Mailed self-sample HPV testing kits to improve cervical cancer screening in a safety net health system: protocol for a hybrid effectiveness-implementation randomized controlled trial

BACKGROUND

Almost 20% of U.S. women remain at risk for cervical cancer due to their inability or unwillingness to participate in periodic clinic-based screening. Self-sampling has been shown to be an effective strategy for screening women for high-risk human papillomavirus (HR-HPV) infection in specific contexts. However, its effectiveness among medically underserved women in safety net health systems has not been evaluated. Furthermore, it is also unclear whether implementation strategies such as patient navigation can be used to improve the success of self-sample screening programs by addressing patient-level barriers to participation.

METHODS/DESIGN

The Prospective Evaluation of Self-Testing to Increase Screening (PRESTIS) trial is a hybrid type 2 effectiveness-implementation pragmatic randomized controlled trial of mailed self-sample HPV testing. The aim is to assess the effectiveness of mailed self-sample HPV testing kits to improve cervical cancer screening participation among patients in a safety net health system who are overdue for clinic-based screening, while simultaneously assessing patient navigation as an implementation strategy. Its setting is a large, urban safety net health system that serves a predominantly racial/ethnic minority patient population. The trial targets recruitment of 2268 participants randomized to telephone recall (enhanced usual care, n = 756), telephone recall with mailed self-sample HPV testing kit (intervention, n = 756), or telephone recall with mailed self-sample HPV testing kit and patient navigation (intervention + implementation strategy, n = 756). The primary effectiveness outcome is completion of primary screening, defined as completion and return of mailed self-sample kit or completion of a clinic-based Pap test. Secondary effectiveness outcomes are predictors of screening and attendance for clinical follow-up among women with a positive screening test. Implementation outcomes are reach, acceptability, fidelity, adaptations, and cost-effectiveness.

DISCUSSION

Hybrid designs are needed to evaluate the clinical effectiveness of self-sample HPV testing in specific populations and settings, while incorporating and evaluating methods to optimize its real-world implementation. The current manuscript describes the rationale and design of a hybrid type 2 trial of self-sample HPV testing in a safety net health system. Trial findings are expected to provide meaningful data to inform screening strategies to ultimately realize the global goal of eliminating cervical cancer.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03898167 . Registered on 01 April 2019.

TRIAL STATUS

Study start data: February 13, 2020. Recruitment status: Enrolling by invitation. Estimated primary completion date: February 15, 2023. Estimated study completion date: May 31, 2024. Protocol version 1.6 (February 25, 2020).

Negative Roche cobas HPV testing in cases of biopsy-proven invasive cervical carcinoma, compared with Hybrid Capture 2 and liquid-based cytology

INTRODUCTION

The objective of this study was to conduct a retrospective analysis of results of cytology and Roche cobas (RC) and Hybrid Capture 2 (HC2) human papillomavirus (HPV) screening tests in cases of biopsy-proven invasive cervical carcinoma.

MATERIALS AND METHODS

The clinical data were obtained at a university hospital in New York, NY, between 2004 and 2017. Results of cytology, reported per Bethesda classification system, and HPV screening in 177 identified cases with cytology and biopsy-proven diagnosis of cervical carcinoma were included in the analysis.

RESULTS

Two cohorts were analyzed. Of the 177 identified cases, cotesting was performed for 100 patients. Among these 100, cotesting screening results would not trigger immediate colposcopy in 6%; HPV screening results were reported as negative in 16% (16% of all RC, 16% of all HC2, 16% total) and, if HPV was the only screening modality, would not trigger a colposcopy. Of the 177 total cases, 128 patients underwent cytology screening prior to biopsy, with a cytology diagnosis that, alone, would not trigger immediate colposcopy in 14%.

CONCLUSIONS

The HPV DNA screening and cytology screening alone were negative for 16% and 14%, respectively, of patients with biopsy-proven diagnoses of invasive carcinoma of cervical origin, without a significant difference in failure rates between cytology, HC2, and RC. The cotesting approach had a significantly lower failure rate (6%) compared with the 2 other screening modalities alone.

An on-going study of three different cervical cancer screening strategies based on primary healthcare facilities in Beijing China

BACKGROUND

To evaluate and compare the results of three different cervical cancer screening strategies including cytology screening, HR-HPV screening which taking HR-HPV testing as primary test and co-testing which taking both tests at the same time, then provide evidence to explore whether the cervical cancer screening can be conducted in community healthcare centers in Beijing.

