The impact of age and high-risk human papillomavirus (hrHPV) status on the prevalence of high-grade cervical intraepithelial neoplasia (CIN2+) in women with persistent hrHPV-positive, cytology-negative screening samples: a prospective cohort study

Immediate risk of cervical intraepithelial neoplasia and diagnostic value of colposcopy among cytology-negative women with oncogenic HPV: a retrospective study

BACKGROUND

Cervical cancer screening results that are negative for cytology but positive for high-risk human papillomavirus (HR-HPV) are not uncommon. One-year follow-up is suggested for patients with no history of HPV positivity under the most recent American Society of Colposcopy and Cervical Pathology (ASCCP) guidelines (2019). The aim of this study was to evaluate the immediate risk of cervical intraepithelial neoplasia (CIN) among cytology-negative patients positive for HR-HPV. The diagnostic accuracy of colposcopy in these patients was investigated.

METHODS

A retrospective study was conducted in patients who were cytology negative but HR-HPV positive and referred for colposcopy from January 2022 to August 2023. Patients were compared in terms of the immediate rate of CIN lesions among the HPV16-positive group, the HPV18-positive group and the non-16/18 HR-HPV-positive group. The distribution of CIN2 + lesions according to age was evaluated. The factors associated with the accuracy of colposcopy were evaluated using univariate and multivariate logistic regression.

RESULTS

Among the 372 patients, 195 had chronic cervicitis, 131 had CIN1, 37 had CIN2/3, and nine had carcinoma. The immediate rates of CIN2 + lesions and CIN3 + lesions in patients who were not HR-HPV16/18-positive were comparable to those in patients who were HPV16/18-positive (P = 0.699). In addition, among patients diagnosed with CIN2 + lesions, 8 (17.39%) patients were women aged < 30 years. When pathological results were used as a reference, the consistency rate of colposcopy was 61.0% (227/372). Multivariate analyses revealed that age and the type of cervical transformation zone were independent factors affecting the accuracy of colposcopy (P < 0.001).

CONCLUSIONS

In countries with limited resources, immediate colposcopy referral should be recommended for patients who are cytology negative but HR-HPV-positive (including non-16/18 HR-HPV-positive), and cervical cancer screening via cotesting should be suggested for women aged < 30 years. Colposcopy has moderate diagnostic value and can be affected by age and the type of cervical transformation zone.

Treatment characteristics, HPV genotype distribution and risk of subsequent disease among women with high-grade cervical intraepithelial neoplasia in Europe: A systematic literature review

INTRODUCTION

High-grade cervical intraepithelial neoplasia (CIN), a premalignant lesion of the uterine cervix, is caused by persistent Human Papillomavirus (HPV) infection. CIN can be identified through screening programs and high-grade CIN is usually treated by ablation or excision. This study aimed to summarize the clinical management and outcomes among women with high-grade CIN in Europe.

METHODS

A systematic literature review was conducted to identify treatment methods and their frequency of use, report HPV genotype prevalence and distribution and summarize patterns for subsequent lesions after primary treatment, among women with high-grade CIN in Europe. Embase®, MEDLINE® and Cochrane databases were searched (1st January 2012 to 30th August 2022), along with relevant conference proceedings (2018-2022), inclusive. Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) compliant methodology was adopted. Eligibility criteria included non-immunosuppressed female patients with CIN2+ from Europe (published in English).

RESULTS

In total, n = 55 studies were included. CIN excisional therapy was the most received treatment approach (15.8-100 %, loop electrosurgical excision procedure/large loop excision of the transformation zone most common), followed by ablative therapies (1-43.3 %, cold coagulation most common). Other approaches included 'wait and watch' (4.8-52.6 %) and hysterectomy (4.8-16.2 %). HPV positivity rates ranged from 67.8-100 % pre-conization and 4.7-32.8 % post-conization. The most prevalent HPV genotypes reported (both pre- and post-treatment) were HPV16 and HPV18. In patients who received excisional or ablative procedures subsequent CIN was most frequently diagnosed ≤6 months after treatment. The overall rate of subsequent CIN reported was 0.5-20.9 %.

CONCLUSION

Conization and ablation were the most common techniques, however, these procedures were associated with sub-optimal outcomes. Close clinical follow-up is important due to the risk of subsequent CIN or invasive cancer. This review serves as a reference point for the comparison of future treatment patterns as they evolve across Europe, following improved implementation of prophylactic HPV vaccination and screening.

