Primary cervical cancer screening by self-sampling of human papillomavirus DNA in internal medicine outpatient clinics

MGMT Methylation Is Associated with Human Papillomavirus Infection in Cervical Dysplasia: A Longitudinal Study

Cervical premalignancy/malignancy, as detected by cervical cytology or biopsy, can develop as a result of human papillomavirus (HPV) infection. Meanwhile, DNA methylation is known to be associated with carcinogenesis. In this study, we thus attempted to identify the association between MGMT methylation and persistent HPV infection using an Epi-TOP MPP assay. Integrative analysis of DNA methylation was carried out here using longitudinal cervical cytology samples of seven patients with atypical squamous cells of undetermined significance/low-grade squamous intraepithelial lesion (ASC-US/LSIL). Then, a gene expression analysis using the longitudinal cervical cytology samples and a public database (The Cancer Genome Atlas (TCGA)) was performed. Upon comparing the ASC-US or LSIL samples at the 1st collection and the paired samples at the 2nd collection more than 6 months later, we found that they became hypermethylated over time. Then, using the longitudinal data, we found that the MGMT methylation was associated with HPV infection. Moreover, TCGA dataset revealed an association between downregulated MGMT mRNA expression and poor overall survival. This decreased MGMT mRNA expression was observed to have an inverse relationship with MGMT methylation levels. In this study, we found that the MGMT methylation level could potentially serve as a valuable prognostic indicator for the transition from ASC-US/LSIL to cervical cancer.

Does self-sampling for human papilloma virus testing have the potential to increase cervical cancer screening? An updated meta-analysis of observational studies and randomized clinical trials

Objectives

A meta-analysis was conducted to examine the effectiveness of HPV self-sampling proposal on cervical cancer screening (CCS) uptake when compared with an invitation to have a clinician to collect the sample. Secondary outcomes were acceptability and preference of self-sampling compared to clinician-collected samples.

Methods

The present systematic review and meta-analysis followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Studies examining the CCS uptake comparing self-sampling over invitation to be sampled by an healthcare professional and examining the proportion of women accepting or preferring self-sampling vs. clinician-collected sampling were included. The CCS uptake was also explored according to strategy of self-samplers' distribution, collection device type and screening status. Peters' test and Funnel Plot inspection were used to assess the publication bias. Quality of the studies was assessed through Cochrane Risk of Bias and NIH Quality Assessment tools.

Results

One hundred fifty-four studies were globally identified, and 482,271 women were involved. Self-sampling procedures nearly doubled the probability (RR: 1.8; 95% CI: 1.7-2.0) of CCS uptake when compared with clinician-collected samples. The opt-out (RR: 2.1; 95% CI: 1.9-2.4) and the door-to-door (RR: 1.8; 95% CI: 1.6-2.0) did not statistically significant differ (p = 1.177) in improving the CCS uptake. A higher relative uptake was shown for brushes (RR: 1.6; 95% CI: 1.5-1.7) and swabs (RR: 2.5; 95% CI: 1.9-3.1) over clinician-collected samples. A high between-studies variability in characteristics of sampled women was shown. In all meta-analyses the level of heterogeneity was consistently high (I 2 > 95%). Publication bias was unlikely.

Conclusions

Self-sampling has the potential to increase participation of under-screened women in the CCS, in addition to the standard invitation to have a clinician to collect the sample. For small communities door-to-door distribution could be preferred to distribute the self-sampler while; for large communities opt-out strategies should be preferred over opt-in. Since no significant difference in acceptability and preference of device type was demonstrated among women, and swabs and brushes exhibited a potential stronger effect in improving CCS, these devices could be adopted.

Comparison of self-collected versus clinician collected cervicovaginal specimens for detection of high risk human papillomavirus among HIV infected women in Ethiopia

Background

In order to meet the WHO 2030 cervical cancer elimination program, evaluation and utilization of sensitive testing method, and feasible sampling technique is a paradigm for enhancing cervical cancer screening coverage. Self-sampling for screening of HPV DNA testing is one of the easiest and sensitive techniques, though the evidence was limited in the Ethiopian context. This study aimed to compare the performance of self-collected vaginal specimen versus clinician collected cervical specimen for detection of HPV among HIV positive women in Ethiopia.

Methods

We conducted a comparative cross-sectional study design to collect cervicovaginal specimens among HIV positive women of age older than 24 years. Data were collected from six government hospitals from January to October 2021. A total of 994 cervicovaginal specimens was collected by clinicians and HIV positive women themselves in the cervical cancer screening unit using Abbott Cervi-Collect Specimen Collection Kit, and molecular HPV testing was conducted. Data were entered into an Excel spreadsheet and analyzed using SPSS version 25. Sensitivity, specificity and kappa were reported with p < 0.05 considered as statistically significant.

Results

The prevalence of high-risk HPV was 29.4% among self-sampled specimen and 23.9% among clinician collected specimens. The overall concordance of the test result was 87.3%. Oncogenic HPV types, other than HPV16&18 were predominant in both sampling techniques, 19.9% from vaginal self-collected specimen and 16.7% of clinician collected cervical specimens. The sensitivity and specificity of self-sampled HPV test was 84.0% and 88.4%, respectively. The level of agreement was good (k = 0.68) and statistically significant (p < 0.001). The discriminatory power of the test as true positive and negative was excellent with an area under the curve of 0.86.

Conclusion

The magnitude of oncogenic HPV was higher in self-collected samples than the clinician collected specimen with good agreement between the two sampling methods. Thus, we recommend the Ministry of Health in Ethiopia to expand utilization of the self-sampled technique and enhance the coverage of screening in the country.

Adjusting for verification bias in diagnostic accuracy measures when comparing multiple screening tests - an application to the IP1-PROSTAGRAM study

Introduction

Novel screening tests used to detect a target condition are compared against either a reference standard or other existing screening methods. However, as it is not always possible to apply the reference standard on the whole population under study, verification bias is introduced. Statistical methods exist to adjust estimates to account for this bias. We extend common methods to adjust for verification bias when multiple tests are compared to a reference standard using data from a prospective double blind screening study for prostate cancer.

Methods

Begg and Greenes method and multiple imputation are extended to include the results of multiple screening tests which determine condition verification status. These two methods are compared to the complete case analysis using the IP1-PROSTAGRAM study data. IP1-PROSTAGRAM used a paired-cohort double-blind design to evaluate the use of imaging as alternative tests to screen for prostate cancer, compared to a blood test called prostate specific antigen (PSA). Participants with positive imaging (index) and/or PSA (control) underwent a prostate biopsy (reference standard).

Results

When comparing complete case results to Begg and Greenes and methods of multiple imputation there is a statistically significant increase in the specificity estimates for all screening tests. Sensitivity estimates remained similar across the methods, with completely overlapping 95% confidence intervals. Negative predictive value (NPV) estimates were higher when adjusting for verification bias, compared to complete case analysis, even though the 95% confidence intervals overlap. Positive predictive value (PPV) estimates were similar across all methods.

Conclusion

Statistical methods are required to adjust for verification bias in accuracy estimates of screening tests. Expanding Begg and Greenes method to include multiple screening tests can be computationally intensive, hence multiple imputation is recommended, especially as it can be modified for low prevalence of the target condition.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12874-021-01481-w.