METHODS

182,119 women aged between 35 and 64, who were screened in the primary healthcare facilities of nine districts in Beijing from January 2014 to March 2015, were enrolled in this study. Cytology screening was performed in participants during January 2014 and December 2014 as a conventional arm. HR-HPV screening strategy and co-testing were randomly allocated to participants on districts level as experimental arm 1 and 2 during January 2015 and March 2015. Cervical Intraepithelial Neoplasia grade 2 or worse (CIN 2+) was defined as endpoint. The screening results and costs to detect a case of three strategies were calculated.

RESULTS

The positivity rate, colposcopy referral rate and biopsy referral rate of co-testing were 8.46%, 6.36% and 4.65% respectively, which were all significantly higher than the other two screening strategies. The detection rate of CIN 2+ by co-testing was 5.06‰ and was much more than the other two screening strategies, while the HR-HPV screening had the highest PPV of 14.40%. The HR-HPV screening ignores some lesion which can be found by co-testing. Co-testing refers a woman to colposcopy with a positive screening result at the least cost, but it costs the most to detect a CIN 2+ case.

CONCLUSIONS

To detect more cases of CIN 2+, co-testing performs better although with the most cost. And the primary healthcare facilities in Beijing have the capability to carry out the cervical cancer screen programs and prompts women with positive screen results to the hospital.

Previous Papanicolaou and Hybrid Capture 2 human papillomavirus testing results of 5699 women with histologically diagnosed cervical intraepithelial neoplasia 2/3

INTRODUCTION

Cervical cancer remains an important public health problem in Chinese women owing to the lack of a national screening program. The aim of the present study was to evaluate human papillomavirus (HPV) and Papanicolaou (Pap) test results preceding the histologic diagnosis of cervical intraepithelial neoplasia 2/3 (CIN2/3) in China's largest College of American Pathologists-certified clinical laboratory.

MATERIALS AND METHODS

All cases of CIN2/3 histologically diagnosed from January 2011 to August 2016 were retrieved from the pathology department records. The Pap cytology and HPV test results from the 6 months before the CIN2/3 diagnoses were analyzed.

RESULTS

A total of 5699 patients with histologically diagnosed CIN2/3 had previous Pap and/or HPV Hybrid Capture 2 testing results within the previous 6 months. The average age was 39.5 years (range, 16-82 years). Of these patients, 4288 had Pap test findings (average, 1.5 months) available. The results were high-grade squamous intraepithelial lesion in 44.1%, low-grade squamous intraepithelial lesion in 20.0%, atypical squamous cells, cannot exclude high-grade squamous intraepithelial lesion, in 16.0%, atypical squamous cells of undetermined significance, in 12.3%, atypical glandular cells in 0.7%, and negative in 6.9%. Of the 5699 patients, 2546 had HPV Hybrid Capture 2 test results (average, 1.4 months) available. Of these, 91.7% had positive results and 8.3% had negative results. Of 1135 patients with both previous Pap and HPV results, 7.1% had negative HPV results and 8.0% had negative Pap results (P = 0.38). Only 21 patients (1.9%) had double negative results.

CONCLUSIONS

The present study has reported the previous results of HPV testing and Pap cytology for patients with high-grade cervical squamous precursor lesions in a population of women in China who had not undergone intensive previous screening. Both high-risk HPV and Pap cytology had similar negative testing rates for these women, although double negative results were less common. These results support the value of combined testing in the detection of cervical cancer precursors.

Systematic Comparison of Different Meta-analyses, Systematic Reviews and HTA Reports on Cervical Cancer Screening based on Cytology or HPV Test

Introduction: Cervical cancer screening programs all over the world are being radically revised; preventive screening is increasingly based on detecting infection with human papillomavirus (HPV). This change was driven by large international studies (comparing cytological and HPV-based screening), which were then summarized in systematic reviews or HTA reports. We carried out a systematic comparison of these meta-analyses, comparing their contents, quality, results and recommendations. Material and Methods: A systematic search in MEDLINE identified eight meta-analyses. Seven more papers were also included in our analysis. The quality of these publications was reviewed using the AMSTAR criteria and presented in tabular form. Results: There were significant differences with regard to the primary studies included in the meta-analyses, the quality of the meta-analyses, the endpoints, and the outcomes and recommendations based on these endpoints. Conclusion: Different meta-analyses on the same or similar issues sometimes came to quite different conclusions because they used different approaches. This is quite significant because the underlying primary data did not change. The data indicated that HPV-based screening was superior. The heterogeneity of the meta-analyses affects the decisions taken by policymakers in the healthcare system.

The sensitivity of Pap cytology and HPV testing to detect incident cervical cancer: prior testing results in 178 patients with invasive cervical cancer at a large general hospital in China

INTRODUCTION

Prior screening results in women diagnosed with cervical carcinoma are only reported in the literature in small numbers. We wish to examine a larger number of prior testing results in women with cervical carcinoma from China to better understand the strengths and weaknesses of Pap (Papanicolaou) cytology and human papillomavirus (HPV) testing.

