Diagnostic Test Accuracy of First-Void Urine Human Papillomaviruses for Presence Cervical HPV in Women: Systematic Review and Meta-Analysis

Enhancing equity in cervical screening - initiatives to increase screening participation

PURPOSE OF REVIEW

Cervical cancer can be eliminated as a public health problem through a three-pillar approach including high coverage of human papillomavirus (HPV) vaccination and HPV-based cervical screening, and treatment of precancers and invasive cancers. However, access inequities prevent many women and people with a cervix benefitting from these life-saving advances. This review focuses on evidence-based interventions that can improve equity and scale-up of cervical screening.

RECENT FINDINGS

The transition from conventional cytology to HPV screening provides multiple opportunities to address equity and a multipronged approach can be used to identify priority groups, understand barriers and develop tailored solutions. There are proven financing mechanisms, tools, technologies and screening delivery methods to overcome screening barriers in different settings. This includes self-sampling interventions, point-of-care testing, health service integration, consumer-led co-design processes and digital screening registries.

SUMMARY

To achieve cervical cancer elimination globally, cervical screening must be delivered in an inclusive, culturally safe and context-appropriate manner. There are multiple tools and strategies that can be implemented to improve participation of never- and under-screened groups, and to enhance equity in cervical screening.

Time-resolved fluorescence (TRF) for total IgG and HPV16-specific antibody detection in first-void urine and serum: A comparative study

Recent studies demonstrated that human papillomavirus (HPV) specific immunoglobulins (IgG) are present and detectable in non-invasively collected first-void urine (FVU) samples. As IgG levels in urine are low, we evaluated the potential of a highly sensitive HPV16-specific assay based on time-resolved fluorescence, DELFIA, and compared it with three immunoassays, GST-L1-MIA, M4ELISA, and M9ELISA. A total of 225 paired serum and FVU samples from two cohorts of healthy female volunteers were analyzed. Strong Spearman rank correlations between HPV16-specific IgG results measured with DELFIA, M4ELISA, GST-L1-MIA, and M9ELISA were found for both sample types (rs > 0.80). Additionally, total human IgG results, determined in all samples using HTRF human IgG kit and BioPlex Pro™ Human Isotyping Assay, were compared. Moderate correlations between total human IgG concentrations in FVU samples were found for the two total IgG assays (rs ≥ 0.42, p < 0.0001), while correlations for serum were non-significant. In conclusion, the HPV16-DELFIA assay is usable for detecting HPV16-specific antibodies in FVU and serum samples. As total human IgG remains an interesting parameter for the normalization of HPV-specific IgG in FVU, the accuracy of both assays needs to be validated further.

Are we ready for human papillomavirus testing? Assessment of patient knowledge of and preferences for cervical cancer screening in Ontario

OBJECTIVE

To determine patient knowledge and preferences about primary human papillomavirus (HPV) testing.

DESIGN

Cross-sectional survey.

SETTING

Two family practice clinics (urban and suburban) and the social media platforms of 2 hospitals in the greater Toronto area between January and February 2023.

PARTICIPANTS

A total of 413 Ontario residents aged 25 to 69 years, with a cervix, who qualified for Papanicolaou (Pap) screening and could communicate in English.

METHODS

Electronic survey containing questions about knowledge of, and preferences for, cervical cancer screening, including types of screening and screening intervals, and about education related to HPV and screening intervals.

MAIN FINDINGS

Of 441 potential participants, 426 were eligible and consented to participate in the study; ultimately 413 provided completed or partially completed surveys (96.9% response rate). Of those who completed a recent Pap test, 57.8% (208 of 360) knew of HPV testing. Initially, 27.8% thought HPV testing was better than Pap testing for cervical cancer screening. After learning HPV tests exist and have self-sampling options, most participants preferred HPV testing (self-sampling 46.3%, provider sampling 34.1%). Annual cervical cancer screening was preferred by 50.1% of participants despite knowing that, for most people, Pap tests should be conducted every 3 years (74.8%). After learning about HPV testing, participants were more likely to prefer 5-year screening intervals (43.8%); however, those in the family practice group were still more likely to prefer 3-year intervals compared with those in the social media group (P<.01).