Improving diagnostic of cervical dysplasia among postmenopausal women aged ≥50 years using local vaginal oestrogen treatment prior to colposcopy: study protocol for a multicentre randomised controlled trial (the IDEAL study)

INTRODUCTION

Colposcopy is the most important diagnostic tool to detect cervical precancerous lesions and thereby prevention of cervical cancer. Due to age-dependent changes of the cervix, colposcopy is challenging in postmenopausal women, as the majority will have a non-visible transformation zone, resulting in increased risk of missing disease, a diagnostic cone biopsy and prolonged follow-up with repeated colposcopies. This study will be among the first to investigate, if treatment with vaginal oestrogen prior to colposcopy will improve the colposcopy performance, to ensure accurate and timely diagnosis of precancerous cervical lesions among postmenopausal women.

METHODS AND ANALYSIS

A randomised blinded controlled multicentre study. Enrolment will be performed at gynaecology departments in Central Denmark Region and Region of Southern Denmark. A total of 150 postmenopausal women aged ≥50 years referred for colposcopy due to abnormal cervical screening results will be randomised 1:1 to either pretreatment with vaginal application of Vagifem 30 µg or placebo once a day for 14 days prior to colposcopy. The primary outcome will be to compare the percentage of women in the two groups with a visible transformation zone at colposcopy, and biopsies representative of the transformation zone. Secondary outcomes will be the proportion of detected cervical intraepithelial neoplasia grade 2 or higher in the cervical biopsies; the proportion of diagnostics cone biopsies; the patients' report on possible side effects and compliance to the pretreatment.

ETHICS AND DISSEMINATION

The study has been approved by the Central Denmark Region Committee on Biomedical Research Ethics (1-10-72-34-22), the Central Denmark Regions' Research Unit (1-16-02-72-22) and The Danish Health Authority (Danish Medicine Agency; 2022015030). The study's EudraCT number is (1-23-456; 2022-000269-42) and it is registered on www.

CLINICALTRIALS

gov. The local Good Clinical Practice (GCP) unit will supervise and monitor the study closely before, during and after the study period. Findings will be disseminated in peer-reviewed scientific journals and presented in relevant conferences.

TRIAL REGISTRATION NUMBER

NCT05283421.

Genotype, cervical intraepithelial neoplasia, and type-specific cervical intraepithelial neoplasia distributions in hrHPV+ cases referred to colposcopy: A multicenter study of Chinese mainland women

To investigate age and type-specific prevalences of high-risk human papillomavirus (hrHPV) and cervical intraepithelial neoplasia (CIN) in hrHPV+ women referred to colposcopy. This is a retrospective, multicenter study. Participants were women referred to one of seven colposcopy clinics in China after testing positive for hrHPV. Patient characteristics, hrHPV genotyping, colposcopic impressions, and histological diagnoses were abstracted from electronic records. Main outcomes were age-related type-specific prevalences associated with hrHPV and CIN, and colposcopic accuracy. Among 4419 hrHPV+ women referred to colposcopy, HPV 16, 52, and 58 were the most common genotypes. HPV 16 prevalence was 39.96%, decreasing from 42.57% in the youngest group to 30.81% in the eldest group. CIN3+ prevalence was 15.00% and increased with age. As lesion severity increases, HPV16 prevalence increased while the prevalence of HPV 52 and 58 decreased. No age-based trend was identified with HPV16 prevalence among CIN2+, and HPV16-related CIN2+ was less common in women aged 60 and above (44.26%) compared to those younger than 60 years (59.61%). Colposcopy was 0.73 sensitive at detecting CIN2+ (95% confidence interval[CI]: 0.71, 0.75), with higher sensitivity (0.77) observed in HPV16+ women (95% CI: 0.74, 0.80) compared to HPV16- women (0.68, 95% CI: 0.64, 0.71). Distributions of hrHPV genotypes, CIN, and type-specific CIN in Chinese mainland hrHPV+ women referred to colposcopy were investigated for the first time. Distributions were found to be age-dependent and colposcopic performance appears related to HPV genotypes. These findings could be used to improve the management of women referred to colposcopy.

Risk Profile of High-grade Cervical Lesions and Cervical Cancer Considering the Combination of Cytology, HPV Genotype, and Age among Women Undergoing Colposcopy

OBJECTIVE

 The present study aims to establish a risk profile for high-grade cervical lesions and cervical cancer (CIN2 + ) in women undergoing colposcopy at the Hospital do Câncer de Barretos, through the analysis of Human Papillomavirus (HPV) infection, cervical cytology, and patient's age.

METHODS

 Retrospective cross-sectional study based on a computerized database of women aged ≥ 18 years old who underwent colposcopy at the Prevention Department of the Hospital do Câncer de Barretos from 2017 to 2019.

