Cervical Cancer Screening with HPV Testing: Updates on the Recommendation

Enhancing Cervical Cancer Screening: Review of p16/Ki-67 Dual Staining as a Promising Triage Strategy

Cervical cancer, primarily caused by high-risk human papillomavirus (HR-HPV) types 16 and 18, is a major global health concern. Persistent HR-HPV infection can progress from reversible precancerous lesions to invasive cervical cancer, which is driven by the oncogenic activity of human papillomavirus (HPV) genes, particularly E6 and E7. Traditional screening methods, including cytology and HPV testing, have limited sensitivity and specificity. This review explores the application of p16/Ki-67 dual-staining cytology for cervical cancer screening. This advanced immunocytochemical method allows for simultaneously detecting p16 and Ki-67 proteins within cervical epithelial cells, offering a more specific approach for triaging HPV-positive women. Dual staining and traditional methods are compared, demonstrating their high sensitivity and negative predictive value but low specificity. The increased sensitivity of dual staining results in higher detection rates of CIN2+ lesions, which is crucial for preventing cervical cancer progression. However, its low specificity may lead to increased false-positive results and unnecessary biopsies. The implications of integrating dual staining into contemporary screening strategies, particularly considering the evolving landscape of HPV vaccination and changes in HPV genotype prevalence, are also discussed. New guidelines and further research are necessary to elucidate the long-term effects of integrating dual staining into screening protocols.

Antenatal and postnatal cervical precancer screening to increase coverage: experience from Battor, Ghana

Background

Cervical precancer screening in low-resource settings is largely opportunistic with low coverage. Many women in these settings, where the burden of cervical cancer is highest, only visit health institutions when pregnant or after delivery. We explored screening during antenatal and postnatal visits aimed at increasing coverage.

Methods

Pregnant women (in any trimester) attending antenatal care (ANC) and women attending postnatal care (PNC; 6-10 weeks) clinics were screened at Catholic Hospital, Battor and at outreach clinics from February to August 2022 (08/02/2022 to 02/08/2022). At the same visit, cervical specimens were obtained for high-risk human papillomavirus (hr-HPV) DNA testing (with the Sansure MA-6000 PCR platform) followed by either visual inspection with acetic acid (VIA) or mobile colposcopy with the enhanced visual assessment system.

Results

Two hundred and seventy and 107 women were screened in the antenatal and postnatal groups, respectively. The mean ages were 29.4 (SD, 5.4) in the ANC group and 28.6 (SD, 6.4) years in the PNC group. The overall hr-HPV prevalence rate was 25.5% (95% confidence interval (CI), 21.1-29.9) disaggregated as 26.7% (95% CI, 21.4-31.9) in the ANC group and 22.4% (95% CI, 14.5-30.3) in the PNC group (p = 0.3946). Overall, 58.9% of pregnant women (28.3% hr-HPV+) and 66.4% of postnatal women (22.5% hr-HPV+) only visited a health facility when pregnant or after delivery (at Child Welfare Clinics). The VIA 'positivity' rate for all screened women was 5.3% (95% CI, 3.1-7.6), disaggregated into 5.2% (95% CI, 2.5-7.8) in the ANC group and 5.7% (95% CI, 1.3-10.1) in the PNC group (p-value = 0.853).

Conclusion

A significant number of women in Ghana only visit a health facility during pregnancy or after delivery. ANC and PNC clinics would offer opportunities to increase coverage in cervical precancer screening in low-resource settings. Relying on community nurses ensures that such programs are readily integrated into routine care of women and no opportunity is missed.

Cervical cancer screening, treatment and prophylaxis in Brazil: Current and future perspectives for cervical cancer elimination

As a middle-income country, Brazil has one of the largest public health systems worldwide, which deals with free and universal access to health care. Regarding cervical cancer, the country possesses a large infrastructure for the screening of premalignant and malignant lesions, but yet based on old technology, having Papanicolaou as the major screening method, followed by colposcopy and treatment. Also, large disparities in access are present, which makes effectiveness of screening and treatment in different regions of the country highly unequal. In this review, we describe and evaluate the current screening, treatment and prophylactic (HPV vaccination) strategies to combat cervical cancer in Brazil, and discuss potential incorporation of more recent technologies in these areas in the country to pave its way toward cervical cancer elimination.

Safety of Conservative Management of High-Grade Squamous Intraepithelial Lesion in Women Under 30 Years Old

Objectives:

To evaluate the outcomes of conservative management in young women with high-grade squamous intraepithelial lesion (HSIL).

Methods:

A retrospective cohort study included women younger than 30 years referred with HSIL (cytology or biopsy) managed conservatively from 2012 to 2019, in Campinas/Brazil. Regression was the outcome when no evidence of HSIL was observed in at least two consecutive follow-ups. Kaplan–Meyer method was used to determine regression probabilities. Other tests were chi-square or Fisher, Mann–Whitney and COX regression.

Results:

During the study period, 89 patients were included. No progression to microinvasive or invasive cancer was observed. Sixty-one (69%) patients were younger than 25 years, and 28 (31%) were aged 25–30 years. Spontaneous regression was seen in 64 (72%) and persistence in 25 (28%) of the overall sample. The average time to regression was 15.4 months (standard deviation [SD] = 7.7), and the follow-up time was 31.6 months (SD 19.0). Age, parity, first sexual intercourse, smoking, hormonal contraception, and colposcopy impression were not different among women with regression or persistence. Regression probabilities were, respectively, 28.9%, 60.2%, and 78.1% after 12, 18, and 24 months. Most of the events happened between 12 and 18 months of follow-up.

Conclusions:

Conservative management in women younger than 30 years was safe: spontaneous regression was observed in 72% of all women younger than 30 with HSIL managed conservatively. No clinical variable was relevant, influencing regression. In 2 years the regression probability was 78%.

Implementation of HPV Tests in Latin America: What We Learned; What Should We Have Learned, and What Can We Do Better?

Cervical cancer is caused by HPV. Although it is the fourth most common type of cancer diagnosed and the fourth cause of cancer death, cervical cancer is nearly completely preventable because of the vaccination and screening available. The present review aims to map the initiatives conducted to implement or evaluate the implementation of HPV testing in Latin American countries. We performed the review by searching on PubMed in the English language and on grey literature, as most of the information about the guidelines used was found in governmental websites in the Spanish language. We only found information in eight countries concerning HPV testing as primary screening. Only Mexico has established HPV-based screening in all territories. There are three countries with regional implementation. Two countries with pilot studies indicated results that supported implementation. Finally, there are another two countries with a national recommendation. We have learned that HPV implementation is feasible and a very promising tool for reducing cervical cancer morbidity and mortality. The costs associated with saving lives and reducing suffering due to morbidity of a preventable disease must be pragmatically evaluated by the Latin America governments, and improving outcomes must be a mandatory priority for those that are responsible for addressing an organized system of cervical cancer screening.