screening, we used standardisation to re-weight the values directly observed in the pilot, to better reflect the wider population. A non-parametric quantile bootstrap was used to calculate 95% confidence intervals (CI) for differences in area-weighted means for indicators. RESULTS The range of area-level statistics in pilot areas covered most of the spectrum observed in the wider population. Pilot areas were on average more deprived than non-pilot areas (average index of multiple deprivation 24.8 vs. 21.3; difference: 3.4, 95% CI: 0.2-6.6). Participants in HPV pilot areas were less deprived than those in cytology pilot areas, matching area-level statistics. Differences in average values of the other six indicators were less pronounced. The observed screening process indicators showed minimal change after standardisation for deprivation. CONCLUSIONS National statistical sources can be helpful in establishing the degree to which the types of areas outside pilot studies are represented, and the extent to which they match selected characteristics of the rest of the health care system ex-post. Our analysis lends support to extrapolation of process indicators from the HPV screening pilot across England.
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Affiliation(s)
- James Alexander Doorbar
- Cancer Prevention Group, School of Cancer & Pharmaceutical Sciences, Faculty of Life Sciences & Medicine, King's College London, London, UK
| | - Christopher S Mathews
- Cancer Prevention Group, School of Cancer & Pharmaceutical Sciences, Faculty of Life Sciences & Medicine, King's College London, London, UK
| | - Karin Denton
- Severn Pathology, Southmead Hospital, North Bristol NHS Trust, Bristol, UK
| | - Matejka Rebolj
- Cancer Prevention Group, School of Cancer & Pharmaceutical Sciences, Faculty of Life Sciences & Medicine, King's College London, London, UK.
| | - Adam R Brentnall
- Wolfson Institute of Population Health, Queen Mary University of London, London, UK
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Wu M, Ma X, Li H, Li B, Wang C, Fan X, Fan A, Xue F. Which is the best management for women with normal cervical cytologic findings despite positivity for non-16/18 high risk human papillomaviruses? Front Public Health 2022; 10:950610. [PMID: 36438260 PMCID: PMC9682294 DOI: 10.3389/fpubh.2022.950610] [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: 05/23/2022] [Accepted: 09/05/2022] [Indexed: 11/11/2022] Open
Abstract
Women who test positive for the human papillomavirus (HPV) but have normal cytology constitute the predominant subgroup of patients in the screening population in the post-vaccination era. The distribution of HPV genotypes changed dramatically, which was attributable to an increase in HPV vaccination coverage. These changes have created uncertainty about how to properly manage women with normal cytology, non-HPV16/18 infections, or persistent infections. Current recommendations include retesting and continued surveillance in the absence of HPV16/18 infection. However, these are not always applicable. The ability to implement genotyping or incorporate HPV16/18 with some additional high-risk HPV (HR-HPV) types for triage and management with the aim of identifying type-specific risks in this population could be acceptable. When the next set of guidelines is updated, generating potential triage strategies for detecting high-grade cervical lesions, such as the p16/Ki67 cytology assay and other alternatives that incorporate genotyping with newer tests, should be considered. Current clinical management is shifting to risk-based strategies; however, no specific risk threshold has been established in this population. Importantly, innovative triage testing should be evaluated in combination with primary screening and management. Furthermore, there is an untapped opportunity to coordinate HPV genotyping in combination with colposcopic characteristics to modify risk in this group. Hence, providing a more personalized schedule through the efficient application of risk stratification and improving the detection of pre-cancer and cancer is an option worth exploring.
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Affiliation(s)
- Ming Wu
- Department of Gynecology and Obstetrics, Tianjin Medical University General Hospital, Tianjin, China,Tianjin Key Laboratory of Female Reproductive Health and Eugenic, Department of Gynecology and Obstetrics, Tianjin Medical University General Hospital, Tianjin, China
| | - Xiaotong Ma
- Department of Gynecology and Obstetrics, Tianjin Medical University General Hospital, Tianjin, China,Tianjin Key Laboratory of Female Reproductive Health and Eugenic, Department of Gynecology and Obstetrics, Tianjin Medical University General Hospital, Tianjin, China
| | - Huiyang Li
- Department of Gynecology and Obstetrics, Tianjin Medical University General Hospital, Tianjin, China,Tianjin Key Laboratory of Female Reproductive Health and Eugenic, Department of Gynecology and Obstetrics, Tianjin Medical University General Hospital, Tianjin, China
| | - Bijun Li
- Department of Gynecology and Obstetrics, Tianjin Medical University General Hospital, Tianjin, China,Tianjin Key Laboratory of Female Reproductive Health and Eugenic, Department of Gynecology and Obstetrics, Tianjin Medical University General Hospital, Tianjin, China
| | - Chen Wang
- Department of Gynecology and Obstetrics, Tianjin Medical University General Hospital, Tianjin, China,Tianjin Key Laboratory of Female Reproductive Health and Eugenic, Department of Gynecology and Obstetrics, Tianjin Medical University General Hospital, Tianjin, China
| | - Xiangqin Fan
- Department of Gynecology and Obstetrics, Tianjin Medical University General Hospital, Tianjin, China,Tianjin Key Laboratory of Female Reproductive Health and Eugenic, Department of Gynecology and Obstetrics, Tianjin Medical University General Hospital, Tianjin, China
| | - Aiping Fan
- Department of Gynecology and Obstetrics, Tianjin Medical University General Hospital, Tianjin, China,Tianjin Key Laboratory of Female Reproductive Health and Eugenic, Department of Gynecology and Obstetrics, Tianjin Medical University General Hospital, Tianjin, China
| | - Fengxia Xue
- Department of Gynecology and Obstetrics, Tianjin Medical University General Hospital, Tianjin, China,Tianjin Key Laboratory of Female Reproductive Health and Eugenic, Department of Gynecology and Obstetrics, Tianjin Medical University General Hospital, Tianjin, China,*Correspondence: Fengxia Xue
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Rebolj M, Pesola F, Mathews C, Mesher D, Soldan K, Kitchener H. The impact of catch-up bivalent human papillomavirus vaccination on cervical screening outcomes: an observational study from the English HPV primary screening pilot. Br J Cancer 2022; 127:278-287. [PMID: 35347326 PMCID: PMC9296648 DOI: 10.1038/s41416-022-01791-w] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Revised: 01/31/2022] [Accepted: 03/08/2022] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND In England, bivalent vaccination (Cervarix) against high-risk human papillomavirus (HR-HPV) genotypes 16/18 was offered in a population-based catch-up campaign in 2008-2010 to girls aged 14-17 years. These women are now entering the national cervical screening programme. We determined the impact of catch-up bivalent vaccination on their screening outcomes. METHODS We studied the overall and genotype-specific screening outcomes in 108,138 women aged 24-25 (offered vaccination) and 26-29 years (not offered vaccination) included in the English HPV screening pilot between 2013 and 2018. RESULTS At 24-25 years, the detection of high-grade cervical intraepithelial neoplasia (CIN2+) associated with HPV16/18 decreased from 3 to 1% (p < 0.001), with estimated vaccine effectiveness of 87% (95% CI: 82-91%). The detection of any CIN2+ halved from 6 to 3% (p < 0.001), with an estimated vaccine effectiveness of 72% (95% CI: 66-77%). The positive predictive value of a colposcopy for CIN2+ decreased for both low-grade (p < 0.001) and high-grade (p = 0.02) abnormalities on triage cytology. The decreases in screen-detected abnormalities at age 26-29 were of a substantially smaller magnitude. CONCLUSIONS These data confirm high effectiveness of bivalent HPV vaccination delivered through a population-based catch-up campaign in England. These findings add to the rationale for extending screening intervals for vaccinated cohorts.