RESULTS

 A total of 3,411 women were included, 58.0% were positive for high-risk-HPV test, with a higher prevalence of CIN2+ for HPV16 (30.3%) and other HPV (45.0%). Cytological findings that suggest invasive cervical cancer (squamous cells or adenocarcinoma), regardless of the status of HPV test, showed 100% diagnosis of CIN2 + , while atypias that suggest high-grade lesions, HSIL and ASC-H, positive for HPV test, showed in 86 and 55.2%, respectively, diagnosis of CIN2 + . ASC-H cytological results among women aged > 40 years old and negative HPV were mainly associated with benign findings. We observed that ≤ CIN1 has a higher prevalence among older women with negative HPV, while for high-grade lesions there is an increase among young women HPV16- and/or 18-positive. In cancer diagnosis, we observed a predominance of HPV 16/18 regardless of the age group.

CONCLUSION

 The highest risks of precursor lesions and cervical cancer were found among women with positive HPV 16/18 tests and severe cytological atypia in population screening tests. In addition, cytological findings of ASC-H HPV negative in women > 40 years old usually represent benign findings in histological investigation.

Added value of electrical impedance spectroscopy in adjunction of colposcopy: a prospective cohort study

OBJECTIVE

To assess whether electrical impedance spectroscopy (EIS) as an adjunctive technology enhances the performance of colposcopy.

DESIGN

Prospective cohort study.

SETTING

University Hospital colposcopy clinic.

PARTICIPANTS

Colposcopy with EIS for 647 women and conventional colposcopy for 962 women.

INTERVENTIONS

Comparison of the performance of colposcopy by referral cervical cytology in two cohorts, with and without EIS as an adjunctive technology.

OUTCOME MEASURES

Prevalence of cervical intraepithelial neoplasia grade 2 or worse (CIN2+), diagnostic testing accuracy to detect CIN2+ with and without EIS and their relative differences between cohorts.

RESULTS

The prevalence of CIN2+ varied between the cohorts according to referral cytology: 17.0% after abnormal squamous cells of unknown significance referral cytology in EIS cohort and 9.1% in the reference cohort, 16.5% and 18.9% after low-grade squamous intraepithelial lesion (LSIL), 44.3% and 58.2% after atypical squamous cells, cannot exclude high-grade squamous intraepithelial lesion (HSIL) (atypical squamous cells that cannot exclude HSIL), and 81.9% and 77.0% after HSIL cytology, respectively. Sensitivity to detect CIN2+ was higher in the EIS cohort, varying from 1.79 (95% CI 1.30 to 2.45) after LSIL referral cytology to 1.16 (95% CI 1.09 to 1.23) after HSIL referral cytology, with correspondingly lower specificity after any referral cytology.

CONCLUSIONS

Colposcopy with EIS had overall higher sensitivity but lower specificity to detect CIN2+ than conventional colposcopy. CIN2+ prevalence rates were, however, not consistently higher in the EIS cohort, suggesting innate differences between the cohorts or truly lower detection rates of CIN2+ for EIS, highlighting the need for randomised controlled trials on the effectiveness of EIS.

Performance of p16/Ki67 Immunostaining for Triage of Elderly Women with Atypical Squamous Cells of Undetermined Significance

BACKGROUND

The p16/Ki67 technique has been poorly studied in postmenopausal women with ASC-US cytology. The objective of this study was to compare the accuracy of p16/Ki67 staining, HPV testing and HPV 16 genotyping for the identification of CIN2 + lesions in postmenopausal women with ASC-US cytology.

METHOD

A total of 324 postmenopausal women with positive ASC-US were included. The women underwent HPV test, colposcopy, and biopsy. The slides were discolored and then stained with the CINtec Plus Kit for p16/Ki67. The HPV test results were classified as HPV16 +, hrHPV+ (other hrHPV genotypes), or HPV negative.

RESULTS

The p16/Ki67 sensitivity for CIN2+ was 94.5%, the specificity 86.6%, PPV of 59% and NPV of 95.9%. The HPV test showed a sensitivity of 96.4% for CIN2+, a specificity of 62.8%, a PPV of 35% and a NPV of 98.8%. In postmenopausal women, the prevalence of genotype 16 decreases in favor of the other high-risk genotypes.

CONCLUSION

Given the low sensitivity of cytology and the low percentage of HPV16-positive cancers among elderly women, triage via cytology and genotyping is not the best strategy; double staining cytology shows high profiles of sensibility and specificity for CIN2+ in ASCUS postmenopausal women.

Which is the best management for women with normal cervical cytologic findings despite positivity for non-16/18 high risk human papillomaviruses?