CONCLUSION

Participants in this study identified a preference for HPV testing and self-sampling options. Concerns were raised about extended screening intervals and the safety of self-collected samples that need to be addressed in public health education initiatives during rollout of new screening programs.

The Impact of Urine-Sample HPV Testing on the Effectiveness of Screening for Cervical Cancer: An Umbrella Review

BACKGROUND

The aim of the study was to evaluate the impact of urine-sample HPV (human papillomavirus) testing on the effectiveness of screening for cervical cancer.

METHODS

The analysis was based on the results of a systematic review. Secondary studies were searched in the following medical databases: Medline, Embase, and the Cochrane Library. The results of the statistical tests presented in the article originate from research conducted by the authors of the included articles.

RESULTS

From a total of 1869 citations, 5 studies were included in this review. Sensitivity and specificity for the detection of any HPV from first-void urine samples were 87% [95% CI: (0.74; 0.94)] and 89% [95% CI: (0.81; 0.93)], respectively. Moreover, participants in the analyzed studies had indicated that they felt comfortable with urine testing.

CONCLUSIONS

The development of methods to detect HPV infection in first-void urine samples and the application of this sampling method in widely available screening tests could significantly increase patients' willingness to participate in testing.

Performance of urine samples compared to cervical samples for detection of precancer lesions among HPV-positive women attending colposcopy clinic in Mexico City

BACKGROUND

High-risk human papillomavirus (hrHPV) detection in self-collected urine samples (SeCUS) may be a promising alternative for cervical cancer screening because of its greater acceptability, as long as it can offer comparable sensitivity to clinician-collected cervical samples (CCoS) for detecting precancer lesions.

OBJECTIVE

To evaluate the performance of the SeCUS compared to that of the CCoS for cervical intraepithelial neoplasia grade 3 (CIN3) detection among hrHPV-positive women receiving colposcopy in Mexico City using different specific extended HPV typing procedures: HPV16/18, HPV16/18/35/39/68 or HPV16/18/35/39/68/31.

METHODS

From March 2017 to August 2018, 4,158 female users of the cervical cancer screening program at Tlalpan Sanitary Jurisdiction in Mexico City were invited to participate in the FRIDA-Tlalpan study. All participants provided ≥ 30 mL of SeCUS, and then a CCoS was obtained with Cervex-Brush®, which was used for hrHPV typing. Participants who tested positive for hrHPV in CCoS were referred for colposcopy for diagnostic confirmation, and all SeCUS of these women were also tested for hrHPV typing.

RESULTS

In total, 561 hrHPV-positive women were identified by CCoS via colposcopy, and 82.2% of the SeCUS of these women were also hrHPV positive. From both CCoS and SeCUS, 7 cases of CIN3 were detected. Considering HPV16/18 typing, CCoS and SeCUS detected 4 cases of CIN3, but after HPV16/18/35/39/68/31 extension typing, both CCoS and SeCUS detected all 7 of the CIN3 cases among the hrHPV-positive women.

CONCLUSIONS

Using extended hrHPV typing based on HPV16/18/35/39/68/31, our results suggest that the performance of SeCUS may be equivalent to that of CCoS for detecting CIN3 lesions. Although our results are inconclusive, they support the hypothesis that SeCUS may be an attractive alternative worthy of further research.

A comparison of the carbon footprint of alternative sampling approaches for cervical screening in the UK: A descriptive study

OBJECTIVE

To understand whether self-sampling can reduce carbon emissions (CO2 e) from the NHS cervical screening programme (NHSCSP) by comparing the carbon footprint of three sampling strategies: routine cervical sampling, vaginal self-sampling and first-void (FV) urine collection.

DESIGN

Descriptive study.

SETTING

National Health Service (NHS), United Kingdom (UK).

POPULATION OR SAMPLE

Patients aged 25-64 years eligible for cervical screening in the UK.