Cervical Cancer Screening Postpandemic: Self-Sampling Opportunities to Accelerate the Elimination of Cervical Cancer

The persisting burden of cervical cancer in underserved populations and low-resource regions worldwide, worsened by the onset of the COVID-19 pandemic, requires proactive strategies and expanded screening options to maintain and improve screening coverage and its effects on incidence and mortality from cervical cancer. Self-sampling as a screening strategy has unique advantages from both a public health and individual patient perspective. Some of the barriers to screening can be mitigated by self-sampling, and resources can be better allocated to patients at the highest risk of developing cervical cancer. This review summarizes the implementation options for self-sampling and associated challenges, evidence in support of self-sampling, the available devices, and opportunities for expansion beyond human papillomavirus testing.

Self-obtained vaginal swabs are not inferior to provider-performed endocervical sampling for emergency department diagnosis of Neisseria gonorrhoeae and Chlamydia trachomatis

OBJECTIVE

Provider-performed endocervical sampling (PPES) in the diagnosis of Neisseria gonorrhoeae (NG) and Chlamydia trachomatis (CT) may be difficult to perform in a busy emergency department (ED) due to patient preference, availability of the pelvic examination room, or provider availability. Our objective was to assess if self-obtained vaginal swabs (SOVS) were noninferior to PPES in the ED diagnosis of NG/CT using a rapid nucleic acid amplification test (NAAT).

METHODS

We conducted a prospective observational cohort study in a single ED. Participants were adult female English- and Spanish-speaking patients in whom the ED provider felt that NG/CT testing was warranted. Each patient had SOVS and PPES performed. For SOVS, a research associate reviewed a one-page handout describing the procedure but gave no other assistance. Patients answered survey questions regarding acceptability of SOVS and symptomatology. We established a minimum sensitivity of 90% for SOVS to be considered clinically noninferior to standard PPES.

RESULTS

A total of 533 patients completed enrollment and answered survey questions, 515 of whom had laboratory results for both SOVS and PPES. There were 86 patients with a positive result: 29 with NG, 47 with CT, and 10 with coinfection. SOVS had a sensitivity of 95% (95% confidence interval = 88% to 99%) for the detection of NG/CT when compared to PPES. SOVS were felt to be an acceptable collection method in 93% of patients and 75% preferred SOVS to PPES.

CONCLUSION

SOVS are noninferior to PPES in NG/CT diagnosis using a rapid NAAT in ED patients and surveys indicate high patient acceptability.

Improved Rates of Cervical Cancer Screening Among Transmasculine Patients Through Self-Collected Swabs for High-Risk Human Papillomavirus DNA Testing

Introduction: Nearly all cervical cancer cases are caused by one of several high-risk strains of the human papillomavirus (hr-HPV). Transmasculine (TM) individuals (persons who have a masculine spectrum gender identity, but were recorded female at birth) have low adherence to standard cervical cancer screening modalities. Introduction of self-collected vaginal swabs for hr-HPV DNA testing may promote initiation and adherence to cervical cancer screening among TM individuals to narrow screening disparities. The purpose of this study was to assess the rate of cervical cancer screening among TM individuals following the introduction of self-collected swabbing for hr-HPV DNA testing in comparison to clinician-administered cervical specimen collection.

Methods: Rates of uptake and adherence to cervical cancer screening among TM individuals were assessed before and after the clinical introduction of self-collected swab testing in October 2017. Rates were compared with the rates of cervical cancer screening among cisgender women at a colocated Comprehensive Health Program during the time period of review.

Results: Of the 121 TM patients seen for primary care in the 6-month baseline period before the October 2017 introduction of self-collected swabbing for hr-HPV DNA testing, 30 (25%) had cervical cancer screening documented in the electronic medical record. Following the implementation of self-swabbing, of 193 patients, 98 (51%) had a documented cervical cancer screening, a two-fold increase in the rates of adherence to cervical cancer screening (p<0.001).

Conclusion: Self-collected swab testing for hr-HPV can increase rates of adherence to screening recommendations among an otherwise under-screened population.

[How can we improve cervical cancer screening: What can we learn from mistakes?]

Cervical cancer screening is considered one of the most significant public health interventions that can reduce not only the incidence, but also the mortality of the disease. One of the most important factors for screening effectiveness is coverage defined as the number of women tested within a recommended interval. In the first years of the cervical screening, the participation rate in National Screening Program in Romania was 14.2% with slight difference in different region of the country. In the northeastern part of the country, in the first four years of the program, the rate was 16.9% with an alarmingly continuous decrease. Thus, increasing the rate of uptake of cervical screening is essential. The policy-makers should take new measures to increase women's participation in this screening program. The objective of this paper was to review situation of the screening program and to identify gaps and needs in the system and to bring or suggest solution.

Interventions to improve the uptake of cervical cancer screening among lower socioeconomic groups: A systematic review

Cervical cancer is the fourth most common cancer in women worldwide. Screening can reduce both the incidence and mortality of the disease but is often not utilized by lower socioeconomic groups. A systematic review, including studies of interventions to improve breast and cervical cancer screening uptake, up to 2006, found targeted interventions could be effective. A formal update has been conducted on the effectiveness of interventions to improve the uptake of cervical cancer screening among lower socioeconomic groups. A systematic computerized literature search was undertaken in June 2016 for relevant papers published since 2006. Data was extracted on study participants, setting, intervention and control using a predefined extraction tool and a full quality assessment was undertaken using the Cochrane risk of bias tool. This update yielded 16 studies of mixed quality, in addition to the 13 studies from the original review. The interventions were categorized into local interventions including HPV self-testing, lay health advisors, inreach, outreach and mixed, and strategies enhancing attendance within an organized program. This review has found two large, randomized controlled trials for the use of HPV self-testing to increase cervical screening uptake. Both reviews have found varying success using lay health advisors, with the majority of included papers reporting a statistically significant increase in screening uptake. HPV self-testing can improve uptake of cervical cancer screening among lower socioeconomic groups. This is a relatively new method of cervical screening that was not included in the earlier review. The findings of this updated review largely support that of the 2006 review for the use of lay health advisors.

Verification bias

This article is part of the Catalogue of Bias series. We present a description of verification bias, and outline its potential impact on research studies and the preventive steps to minimise its risk. We also present teaching slides in the online supplementary file. Verification bias (sometimes referred to as 'work-up bias') concerns the test(s) used to confirm a diagnosis within a diagnostic accuracy study. Verification bias occurs when only a proportion of the study participants receive confirmation of the diagnosis by the reference standard test, or if some participants receive a different reference standard test.

Test performance and acceptability of self- versus provider-collected swabs for high-risk HPV DNA testing in female-to-male trans masculine patients

Background

High-risk human papillomavirus (hrHPV) causes virtually all cervical cancers. Trans masculine (TM) people (those assigned female at birth who identify with a gender other than female) have low uptake of conventional cervical cancer screening. Self-collected hrHPV DNA testing has high levels of acceptability among cisgender (non-transgender) females and may support increased cervical cancer screening uptake in TM individuals.

Objective

To assess the test performance and acceptability of self-collected vaginal specimens in comparison to provider-collected cervical swabs for hrHPV DNA detection in TM individuals ages 21–64 years.

Methods

Between March 2015-September 2016, 150 TM participants with a cervix (mean age = 27.5 years; SD = 5.7) completed a one-time study visit comprised of a self-report survey, self-collected vaginal HPV DNA swab, clinician-administered cervical HPV swab, and brief interview on acceptability of clinical procedures. Participants were randomized to complete either self- or provider-collection first to minimize ordering effects. Self- and provider-collected samples were tested for 13 hrHPV DNA types using a DNA Hybridization Assay. The primary outcome variable was the concordance (kappa statistic) and performance (sensitivity, specificity) of self-collected vaginal HPV DNA specimens versus provider-collected cervical HPV swabs as the gold standard.