Women who test positive for the human papillomavirus (HPV) but have normal cytology constitute the predominant subgroup of patients in the screening population in the post-vaccination era. The distribution of HPV genotypes changed dramatically, which was attributable to an increase in HPV vaccination coverage. These changes have created uncertainty about how to properly manage women with normal cytology, non-HPV16/18 infections, or persistent infections. Current recommendations include retesting and continued surveillance in the absence of HPV16/18 infection. However, these are not always applicable. The ability to implement genotyping or incorporate HPV16/18 with some additional high-risk HPV (HR-HPV) types for triage and management with the aim of identifying type-specific risks in this population could be acceptable. When the next set of guidelines is updated, generating potential triage strategies for detecting high-grade cervical lesions, such as the p16/Ki67 cytology assay and other alternatives that incorporate genotyping with newer tests, should be considered. Current clinical management is shifting to risk-based strategies; however, no specific risk threshold has been established in this population. Importantly, innovative triage testing should be evaluated in combination with primary screening and management. Furthermore, there is an untapped opportunity to coordinate HPV genotyping in combination with colposcopic characteristics to modify risk in this group. Hence, providing a more personalized schedule through the efficient application of risk stratification and improving the detection of pre-cancer and cancer is an option worth exploring.

Increased detection of high grade CIN, when using electrical impedance spectroscopy as an adjunct to routine colposcopy, is maintained when used across international boundaries: Prospective data from nine European countries

OBJECTIVE

To evaluate the performance of EIS (ZedScan) with colposcopy in the detection of high grade CIN (HG-CIN) in different health care settings.

METHOD

Pooled analysis of data from 26 colposcopy centres in 9 countries. All women underwent colposcopy and ZedScan examination. Data was recorded prospectively via a proforma. Indications for referral to colposcopy were according to national guidelines. Pathology was reported according to national guidelines.

RESULTS

5257 women were examined by 82 colposcopists, median 93 women per centre (range 41 - 2684), 3 users per centre (range 1-8). Referral indications were; 19.3% high grade cytology, 50.4% low grade, 30.3% clinical or HPV positive / cytology negative. The prevalence of HG-CIN was 26.5%; 79.1% in high grade referrals, 16.7% low grade, 9.4% clinical or HPV positive / cytology negative. The use of ZedScan detected an extra 269 cases of high grade CIN (24% increase) (7.5% increase for high grade referrals, 57.9% for low grade and 52% for clinical or HPV positive/cytology negative). Based upon colposcopic impression (CI), the sensitivity of colposcopy for CIN2 + was 74.1% compared with 91.6% for colposcopy with ZedScan (Chi² p < 0.0001). The PPV for a ZedScan directed biopsy varied according to referral cytology and colposcopic impression (19.5% to 85.7%). 489 women underwent treatment at first visit, when ZedScan suggested treatment, 95.1% had HG-CIN/HG-CGIN or cervical cancer. The pooled results for the whole 26 centres were consistent with the results obtained for the largest centre (Sheffield) alone and also with the results with this largest centre excluded.

CONCLUSIONS

The addition of EIS (ZedScan) increases detection of HG-CIN with the PPV for a ZedScan directed biopsy consistent with the published literature. Results were similar in multiple healthcare settings. With more women being referred to colposcopy at low risk of HG-CIN, due to HPV vaccination and primary HPV screening, this study confirms the value of a real time adjunctive technology.

Adherence to follow-up after the exit cervical cancer screening test at age 60-64: A nationwide register-based study

BACKGROUND

In Denmark, human papillomavirus (HPV) testing has replaced cytology in primary cervical cancer screening for women aged 60-64; at this age, women are invited for the last (exit) screening test within the national organized program.

AIM

We investigated the adherence of these women to the recommended follow-up after a non-negative (positive or inadequate) HPV test and the overall resource use during that follow-up.

MATERIALS & METHODS

We included all 2926 women aged 60-64 years with nonnegative HPV screening tests between March 2012 and December 2016. All relevant follow-up tests and procedures were retrieved until the end of 2020 from the highly complete Danish administrative health registers, and the data were linked at the individual level. We determined the extent to which the adherence patterns followed the national recommendations for follow-up and estimated the total numbers of tests and diagnostic procedures utilized during the entire process.

RESULTS

In total, only 26% of women had follow-up in accordance with the recommendations; 4% had no follow-up, 46% had insufficient follow-up, and 24% had more follow-up than recommended. We estimated that 17% of women remained in follow-up for longer than 4 years. The average numbers of diagnostic tests and procedures used after positive HPV screening were higher than expected, even among women who had insufficient follow-up, that is, those who received less invasive procedures than recommended, or experienced delays in receiving those procedures.