MATERIALS AND METHODS

In our study, 178 patients with histologically diagnosed cervical carcinoma and Pap cytology and/or HPV testing in the year prior to diagnosis were retrospectively studied. Pap cytology was performed using liquid-based preparations and HPV testing was done with mostly Hybrid Capture 2 but also included other methods.

RESULTS

In our study, 82.0% of women were symptomatic at presentation with vaginal bleeding or abnormal vaginal discharge. HPV testing was negative in 9.8% of women in the short period before diagnosis of cervical cancer and Pap cytology had a higher rate of false negative results at 16.7%. Adenocarcinoma showed a higher negative testing rate than squamous cell carcinoma did with both cytology and HPV testing. Only 1 of 78 patients (1.3%) having both tests showed a double negative result. Negative high-risk HPV testing was noted in 2 of 9 squamous cell carcinoma patients with routine gynecological examination.

CONCLUSIONS

Both Pap cytology and HPV testing have higher rates of prior negative results in women with cervical carcinoma. When testing is performed using both methods, the greatest number of cervical carcinomas can be detected. These results should also be considered when making screening recommendations with the understanding that HPV testing alone will miss at least a proportion of women with incident cervical carcinoma.

Increased cervical cancer risk associated with extended screening intervals after negative human papillomavirus test results: Bayesian risk estimates using the Pittsburgh Cervical Cancer Screening Model

INTRODUCTION

Questions have recently been raised about the acceptability of increased cervical cancer risk projected with the new guideline-recommended rescreening interval of 5 years after negative cytology and human papillomavirus (HPV) cotest results. Additional data sources capable of evaluating cervical cancer risk over time are being sought. We employed the continuously updated Bayesian Pittsburgh Cervical Cancer Screening Model (PCCSM) to estimate invasive cancer risks for patients screened at extended screening intervals after negative HPV test results.

MATERIALS AND METHODS

The analyzed database included cervical screening data collected over 10 years (2005-2014) at Magee Womens Hospital with 976,624 liquid-based cytology (LBC) results, 285,351 companion high-risk US Food and Drug Administration-approved HPV test results from LBC vials, and 112,435 follow-up histopathologic results from surgical procedures with cervical tissue sampling. Histopathologic cervical cancer risk estimates for patients with prior double negative results with cervical LBC and from-the-vial HPV cotesting were computed using the PCCSM for women rescreened at intervals ranging from 1 to 9 years. Similar risks were computed for women with any negative HPV test result, not considering cytology results.

RESULTS

Histopathologic invasive cervical cancer risk computed following LBC and HPV cotesting double negative results progressively increased with rescreening intervals of 1 to 9 years. Cervical cancer risks computed following any HPV-negative result, not considering cytology results, were consistently even higher at each comparable extended rescreening interval.

CONCLUSIONS

The PCCSM is a new data source that allows evaluation of cervical cancer risk over time. Cervical cancer risk is minimized with more frequent cytology and HPV cotesting.

Comparison of the Roche cobas® 4800 and Digene Hybrid Capture® 2 HPV tests for primary cervical cancer screening in the HPV FOCAL trial

BACKGROUND

HPV FOCAL is a randomized trial (ISRCTN79347302, registered 20 Apr 2007) comparing high-risk (hr) HPV testing vs. liquid-based cytology (LBC) for cervical cancer screening of women aged 25-65. We compared the Digene Hybrid Capture® 2 High-Risk HPV DNA Test® (HC2) and the Roche cobas® 4800 HPV Test (COBAS) for primary screening.

METHODS

Women (n=6,172) were screened at baseline by HC2 and COBAS and by LBC 24 months later. We assessed HPV genotyping and reflex LBC for colposcopy triage of baseline HPV positive women.

RESULTS

Overall HC2/COBAS agreement was 96.1% (kappa 0.75) and positive agreement was 77.5%. Baseline CIN2 and CIN3+ rates based on HPV screening were 8.6/1,000 and 6.6/1,000 respectively; 24 month rates were 0.7/1,000 and 0.4/1,000 (LBC screening). HC2 and COBAS were concordant positive for 91% of round 1 CIN2 and 98% of CIN3+. CIN3+ was significantly associated with HPV 16 (Odds Ratio [OR] 5.11; 95% confidence interval [CI] 2.30, 11.37), but not HPV 18 (OR 2.62; 95% CI 0.73, 9.49), vs. non-HPV 16/18 HPV at baseline. There was no significant association between HPV genotype and CIN2. CIN3+ was significantly more likely for high-grade (OR 5.99; 95% CI 2.53, 14.18), but not low-grade (OR 0.54; 95% CI 0.20, 1.49), vs. negative LBC. No significant association was observed between LBC grade and CIN2. HPV 16 and 18 were associated with 33% of CIN2 and 68% of CIN3+ identified at baseline.