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Affiliation(s)
- Matejka Rebolj
- Cancer Prevention Group, School of Cancer & Pharmaceutical Sciences, Faculty of Life Sciences & Medicine, King's College London, Great Maze Pond, London, SE1 9RT, UK.
| | - Francesca Pesola
- Cancer Prevention Trials Unit, School of Cancer & Pharmaceutical Sciences, Faculty of Life Sciences & Medicine, King's College London, Great Maze Pond, London, SE1 9RT, UK
- Health and Lifestyle Research Unit, Wolfson Institute of Preventive Medicine, Queen Mary University of London, London, UK
| | - Christopher Mathews
- Cancer Prevention Group, School of Cancer & Pharmaceutical Sciences, Faculty of Life Sciences & Medicine, King's College London, Great Maze Pond, London, SE1 9RT, UK
| | - David Mesher
- Blood Safety, Hepatitis, STI and HIV (BSHSH) Division, National Infection Service, Public Health England, 61 Colindale Avenue, London, NW9 5EQ, UK
| | - Kate Soldan
- Blood Safety, Hepatitis, STI and HIV (BSHSH) Division, National Infection Service, Public Health England, 61 Colindale Avenue, London, NW9 5EQ, UK
| | - Henry Kitchener
- Division of Cancer Sciences, University of Manchester, Oxford Road, Manchester, M13 9PL, UK
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Rebolj M, Mathews CS, Denton K. Cytology interpretation after a change to HPV testing in primary cervical screening: Observational study from the English pilot. Cancer Cytopathol 2022; 130:531-541. [PMID: 35377967 PMCID: PMC9542289 DOI: 10.1002/cncy.22572] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Revised: 02/23/2022] [Accepted: 03/03/2022] [Indexed: 12/03/2022]
Abstract
BACKGROUND Overcalling of abnormalities has been a concern for using cytology triage after positive high-risk human papillomavirus (HPV) tests in cervical screening. METHODS The authors studied the detection of cytological and histological abnormalities at age 24 to 64 years, using data from the English HPV pilot. The pilot compared routine implementation of primary cervical screening based on cytology (N = 931,539), where HPV test results were not available before cytology reporting, with that based on HPV testing (N = 403,269), where cytology was only required after positive HPV tests. RESULTS Revealed HPV positivity was associated with a higher direct referral to colposcopy after any abnormality (adjusted odds ratio [ORadj ], 1.16; 95% confidence interval [CI], 1.14-1.18). Laboratories with higher direct referral referred fewer persistently HPV-positive women after early recall. The detection of high-grade cervical intraepithelial neoplasia (CIN2+) after direct referral increased with an ORadj of 1.17 (95% CI, 1.13-1.20) for informed versus uninformed cytology. Generally, the positive predictive value (PPV) of colposcopy for CIN2+ remained comparable under both conditions of interpreting cytology. In women 50 to 64 years old with high-grade dyskaryosis, however, the PPV increased from 71% to 83% after revealing HPV positivity (ORadj , 2.05; 95% CI, 1.43-2.93). CONCLUSIONS Quality-controlled cervical screening programs can avoid inappropriate overgrading of HPV-positive cytology.
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Affiliation(s)
- Matejka Rebolj
- Cancer Prevention GroupSchool of Cancer and Pharmaceutical SciencesFaculty of Life Sciences and MedicineKing's College LondonLondonUnited Kingdom
| | - Christopher S. Mathews
- Cancer Prevention GroupSchool of Cancer and Pharmaceutical SciencesFaculty of Life Sciences and MedicineKing's College LondonLondonUnited Kingdom
| | - Karin Denton
- Severn PathologySouthmead HospitalNorth Bristol NHS TrustBristolUnited Kingdom
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Rebolj M, Mathews CS, Pesola F, Cuschieri K, Denton K, Kitchener H. Age-specific outcomes from the first round of HPV screening in unvaccinated women: Observational study from the English cervical screening pilot. BJOG 2022; 129:1278-1288. [PMID: 34913243 DOI: 10.1111/1471-0528.17058] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Revised: 11/28/2021] [Accepted: 12/03/2021] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To report detailed age-specific outcomes from the first round of an English pilot studying the implementation of high-risk human papillomavirus (HR-HPV) testing in primary cervical screening. DESIGN Observational study with screening in 2013-2016, followed by two early recalls and/or colposcopy until the end of 2019. SETTING Six NHS laboratory sites. POPULATION A total of 1 341 584 women undergoing screening with HR-HPV testing or liquid-based cytology (LBC). METHODS Early recall tests and colposcopies were recommended, depending on the nature of the screening-detected abnormality. MAIN OUTCOME MEASURES We reported standard screening process indicators, e.g. proportions with an abnormality, including high-grade cervical intraepithelial neoplasia (CIN2+) or cancer, and the positive predictive value (PPV) of colposcopy for CIN2+, by screening test and age group. RESULTS Among unvaccinated women screened with HR-HPV testing at age 24-29 years, 26.9% had a positive test and 10.4% were directly referred to colposcopy following cytology triage, with a PPV for CIN2+ of 47%. At 50-64 years of age, these proportions were much lower: 5.3%, 1.2% and 27%, respectively. The proportions of women testing positive for HR-HPV without cytological abnormalities, whose early recall HR-HPV tests returned negative results, were similar across the age spans: 54% at 24-29 years and 55% at 50-64 years. Two-thirds of infections at any age were linked to non-16/18 genotypes. Among women with CIN2, CIN3 or cervical cancer, however, the proportion of non-16/18 infections increased with age. As expected, the detection of abnormalities was lower following screening with LBC. CONCLUSIONS These data provide a reliable reference for future epidemiological studies, including those concerning the effectiveness of HPV vaccination. TWEETABLE ABSTRACT Data from the English pilot study provide a comprehensive overview of abnormalities detected through HPV screening.
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Affiliation(s)
- Matejka Rebolj
- Cancer Prevention Group, School of Cancer & Pharmaceutical Sciences, Faculty of Life Sciences & Medicine, King's College London, London, UK
| | - Christopher S Mathews
- Cancer Prevention Group, School of Cancer & Pharmaceutical Sciences, Faculty of Life Sciences & Medicine, King's College London, London, UK
| | - Francesca Pesola
- Cancer Prevention Group, School of Cancer & Pharmaceutical Sciences, Faculty of Life Sciences & Medicine, King's College London, London, UK
| | - Kate Cuschieri
- Scottish HPV Reference Laboratory, Royal Infirmary of Edinburgh, NHS Lothian Scotland, Edinburgh, UK
| | - Karin Denton
- Severn Pathology, Southmead Hospital, North Bristol NHS Trust, Bristol, UK
| | - Henry Kitchener
- Division of Cancer Sciences, University of Manchester, Manchester, UK
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Rebolj M, Cuschieri K, Mathews CS, Pesola F, Denton K, Kitchener H. Extension of cervical screening intervals with primary human papillomavirus testing: observational study of English screening pilot data. BMJ 2022; 377:e068776. [PMID: 35640960 PMCID: PMC9153243 DOI: 10.1136/bmj-2021-068776] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/05/2022] [Indexed: 12/14/2022]
Abstract
OBJECTIVES To provide updated evidence about the risk of cervical intraepithelial neoplasia grade 3 or higher (CIN3+) and cervical cancer after a negative human papillomavirus (HPV) test in primary cervical screening, by age group and test assay. DESIGN Observational study. SETTING Real world data from the English HPV screening pilot's first and second rounds (2013-16, follow-up to end of 2019). PARTICIPANTS 1 341 584 women. INTERVENTIONS Cervical screening with HPV testing or liquid based cytological testing (cytology or smear tests). Women screened with cytology were referred to colposcopy after high grade cytological abnormalities or after borderline or low grade abnormalities combined with a positive HPV triage test. Women screened with HPV testing who were positive were referred at baseline if their cytology triage test showed at least borderline abnormalities or after a retest (early recall) at 12 and 24 months if they had persistent abnormalities. MAIN OUTCOME MEASURES Detection of CIN3+ and cervical cancer after a negative HPV test. RESULTS For women younger than 50 years, second round detection of CIN3+ in this study was significantly lower after a negative HPV screen in the first round than after cytology testing (1.21/1000 v 4.52/1000 women screened, adjusted odds ratio 0.26, 95% confidence interval 0.23 to 0.30), as was the risk of interval cervical cancer (1.31/100 000 v 2.90/100 000 woman years, adjusted hazard ratio 0.44, 0.23 to 0.84). Risk of an incident CIN3+ detected at the second screening round in the pilot five years after a negative HPV test was even lower in women older than 50 years, than in three years in women younger than 50 years (0.57/1000 v 1.21/1000 women screened, adjusted odds ratio 0.46, 0.27 to 0.79). Women with negative HPV tests at early recall after a positive HPV screening test without cytological abnormalities had a higher detection rate of CIN3+ at the second routine recall than women who initially tested HPV negative (5.39/1000 v 1.21/1000 women screened, adjusted odds ratio 3.27, 95% confidence interval 2.21 to 4.84). Detection after a negative result on a clinically validated APTIMA mRNA HPV test was similar to that after clinically validated cobas and RealTime DNA tests (for CIN3+ at the second round 1.32/1000 v 1.14/1000 women screened, adjusted odds ratio 1.05, 0.73 to 1.50). CONCLUSIONS These data support an extension of the screening intervals, regardless of the test assay used: to five years after a negative HPV test in women aged 25-49 years, and even longer for women aged 50 years and older. The screening interval for HPV positive women who have negative HPV tests at early recall should be kept at three years.
