Human papillomavirus testing in primary cervical screening and abnormal Papanicolaou management

Evaluation of High-Risk Human Papillomavirus Testing in Women with Atypical Squamous Cells of Undetermined Significance to Detect Cervical Intraepithelial Neoplasia

Introduction We retrospectively examined the changes in the management and outcomes of the cases with atypical squamous cells of undetermined significance (ASC-US) according to the Bethesda system (TBS).

Materials and Methods Between May 2009 and December 2018, 432 cases with ASC-US were retrospectively examined for the implementation of high-risk human papillomavirus (hrHPV) testing and/or cervical biopsy and clinical courses.

Results The hrHPV testing was performed in 277 cases (64.1%). Of these, there were 80 with positive hrHPV (28.9%). Of the 80 cases, cervical biopsy was performed in 71 (88.9%) cases based on the finding of colposcopy. Cervical intraepithelial neoplasia (CIN) was diagnosed in 55 cases (77.4%). The sensitivity, specificity, positive predictive value, and negative predictive value of CIN diagnosis by hrHPV testing in cases of ASC-US were 72.5, 95.0, 88.7, and 86.3%, respectively (p < 0.01).

Conclusion The conducting of hrHPV test on women who were evaluated as ASC-US according to TBS affirmed its clinical usefulness.

Current status of cervical cytology during pregnancy in Japan

In Japan, uterine cancer screening during pregnancy is subsidized by public funds. We examined the current status of the results of cervical cytology conducted during pregnancy in Japan. We requested 2,293 obstetrical facilities to provide information on cervical cytology in pregnant women who delivered between October 2018 and March 2019. A total of 1,292 obstetrical facilities responded, with valid information on a total of 238,743 women. The implementation rate of cervical cytology during pregnancy was 86.8% in Japan. The prevalence of abnormal cervical cytology during pregnancy was 3.3% in total and 4.9% using a spatula/brush with liquid-based cytology (LBC). The prevalence of positive high-risk human papillomavirus (HPV) in teenagers with atypical squamous cells of undetermined significance (ASC-US) was significantly higher than women of other ages (p < 0.01). Because HPV vaccine coverage has dropped to less than 1% in Japan, a further study with various conditions will be needed to improve the accuracy of cervical cancer screening during pregnancy.

High-risk human papilloma virus management in pregnancy with cervical intraepithelial neoplasia during pregnancy and postpartum in China

AIM

To investigate the relationship between cervical intraepithelial neoplasia (CIN) and high-risk human papilloma virus (HR-HPV) during pregnancy and postpartum in China.

METHODS

In this prospective case-control study, 168 pregnant women with CIN and cervicitis were diagnosed by colposcopic cervical biopsy. All the cases underwent hybrid capture assay version II (HCII) to detect HR-HPV DNA load amounts and the tests were completed in 3-6 months after childbirth.

RESULTS

During pregnancy: as the CIN grade increased, the HR-HPV infection rates increased (P = 0.002), but HR-HPV DNA load amounts (in logarithms) did not change obviously (P = 0.719). 3-6 months postpartum: as the CIN grade increased, the natural negative rate of HR-HPV decreased (P = 0.000), while the amount of HR-HPV DNA (in logarithms) increased (P = 0.036); especially the amount of HR-HPV DNA in pregnant women with CINIII was significantly higher than that of other grades. During pregnancy and 3-6 months postpartum : the amount of HR-HPV DNA (in logarithms) during pregnancy was higher than that of 3-6 months postpartum with the same grade of CIN.

CONCLUSION

The findings emphasize the importance of undergoing the HCII test 3-6 months postpartum. It should be noted that HR-HPV may turn negative in pregnancy with CINIII 3-6 months after childbirth. Further treatments of pregnancy with CIN should be considered according to the CIN grade diagnosed by cervical biopsy via colposcopy 3-6 months after birth, but not according to the persistence of HR-HPV during pregnancy.

HPV genotypes in paraffin sections of non-cervical squamous cell carcinoma in Qingdao of China

Human papillomaviruses (HPVs) are the cause of cervical cancer and possibly a subset of squamous cell carcinomas (SCCs) in other sites. However, the prevalence and distribution of HPV subtypes remain unclear. In the present study, we collected and analyzed 511 paraffin sections of non-cervical SCC from patients in Qingdao, China, for the presence of HPV using polymerase chain reaction (PCR). We identified that 55.77% (285/511) of the samples were positive for HPV infection. There was a significant association between HPV type and the different sites of SCC. An association between HPV-positive cases and tobacco, alcohol, age and tumor differentiation was demonstrated. The information provided by this study may be important for further investigation into the association between HPV and SCC. High-risk HPV subtypes were associated with the malignant degree of SCC. This study provided a theoretical basis for the preventative treatment of non-cervical SCC using HPV vaccines.