METHODS

A carbon footprint analysis was undertaken for three cervical screening sampling approaches, from point of invitation to screening through to preparation for transport to the laboratory for HPV testing. A combination of primary and secondary data were used, with a bottom-up approach applied to collection of primary data.

MAIN OUTCOME MEASURES

We report CO2 e per sampling approach, which is the unit used to express carbon footprint and harmonise the contributions of greenhouse gases with different global warming potentials.

RESULTS

The total carbon footprint of routine cervical sampling is 3670 g CO2 e. By comparison, vaginal self-sampling had a total carbon footprint of 423 g CO2 e, and FV urine sampling 570 g CO2 e. The largest share of emissions for routine sampling was attributable to the carbon footprint associated with an appointment in a primary care setting, which totalled 2768 g CO2 e.

CONCLUSIONS

Routine cervical sampling is up to 8.7-fold more carbon-intensive than self-sampling approaches with equivalent effectiveness. We found negligible differences in the carbon footprint of alternative self-sampling methods, supporting the need for an informed choice of screening options for participants, which includes sharing information on their environmental impacts.

Genital and Oral HPV Geno-Prevalence Measured through Urine and Saliva Samples in Young Adults in Italy

BACKGROUND

The aims of the study were to determine, in the urine and oral samples of young adults, the genotype-specific prevalence of Human Papilloma Virus (HPV) infection, the HPV DNA type-specific prevalence in unvaccinated and vaccinated individuals, and the determinants of HPV infection.

METHODS

Selected participants were asked to fill in a self-administered questionnaire and to self-collect urine and saliva samples.

RESULTS

Among the 1002 participants, 81 (8.1%) resulted positive for HPV DNA. The most common low-risk genotype was HPV 42 (2.2%), followed by HPV 43 (0.8%), and 40 (0.5%). The HPV 51 was the most common high-risk genotype (1.5%) followed by HPV 66 (1%) and HPV 68 (1%), and no participants were infected with HPV genotypes 18, 33, 45. Females, those who have had one or more occasional sexual partner, those who never/rarely/sometimes used condoms during their sexual activity, those with a previous diagnosis of sexually transmitted infection, and those who were not vaccinated were more likely to be tested positive for HPV infection.

CONCLUSIONS

The low prevalence of genital HPV infections has provided evidence of the effectiveness of HPV vaccination both in vaccinated and not yet vaccinated subjects through herd immunity and indicated its decisive role in the changing epidemiology of circulating HPV genotypes in the population.

Human papillomavirus DNA testing with the urine sample is not yet available: the accuracy of two distinct kits

OBJECTIVE

The aim of this study was to assess the results and efficiency of two real-time polymerase chain reaction procedures for detecting human papillomavirus utilizing urine samples.

METHODS

This study comprised 151 patients who had previously tested positive for human papillomavirus in their cervical samples. Two different commercial real-time polymerase chain reaction techniques were used for identification and genotyping human papillomavirus in urine specimens. The urine samples of 151 patients were evaluated via the Roche Cobas test, and the urine samples of 91 patients were also evaluated via the Qiagen test.

RESULTS

The overall consistency of urine and cervical swab specimens for the identification of human papillomavirus in Roche Cobas and Qiagen tests were 44.8 and 44%, respectively. The rates of positive human papillomavirus results from urine samples were 57 and 70.3%, respectively. The overall concordance among Roche Cobas and Qiagen tests utilizing urine samples for human papillomavirus type 16/18 was 84.3% with a kappa value of 0.675, and for other high-risk-human papillomavirus, it was 75.60% with a kappa value of 0.535. Roche Cobas showed high concordance with Qiagen test.

CONCLUSION

human papillomavirus positivity was not detected in all urine samples. It is still inappropriate to recommend the use of urine liquid biopsy for the accurate and reliable detection of human papillomavirus. Due to the lack of a standardized tool, the utilization of urine samples as a screening human papillomavirus test remains a challenge.