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Affiliation(s)
- Matejka Rebolj
- Cancer Prevention Group, School of Cancer and Pharmaceutical Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Kate Cuschieri
- Scottish HPV Reference Laboratory, Royal Infirmary of Edinburgh, NHS Lothian Scotland, Edinburgh, UK
| | - Christopher S Mathews
- Cancer Prevention Group, School of Cancer and Pharmaceutical Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Francesca Pesola
- Cancer Prevention Group, School of Cancer and Pharmaceutical Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Karin Denton
- Severn Pathology, Southmead Hospital, North Bristol NHS Trust, Bristol, UK
| | - Henry Kitchener
- Division of Cancer Sciences, University of Manchester, Manchester, UK
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Rebolj M, Mathews CS, Pesola F, Castañon A, Kitchener H. Acceleration of cervical cancer diagnosis with human papillomavirus testing below age 30: Observational study. Int J Cancer 2022; 150:1412-1421. [PMID: 34897665 DOI: 10.1002/ijc.33900] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Revised: 11/04/2021] [Accepted: 11/29/2021] [Indexed: 01/08/2023]
Abstract
Several international cervical screening guidelines advise against using high-risk human papillomavirus (HR-HPV) testing in women younger than 30. The rationale for this in young women, lies in the potential for additional detection of both low-grade and high-grade cervical intraepithelial neoplasia (CIN) leading to unnecessary treatments without reducing the burden of cervical cancer. We studied 56 544 women screened at 24 to 29 with HR-HPV testing and 116 858 screened with liquid-based cytology (LBC) in the English HPV screening pilot. They were compared to 528 460 women screened at the age of 30 to 49. We studied the detection of cervical cancer and CIN2/3 across two consecutive screening rounds 3 years apart. At 24 to 29, a positive HR-HPV test detected more cases of cervical cancer in the prevalence round than did a positive LBC test (1.36/1000 screened vs 0.82/1000, ORadj : 1.61, 95% CI: 1.18-2.19). In women with a negative HR-HPV test, cervical cancer was diagnosed before or at the incidence round in 0.07/1000. After a negative LBC test, cancer detection reached 0.47/1000 and 40% of these cases were diagnosed at FIGO stage IB+. HR-HPV testing increased the detection of CIN2/3 diagnoses in two consecutive rounds combined by 30% (71.9/1000 vs 55.2/1000). The patterns of detection of cervical cancer and CIN2/3 were almost identical at older ages. These data support using HR-HPV testing for screening of women younger than 30, which not only accelerates the diagnosis of cervical cancer but leads to a similar relative increase in CIN2/3 diagnosis to that found in women aged 30 to 49.
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Affiliation(s)
- Matejka Rebolj
- Cancer Prevention Group, School of Cancer & Pharmaceutical Sciences, Faculty of Life Sciences & Medicine, King's College London, London, UK
| | - Christopher S Mathews
- Cancer Prevention Group, School of Cancer & Pharmaceutical Sciences, Faculty of Life Sciences & Medicine, King's College London, London, UK
| | - Francesca Pesola
- Cancer Prevention Group, School of Cancer & Pharmaceutical Sciences, Faculty of Life Sciences & Medicine, King's College London, London, UK
| | - Alejandra Castañon
- Cancer Prevention Group, School of Cancer & Pharmaceutical Sciences, Faculty of Life Sciences & Medicine, King's College London, London, UK
| | - Henry Kitchener
- Division of Cancer Sciences, University of Manchester, Manchester, UK
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Ejegod DM, Pedersen H, Pedersen BT, Jonassen CM, Lie AK, Hulleberg LS, Arbyn M, Bonde J. Clinical Validation of the Onclarity Assay After Assay Migration to the High-Throughput COR Instrument Using SurePath Screening Samples From the Danish Cervical Cancer Screening Program. Am J Clin Pathol 2022; 157:390-398. [PMID: 34546350 PMCID: PMC8891819 DOI: 10.1093/ajcp/aqab138] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Accepted: 08/03/2021] [Indexed: 11/13/2022] Open
Abstract
Objectives This study presents the clinical assessment of the Onclarity HPV Assay (Becton Dickinson) on the novel COR high-throughput instrument (Becton Dickinson) using the international guidelines in a routine setting. Methods Screening samples collected in BD SurePath from women aged 30 years and older were used in this validation. Noninferiority of the Onclarity HPV Assay on the COR instrument (Onclarity-COR) was assessed with the comparator assay glycoprotein 5–positive (GP5+)/6+ enzyme immunoassay (GP-EIA) for clinical sensitivity on 122 cervical intraepithelial neoplasia 2 and greater samples. Specificity was assessed using 887 samples with twice-normal cytology. Inter- and intralaboratory reproducibility analysis was assessed using 525 samples. Finally, a time-and-motion study was performed to evaluate COR instrument performance characteristics. Results The Onclarity-COR was noninferior to the GP-EIA for both sensitivity (P = .0016) and specificity (P < .0001). The intralaboratory reproducibility was 98.3% (κ = 0.96), and interlaboratory agreement was 98.5 % (κ = 0.96). The daily hands-on time for the COR instrument was 58 minutes, and walk-away time was 7 hours, 2 minutes per 8-hour day shift. Conclusions The Onclarity-COR instrument fulfills international validation criteria on sensitivity, specificity, and laboratory reproducibility. The Onclarity assay’s extended genotyping capability, together with its high-throughput characteristics, makes the COR instrument an excellent candidate for use in human papillomavirus primary cervical cancer screening.
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Affiliation(s)
- Ditte Møller Ejegod
- Molecular Pathology Laboratory, Department of Pathology, Copenhagen University Hospital AHH-Hvidovre, Hvidovre, Denmark
| | - Helle Pedersen
- Molecular Pathology Laboratory, Department of Pathology, Copenhagen University Hospital AHH-Hvidovre, Hvidovre, Denmark
| | - Birgitte Tønnes Pedersen
- Molecular Pathology Laboratory, Department of Pathology, Copenhagen University Hospital AHH-Hvidovre, Hvidovre, Denmark
| | | | | | | | - Marc Arbyn
- Unit of Cancer Epidemiology, Belgian Cancer Centre, Sciensano, Brussels, Belgium
| | - Jesper Bonde
- Molecular Pathology Laboratory, Department of Pathology, Copenhagen University Hospital AHH-Hvidovre, Hvidovre, Denmark
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Murillo R, Gamboa O, Hernández G, González M, Olejua P, Molano M, Wiesner C. Accuracy of combined molecular and morphology-based triage for HPV-positive women in routine cervical cancer screening services from Colombia. Prev Med 2021; 153:106801. [PMID: 34508733 DOI: 10.1016/j.ypmed.2021.106801] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Revised: 08/12/2021] [Accepted: 09/06/2021] [Indexed: 11/26/2022]
Abstract
WHO cervical cancer elimination goals comprise 70% of highly-sensitive screening coverage and 90% treatment of precancerous lesions. Triage for HPV-positive women may challenge sensitivity of screening algorithms and women's follow-up, particularly in low- and middle-income countries (LMIC) where screening quality and protocol adherence are frequently deficient. We aimed to determine the accuracy of triage for HPV positive women in routine screening services from Colombia by a prospective cross-sectional study. Consecutively, HPV DNA-positive women underwent six triage strategies (conventional cytology, two methods of visual inspection, HPV16/18/45-genotyping, telomerase, and HPV mRNA). Positive triage results underwent regular colposcopy/biopsy in public hospitals. Adjusted sensitivity, specificity, and predictive values for CIN2+/CIN3+ were estimated for stand-alone and combined tests. We explored the impact of triage strategies on referral rates and the complete screening algorithm (screening plus triage). Overall 16,242 women underwent HPV screening and 1789 (11.0%) were HPV-positive. In total, 20.1% of women were lost to follow-up. mRNA showed the highest positivity rate (0.64 among HPV-positive and 0.05 among the total screened cohort), the highest sensitivity (0.94 95%CI 0.75-0.96), and the lowest specificity (0.36 95%CI 0.29-0.43). Parallel testing with HPV-mRNA revealed the highest increase in sensitivity for all triage strategies. Accuracy of cytology and visual inspection differ between screening units but parallel testing with HPV16/18/45 genotyping significantly increased their sensitivity (over 0.80). Morphology-based triage for HPV-positive women remains a suitable alternative for routine practice in LMIC if combined with HPV16/18/45-genotyping; however, point-of-care triage would be preferable to reduce losses to follow-up. HPV-mRNA triage deserves cost-benefit analyses.