CONCLUSIONS

For hrHPV positive women, abnormal reflex LBC is appropriate for colposcopy triage. In addition, immediate referral of women with HPV 16/18 and normal cytology may allow for earlier detection of CIN2+ lesions which would not be detected until after follow-up testing.

Point-Counterpoint: Cervical Cancer Screening Should Be Done by Primary Human Papillomavirus Testing with Genotyping and Reflex Cytology for Women over the Age of 25 Years

Screening for cervical cancer with cytology testing has been very effective in reducing cervical cancer in the United States. For decades, the approach was an annual Pap test. In 2000, the Hybrid Capture 2 human papillomavirus (HPV) test was approved by the U.S. Food and Drug Administration (FDA) for screening women who have atypical squamous cells of underdetermined significance (ASCUS) detected by Pap test to determine the need for colposcopy. In 2003, the FDA approved expanding the use of the test to include screening performed in conjunction with a Pap test for women over the age of 30 years, referred to as "cotesting." Cotesting allows women to extend the testing interval to 3 years if both tests have negative results. In April of 2014, the FDA approved the use of an HPV test (the cobas HPV test) for primary cervical cancer screening for women over the age of 25 years, without the need for a concomitant Pap test. The approval recommended either colposcopy or a Pap test for patients with specific high-risk HPV types detected by the HPV test. This was based on the results of the ATHENA trial, which included more than 40,000 women. Reaction to this decision has been mixed. Supporters point to the fact that the primary-screening algorithm found more disease (cervical intraepithelial neoplasia 3 or worse [CIN3+]) and also found it earlier than did cytology or cotesting. Moreover, the positive predictive value and positive-likelihood ratio of the primary-screening algorithm were higher than those of cytology. Opponents of the decision prefer cotesting, as this approach detects more disease than the HPV test alone. In addition, the performance of this new algorithm has not been assessed in routine clinical use. Professional organizations will need to develop guidelines that incorporate this testing algorithm. In this Point-Counterpoint, Dr. Stoler explains why he favors the primary-screening algorithm, while Drs. Austin and Zhao explain why they prefer the cotesting approach to screening for cervical cancer.

Comparison of cervical cancer screening results among 256,648 women in multiple clinical practices

BACKGROUND

In the United States, human papillomavirus (HPV) and Papanicolaou (Pap) testing (cotesting) for cervical screening in women ages 30 to 65 years is the preferred strategy, and cytology alone is acceptable. Recently, a proprietary automated test for identifying high-risk HPV types for primary cervical screening was approved by the US Food and Drug Administration. The objective of the current study was to document extensive cervical screening among these screening options.

METHODS

To investigate the sensitivity of various testing options for biopsy-proven cervical intraepithelial neoplasia grade 3 or worse (≥CIN3) and cancer, the authors reviewed 256,648 deidentified results from women ages 30 to 65 years at the time of cotest who had a cervical biopsy specimen obtained within 1 year of the cotest.

RESULTS

A positive cotest result was more sensitive (98.8%; 4040 of 4090 cotests) for diagnosing ≥CIN3 than either a positive HPV-only test (94%; 3845 of 4090 HPV-only tests) or a positive Pap-only test (91.3%; 3734 of 4090 Pap-only tests; P <. 0001). A positive Pap-only result was more specific (26.3%; 66,145 of 251,715 Pap-only tests) for diagnosing ≥CIN3 than a positive HPV-only test (25.6%; 64,625 of 252,556 HPV-only tests) or a positive cotest (10.9%; 27,578 of 252,558 cotests; P <. 0001). Of 526 cervical cancers, 98 (18.6%) were HPV-only negative, 64 (12.2%) were Pap-only negative, and 29 (5.5%) were cotest negative.

CONCLUSIONS

Compared with HPV-only testing, cotesting was more sensitive for the detection of ≥CIN3 in women ages 30 to 65 years. The current data suggest that approximately 19% of women with cervical cancer may be misdiagnosed by an HPV-only cervical screen. It is important to consider these data as the guidelines for cervical cancer screening undergo revision. Cancer (Cancer Cytopathol) 2015;123:282–8. © 2015 The Authors. Cancer Cytopathology published by Wiley Periodicals, Inc. on behalf of American Cancer Society. This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License, which permits use and distribution in any medium, provided the original work is properly cited, the use is non-commercial and no modifications or adaptations are made.