Cancer risk models and preselection for screening

OBJECTIVE

The invitation to population screening is based on age criteria in many countries. Screening is not offered to younger or older participants, because the benefits in these age groups do not outweigh the harms. One could argue that it is not so much age that determines the benefits but the risk of developing preclinical and treatable cancer. Cancer risk varies with age but is also affected by other factors.

METHODS

We performed a systematic review for risk models for the three types of cancer for which population screening programs exist: breast, cervical and colon cancer. We used an evaluation scheme that distinguishes three phases of model development: model derivation, validation and impact analysis. Data were collected in August 2010.

RESULTS

We identified two colorectal, four breast and three cervix cancer risk models. One colorectal, four breast and none of the cervix cancer models have been externally validated. We could not identify evaluations of the impact on population screening effectiveness.

CONCLUSION

We conclude that risk models for the pre-selection of screening have been developed. These models could improve the pre-selection for screening, help in making personal decisions about participation, and reduce adverse effects of population screening. The validity of this hypothesis, as well as practicalities and issues of equity and reliability, have to be tested in further studies.

Human papillomavirus and Papanicolaou tests screening interval recommendations in the United States

OBJECTIVE

Guidelines recommend when the human papillomavirus (HPV) and Papanicolaou tests are used together (HPV co-test) for routine cervical cancer screening, screening intervals can be extended to 3 years. We assessed HPV test practices and Papanicolaou test screening interval recommendations of US providers.

STUDY DESIGN

Using a multistage probability design, we analyzed nationally representative data that were collected in 2006 through the Centers for Disease Control and Prevention's National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey.

RESULTS

Approximately 51% of providers ordered the HPV co-test; however, clinical vignettes found that <15% of providers who ordered the HPV test recommend the next Papanicolaou test in 3 years for women with concurrent normal HPV co-test results and a documented normal screening history.

CONCLUSION

Overall, annual cervical cancer screening continues to be a common recommendation, regardless of whether a screening history has been established or an HPV test has been ordered.

Cancer screening practices among physicians in the national breast and cervical cancer early detection program

BACKGROUND

The National Breast and Cervical Cancer Early Detection Program (NBCCEDP) provides low-income, uninsured women with screening and diagnostic services for breast and cervical cancer. Our study was conducted to describe the demographic and practice characteristics of participating and nonparticipating physicians, as well as their beliefs, adoption of new screening technologies, and recommendations for breast and cervical cancer screening.

METHODS

From a 2006-2007 nationally representative survey, we identified 1,111 practicing primary care physicians who provide breast and cervical cancer screenings and assessed their recommendations using clinical vignettes related to screening initiation, frequency, and cessation. Responses of physicians participating in the NBCCEDP were compared with those from nonparticipating physicians.

RESULTS

Of the physicians surveyed, 15% reported participation in the NBCCEDP, 65% were not participants, and 20% were not sure or did not respond to this question. Program physicians were significantly more likely to practice in multispecialty settings, in a rural location, and in a hospital or clinic setting and had more patients who were female and insured by Medicaid or uninsured compared with nonprogram physicians. Beliefs about the effectiveness of screening tools or procedures in reducing breast or cervical cancer mortality were similar by program participation. Adoption of new technologies, including digital mammography and human papillomavirus (HPV) testing, and making guideline-consistent recommendations for screening initiation, frequency, and cessation did not differ significantly by program participation.

CONCLUSIONS

Although there may be differences in physician characteristics and practice settings, the beliefs and screening practices for both breast and cervical cancer are similar between program and nonprogram providers.

Asia oceania guidelines for the implementation of programs for cervical cancer prevention and control

This paper aims to provide evidence-based recommendations for health professionals, to develop a comprehensive cervical cancer program for a clinic, a community, or a country. Ensuring access to healthcare is the responsibility of all societies, and the Asia Oceania Research Organisation in Genital Infections and Neoplasia (AOGIN) is committed to working collaboratively with governments and health professionals to facilitate prevention programs, to protect girls and women from cervical cancer, a disease that globally affects 500,000 and kills nearly 300,000 women annually, just over half of whom are in the Asia Oceania region. We share the vision that a comprehensive program of vaccination, screening, and treatment should be made accessible to all girls and women in the world. The primary purpose of these guidelines is to provide information on scientific evidence on the different modalities and approaches of cervical cancer prevention programs, for high resource and low resource settings. The secondary purpose is to provide an overview of the current situation of cervical cancer control and prevention in various Asian Oceania countries: their views of an ideal program, identified obstacles, and suggestions to overcome them are discussed.

p16(INK4a) is superior to high-risk human papillomavirus testing in cervical cytology for the prediction of underlying high-grade dysplasia

BACKGROUND

The primary goal of this study was to compare the clinical performance of an optimized and rigorously controlled immunocytochemical (ICC) assay for p16(INK4a) to high-risk (HR) human papillomavirus (HPV) detection by polymerase chain reaction (PCR) as diagnostic adjuncts for cytology specimens from colposcopy patients.