Results

Of the 131 participants completing both the self- and provider-collected HPV tests, 21 cases of hrHPV were detected by the provider cervical swab (gold standard; 16.0% hrHPV prevalence); 15 of these cases were accurately detected by the self-collected vaginal swab (71.4% concordance) (Kappa = 0.75, 95% Confidence Interval [CI]: 0.59, 0.92; p<0.001). Compared to the provider-collected cervical hrHPV DNA sample (gold standard), the self-collected vaginal hrHPV DNA test demonstrated a sensitivity of 71.4% (95% CI: 0.52, 0.91; p = 0.0495) and specificity of 98.2% (95% CI: 0.96, 1.00; p<0.0001). Over 90% of participants endorsed a preference for the self-collected vaginal swab over provider-collected cervical swab.

Conclusion

Self-collected vaginal swabs are highly acceptable to TM as a means to test for hrHPV DNA. Test performance of this self-collection method for hrHPV detection in TM is consistent with previous studies in cisgender females. Self-collected vaginal swab testing for hrHPV DNA represents a reasonable and patient-centered strategy for primary cervical cancer screening in TM patients unwilling to undergo provider collection of specimens via speculum exam.

Comparing self- and provider-collected swabbing for HPV DNA testing in female-to-male transgender adult patients: a mixed-methods biobehavioral study protocol

Background

Cervical cancer, nearly all cases of which are caused by one of several high-risk strains of the human papillomavirus (hr-HPV), leads to significant morbidity and mortality in individuals with a cervix. Trans masculine (TM) individuals were born with female reproductive organs and identify as male, man, transgender man, or another diverse gender identity different from their female assigned sex at birth. Routine preventive sexual health screening of TM patients is recommended, including screening for cervical cancer and other sexually transmitted infections (STIs); however, as many as one in three TM patients are not up-to-date per recommended U.S. guidelines. Among cisgender (non-transgender) women, self-swab hr.-HPV DNA testing as a primary cervical cancer screening method and self-swab specimen collection for other STIs have high levels of acceptability. No study has yet been conducted to compare the performance and acceptability of self- and provider-collected swabs for hr.-HPV DNA testing and other STIs in TM patients.

Methods

This article describes the study protocol for a mixed-methods biobehavioral investigation enrolling 150 sexually active TM to (1) assess the clinical performance and acceptability of a vaginal self-swab for hr.-HPV DNA testing compared to provider cervical swab and cervical cytology, and (2) gather acceptability data on self-collected specimens for other STIs. Study participation entails a one-time clinical visit at Fenway Health in Boston, MA comprised of informed consent, quantitative assessment, venipuncture for syphilis testing and HIV (Rapid OraQuick) testing, randomization, collection of biological specimens/biomarkers, participant and provider satisfaction survey, and qualitative exit interview. Participants are compensated $100. The primary study outcomes are concordance (kappa statistic) and performance (sensitivity and specificity) of self-collected vaginal HPV DNA specimens vs provider-collected cervical HPV swabs as a gold standard.

Discussion

This study addresses critical gaps in current clinical knowledge of sexual health in TM patients, including comparing alternative strategies for screening and diagnosis of cervical cancer, hr.-HPV, and other STIs. Findings have implications for improving the delivery of sexual health screening to this often overlooked and underserved patient population. Less-invasive patient-centered strategies may also generalize to other at-risk cisgender female populations that face barriers to timely and needed STI and cervical cancer screening.

Trial registration

ClinicalTrials.gov ID: NCT02401867

Electronic supplementary material

The online version of this article (doi:10.1186/s12879-017-2539-x) contains supplementary material, which is available to authorized users.

Acceptability of unsupervised HPV self-sampling using written instructions

Objectives

The study measured the acceptability of self-sampling for human papillomavirus (HPV) testing in the context of cervical cancer screening. Women carried out self-sampling unsupervised, using a written instruction sheet.

Setting

Participants were women attending either a family planning clinic or a primary care trust for routine cervical screening.

Methods

Women (n = 902) carried out self-sampling for HPV testing and then a clinician did a routine cervical smear and HPV test. Immediately after having the two tests, participants completed a measure of acceptability for both tests, and answered questions about ease of using the instruction sheet and willingness to use self-sampling in the future.

Results

The majority of women found self-sampling more acceptable than the clinician-administered test, but there was a lack of confidence that the test had been done correctly. Significant demographic differences in attitudes were found, with married women having more favourable attitudes towards self-sampling than single women, and Asian women having more negative attitudes than women in other ethnic groups. Intention to use self-sampling in the future was very high across all demographic groups.

Conclusion

Self-sampling for HPV testing was highly acceptable in this large and demographically diverse sample, and women were able to carry out the test alone, using simple written instructions. Consistent with previous studies, women were concerned about doing the test properly and this issue will need to be addressed if self-sampling is introduced. More work is needed to see whether the demographic differences we found are robust and to identify reasons for lower acceptability among single women and those from Asian background.

Women's Attitudes Toward Cervicovaginal Self-Sampling for High-Risk HPV Infection on the US-Mexico Border

OBJECTIVE

The purpose of this study was to assess the acceptability and intention to use cervicovaginal self-sampling for high-risk human papillomavirus infection after receiving an educational intervention among the predominantly Hispanic population residing along the US-Mexico border.

METHODS

Women received an educational intervention about cervical cancer prevention through screening with conventional cytology and with self-sampling for high-risk human papillomavirus. After the educational intervention, women performed the self-sampling test. Women's attitudes toward the self-sampling test and cervical cytology were assessed and compared.

RESULTS

A total of 110 women aged 30 to 65 years completed the study. The mean (SD) age of the population was 48 (9.3) years. Most (87%) self-identified as being Hispanic and half were born in Mexico; 16% had not had cervical cytology done in 3 years. Self-sampling was more acceptable than cervical cytology; mean (SD) acceptability scores were 25.0 (2.9) and 22.7 (3.0), respectively, with the maximum possible score being 28 (p < .001). A large proportion (42.7%) of women preferred both tests equally. We found high intention to use and recommend self-sampling. Contrary to previous studies, there were no differences between cervical cytology and self-sampling regarding women's concerns about performing the test well and the accuracy of the test, which we attribute to the educational intervention.

CONCLUSION

The high acceptability of self-sampling after participants received education about the test and the reported intention to use it if made available add to the evidence on the feasibility of integrating self-testing within cervical cancer screening guidelines.

Factors influencing Malawian women's willingness to self-collect samples for human papillomavirus testing

BACKGROUND

Malawi has the highest incidence of cervical cancer in the world. Only 3% of Malawian women have ever been screened for cervical cancer. Self-collection of samples for human papillomavirus (HPV) testing could increase screening among under-screened and hard-to-reach populations. However, little is known about the acceptability of self-collection in rural African settings.

AIM

We aimed to characterise Malawian women's willingness to self-collect vaginal samples for HPV testing and to identify potential barriers.

DESIGN

We used data from the baseline wave of a community-based cohort study, collected from July 2014 to February 2015.

SETTING

Participants were enrolled from the catchment area of a clinic in rural Lilongwe District, Malawi.

METHODS

We enrolled women aged 15-39 years (n=824). Participants answered questions assessing willingness to self-collect a sample for HPV testing, concerns about testing and other hypothesised correlates of willingness to self-collect.