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Affiliation(s)
- Raúl Murillo
- Centro Javeriano de Oncología - Hospital Universitario San Ignacio, Bogotá, Colombia; Facultad de Medicina - Pontificia Universidad Javeriana, Bogotá, Colombia.
| | - Oscar Gamboa
- Servicio de Radioterapia - Instituto Nacional de Cancerología, Bogotá, Colombia
| | - Gustavo Hernández
- Subdirección de Investigación - Instituto Nacional de Cancerología, Bogotá, Colombia
| | - Mauricio González
- Subdirección de Investigación - Instituto Nacional de Cancerología, Bogotá, Colombia
| | - Peter Olejua
- Oficina Investigaciones - Hospital Universitario San Ignacio, Bogotá, Colombia.
| | - Mónica Molano
- Subdirección de Investigación - Instituto Nacional de Cancerología, Bogotá, Colombia; Centre for Women's Infectious Disease, The Royal Women's Hospital, Melbourne, Australia.
| | - Carolina Wiesner
- Subdirección de Investigación - Instituto Nacional de Cancerología, Bogotá, Colombia.
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Clinical Utility of ZedScan When Used as an Adjunct to Colposcopy. INDIAN JOURNAL OF GYNECOLOGIC ONCOLOGY 2021. [DOI: 10.1007/s40944-021-00540-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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12
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Weston G, Dombrowski C, Steben M, Popadiuk C, Bentley J, Adams EJ. A health economic model to estimate the costs and benefits of an mRNA vs DNA high-risk HPV assay in a hypothetical HPV primary screening algorithm in Ontario, Canada. Prev Med Rep 2021; 23:101448. [PMID: 34381664 PMCID: PMC8334715 DOI: 10.1016/j.pmedr.2021.101448] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Revised: 06/02/2021] [Accepted: 06/05/2021] [Indexed: 01/07/2023] Open
Abstract
Using an mRNA HPV test in cervical screening can reduce costs and avoid procedures. This could benefit both the healthcare system and women by optimizing resource use. These results can inform choices in cervical screening programs in Canada.
This study models the impact of using two different types of high-risk (HR) human papillomavirus (HPV) tests: mRNA (Aptima) and DNA (Hybrid Capture 2) as part of a hypothetical primary HPV screening program in Ontario, Canada. Outcomes were the costs of the screening program, and number of colposcopies, HPV tests and cytology tests. Results were estimated for one cohort going through the screening algorithm. A decision tree model was adapted from a published UK study, with inputs drawn from published Canadian data for the probabilities through the model, costs, demographic, and screening data from Ontario. Sensitivity and scenario analyses explored uncertainty in the model inputs and assumptions. Results indicated that screening using an mRNA test could yield cost savings of CAD $4,007,266 (95% credibility interval [CI]: −7,866,251 – 8,035) compared to using a DNA test, with 10,639 (95% CI: 10,170 – 11,094) fewer women undergoing unnecessary colposcopies, and reductions in unnecessary HR-HPV and cytology tests. The HR-HPV test comprised the largest percentage of the costs saved, and the probability of being HPV positive in the first year had the biggest impact on results. These results indicate that the choice of HR-HPV test is important when implementing a primary HPV screening program to avoid unnecessary resource use and cost, which will benefit both women and healthcare providers.
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Affiliation(s)
- Georgie Weston
- Aquarius Population Health, Unit 29 Tileyard Studios, London N7 9AH, UK
| | | | - Marc Steben
- School of Public Health, Université de Montréal, Montréal, QC H3N 1X9, Canada
| | - Catherine Popadiuk
- Faculty of Medicine, Memorial University, 300 Prince Philip Drive, St. John's, NL A1B 3V6, Canada
| | - James Bentley
- Nova Scotia Health Authority, Room 5006, Dickson Building, QEII Health Sciences Centre, 5820, University Avenue, Halifax, NS B3H 2Y9, Canada
| | - Elisabeth J Adams
- Aquarius Population Health, Unit 29 Tileyard Studios, London N7 9AH, UK
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Pesola F, Rebolj M, Leeson S, Dunk L, Pickford L, Gjini A, Sasieni P. Introducing human papillomavirus (HPV) primary testing in the age of HPV vaccination: projected impact on colposcopy services in Wales. BJOG 2021; 128:1226-1235. [PMID: 33247993 PMCID: PMC8246959 DOI: 10.1111/1471-0528.16610] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/19/2020] [Indexed: 12/23/2022]
Abstract
OBJECTIVE To determine the demand for colposcopy in the Cervical Screening Wales programme after the introduction of human papillomavirus (HPV) cervical screening, which coincided with the start of screening of women vaccinated against HPV types 16/18. DESIGN The study used a computational model that assigns screening and screening-related colposcopy events to birth cohorts in individual calendar years. SETTING Cervical Screening Wales. POPULATION Women aged 25-64 years from birth cohorts 1953-2007. METHODS AND MAIN OUTCOME MEASURES We estimated the numbers of colposcopies and high-grade cervical intraepithelial lesions (CIN2+) within Cervical Screening Wales in 2018-32, using official population projections for Wales and published estimates of the effects of HPV screening and vaccination. RESULTS Vaccination will reduce the number of colposcopies by 10% within the first 3-4 years after the national roll-out of HPV screening, and by about 20% thereafter. The number of screening colposcopies is estimated to increase from 6100 in 2018 and peak at 8000 (+31%) in 2021, assuming current screening intervals are maintained. The numbers of CIN2+ lesions follow similar patterns, stabilising at around 1000 diagnoses per year by 2026, approximately 60% lower than at present. Extending the screening intervals to 5 years for all women shows similar trends but introduces peaks and troughs over the years. CONCLUSIONS Vaccination will not fully prevent an increase in colposcopies and detected CIN2+ lesions during the first 2-3 years of HPV-based screening but the numbers are expected to decrease substantially after 5-6 years. TWEETABLE ABSTRACT HPV-based cervical screening will initially increase colposcopy referral. In 6 years, this increase will be reversed, partly by HPV vaccination.