METHODS

: The study included 403 cervical cytology specimens collected within 3 months of colposcopy. The colposcopic impression and cervical biopsy diagnosis served as the standards for correlation with cytological, p16(INK4a), and HPV data. p16(INK4a) was evaluated using an immunoperoxidase-based assay that was linear over 4 logs for the detection of HeLa-spiked positive control cytology specimens, using a threshold for positive test results that was based on receiver operating characteristic curve analysis. HR-HPV was detected by multiplex PCR using genotype-specific primers.

RESULTS

: In all combined diagnostic categories (negative for intraepithelial lesion and malignancy, atypical glandular cells, atypical squamous cells of undetermined significance, atypical squamous cells cannot exclude high-grade squamous intraepithelial lesion, low-grade squamous intraepithelial lesion, and high-grade squamous intraepithelial lesion), the p16(INK4a) ICC and HR-HPV assays, respectively, had sensitivity of 81.7% and 83.3% (P = .81) and specificity of 78.1% and 50.9% (P < .001) for the detection of underlying > or =grade 2 cervical intraepithelial neoplasia (CIN) lesions on biopsy. Furthermore, the positive predictive value of p16(INK4a) ICC was greater than that of HR-HPV for patients with biopsies > or =CIN-2 (41.2% and 24.2%, respectively, P = .001).

CONCLUSIONS

: This p16(INK4a) immunocytochemical assay has superior specificity but similar sensitivity to HR-HPV testing to predict underlying high-grade dysplastic lesions in patients who are referred for colposcopy. The determination of the overall performance characteristics of p16(INK4a) immunocytochemistry, as an independent test or in combination with HPV testing in low-risk screening populations, however, will require subsequent large-scale prospective clinical trials.

Cervical cytology in vulnerable pregnant women

PURPOSE

To identify the prevalence of abnormal Papanicolau (Pap) smears in pregnancy in a vulnerable urban family practice, determine the percentage of abnormal Pap smears that persist into the postpartum period, and identify associated risk factors.

DATA SOURCES

A retrospective chart review of all prenatal patients (N = 192) from a large urban family practice in upstate New York from 2000 to 2004. Descriptive statistic analysis was performed on demographic information, risk factors for abnormal Pap smears, and disposition of the patients.

CONCLUSIONS

This study provides information on the risk factors associated with abnormal Pap smears in pregnancy in a population at high risk. A significant relationship was seen between a positive marijuana toxicology screen and an abnormal Pap smear. In addition, the younger the patient age, the higher the probability of having a positive toxicology result. As expected, human papillomavirus (HPV) was the only sexually transmitted infection associated with an abnormal Pap smear in those that had reflex testing with liquid based cytology. Patients with primary care providers were much more likely to return for cervical cancer screening within 1 year of previous testing.

IMPLICATIONS FOR PRACTICE

There are many barriers to screening and prevention for cervical cancer in vulnerable populations. Newer technologies with HPV testing have helped to identify those women at highest risk for cervical cancer. Implementing strategies among healthcare providers to avoid missed opportunities for screening, assessment and education of risk factors, and offering vaccination against HPV are needed. Empowering women may begin to reduce disparities through the development of educational programs that reduce cultural and linguistic barriers to screening and awareness that socioeconomic factors may be impediments to care and adherence.

Evaluating the impact of human papillomavirus vaccines

While two prophylactic HPV vaccines have been proven notably efficacious in clinical trials, the effectiveness of these vaccines at the population level remains to be evaluated. To lay the foundation for understanding the strengths and limitations of different endpoints for future effectiveness research, we present a comprehensive review of HPV-related clinical outcomes, including: (i) HPV type-specific positivity and persistence, (ii) Pap diagnoses (ASC-US, LSIL, and HSIL), (iii) histologic cervical cancer precursor lesions (i.e., CIN1, CIN2, and CIN3), (iv) invasive cervical cancer (ICC), (v) anogenital warts, (vi) recurrent respiratory papillomatosis (RRP), and (vii) other HPV-associated cancers (vulvar, vaginal, anal, penile, and oropharyngeal). While research on the vaccines' effects on these HPV clinical outcomes in the general population is presently limited, numerous large trials will soon be completed, making a priori discussion of these potential outcomes especially urgent. Furthermore, population level systems to track HPV-associated clinical outcomes may need to be developed for HPV vaccine effectiveness evaluation.