RESULTS

Two-thirds (67%) of the women reported willingness to self-collect a vaginal sample in their homes. Awareness of cervical cancer, supportive subjective norms, perceived behavioural control, and clinician recommendations were all positively associated with increased willingness to self-collect samples for HPV testing. Identified barriers to self-testing endorsed by women included: concerns that the test might hurt (22%), that they might not do the test correctly (21%), and that the test might not be accurate (17%).

CONCLUSIONS

This study suggests that self-collection for HPV testing could be an acceptable cervical cancer screening method in this rural population. Findings identify modifiable beliefs and barriers that can inform the development of effective screening programmes.

Human Papillomavirus Infection in Women Who Submit Self-collected Vaginal Swabs After Internet Recruitment

Submission of vaginal samples collected at home could remove barriers that women face in getting screened for cervical cancer. From December 2013 to January 2014, women aged 21-30 years were recruited online to participate in either (1) self-collected testing for human papillomavirus (HPV) infection and an online survey, or (2) an online survey regarding their perceptions of self-collected testing for HPV infection. Demographics, risk factors, testing perceptions, and satisfaction with self-collected testing were assessed with online questionnaires. Women who performed self-collection were sent a home sampling kit by US mail, which was returned via US mail for HPV testing. A total of 197 women were enrolled, with 130 completing the online survey and 67 participating in both the survey and self-collection. Of the 67 women who were sent kits, 62 (92.5%) were returned for testing. Sixty kits contained a sample sufficient for testing. The overall prevalence of HPV infection was 17.8%, however 6 women (9.7%) were infected with >1 type of HPV. Women who self-collected a sample reported more favorable attributes of self-collection compared to women who only participated in the online survey, including ease of sampling (87.1 vs. 18.9%), no pain during sampling (72.6 vs. 5.6%), and lack of embarrassment (67.7 vs. 12.9%). A high prevalence of HPV infection was demonstrated among women recruited via the internet. Online recruitment and at home screening methods have the potential to engage women in screening by offering an approach that might be more acceptable to women of different backgrounds.

WITHDRAWN: Comparative evaluation of two vaginal self-sampling devices for the detection of human papillomavirus infections

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Conocimientos sobre virus del papiloma humano (VPH) y aceptación de auto-toma vaginal en mujeres mexicanas

<p><strong>Objetivo </strong>Analizar la asociación del grado de conocimiento sobre Papillomavirus Humano y la aceptación de la auto-toma vaginal como prueba diagnóstica para la detección de cáncer cervical en mujeres mexicanas que ya han tenido la experiencia de una auto-toma vaginal en casa.</p><p><strong>Métodos </strong>Cuestionario estructurado de 22 preguntas a 690 mujeres del estado de Morelos que se realizaron la auto-toma vaginal en casa para explorar el nivel de conocimientos sobre transmisión del Papillomavirus Humano, identificación del virus como causa necesaria para cáncer cervicouterino, manifestaciones clínicas de la infección y tratamiento. Se construyó un índice de conocimientos identificando su asociación con la aceptación de la auto-toma y la confianza que las mujeres tienen en ella. El análisis estadístico incluyó regresión logística con estimación de medidas de asociación y sus respectivos intervalos de confianza al 95 %.</p><p><strong>Resultados</strong> El nivel de conocimientos sobre Papilloma virus Humano presentó una asociación positiva con el grado de aceptación de la auto-toma vaginal (OR 2.9 IC 95 % 1.0-5.01) y con el nivel de confianza de las mujeres (OR 2.9 IC 95 % 1.8-4.67). El nivel de conocimientos se incrementa con el grado de escolaridad y es mayor en las mujeres más jóvenes.</p><p><strong>Conclusiones</strong> Para lograr una participación continuada de las mujeres con mayor riesgo de cáncer cervicouterino en la auto-toma vaginal es necesario informarlas ampliamente sobre los aspectos generales del virus, en especial a aquellas mujeres de edad avanzada, de nivel escolar y socioeconómico bajos. </p>

Performance of self-sampled HPV test in comparison with liquid based cytology

OBJECTIVE

Strong evidences shows that HPV testing is more sensitive than cytology in detecting high-grade CIN. HPV test can be performed on samples collected by women themselves by means of self-sampling devices. This study compares the results of self-sampled HPV tests with the results of liquid based cytology (LBC).

STUDY DESIGN

Seven hundred women scheduled for cervical cytology self-collected a cervicovaginal sample for HPV testing and then underwent a clinician-collected LBC at the European Institute of Oncology. The HPV and LBC results were compared with the McNemar test.

RESULTS

All HSIL (N=5) resulted hrHPV positive. LBC resulted LSIL or worse in 38 (5.4%) women (out of 700). Self-sampled HPV was positive in 96 women (13.7%). A LSIL or worse LBC result was found in 15 (2.5%) patients, out of the 604 hrHPV negative women and in 23 (24%) patients, out of the 96 hrHPV positive women. Positive cytology after a self-sampled HPV positive result had an Odds Ratio of 12.4 (95% CI: 5.8-26.6).

CONCLUSION

Self-collected HPV testing identifies a group of women at high risk of positive LBC and high grade SIL.

Dry storage and transport of a cervicovaginal self-sample by use of the Evalyn Brush, providing reliable human papillomavirus detection combined with comfort for women

Primary screening using high-risk human papillomavirus (hrHPV) detection has been suggested as a way of improving cervical cancer prevention. Women currently not attending screening (nonresponders) are more likely to participate when given the opportunity of self-sampling for hrHPV testing. The Evalyn Brush is a new cervicovaginal self-sampling device, developed specifically to meet women's demands, which is user-friendly and easy to use. The aims of this study were to investigate agreement of hrHPV detection by two PCR methods between the Evalyn Brush and physician-obtained samples and to study women's acceptance of this self-sampling device. Each of 134 women visiting the gynecology outpatient clinic collected a self-obtained sample (self-sample) and completed a questionnaire. The brush was stored dry. After self-sampling, a trained physician obtained a conventional cervical cytology specimen in ThinPrep medium. HrHPV detection was performed using the SPF(10)-DEIA-LiPA(25) and GP5+/6+-LQ-test. The overall agreement for hrHPV detection using SPF(10)-DEIA-LiPA(25) between the self-sample and the physician-taken sample was 85.8% (kappa value, 0.715; 95% confidence interval [CI], 0.597 to 0.843; P = 1.000). The overall agreement for hrHPV detection using GP5+/6+-LQ between the self-sample and the physician-taken sample was 86.6% (kappa value, 0.725; 95% CI, 0.607 to 0.843; P = 0.815). Ninety-eight percent of the women rated their experience as good to excellent. Moreover, 95% of women preferred self-sampling to physician sampling. Self-sampling using the dry Evalyn Brush system is as good as a physician-taken sample for hrHPV detection and is highly acceptable to women. To validate this self-sampling device for clinical use, a large screening cohort should be studied.