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Affiliation(s)
- F Pesola
- Cancer Prevention GroupSchool of Cancer & Pharmaceutical SciencesFaculty of Medicine and Life SciencesKing’s College LondonLondonUK
| | - M Rebolj
- Cancer Prevention GroupSchool of Cancer & Pharmaceutical SciencesFaculty of Medicine and Life SciencesKing’s College LondonLondonUK
| | - S Leeson
- Department of Obstetrics and GynaecologyBetsi Cadwaladr University Health BoardBangorUK
| | - L Dunk
- Public Health WalesCardiffUK
| | | | - A Gjini
- Public Health WalesCardiffUK
| | - P Sasieni
- Cancer Prevention GroupSchool of Cancer & Pharmaceutical SciencesFaculty of Medicine and Life SciencesKing’s College LondonLondonUK
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Dong B, Zou H, Mao X, Su Y, Gao H, Xie F, Lv Y, Chen Y, Kang Y, Xue H, Pan D, Sun P. Effect of introducing human papillomavirus genotyping into real-world screening on cervical cancer screening in China: a retrospective population-based cohort study. Ther Adv Med Oncol 2021; 13:17588359211010939. [PMID: 33995595 PMCID: PMC8107662 DOI: 10.1177/17588359211010939] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2020] [Accepted: 03/25/2021] [Indexed: 12/27/2022] Open
Abstract
Background: China’s Fujian Cervical Pilot Project (FCPP) transitioned cervical cancer screening from high-risk human papillomavirus (HR-HPV) nongenotyping to genotyping. We investigated the clinical impact of this introduction, comparing performance indicators between HR-HPV genotyping combined with cytology screening (HR-HPV genotyping period) and the previous HR-HPV nongenotyping combined with cytology screening (HR-HPV nongenotyping period). Methods: A retrospective population-based cohort study was performed using data from the FCPP for China. We obtained data for the HR-HPV nongenotyping period from 1 January 2012 to 31 December 2013, and for the HR-HPV genotyping period from 1 January 2014 to 31 December 2016. Propensity score matching was used to match women from the two periods. Multivariable Cox regression was used to assess factors associated with cervical intraepithelial neoplasia of grade 2 or worse (CIN2+). The primary outcome was the incidence of CIN2+ in women aged ⩾25 years. Performance was assessed and included consistency, reach, effectiveness, adoption, implementation and cost. Results: Compared with HR-HPV nongenotyping period, in the HR-HPV genotyping period, more CIN2+ cases were identified at the initial screening (3.06% versus 2.32%; p < 0.001); the rate of colposcopy referral was higher (10.87% versus 6.64%; p < 0.001); and the hazard ratio of CIN2+ diagnosis was 1.64 (95% confidence interval, 1.43–1.88; p < 0.001) after controlling for health insurance status and age. The total costs of the first round of screening (US$66,609 versus US$65,226; p = 0.293) were similar during the two periods. Higher screening coverage (25.95% versus 25.19%; p = 0.007), higher compliance with age recommendations (92.70% versus 91.69%; p = 0.001), lower over-screening (4.92% versus 10.15%; p < 0.001), and reduced unqualified samples (cytology: 1.48% versus 1.73%, p = 0.099; HR-HPV: 0.57% versus 1.34%, p < 0.001) were observed in the HR-HPV genotyping period. Conclusions: Introduction of an HR-HPV genotyping assay in China could detect more CIN2+ lesions at earlier stages and improve programmatic indicators. Evidence suggests that the introduction of HR-HPV genotyping is likely to accelerate the elimination of cervical cancer in China.
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Affiliation(s)
- Binhua Dong
- Laboratory of Gynecologic Oncology, Department of Gynecology, Fujian Maternity and Child Health Hospital, Affiliated Hospital of Fujian Medical University, Fuzhou, Fujian, P.R. China
| | - Huachun Zou
- School of Public Health (Shenzhen), Sun Yat-sen University, Shenzhen, P.R. China
| | - Xiaodan Mao
- Laboratory of Gynecologic Oncology, Department of Gynecology, Fujian Maternity and Child Health Hospital, Affiliated Hospital of Fujian Medical University, Fuzhou, Fujian, P.R. China
| | - Yingying Su
- State Key Laboratory of Molecular Vaccinology and Molecular Diagnostics, National Institute of Diagnostics and Vaccine Development in Infectious Diseases, Strait Collaborative Innovation Center of Biomedicine and Pharmaceutics, School of Public Health, Xiamen University, Xiamen, Fujian, P.R. China
| | - Hangjing Gao
- Laboratory of Gynecologic Oncology, Department of Gynecology, Fujian Maternity and Child Health Hospital, Affiliated Hospital of Fujian Medical University, Fuzhou, Fujian, P.R. China
| | - Fang Xie
- Department of Obstetrics and Gynecology, Mindong Hospital of Fujian Medical University, Fuan, Fujian, P.R. China
| | - Yuchun Lv
- Department of Obstetrics and Gynecology, Quanzhou First Hospital Affiliated to Fujian Medical University, Quanzhou, Fujian, P.R. China
| | - Yaojia Chen
- Laboratory of Gynecologic Oncology, Department of Gynecology, Fujian Maternity and Child Health Hospital, Affiliated Hospital of Fujian Medical University, Fuzhou, Fujian, P.R. China
| | - Yafang Kang
- Laboratory of Gynecologic Oncology, Department of Gynecology, Fujian Maternity and Child Health Hospital, Affiliated Hospital of Fujian Medical University, Fuzhou, Fujian, P.R. China
| | - Huifeng Xue
- Fujian Provincial Cervical Disease Diagnosis and Treatment Health Center, Fujian Maternity and Child Health Hospital, Affiliated Hospital of Fujian Medical University, Fuzhou, Fujian, P.R. China
| | - Diling Pan
- Department of Pathology, Fujian Maternity and Child Health Hospital, Affiliated Hospital of Fujian Medical University, Fuzhou, Fujian, P.R. China
| | - Pengming Sun
- Laboratory of Gynecologic Oncology, Department of Gynecology, Fujian Maternity and Child Health Hospital, Affiliated Hospital of Fujian Medical University, 18 Daoshan Road, Fuzhou, Fujian 350001, P.R. China
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Green LI, Mathews CS, Waller J, Kitchener H, Rebolj M. Attendance at early recall and colposcopy in routine cervical screening with human papillomavirus testing. Int J Cancer 2021; 148:1850-1857. [PMID: 33070318 DOI: 10.1002/ijc.33348] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Revised: 09/25/2020] [Accepted: 09/29/2020] [Indexed: 11/06/2022]
Abstract
Attendance at early recall and colposcopy is crucial to attaining the benefits of primary high-risk human papillomavirus (HR-HPV)-based screening. Within the English HPV pilot, we analysed deprivation- and age-related patterns of attendance at colposcopy and 12- and 24-month early recall of HR-HPV positive women screened in 2013 to 2015 (N = 36 466). We fitted logistic regression models for adjusted odds ratios (OR). Despite high overall attendance, area deprivation had a small but significant impact at both early recalls, for example, attendance at 24 months was 86.3% and 83.0% in less vs more deprived areas, respectively (ORadj : 0.76; 95% CI: 0.67-0.87). Older women (≥30 years) were more likely to attend early recall than younger women (<30 years), for example, attendance at 24 months was 86.1% vs 82.3%, respectively (ORadj : 1.32, 95% CI: 1.16-1.51). Most women attended colposcopy following a baseline referral, with 96.9% attendance among more deprived and 97.8% among less deprived areas (ORadj : 0.70; 95% CI: 0.55-0.88). Differences in colposcopy attendance by deprivation level at 12 and 24 months were of approximately the same magnitude. In conclusion, attendance at early recall and colposcopy was reassuringly high. Although there were statistically significant differences by deprivation and age group, these were small in absolute terms.
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Affiliation(s)
- Leonardo I Green
- Cancer Prevention Group, School of Cancer and Pharmaceutical Sciences, Faculty of Life Sciences and Medicine, King's College London, Great Maze Pond, London, UK
| | - Christopher S Mathews
- Cancer Prevention Group, School of Cancer and Pharmaceutical Sciences, Faculty of Life Sciences and Medicine, King's College London, Great Maze Pond, London, UK
| | - Jo Waller
- Cancer Prevention Group, School of Cancer and Pharmaceutical Sciences, Faculty of Life Sciences and Medicine, King's College London, Great Maze Pond, London, UK
| | - Henry Kitchener
- Institute of Cancer Sciences, University of Manchester, St. Mary's Hospital, Manchester, UK
| | - Matejka Rebolj
- Cancer Prevention Group, School of Cancer and Pharmaceutical Sciences, Faculty of Life Sciences and Medicine, King's College London, Great Maze Pond, London, UK
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Options for triage and implications for colposcopists within European HPV-based cervical screening programmes. Eur J Obstet Gynecol Reprod Biol 2021; 258:332-342. [PMID: 33524777 DOI: 10.1016/j.ejogrb.2020.12.061] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Revised: 11/07/2020] [Accepted: 12/23/2020] [Indexed: 11/23/2022]
Abstract
The development of human papillomavirus (HPV)-based screening should detect more pre-cancerous changes and so reduce the incidence and mortality from cervical squamous carcinoma and cervical adenocarcinoma. However, many more women are high risk HPV (hrHPV) screen positive compared to cytology-based screening, especially in younger age-women. A variety of tests have become available which may triage into those hrHPV test-positive women who need immediate referral to colposcopy from those who need early repeat HPV tests or recall on the basis of their disease status. We performed a literature review of publications and a manual search from 2010, reporting cytology, HPV partial genotyping, dual-staining and DNA methylation for triage of hrHPV positive tests, including their comparative performance between these methods as well as the effectiveness of some triage combinations with reference to HPV-based screening services in Europe. Cost effectiveness and the structure of triage algorithms for colposcopists also have been considered. From one report evaluating four options for triage as single options or as combined algorithms, partial genotyping for HPV 16 and 18 with dual-staining yielded the highest risk of cervical intraepithelial neoplasia grade three or worse within an HPV positive population and with an acceptable colposcopy rate. From a separate paper, this option appeared cost effective. However, publications were difficult to compare objectively. All options have their merits but a combination triage involving any two of cytology, HPV partial genotyping or dual-staining seems most efficient at present. HPV vaccination may impact upon the performance of future partial genotyping. DNA Methylation may become an acceptable future option.