Follow-up of humoral immune response after HPV vaccination using first-void urine: A longitudinal cohort study

Assessment of humoral immune responses following human papillomavirus (HPV) vaccination currently relies on invasive blood sampling. This longitudinal cohort study explores the usability of first-void urine as a noninvasive alternative sample for antibody detection. In this study, 58 women receiving three doses of the 9vHPV vaccine within a Gardasil9 (9vHPV) Phase III randomized controlled trial were included. Participants provided paired first-void urine and blood samples before vaccination (M0), 1 month after the third dose (M7), and ~3 years after the third dose (M43). Type-specific antibody responses to the 9vHPV types were analyzed in 174 first-void urine and 172 serum samples using a virus-like particle-based IgG multiplex enzyme-linked immunosorbent assay. Additionally, total human IgG concentrations were determined using the BioPlex assay. At M7, 1 month after complete 9vHPV vaccination, 95%-100% of first-void urine and 100% of serum samples had detectable concentrations, varying by HPV type. At M43, 84%-100% of first-void urine and 98%-100% of serum samples had HPV-specific antibody concentrations. Results show significant Spearman rank correlations between type-specific HPV-antibody concentrations for paired first-void urine and serum at all time points. This study confirms the potential feasibility of utilizing first-void urine as a noninvasive immunological sample within HPV vaccine trials.

Can HPV Test on Random Urine Replace Self-HPV Test on Vaginal Self-Samples or Clinician-Collected Cervical Samples?

Objective

This study investigated whether random urine (RU) samples can be used to accurately identify human papillomavirus (HPV) and whether these samples can replace self-collected vaginal samples in HPV tests.

Methods

A total of 167 patients with abnormal Pap smears were recruited. The patients provided self-collected vaginal and RU samples for HPV testing. Clinicians obtained cervical samples from the patients. Colposcopy examination and cervical biopsy were performed. Hybrid Capture II (HC II) and Cervista tests were used to detect HPV in the RU samples.

Results

The results of tests on clinician-collected cervical samples were used as the benchmark. The sensitivities of the Cervista tests on vaginal samples and the HC II and Cervista tests on RU samples were 75.00%, 49.07%, and 44.44%, respectively. After we adjusted the HPV detection cutoff value for urine samples based on values in the receiver operating characteristic curve, the sensitivities of the HC II and Cervista tests increased to 63.89% and 58.33%, respectively. In 167 patients, 59 had cervix biopsies showing CIN2 or worse (CIN2+). For CIN2+, the sensitivity was 47.5% and 50.8% in the HC II and Cervista tests on RU samples, respectively.

Conclusion

HPV tests on RU samples had approximately 60% sensitivity to HPV tests on clinician-collected cervical samples after the cutoff values were adjusted. For CIN2+, the sensitivity was only approximately 50%. Further studies and improvements in urine-based HPV testing are needed to establish it as a more convenient and accessible method for detecting HPV and cervical dysplasia in patients.

Testing for Human Papillomaviruses in Urine, Blood, and Oral Specimens: an Update for the Laboratory

Twelve high-risk alpha human papillomavirus (HPV) genotypes cause approximately 690,000 cancer cases annually, with cervical and oropharyngeal cancer being the two most prominent types. HPV testing is performed in laboratory settings for various applications of a clinical, epidemiological, and research nature using a range of clinical specimens collected by clinicians or by individuals (self-collected specimens). Here, we reflect on the importance and justification of using the right test for the right application and provide practical updates for laboratories either participating in or anticipating involvement in HPV testing in three specimen types, namely, urine, blood, and oral specimens, which are considered "alternative" specimens by many. In addition to clinician-collected cervical samples and self-collected cervicovaginal samples, first-void urine is emerging as a credible specimen for HPV-based cervical cancer screening, triage of HPV screen-positive women, monitoring HPV vaccine impact, and HPV testing in groups for which a less invasive sample is preferred. Detection of cell-free DNA (including HPV DNA) in blood has great promise for the early detection of HPV-attributable oropharyngeal cancer (HPV-AOC) and potentially other HPV-driven cancers and as an adjunct prognostic marker in long-term tumor surveillance, including treatment response. The moderate sensitivity of HPV testing in oral rinses or swabs at HPV-AOC diagnosis prevents its use in HPV-AOC secondary prevention but represents a promising prognostic tool in HPV-AOC tertiary prevention, where the HPV persistence in oral rinses throughout treatment may predict early HPV-AOC recurrences and/or the development of secondary HPV-AOC. The increasing sophistication of specific collection devices designed for alternative samples and the enhanced precision of novel molecular technologies are likely to support the evolution of this field and catalyze potential translation into routine practice.