Cervicovaginal self-sampling is a reliable method for determination of prevalence of human papillomavirus genotypes in women aged 20 to 30 years

Self-sampling by cervicovaginal lavage could be an attractive method to detect high-risk human papillomavirus (hr-HPV) infections to identify women with a risk of cervical precancer. The objective of our study was to use self-sampling for the first time in a cross-sectional approach to determine HPV prevalence and genotype distribution. We evaluated participants' acceptance and laboratory results from self-obtained samples versus endocervical brush samples obtained by gynecologists. To determine the sensitivity of both sampling methods in presumed high- and low-prevalence settings, two groups of women 20 to 30 years of age with (n = 55) and without (n = 101) a recent suspicious cytological smear were compared. Overall, 76% (95% confidence interval [95% CI], 65 to 88) of women with and 40% (95% CI, 30 to 49) of women without a recent suspicious cytological smear tested HPV positive. The prevalences of high-risk HPV strains were 71% (95% CI, 59 to 83) and 32% (95% CI, 22 to 41), respectively, for these two groups. The agreement for hr-HPV between the two sampling methods for women with and without suspicious cytology was 84% (κ = 0.65; 95% CI, 0.44 to 0.86) and 91% (κ = 0.78; 95% CI, 0.64 to 0.92), respectively. Participants rated the user-friendliness of the self-sampling method on a visual analog scale from 0 (easy) to 100 (difficult) with a median of 12. In conclusion, self-sampling by cervicovaginal lavage is a reliable method to determine hr-HPV prevalence and is well accepted by young adult females.

Looking ahead: a case for human papillomavirus testing of self-sampled vaginal specimens as a cervical cancer screening strategy

Even in the era of highly effective human papillomavirus (HPV) prophylactic vaccines, substantial reduction in worldwide cervical cancer mortality will only be realized if effective early detection and treatment of the millions of women already infected and the millions who may not receive vaccination in the next decade can be broadly implemented through sustainable cervical cancer screening programs. Effective programs must meet three targets: (i) at least 70% of the targeted population should be screened at least once in a lifetime, (ii) screening assays and diagnostic tests must be reproducible and sufficiently sensitive and specific for the detection of high-grade precursor lesions (i.e., CIN21), and (iii) effective treatment must be provided. We review the evidence that HPV DNA screening from swabs collected by the women in their home or village is sufficiently sound for consideration as a primary screening strategy in the developing world, with sensitivity and specificity for detection of CIN21 as good or better than Pap smear cytology and VIA. A key feature of a self-collected HPV testing strategy (SC-HPV) is the move of the primary screening activities from the clinic to the community. Efforts to increase the affordability and availability of HPV DNA tests, community education and awareness, development of strong partnerships between community advocacy groups, health care centers and regional or local laboratories, and resource appropriate strategies to identify and treat screen-positive women should now be prioritized to ensure successful public health translation of the technologic advancements in cervical cancer prevention.

Barriers to acceptance of self-sampling for human papillomavirus across ethnolinguistic groups of women

OBJECTIVES

Immigrant and low socio-economic (SES) women in North America underutilize Papanicolaou screening. Vaginal swab self-sampling for oncogenic human papillomavirus (HPV) has the potential to increase cervical cancer screening participation. The purpose of this qualitative study was to understand the perceptions of lower SES and immigrant women regarding self-sampling for HPV.

METHODS

Eleven focus-group interviews were conducted: one with Canadian-born English-speaking lower SES women, and two groups each with Arabic, Cantonese, Dari (Afghani), Somali and Spanish (Latino)-speaking women (one group conducted in English, the other in the native language) recently immigrated to Canada. Five to nine women aged 35 to 65 years and married with children participated in each group.

RESULTS

Themes included 1) who might use self-sampling and why; 2) aversion to self-sampling and reasons to prefer physician; 3) ways to improve the appeal of self-sampling. Women generally perceived benefits of self-sampling and a small number felt they might use the method, but all groups had some reservations. Reasons included: uncertainty over performing the sampling correctly; fear of hurting themselves; concern about obtaining appropriate material; and concerns about test accuracy. Women preferred testing by a health care professional because they were accustomed to pelvic examinations, it was more convenient, or they trusted the results.

CONCLUSIONS

Perceptions of self-sampling for HPV were similar across cultures and pertained to issues of confidence in self-sampling and need for physician involvement in care. These findings can inform programs and studies planning to employ self-sampling as a screening modality for cervical cancer.

Accuracy and cost-effectiveness of cervical cancer screening by high-risk human papillomavirus DNA testing of self-collected vaginal samples

OBJECTIVE

Estimate the accuracy and cost-effectiveness of cervical cancer screening strategies based on high-risk human papillomavirus (HPV) DNA testing of self-collected vaginal samples.

MATERIALS AND METHODS

A subset of 1,665 women (age range, 18-50 y) participating in a cervical cancer screening study were screened by liquid-based cytology and by high-risk HPV DNA testing of both self-collected vaginal swab samples and clinician-collected cervical samples. Women with positive/abnormal screening test results and a subset of women with negative screening test results were triaged to colposcopy. On the basis of individual and combined test results, 5 screening strategies were defined. Estimates of sensitivity and specificity for cervical intraepithelial neoplasia grade 2 or worse were calculated, and a Markov model was used to estimate the incremental cost-effectiveness ratios for each strategy.

RESULTS

Compared with cytology-based screening, high-risk HPV DNA testing of self-collected vaginal samples was more sensitive (68%, 95% CI = 58%-78% vs 85%, 95% CI = 76%-94%) but less specific (89%, 95% CI = 86%-91% vs 73%, 95% CI = 67%-79%). A strategy of high-risk HPV DNA testing of self-collected vaginal samples followed by cytology triage of HPV-positive women was comparably sensitive (75%, 95% CI = 64%-86%) and specific (88%, 95% CI = 85%-92%) to cytology-based screening. In-home self-collection for high-risk HPV DNA detection followed by in-clinic cytology triage had a slightly lower lifetime cost and a slightly higher quality-adjusted life year (QALY) expectancy than did cytology-based screening (incremental cost-effectiveness ratio of triennial screening compared with no screening was $9,871/QALY and $12,878/QALY, respectively).

CONCLUSIONS

Triennial screening by high-risk HPV DNA testing of in-home, self-collected vaginal samples followed by in-clinic cytology triage was cost-effective.

Discussions about self-obtained samples for HPV testing as an alternative for cervical cancer prevention

OBJECTIVES

Patient-collected samples for human papillomavirus (HPV) testing have shown promise, thus opening up a new possibility for cervical cancer screening. The purpose of this study was to explore women's beliefs about collecting their own samples for HPV testing instead of participating in conventional Pap testing.

METHODS

Three focus groups were conducted in diverse cities in Ontario, Canada. One group included women from a small under-serviced northern city, one included culturally diverse women from a large urban city, and one included culturally diverse women from a medium sized under-serviced city. Transcripts were coded using open and axial coding as well as focused coding procedures and were organized using qualitative software. The Health Belief Model (HMB) was used as a framework for designing the focus group guide and interpreting the results.

RESULTS

Six overriding themes were identified in the analysis: (1) need (and desire) for information about cervical cancer and HPV, (2) concerns about self-sampling, (3) perceived potential of self-sampling, (4) logistics remain unanswered, (5) need for education and promotion of self-sampling, and (6) need for options.

CONCLUSION

The six themes were connected to some or all of the HBM components. In particular, self-sampling provides a different benefits-minus-barriers equation, which might make it a preferred screening option for some women.

Statistical methods to correct for verification bias in diagnostic studies are inadequate when there are few false negatives: a simulation study

BACKGROUND

A common feature of diagnostic research is that results for a diagnostic gold standard are available primarily for patients who are positive for the test under investigation. Data from such studies are subject to what has been termed "verification bias". We evaluated statistical methods for verification bias correction when there are few false negatives.

METHODS

A simulation study was conducted of a screening study subject to verification bias. We compared estimates of the area-under-the-curve (AUC) corrected for verification bias varying both the rate and mechanism of verification.