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Gori S, Battagello J, Gustinucci D, Campari C, Zorzi M, Frayle H, Passamonti B, Sartori G, Bulletti S, Fodero C, Cesarini E, Faggiano R, Del Mistro A. Clinical relevance of partial HPV16/18 genotyping in stratifying HPV-positive women attending routine cervical cancer screening: a population-based cohort study. BJOG 2021; 128:1353-1362. [PMID: 33326680 PMCID: PMC8248328 DOI: 10.1111/1471-0528.16631] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/08/2020] [Indexed: 12/14/2022]
Abstract
Objective To evaluate partial HPV16/18 genotyping as a possible biomarker to select women attending HPV‐based cervical cancer screening at higher risk to be referred to colposcopy. Design Population‐based cohort study. Setting Organised cervical cancer screening programmes (Italy). Population Women with high‐risk HPV infection (period: 2015–2019). Methods We analysed the association between partial HPV16/18 genotyping, cytology triage and histologically confirmed diagnosis of high‐grade cervical intraepithelial neoplasia (CIN3+) lesions. Main outcome measures Detection rate (DR) and positive predictive value (PPV) for histologically confirmed CIN3+ (any episode in the 2 years after baseline); sensitivity for CIN3+ and number of colposcopies needed for lesion detection. Results The study included 145 437 women screened with HPV testing by the clinically validated COBAS 4800 HPV assay (Roche). Overall, 9601 (6.6%) women were HPV+ at baseline; HPV16 and HPV18 were present in 1865 and 594 samples, respectively. The cumulative (baseline plus 1‐year repeat) cytology positivity was 42.8% and high‐grade cytology was significantly higher (P < 0.0001) among women with HPV16 infection at baseline (15.2%). The cumulative CIN3+ DR for women with HPV16, HPV18 and other HPV‐type infections was 9.8%, 3.4% and 1.8%, respectively. Conclusions Partial HPV16 genotyping may play a role in triage, whereas HPV18 seems to behave much more similarly to the other HPV types and does not provide additional stratification. HPV16 genotyping combined with high‐grade cytology can be envisaged as a triage biomarker in cervical screening to maximise CIN3+ detection while minimising colposcopy at baseline or 1‐year repeat. Tweetable abstract HPV16 genotyping combined with high‐grade cytology can be used as triage biomarker for CIN3+ in HPV‐positive women. HPV16 genotyping combined with high‐grade cytology can be used as a triage biomarker for CIN3+ in HPV‐positive women.
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Affiliation(s)
- S Gori
- Immunology and Diagnostic Molecular Oncology Unit, Veneto Institute of Oncology IOV-IRCCS, Padua, Italy
| | - J Battagello
- Veneto Tumour Registry, Azienda Zero, Padua, Italy
| | - D Gustinucci
- Laboratorio Unico di Screening USL Umbria 1, Perugia, Italy
| | - C Campari
- Cancer Screening Unit, Azienda Unità Sanitaria Locale - IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - M Zorzi
- Veneto Tumour Registry, Azienda Zero, Padua, Italy
| | - H Frayle
- Immunology and Diagnostic Molecular Oncology Unit, Veneto Institute of Oncology IOV-IRCCS, Padua, Italy
| | - B Passamonti
- Laboratorio Unico di Screening USL Umbria 1, Perugia, Italy
| | - G Sartori
- Laboratorio citologia cervico-vaginale, Azienda Unità Sanitaria Locale - IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - S Bulletti
- Cancer Screening Unit, Azienda Unità Sanitaria Locale - IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - C Fodero
- Laboratorio citologia cervico-vaginale, Azienda Unità Sanitaria Locale - IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - E Cesarini
- Laboratorio Unico di Screening USL Umbria 1, Perugia, Italy
| | - R Faggiano
- Cancer Screening Unit, Azienda Unità Sanitaria Locale - IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - A Del Mistro
- Immunology and Diagnostic Molecular Oncology Unit, Veneto Institute of Oncology IOV-IRCCS, Padua, Italy
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Bonde J, Bottari F, Iacobone AD, Cocuzza CE, Sandri MT, Bogliatto F, Khan KS, Ejegod DM, Gary DS, Andrews JC. Human Papillomavirus Same Genotype Persistence and Risk: A Systematic Review. J Low Genit Tract Dis 2021; 25:27-37. [PMID: 33105450 PMCID: PMC7748037 DOI: 10.1097/lgt.0000000000000573] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The aim of the study was to examine whether high-grade cervical intraepithelial neoplasia (CIN) was more closely associated with human papillomavirus (HPV) same-genotype persistence (SGTP) versus clearance of prior infection with a subsequent infection by a new genotype (genotype switch [GS]), clearance of HPV infection, or acquisition of a new HPV infection after a negative infection status, during a follow-up testing subsequent to abnormal screening results. MATERIALS AND METHODS MEDLINE, Cochrane Library, Health Technology Assessment, and clinicaltrials.gov were searched from January 2000 to July 2019 for prospective controlled trials and observational studies of women and retrospective studies using HPV assays with extended- or full-genotype reporting. The primary outcome was high-grade CIN after at least 2 rounds of testing. Overall quality of evidence for the risk estimate outcomes was assessed. Of the 830 identified abstracts, 66 full-text articles were reviewed, and 7 studies were included in the synthesis. The study protocol was registered with the PROSPERO International Prospective Register of Systematic Reviews (CRD42018091093). RESULTS Continued HPV-positive women falls in 2 equally large groups: SGTP and GS. Sensitivity, positive predictive value, and positive likelihood ratio of SGTP were significantly higher than for GS. Human papillomavirus genotypes may be ranked into 3 tiers (immediate colposcopy, follow-up testing, return to routine screening), according to associated risk of persistence for high-grade CIN and to prevailing clinical action thresholds. CONCLUSIONS There is moderately high-quality evidence to support the clinical utility of SGTP to improve risk discrimination for high-grade CIN compared with qualitative HPV testing without genotype-specific information.