Human papillomavirus and vaccination in cervical cancer

Cervical cancer is not only the most frequently reported cancer among women, but also the most common female genital tract neoplasm in Taiwan. Early detection is effective, because the development, maintenance and progression of precursor lesions (cervical intraepithelial neoplasia [CIN]) evolve slowly into invasive cancer, typically over a period of more than 10 years. It is now recognized that human papillomavirus (HPV) infection is a necessary cause for over 99% of cervical cancer cases. Advances in the understanding of the causative role of HPV in the etiology of high-grade cervical lesions (CIN 2/3) and cervical cancer have led to the development, evaluation and recommendation of HPV-based technologies for cervical cancer prevention and control. The prevention of HPV infection before the onset of CIN is now possible with recently available prophylactic HPV vaccines, e.g. the quadrivalent Gardasil (Merck & Co., NJ, USA) and bivalent Cervarix (GlaxoSmithKline, London, UK). This review article provides an up-to-date summary of recent studies and available information concerning HPV and vaccination in cervical cancer.

Emerging biomarkers in the detection, diagnosis and management of cervical dysplasia and carcinoma

Despite the success of widespread screening, cervical cancers continue to occur. Recently, the role of human papillomavirus (HPV) in cervical carcinogenesis has been firmly established. HPV prophylactic vaccines are expected to eradicate ∼ 70% of cervical cancers. An HPV test was demonstrated to improve the sensitivity of cytology and prolong the screening interval safely. Type-specific HPV testing will play an important role in the detection and follow up of cervical neoplastic lesions, as well as monitoring the efficacy of HPV vaccines. The combined use of cell proliferation markers with cytology can improve sensitivity, and some molecular markers seem to be related to the degree of dysplasia. Further studies are needed to evaluate the use of biomarkers in clinical settings.

Development of an HPV educational protocol for adolescents

STUDY OBJECTIVES

To develop an educational protocol about HPV and Pap tests for adolescents, to evaluate the protocol for understandability and clarity, and to evaluate the protocol for its effectiveness in increasing knowledge about HPV.

DESIGN

In phase 1, investigators and adolescents developed the protocol. In phase 2, adolescents evaluated the protocol qualitatively, investigators evaluated its effectiveness in increasing HPV knowledge in a sample of adolescents, and the protocol was revised. In phase 3, investigators evaluated the effectiveness of the revised protocol in an additional adolescent sample.

SETTING

Urban, hospital-based teen health center.

PARTICIPANTS

A total of 252 adolescent girls and boys in the three study phases.

MAIN OUTCOME MEASURES

Pre- and post-protocol knowledge about HPV, measured using a 10- or 11-item scale.

RESULTS

Scores on the HPV knowledge scale increased significantly (P < 0.0001) among adolescents who participated in phases 2 and 3 after they received the protocol. Initial differences in scores based on race, insurance type, and condom use were not noted post-protocol.

CONCLUSION

The protocol significantly increased knowledge scores about HPV in this population, regardless of sociodemographic characteristics and risk behaviors. Effective, developmentally appropriate educational protocols about HPV and Pap tests are particularly important in clinical settings as cervical cancer screening guidelines evolve, HPV DNA testing is integrated into screening protocols, and HPV vaccines become available. In-depth, one-on-one education about HPV may also prevent adverse psychosocial responses and promote healthy sexual and Pap screening behaviors in adolescents with abnormal HPV or Pap test results.

Human papillomavirus testing and molecular markers of cervical dysplasia and carcinoma

Cervical cancer is the second most common cancer in women worldwide. Human papillomavirus (HPV) is the etiologic agent for the vast majority of premalignant and malignant lesions, and high-risk HPV types can be detected in almost all cases of cervical dysplasia and carcinoma. HPV testing has been widely adopted for the triage of patients after a cervical cytology screening test (Papanicolaou smear or liquid-based cervical cytology such as ThinPrep or SurePath) interpretation of atypical squamous cells of undetermined significance (ASCUS), and HPV testing is increasingly used for screening in conjunction with cervical cytology. Although cervical cytology is a highly effective screening test for cancer, it has limited specificity for clinically significant lesions in cases with low-grade cytologic abnormalities. Up to a quarter of all patients may have a false-negative result on the basis of cervical cytology testing alone. This review focuses on HPV testing methods and molecular markers and their clinical relevance. HPV testing and surrogate molecular markers of HPV infection (p16INK4a) may help identify cases that are associated with underlying high-grade premalignant or malignant lesions and may also reduce aggressive treatment of patients with low-grade lesions.