RESULTS

In a single simulated data set, varying false negatives from 0 to 4 led to verification bias corrected AUCs ranging from 0.550 to 0.852. Excess variation associated with low numbers of false negatives was confirmed in simulation studies and by analyses of published studies that incorporated verification bias correction. The 2.5th - 97.5th centile range constituted as much as 60% of the possible range of AUCs for some simulations.

CONCLUSION

Screening programs are designed such that there are few false negatives. Standard statistical methods for verification bias correction are inadequate in this circumstance.

Determinants of incidence and clearance of high-risk human papillomavirus infections in rural Rakai, Uganda

BACKGROUND

We used self-administered vaginal swabs to assess the incidence and clearance of carcinogenic human papillomavirus (HPV) infections in rural Rakai, Uganda.

METHODS

Women provided self-administered vaginal swab at annual home-based visits. Type-specific carcinogenic HPV incidence and clearance and risk factors were assessed.

RESULTS

Carcinogenic HPV incidence was 17.3 per 100 person-years among HIV-positive women compared with 7.0 per 100 person-years among HIV-negative women (P < 0.001). HPV-51 had the highest incidence followed by HPV-16 (1.8 per 100 and 1.5 per 100 person-years, respectively). In multivariate model, HIV-positive women were twice as likely to have incident infection compared with HIV-negative women. Younger women were at higher risk for incident infection, as were women with higher lifetime and recent sexual partners, and high perception of AIDS. Married women were less likely to have incident infection. Approximately half of all carcinogenic HPV infections cleared over the study follow-up of 3 years. HPV-31, HPV-35, and HPV-16 had the lowest clearance (16.7%, 27.9%, and 38.3%, respectively). In multivariate model, HIV-positive, women over 30 years with higher HPV viral, burden and more lifetime sex partners were less likely to clear infections.

CONCLUSIONS

Self-collected vaginal swabs provide accurate HPV exposure assessment for studying HPV exposure and epidemiology and can be an important tool for research in populations unwilling to undergo pelvic exam.

Persistent human papillomavirus infection and cervical neoplasia: a systematic review and meta-analysis

Detection of persistent cervical carcinogenic human papillomavirus (HPV) DNA is used as a marker for cervical cancer risk in clinical trials. The authors performed a systematic review and meta-analysis of the association between persistent HPV DNA and high-grade cervical intraepithelial neoplasia (CIN2-3), high-grade squamous intraepithelial lesions (HSIL), and invasive cervical cancer (together designated CIN2-3/HSIL+) to evaluate the robustness of HPV persistence for clinical use. MEDLINE and Current Contents were searched through January 30, 2006. Relative risks (RRs) were stratified by HPV comparison group. Of 2,035 abstracts, 41 studies were eligible for inclusion in the meta-analysis. Over 22,500 women were included in calculation of RRs for persistent HPV DNA detection and cervical neoplasia. RRs ranged from 1.3 (95% confidence interval: 1.1, 1.5) to 813.0 (95% confidence interval: 168.2, 3,229.2) for CIN2-3/HSIL+ versus <CIN2-3/HSIL+; 92% of RRs were above 3.0. Longer durations of infection (>12 months), wider testing intervals, CIN2-3/HSIL+, and use of an HPV-negative reference group were consistently associated with higher RRs. Thus, HPV persistence was consistently and strongly associated with CIN2-3/HSIL+, despite wide variation in definitions and study methods. The magnitude of association varied by duration of persistence and testing interval. Precise definition and standardization of HPV testing, sampling procedure, and test interval are needed for reliable clinical testing. These findings validate HPV persistence as a clinical marker and endpoint.

Human papillomavirus (HPV) infection and intraepithelial neoplasia and invasive cancer of the uterine cervix: a case-control study in Zaragoza, Spain

Introduction

The raw incidence of cancer of the uterine cervix is Spain is 7,8 per 100.000 inhabitants (adjusted incidence is 5.6). The incidence of this tumor is still low, but a steady increase has been seen, probably related to increasing risk factors.

Aim

To determine the frequency of infection by different types of human papillomavirus (HPV) in Papanicolau smears from women with and without cancer of the uterine cervix in Spain.

Patients and methods

A case-control study was performed in women with and without cervical cancer from Zaragoza, Spain. Pap smears from 600 cases (540 women with cervical intraepithelial neoplasms (CIN) and 60 with invasive cancer) and 1200 controls (women without those lesions) were tested by polymerase chain reaction (PCR) and typed by oligonucleotide microarray-based detection.

Results

HPV was detected in 93.3% of all samples with invasive cancer versus 17.5% of controls. OR for invasive cancer was 55 (95% CI 21.5–140,5). Statistically significant associations were also found for different grades of cervical dysplasia.

Conclusion

The strong association found between HPV infection, specifically types 16 and 18 and cancer of the uterine cervix in Zaragoza, Spain, stresses the importance of ongoing efforts to institute a vaccine program with recently approved HPV vaccines in order to prevent cervical cancer in this population.

From the NIH: proceedings of a workshop on the importance of self-obtained vaginal specimens for detection of sexually transmitted infections

On June 27, 2006, the NIH conducted a workshop to review published data and current field practices supporting the use of self-obtained vaginal swabs (SOVs) as specimens for diagnosis of sexually transmitted infections (STIs). The workshop also explored the design of studies that could support FDA clearance of SOVs for STI testing, particularly for specimens collected in nonclinical settings including patients' homes. This report summarizes the workshop findings and recommendations. Participants concluded that self-obtained vaginal swabs are well accepted by women of all ages and that SOVs perform as well as or better than other specimen types for Chlamydia trachomatis and Neisseria gonorrhoeae detection using transcription-mediated amplification. In addition, workshop participants recommended the validation of SOV testing by public health practitioners and manufacturers of STI diagnostic tests to expedite incorporation of SOVs as a diagnostic option in clinical and nonclinical settings for Chlamydia trachomatis and Neisseria gonorrhoeae testing. Similarly, SOVs should be explored for use in the diagnosis of other sexually transmitted pathogens.

[Integrating HPV testing for primary screening?]

Cervical cancer, the second most common cancer in young women in France, is still today imperfectly screened even with the advent of primary prevention for this cancer in the form of prophylactic HPV vaccination. Indeed, the cervical Pap smear and its cytologic analysis, both operator and reader dependent, have limited sensitivities requiring repeated samplings and above all, producing a high rate of falsely negative tests. Although most cancers occur in women who are either not or insufficiently screened, the problem with cervical smears is the fact that cancers are also often diagnosed in young women having follow-ups in accordance with professional guidelines. The absence of an organized screening in France results in an inadequate female population coverage. Nowadays, it is unanimously recognized that high-risk papillomaviruses (HR HPV) represent the only independent risk factor for cervical cancer and that there cannot be any disease without this virus. It is therefore this strong association between a viral agent and the cervical cancer which opened the door firstly, to the notion of prophylactic vaccination and secondly, to the integration of HR HPV testing in the screening for precancerous lesions. Molecular biological techniques based on the HR HPV genome detection within the female genital tract have shown a very high sensitivity without any inter and intraobserver variability and an excellent negative predictive value. Their integration in the primary screening for cervical cancer would improve the relevance of the latter and would suit the need for a wider population coverage and even for an organized screening thanks to the possibility for self-sampling. The specificity of these tests is inferior to that of the cervical smear, but the management of the falsely positive HPV tests has proved to be efficient by sorting residual cells obtained from liquid-based cytology. What is urgent in France is the need for an organized screening programme in order to improve population coverage and, this does not go against neither a vaccination promotion nor the integration of new technologies. Moreover, the last three randomized trials published in October 2007 have shown that it was quite safely possible to extend the time interval between two consecutive viral testing and thus improving the cost-effectiveness of cervical cancer screening. The aim of this work was to analyze publications on the subject in order to conclude, according to proof levels obtained by different studies, on its usefulness in the secondary prevention of cervical cancer.