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Affiliation(s)
- Jesper Bonde
- Molecular Pathology Laboratory, Department of Pathology, Copenhagen University Hospital, Hvidovre, Denmark
| | - Fabio Bottari
- Division of Laboratory Medicine, European Institute of Oncology IRCCS, Milan, Italy
- Department of Biomedical Sciences, University of Sassari, Sassari, Italy
| | - Anna D. Iacobone
- Department of Biomedical Sciences, University of Sassari, Sassari, Italy
- Preventive Gynecology Unit, European Institute of Oncology IRCCS, Milan, Italy
| | | | - Maria-Teresa Sandri
- Division of Laboratory Medicine, Humanitas Clinical and Research Center IRCCS, Milan, Italy
| | | | - Khalid S. Khan
- Department of Preventive Medicine and Public Health, University of Granada, Granada, Spain
| | - Ditte M. Ejegod
- Molecular Pathology Laboratory, Department of Pathology, Copenhagen University Hospital, Hvidovre, Denmark
| | - Devin S. Gary
- Becton, Dickinson and Company, BD Life Sciences – Diagnostic Systems, Sparks, MD
| | - Jeffrey C. Andrews
- Becton, Dickinson and Company, BD Life Sciences – Diagnostic Systems, Sparks, MD
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Real-world data on cervical cancer risk stratification by cytology and HPV genotype to inform the management of HPV-positive women in routine cervical screening. Br J Cancer 2020; 122:1715-1723. [PMID: 32242098 PMCID: PMC7250848 DOI: 10.1038/s41416-020-0790-1] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2019] [Revised: 02/03/2020] [Accepted: 02/12/2020] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND HPV16/18 detection may improve cervical cancer risk stratification and better guide which HPV-positive women warrant immediate colposcopy/biopsy. We estimated risks of cervical precancer and cancer by HPV genotype and cytology during the implementation phase of primary HPV testing in Norway. METHODS A total of 3111 women, aged 34-69 years, testing HPV-positive at baseline and undergoing cytology testing from February 2015 to April 2018 had data available for analysis. Risk estimates with 95% confidence intervals (95%CIs) of cervical intraepithelial neoplasia grade 3 or more severe (CIN3+) were estimated for cytology results and HPV genotypes (HPV16, HPV18, and other high-risk HPV). RESULTS CIN3+ risks were higher for HPV16/18 than other high-risk HPV genotypes. Among women with any cytologic abnormality [atypical squamous cells of undetermined significance or worse], immediate risks were 57.8% (95%CI = 53.0-62.6%) for HPV16, 40.2% (95%CI = 32.3-49.2%) for HPV18, and 31.4% (95%CI = 28.7-34.3%) for other high-risk HPV. Among those with normal cytology, CIN3+ risks were 19.9% (95%CI = 15.0-26.1%) for HPV16 positives, 10.8% (95%CI = 5.6-20.5%) for HPV18 positives, and 5.5% (95%CI = 4.2-7.1%) for other high-risk HPV. CONCLUSIONS The benefits and harms of managing women based on HPV positivity and cytology results can be better balanced by inclusion of HPV genotyping in screening and choosing more conservative management for other high-risk HPV compared to HPV16/18.
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Ejegod DM, Hansen M, Christiansen IK, Pedersen H, Quint W, Xu L, Arbyn M, Bonde J. Clinical validation of the Cobas 4800 HPV assay using cervical samples in SurePath medium under the VALGENT4 framework. J Clin Virol 2020; 128:104336. [PMID: 32446166 DOI: 10.1016/j.jcv.2020.104336] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Revised: 03/05/2020] [Accepted: 03/23/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND The VALidation of HPV Genotyping Tests (VALGENT) framework is an international cooperation designed for comparison and clinical validation of HPV assays with genotyping capabilities. OBJECTIVES Here we addressed the accuracy of the Roche cobas 4800 HPV test using SurePath samples from the Danish cervical cancer screening program under the VALGENT framework. MATERIAL AND METHODS The VALGENT4 panel comprises 998 consecutive SurePath cervical samples from routine screening and 297 SurePath samples enriched for disease (100 ASC-US, 100 LSIL, 97 HSIL). The cobas HPV test is a real-time PCR assay which detects HPV16 and 18 individually and 12 other high-risk (hr) HPV genotypes in one bulk. RESULTS The clinical performance of the cobas test was assessed relative to that of the comparator assay GP5+/6 + PCR Enzyme ImmunoAssay (GP-EIA) by a non-inferiority test. The relative sensitivity for ≥ CIN2 was 1.00 (95% CI: 0.97-1.04) and relative specificity for the control group was 1.02 (95% CI: 1.01-1.04). The cobas test was found non-inferior to that of GP-EIA for both sensitivity and specificity (p-0.0006 and p < 0.0001, respectively). The type specific performance of the cobas test was evaluated using the GP5+/6 + PCR with Luminex genotyping (GP-LMNX) as comparator. The cobas test showed excellent to good concordance (Kappa: 0.70 to 0.90) with GP-LMNX for all three genotype groups in the overall VALGENT population but good to moderate concordance in the Screening population (kappa from 0.56 to 0.80). CONCLUSIONS The cobas HPV test demonstrated non-inferiority to the comparator assay on cervical SurePath screening samples using the VALGENT4 panel.
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Affiliation(s)
- Ditte Møller Ejegod
- Molecular Pathology Laboratory, Department of Pathology, Copenhagen University Hospital, Hvidovre, Kettegård Alle 30, 2650 Hvidovre, Denmark.
| | - Mona Hansen
- National HPV Reference Laboratory, Department of Microbiology and Infection Control, Akershus University Hospital, 1478 Lørenskog, Norway
| | - Irene Kraus Christiansen
- National HPV Reference Laboratory, Department of Microbiology and Infection Control, Akershus University Hospital, 1478 Lørenskog, Norway
| | - Helle Pedersen
- Molecular Pathology Laboratory, Department of Pathology, Copenhagen University Hospital, Hvidovre, Kettegård Alle 30, 2650 Hvidovre, Denmark
| | - Wim Quint
- DDL diagnostics Laboratory, Rijswijk, Nederlands
| | - Lan Xu
- Unit Cancer Epidemiology, Belgian Cancer Centre, Juliette Wytsmanstreet 14, 1050 Brussels, Belgium
| | - Marc Arbyn
- Unit Cancer Epidemiology, Belgian Cancer Centre, Juliette Wytsmanstreet 14, 1050 Brussels, Belgium
| | - Jesper Bonde
- Molecular Pathology Laboratory, Department of Pathology, Copenhagen University Hospital, Hvidovre, Kettegård Alle 30, 2650 Hvidovre, Denmark
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21
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Tidy JA, Lyon R, Ellis K, Macdonald M, Palmer JE. The impact of age and high-risk human papillomavirus (hrHPV) status on the prevalence of high-grade cervical intraepithelial neoplasia (CIN2+) in women with persistent hrHPV-positive, cytology-negative screening samples: a prospective cohort study. BJOG 2020; 127:1260-1267. [PMID: 32279427 DOI: 10.1111/1471-0528.16250] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/31/2020] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To establish the prevalence of high-grade cervical intraepithelial neoplasia (CIN2+) in women referred to colposcopy with persistent high-risk human papillomavirus (hrHPV) cytology-negative screening sample according to hrHPV genotype, age at referral and colposcopic performance. DESIGN Prospective cohort study. SETTING Single colposcopy clinic linked to a population-based screening programme. POPULATION Women referred with persistent hrHPV cytology-negative routine screening samples. METHODS Prospective study with descriptive statistics from a single colposcopy unit between June 2014 and July 2019. MAIN OUTCOME MEASURES Prevalence of hrHPV genotypes and CIN2+, positive predictive value for colposcopic impression, and inadequate colposcopic examinations. RESULTS A total of 3107 women were referred. Prevalence of CIN2+ was highest for persistent HPV16 infections (10.7%) compared with HPV18 (3.6%) or HPVO (4.7%). Prevalence of CIN2+ declined with age (25-34 years 14.2% to 55-64 years 1.1%) whereas the percentage of women with an inadequate colposcopic examination increased (25-34 years 0.9% to 55-64 years 29.5%). High-grade colposcopic impression fell over time during the study from 16.1 to 5.1%. The positive predictive value for colposcopic impression of CIN2+ was affected by hrHPV genotype (57.3% for HPV16 versus 32.1% for nonHPV16). The adjunctive use of electrical impedance spectroscopy detected an extra 42 cases of CIN2+, which was irrespective of hrHPV genotype. CONCLUSIONS Primary hrHPV cervical screening increases detection of CIN2+; however, low specificity results in more women being referred to colposcopy with a low prevalence of CIN2+. Colposcopy performs poorly in some groups, particularly with HPVO infections and women over 50 years of age. An appropriate threshold for referral to colposcopy in primary hrHPV screening has not been established. TWEETABLE ABSTRACT Low prevalence of CIN2+ in HPV-positive negative cytology samples. HPV genotype, age and prevalence of CIN2+ affect colposcopic performance.