CONCLUSION

To conclude, we found that the patterns of follow-up of women with nonnegative primary HPV screening tests at 60-64 often diverged from the recommendations. Addressing these inconsistencies in follow-up by providing evidence for optimal clinical management should help improve the quality of screening programs and secure an equal and reliable follow-up care service for all women.

Cervical cancer prevention among older women - challenges in screening, diagnostic workup and treatment

Cervical cancer incidence and mortality have declined dramatically after screening for cervical cancer was implemented. Yet, studies have reported high cervical cancer incidence and mortality rates at older age despite low HPV prevalence and incidence of precursor lesions. The underlying reason for these findings remains unclear. However, it is well known that the impact of screening depends not only on the uptake and effectiveness of screening but also on the uptake and effectiveness of diagnostic workup (ie colposcopy), treatment and follow-up. In older women, sensitivity of screening and performance of colposcopy are impaired due to age-dependent changes to the cervix. In this commentary, we aimed to discuss challenges in screening and clinical management of older women, and to identify crucial areas of particular interest for future research.

Genotype-specific Distribution and Change of High-risk Human Papillomavirus Infection and the Association with Cervical Progression Risk in Women with Normal Pathology and Abnormal Cytology in a Population-based Cohort Study in China

Objectives: Women with normal pathology screened from abnormal cervical cytology are a special population with higher progression risk than women with normal cytology. However, the associations between genotype distribution and changes of high-risk human papillomavirus (HR-HPV) infection and cervical progression risk in this special population remain unclear.

Methods: A total of 1232 women with normal pathology screened from abnormal cervical cytology were enrolled into this cohort with 2-year follow-up. HPV genotyping detection was performed through flow-through hybridization. Hazard ratios (HRs) and Odds ratios (ORs) were calculated using Cox proportional hazard regression and logistic regression models, respectively.

Results: Overall HR-HPV prevalence at baseline was 29.0%, with HPV16, 52, 58, 53 and 51 the top five genotypes. The 2-year persistence rate of HR-HPV infection was 31.9%. Compared with HR-HPV negative, the adjusted HRs of overall HR-HPV, HPV16, 31/33, 58, 51, and 53 infections for the progression risk of normal cervix were 5.31, 7.10, 6.95, 5.74, 5.04, and 4.88, respectively. Multiple HR-HPV infection cannot lead to an additional risk of progression relative to single HR-HPV infection. In comparison with HR-HPV persistently negative, same-type HR-HPV persistence was positively associated with progression risk of normal cervix (adjusted OR: 22.26), but different-type HR-HPV persistence was not linked to cervical progression.

Conclusion: Genotypes and persistence of HR-HPV infection could stratify the cervical progression risk in women with normal cervical pathology and abnormal cytology and provide evidence for development of next generation of vaccines. HPV51 and 53 deserved attention apart from HPV16, 31, 33, and 58.

Prognostic Value of Electrical Impedance Spectroscopy (EIS) When Used as an Adjunct to Colposcopy - A Longitudinal Study

OBJECTIVE

Colposcopy can be used with Electrical Impedance Spectroscopy (EIS) as an adjunct, to assess the presence of High Grade Cervical Intra-epithelial Neoplasia (CIN2+). This analysis of longitudinal data has used the results from women with a negative colposcopy, in order to see if the initial (index) EIS results were able to predict the women who subsequently developed CIN2+. A further objective was to investigate what tissue structural changes might be reflected in the electrical impedance spectra.

METHODS

847 patients were referred with low grade cytologly. EIS measurements were made around the transformation zone of the cervix during colposcopy. Every EIS spectrum was matched to a template representing CIN2+ and the result was positive if the match exceeded a probability index threshold. The colposcopic impression was also recorded. All the women who developed biopsy proven CIN2+ within three years of the index colposcopy were identified.

RESULTS

The median follow-up was 30.5 months. Where both CI and EIS were initially positive, there was an increased prevalence (8.13%) of CIN2+ developing as opposed to 3.45% in the remaining patients (p=0.0159). In addition, if three or more EIS spectra were positive there was a higher prevalence (9.62% as opposed to 3.56% p=0.0132) of CIN2+ at three years. The index spectra recorded from the women who developed CIN2+ showed EIS changes consistent with increases in the extracellular volume and in cell size inhomogeneity.

CONCLUSION

EIS does offer prognostic information on the risk of CIN2+ developing over the three-year period following the EIS measurements. The changes in EIS spectra are consistent with an increase in cell size diversity as pre-malignancy develops. These changes may be a consequence of increased genetic diversity as neoplasia develops.