Promoter hypermethylation of tumor suppressor genes in urine from patients with cervical neoplasia

We examined the feasibility of using detection of high-risk human papillomavirus (HPV) DNA in combination with the presence of aberrantly methylated genes (DAPK1, RARB, TWIST1, and CDH13) for urine-based cervical cancer screening. Urine samples from 129 Senegalese women, aged 35 years or older, 110 with (same day) biopsy-proven cervical neoplasia [cervical intraepithelial neoplasia grade 1 (CIN-1): n = 9; CIN-2-3/carcinoma in situ (CIS): n = 29; invasive cervical cancer (ICC): n = 72], and 19 without cervical neoplasia on biopsy were examined. Hypermethylation of at least one of the four genes identified 62% of ICC and 28% of CIN-2-3/CIS and was present in only 4% of CIN-1 or normal urines. High-risk HPV DNA was detected in urine in 70% of those with biopsy-proven ICC, 59% of those with CIN-2-3/CIS on biopsy, 44% of those with CIN-1 on biopsy, and only 11% of women negative for cervical neoplasia on biopsy. Urine-based detection of either high-risk HPV or hypermethylation of any of the four genes identified 84% of ICC, 64% of CIN-2-3/CIS, 44% of CIN-1, but only 19% of women negative for cervical neoplasia. The sensitivity for detection of CIN-2-3/CIS/ICC by high-risk HPV DNA or aberrant DNA methylation of four genes seems to be comparable to that of an exfoliated cervical cytology. This study shows the potential feasibility of using molecular markers detected in urine for cervical cancer screening.

Self-Collected Samples for Testing of Oncogenic Human Papillomavirus: A Systematic Review

BACKGROUND

To investigate the role of self-sampling for human papillomavirus (HPV) testing as an alternative to cervical cancer screening by clinicians (i.e., Papanicolaou [Pap] test).

METHODS

A systematic search of MEDLINE, EMBASE, Cochrane Library, and other sources for evidence related to the efficacy and feasibility of HPV DNA self-collection.

RESULTS

A total of 25 studies were identified. In 22 comparisons across 19 studies, the concordance between samples collected by patients and those obtained by clinicians was reasonably high in the majority of cases. Women in many countries across wide age ranges were successful in collecting samples for HPV DNA testing. In four studies, the quality of the cytology from patient samples was as good as clinician samples, with more than 95% of samples yielding HPV DNA results. The studies that examined acceptability found that women were generally very positive about collecting their own samples, although some concerns were noted. No study evaluated the effect of HPV DNA self-sampling on screening participation rates, early detection, survival, or quality of life.

CONCLUSIONS

Self-sampling for HPV DNA testing is a viable screening option, but there is insufficient evidence to conclude that self-sampling for HPV DNA testing is an alternative to the Pap test. Although HPV DNA testing using self-collected samples holds promise for use in under-resourced areas or for women who are reluctant to participate in Pap testing programs, the evidence supporting it is limited. Further definitive research is needed to provide a solid evidence base to inform the use of self-sampling for HPV DNA testing for the purpose of increasing screening rates, especially in women who are never or seldom screened.

Comparability of self-collected vaginal swabs and physician-collected cervical swabs for detection of human papillomavirus infections in Rakai, Uganda

OBJECTIVE

The objective of this study was to compare human papillomavirus (HPV) DNA testing between self-administered vaginal swabs and physician-administered cervical swabs in women from rural Rakai District, Uganda.

STUDY DESIGN

Between 2002 and 2003, women from a population-based cohort participated in an HPV study. Women collected self-administered vaginal swabs and were also offered a pelvic examination, which included physician-collected cervical samples.

METHODS

Hybrid-capture 2 was used to determine carcinogenic HPV status. Polymerase chain reaction was used to determine HPV genotypes. Unweighted kappa statistics were used to determine agreement.

RESULTS

Compliance with self-collected swabs was > or =86%; however, only 51% accepted a pelvic examination. Carcinogenic HPV prevalence was 19% in self-collected and 19% in physician-collected samples. Agreement among paired observations was 92% with a kappa of 0.75. Kappa between self- and physician-collected samples was similar in HIV strata (k = 0.71 and 0.75 for HIV-positive and HIV-negative, respectively).

DISCUSSION

In this community-based setting, detection of carcinogenic HPV was comparable among self- and physician-administered samples. Self-collection is a feasible and accurate means of obtaining HPV samples from women in resource-poor settings or persons reluctant to undergo a pelvic examination.

Concordance of self-collected and clinician-collected swab samples for detecting human papillomavirus DNA in women 18 to 32 years of age

OBJECTIVE

The objective of this study was to determine whether self- and clinician-collected samples are comparable for human papillomavirus (HPV) detection.

STUDY DESIGN

Three hundred seventy-four women aged 23 to 32 (population 1) and 211 women aged 18 to 25 (population 2) contributed self-collected vaginal and clinician-collected cervical and vulvovaginal samples for HPV DNA testing. Eighty-six women mailed in self-collected samples.

RESULTS

Agreement between self-collected vaginal and clinician-collected combined cervical/vulvovaginal samples was excellent (population 1:92.0%, kappa = 0.81; population 2: 96.4%, kappa = 0.88), but self-collected samples were more concordant with clinician-collected cervical samples in population 2 (kappa = 0.84) than population 1 (kappa = 0.65) (P = 0.01). Age-adjusted HPV prevalence was slightly lower in mailed-in (21.5%) than in-clinic self-collected samples (26.8%).

CONCLUSIONS

The combined clinician-collected cervical/vulvovaginal sample is most sensitive for detecting all female genital tract HPV infections. HPV concordance between cervical and vaginal samples may be better for newer infections. Larger studies are needed to determine whether mailed-in self-samples are as effective as those collected in a clinical setting.

Are self-collected samples comparable to physician-collected cervical specimens for human papillomavirus DNA testing? A systematic review and meta-analysis

OBJECTIVE

To compare the detection rate of genital human papillomavirus (HPV) infection in self- and physician-obtained samples.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

Studies published between 1966 and November 2005 identified through Medline and Embase that compared both sampling methods.

MAIN OUTCOME MEASURES

We calculated the concordance and kappa statistic between physician- and self-sampling and the difference between proportions of HPV positive samples. Weighted averages were reported with 95% confidence intervals (CI) using a random-effects model.

RESULTS

Eighteen studies (5441 participants) were included that evaluated broad HPV type categories, 10 (3688 patients) that of high-risk (HR) HPV and three (530) that of low-risk (LR) HPV. A high level of concordance of 0.87 (95%CI, 0.82 to 0.91) between self- and physician-sampling was obtained for detection of HPV DNA (kappa 0.66, 95%CI, 0.56 to 0.76). The prevalence difference of HPV DNA between sampling methods was -0.5 (95%CI, -2.8 to 1.8). Results were similar when restricting the analysis to HR-HPV but the prevalence of LR-HPV types was higher in self-collected samples.