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Affiliation(s)
- J A Tidy
- Department of Gynaecological Oncology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - R Lyon
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - K Ellis
- Department of Cytology, Sheffield Teaching Hospital NHS Foundation Trust, Sheffield, UK
| | - M Macdonald
- Department of Gynaecological Oncology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - J E Palmer
- Department of Gynaecological Oncology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
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22
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Demarco M, Hyun N, Carter-Pokras O, Raine-Bennett TR, Cheung L, Chen X, Hammer A, Campos N, Kinney W, Gage JC, Befano B, Perkins RB, He X, Dallal C, Chen J, Poitras N, Mayrand MH, Coutlee F, Burk RD, Lorey T, Castle PE, Wentzensen N, Schiffman M. A study of type-specific HPV natural history and implications for contemporary cervical cancer screening programs. EClinicalMedicine 2020; 22:100293. [PMID: 32510043 PMCID: PMC7264956 DOI: 10.1016/j.eclinm.2020.100293] [Citation(s) in RCA: 86] [Impact Index Per Article: 21.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2019] [Revised: 02/11/2020] [Accepted: 02/11/2020] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND HPV testing is replacing cytology for cervical cancer screening because of greater sensitivity and superior reassurance following negative tests for the dozen HPV genotypes that cause cervical cancer. Management of women testing positive is unresolved. The need for identification of individual HPV genotypes for clinical use is debated. Also, it is unclear how long to observe persistent infections when precancer is not initially found. METHODS In the longitudinal NCI-Kaiser Permanente Northern California Persistence and Progression (PaP) Study, we observed the clinical outcomes (clearance, progression to CIN3+, or persistence without progression) of 11,573 HPV-positive women aged 30-65 yielding 14,158 type-specific infections. FINDINGS Risks of CIN3+ progression differed substantially by type, with HPV16 conveying uniquely elevated risk (26% of infections with seven-year CIN3+ risk of 22%). The other carcinogenic HPV types fell into 3 distinct seven-year CIN3+ risk groups: HPV18, 45 (13% of infections, risks >5%, with known elevated cancer risk); HPV31, 33, 35, 52, 58 (39%, risks >5%); and HPV39, 51, 56, 59, 68 (23%, risks <5%). In the absence of progression, HPV clearance rates were similar by type, with 80% of infections no longer detected within three years; persistence to seven years without progression was uncommon. The predictive value of abnormal cytology was most evident for prevalent CIN3+, but less evident in follow-up. A woman's age did not modify risk; rather it was the duration of persistence that was important. INTERPRETATION HPV type and persistence are the major predictors of progression to CIN3+; at a minimum, distinguishing HPV16 is clinically important. Dividing the other HPV types into three risk-groups is worth considering.
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Key Words
- AGC, Atypical glandular cells
- AIS, Adenocarcinoma in-situ
- ASC-H+, Atypical squamous cells - cannot exclude HSIL
- ASC-US, Atypical squamous cells of undetermined significance
- BD, Becton Dickinson
- CIN, Cervical intraepithelial neoplasia
- HC2, Hybrid Capture 2
- HPV genotype
- HPV outcome, Clearance
- HPV, human papillomavirus
- KPNC, Kaiser Permanente Northern California
- LSIL, Low-grade squamous intraepithelial lesion
- NCI, National Cancer Institute
- NILM, Negative for intraepithelial lesion or malignancy
- PCR, Polymerase chain reaction
- PaP, Persistence and Progression
- Persistence
- Progression
- STM, Specimen transport medium
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Affiliation(s)
- Maria Demarco
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Rockville, MD, United States
- University of Maryland School of Public Health, College Park, MD, United States
| | - Noorie Hyun
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Rockville, MD, United States
- Division of Biostatistics, Institute of Health and Equity, Medical College of Wisconsin, Milwaukee, WI, United States
| | | | - Tina R. Raine-Bennett
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, United States
| | - Li Cheung
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Rockville, MD, United States
| | - Xiaojian Chen
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Rockville, MD, United States
| | - Anne Hammer
- Department of Obstetrics and Gynecology, Aarhus University Hospital, Denmark
- Department of Clinical Medicine, Aarhus University, Denmark
| | - Nicole Campos
- Center for Health Decision Science, Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA, United States
| | - Walter Kinney
- Regional Laboratory, Kaiser Permanente Northern California, Berkeley, CA, United States
| | - Julia C. Gage
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Rockville, MD, United States
| | - Brian Befano
- Information Management Services Inc., Calverton, MD, United States
| | - Rebecca B. Perkins
- Department of Obstetrics and Gynecology, Boston Medical Center/Boston University School of Medicine, Boston, MA, United States
| | - Xin He
- University of Maryland School of Public Health, College Park, MD, United States
| | - Cher Dallal
- University of Maryland School of Public Health, College Park, MD, United States
| | - Jie Chen
- University of Maryland School of Public Health, College Park, MD, United States
| | - Nancy Poitras
- Regional Laboratory, Kaiser Permanente Northern California, Berkeley, CA, United States
| | - Marie-Helene Mayrand
- Department of Obstetrics and Gynecology, Université de Montréal and Centre de recherche du Centre hospitalier de l'Université de Montréal (CRCHUM), Montreal, Canada
- Department of Social and Preventive Medicine, Université de Montréal and Centre de recherche du Centre hospitalier de l'Université de Montréal (CRCHUM), Montreal, Canada
| | - Francois Coutlee
- Department of Microbiology, Université de Montréal and CRCHUM, Montreal, Canada
| | - Robert D. Burk
- Albert Einstein College of Medicine, Bronx, NY, United States
| | - Thomas Lorey
- Regional Laboratory, Kaiser Permanente Northern California, Berkeley, CA, United States
| | | | - Nicolas Wentzensen
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Rockville, MD, United States
| | - Mark Schiffman
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Rockville, MD, United States
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23
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Weston G, Dombrowski C, Harvey MJ, Iftner T, Kyrgiou M, Founta C, Adams EJ. Use of the Aptima mRNA high-risk human papillomavirus (HR-HPV) assay compared to a DNA HR-HPV assay in the English cervical screening programme: a decision tree model based economic evaluation. BMJ Open 2020; 10:e031303. [PMID: 32152154 PMCID: PMC7064071 DOI: 10.1136/bmjopen-2019-031303] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE To estimate the impact of using the Aptima messenger RNA (mRNA) high-risk human papilloma virus (HR-HPV) assay versus a DNA HR-HPV assay in a primary HPV cervical screening programme. DESIGN One hypothetical cohort followed for 3 years through HPV primary cervical screening. SETTING England. PARTICIPANTS A hypothetical cohort of women aged 25-65 years tested in the National Health Service (NHS) Cervical Screening Programme (CSP) for first call or routine recall testing. METHODS A decision tree parameterised with data from the CSP (2017/18) and the HORIZON study. Uncertainty analyses were conducted using data from the FOCAL and GAST studies, other DNA HPV tests in addition to one-way and probabilistic sensitivity and scenarios analyses, to test the robustness of results. INTERVENTIONS Aptima mRNA HR-HPV assay and a DNA HR-HPV assay (cobas 4800 HPV assay). MAIN OUTCOME MEASURES Primary: total colposcopies and total costs for the cohort. Secondary: total HPV and cytology tests, number lost to follow-up. RESULTS At baseline for a population of 2.25 million women, an estimated £15.4 million (95% credibility intervals (CI) £6.5 to 24.1 million) could be saved and 28 009 (95% CI 27 499 to 28 527) unnecessary colposcopies averted if Aptima mRNA assays are used instead of a DNA assay, with 90 605 fewer unnecessary HR-HPV and 253 477 cytology tests performed. These savings are due to a lower number of HPV positive samples in the mRNA arm. When data from other primary HPV screening trials were compared, results indicated that using the Aptima mRNA assay generated cost savings and reduced testing in every scenario. CONCLUSION Using the Aptima mRNA assay versus a DNA assay would almost certainly yield cost savings and reduce unnecessary testing and procedures, benefiting the NHS and women in the CSP.
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Affiliation(s)
| | | | | | - Thomas Iftner
- Department of Medical Virology, University Hospital Tübingen, Tübingen, Germany
| | - Maria Kyrgiou
- Institute of Reproductive and Developmental Biology, Department of Surgery & Cancer, Imperial College London, London, UK
- Queen Charlotte's and Chelsea, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Christina Founta
- Department of Gynaecological Oncology, Musgrove Park Hospital, Taunton & Somerset NHS Foundation Trust, Taunton, Somerset, UK
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