CONCLUSION

Self-sampling was as sensitive as physician-obtained sampling to detect HR-HPV or HPV DNA. Self-sampling may be a suitable alternative method for studies on HPV transmission and vaccine trials.

Human papillomavirus testing on self-sampled cervicovaginal brushes: An effective alternative to protect nonresponders in cervical screening programs

Women not attending cervical screening programs are at increased risk of cervical cancer. We investigated in these nonresponders to what extent offering self-sampling devices for cervicovaginal brushes for high-risk human papillomavirus (hrHPV) testing would induce participation and, if so, what the yield of precursor (i.e. CIN2 or worse) lesions following self-sampling would be. In addition, we assessed screening history of participants and costs per detected high-grade CIN2 or worse ("CIN2+") lesion in comparison to the regular program in the Netherlands. Nonresponders received a device for hrHPV testing (self-sampling group, n=2,546) or an extra recall for conventional cytology (control group, n=284). The percentage of self-sampling responders were compared with responders in the recall group. hrHPV positive self-sampling responders were invited for cytology and colposcopy. CIN2+ yield and costs per detected CIN2+ were evaluated. Active response was higher in the self-sampling than in the control group (34.2 vs. 17.6%; p<0.001). hrHPV positive self-sampling responders were less likely to have a prior screening history than screening participants (p<0.001), indicating that they are regular nonresponders. hrHPV prevalence was similar (8.0 vs. 6.8%; p=0.11), but CIN2+ yield was higher in self-sampling responders compared to screening participants (1.67 vs. 0.97%; OR=2.93, 95% CI 1.48-5.80; p=0.0013). Costs per CIN2+ lesion detected via self-sampling were in the same range as those calculated for conventional cytological screening (euro 8,836 vs. euro 7,599). Offering self-sampling for hrHPV testing in nonresponders is an attractive adjunct to effectively increase population coverage of screening without the adverse effect of markedly increased costs per detected CIN2+ lesion.

Evaluation of HPV 16 PCR detection in self- compared with clinician-collected samples in women referred for colposcopy

OBJECTIVES

A clinical prospective evaluation study was conducted to evaluate PCR detection of high-risk human papillomavirus (HPV) type 16 in self-sampled vaginal compared with clinician-collected cervical specimens.

METHODS

Paired vaginal and cervical specimens were collected from 137 consecutive women referred for colposcopy because of abnormal cervical cytology. In-house and a commercial PCR method for HPV type 16 were used. Self-sampled vaginal HPV 16 detection was compared to histology and physician-collected cervical specimens.

RESULTS

Of the 137 patients, 98 had proven abnormal histology and were included in the analysis. Overall, using the cervix HPV detection as reference method, the self-sampled vaginal sample showed sensitivity 91.8%, specificity 96.1% and agreement kappa (kappa) 0.881. Using the histology as reference, all 11 cervical cancer cases were HPV-16-positive in both cervical and vaginal samples, and in 43 high-grade lesions, detection sensitivity in cervix was 72.1% (kappa 0.588) and vagina 67.4% (kappa 0.516). HPV 16 detection did not differ (P=0.27) between clinician-collected cervical and self-sampled vaginal specimens.

CONCLUSIONS

The self-collected vaginal sample is highly concordant with the physician-collected cervical sample in HPV 16 detection.

High concordance of results of testing for human papillomavirus in cervicovaginal samples collected by two methods, with comparison of a novel self-sampling device to a conventional endocervical brush

A user-friendly self-sampling method for collecting representative cervical cell material would lower the threshold for women to respond to the invitation for cervical screening. In the present article, we introduce such a device; we have evaluated its sensitivity and specificity to detect high-grade cervical intraepithelial neoplasia (CIN), via high-risk human papillomavirus (hrHPV) detection and liquid-based cytology (LBC), compared to endocervical brush samples obtained by gynecologists. Women who had a cervical smear reading of moderate dyskaryosis or worse or a repeat equivocal Pap smear result in the cervical screening program (n=64) and healthy volunteers (n=32) took a self-obtained sample at home prior to their visit to the gynecological outpatient department. At the outpatient department, an endocervical brush smear was taken, followed by colposcopy and biopsy whenever applicable. Both self-obtained samples and endocervical brush samples were immediately collected in Surepath preservation solution and used for LBC and hrHPV testing (by general primer-mediated GP5+/6+PCR). hrHPV test results showed a good concordance between the two sample types (87%; kappa=0.71), with sensitivities for prevalent high-grade CIN that did not differ significantly (92% and 95%; P=1.0). The hrHPV test on self-obtained samples proved to be at least as sensitive for high-grade CIN as cytology on endocervical brush samples (34/37 versus 31/37; P=0.5). LBC showed a poor concordance between self-obtained and endocervical brush samples (60%; kappa=0.27). In conclusion, self-obtained samples taken by this novel device are highly representative of the hrHPV status of the cervix. In combination with hrHPV testing, the use of this device may have implications for increasing the attendance rate for cervical screening programs.

Bead-based multiplex genotyping of human papillomaviruses

Typing of human papillomaviruses (HPV) by DNA hybridization procedures, such as reverse line blot (RLB) assay, is sensitive and well validated. However, the application of these assays to high-throughput analyses is limited. Here, we describe the development of multiplex human papillomavirus genotyping (MPG), a quantitative and sensitive high-throughput procedure for the identification of multiple high- and low-risk genital HPV genotypes in a single reaction. MPG is based on the amplification of HPV DNA by a general primer PCR (GP5+/6+) and the subsequent detection of the products with type-specific oligonucleotide probes coupled to fluorescence-labeled polystyrene beads (Luminex suspension array technology). Up to 100 different HPV types can be detected simultaneously with MPG, and the method is fast and labor saving. We detected all 22 HPV types examined with high specificity and reproducibility (the median interplate coefficient of variation was below 10%). Detection limits for the different HPV types varied between 100 and 800 pg of PCR products. We compared the performance of MPG to an established RLB assay on GP5+/6+-PCR products derived from 94 clinical samples. The evaluation showed an excellent agreement (kappa = 0.922) but also indicated a higher sensitivity of MPG. In conclusion, MPG appears to be highly suitable for large-scale epidemiological studies and vaccination trials as well as for routine diagnostic purposes.

Good correlation of HPV DNA test between self-collected vaginal and clinician-collected cervical samples by the oligonucleotide microarray

OBJECTIVES

To evaluate the efficacy of self-collected vaginal samples for high-risk HPV detection by the HPV oligonucleotide microarray method (HPVDNAChip).

METHODS

One hundred and eighteen patients with abnormal Pap smears were included. Self-collected vaginal and clinician-collected cervical samples for HPV testing were obtained. The result of the HPV DNA test was compared with the histopathological diagnosis or colposcopic finding.

RESULTS

Of the 118 patients, 42 (35.6%) had >or= cervical intraepithelial neoplasia (CIN) III lesions. Using the HPVDNAChip, high-risk types of HPV were detected in 38 of these 42 patients (90.5%) with the self-collected vaginal samples and in 37 of 42 (88.1%) with the clinician-collected cervical samples. The agreement of HPVDNAchip results between self- and clinician-collected samples was very good (kappa = 0.81) with a 93.2% concordance rate. Multiple HPV infections were found in 17 of 88 (19.3%) HPV-positive clinician-collected cervical samples. The rate of multiple HPV infection tended to decrease as the degree of pathologic classification increased.

CONCLUSION

Using the HPVDNAchip to assay for HPV infection, results from self-collected vaginal samples were compatible with those from clinician-collected cervical samples.