Comparison of Human Papillomavirus Genotype Detection in Paired Urine and Self-Collected Cervical Swabs: A Pilot Study

OBJECTIVES

With the objective of establishing a simple, cost-effective, and effective screening tool for the screening of Human Papilloma Virus infection, the study was undertaken.

MATERIAL METHODS

This pilot study was conducted on 20 urine samples of women whose cervical swabs were tested positive while screening for Human papilloma virus in asymptomatic women.

RESULTS

HPV genotypes were detected in 94% (16/17) patients in urine samples by real-time PCR while a 100% detection rate (15/15) was observed in the cervical swab samples. The results of the urine and cervical swab samples, tested by the TRUPCR ®HPV high-risk genotyping kit, are shown in Table 2. HPV genotype 68 was found in 82.3% urinary samples and 100% of self-collected vaginal swab samples. Out of 16 positive urine samples, 2 were positive for HPV genotype 16 and 5 were positive for HPV genotype 18, and in cervical swab testing out of 15 positive samples, 3 were positive for HPV genotype 16, and 5 were positive for HPV genotype 18. Diagnostic accuracy of urine was found to be 98.8% (95% CI 79.43% - 100.00%).

CONCLUSION

This pilot study aims to assess the accuracy of urine samples in the screening of HPV infection among asymptomatic women and establish the distribution of prevalent HPV genotypes. This may further contribute to standardizing the urine and cervical swab testing methods for cervical cancer screening strategies.

Comparison of Urine and Genital Samples for Detecting Human Papillomavirus (HPV) in Clinical Patients

Background. Human papillomavirus (HPV) is the main cause of cervical cancer. The aim of the present study was to investigate HPV DNA detection and genotyping on paired genital and urine samples and to evaluate if urine samples could be used to monitor HPV infection. Methods. Study subjects were recruited from one local hospital in Guangdong of China from September 1, 2011, to June 30, 2012. They were invited to participate if they have taken an HPV genotyping assay for clinical diagnosis of the genital-urinary disease or for a health check-up 3–5 days ago. DNA was extracted from paired genital and urine samples; genotyping was performed with the GenoArray assay. Results. A total of 250 patients were recruited, which included 203 females and 47 males. Our results showed that the overall agreement on HPV status between the paired samples was 77.1% (155/201, 95% CI: 0.713–0.829) for females, with a kappa value of 0.523 (95% CI: 0.469–0.632), while the agreement was extremely low in the paired male samples. As to individual genotyping, the greatest agreement was found for HPV16 type-specific identification in females (96.02%, 0.933–0.987), followed by the other 12 high oncogenic risk (HR-HPV) types, while the agreement for low-risk HPV detection is poor (κ < 0.6). Agreement between paired samples showed that HPV detection had a significantly greater concordance in the samples obtained in females than males ( $p$  = 0.002). Moreover, the agreement for low-risk HPV detection was significantly lower as compared to HR-HPV detection (48.1% vs. 62.3%, $p$  = 0.044). Conclusion. Despite reduced sensitivity, HPV detection in urine closely represents the same trend that is seen with genital sampling. Urine appears to be an appropriate surrogate sample for HPV DNA detection in women with very limited access to healthcare, while the utility of urine for HPV DNA detection in males is less certain.

Evaluation of the optimal sampling approach for HPV genotyping in circumcised heterosexual men with genital warts

BACKGROUND

Human papillomavirus (HPV) causes a serious socioeconomic burden globally. However, there is currently no consensus on the optimal sampling method for HPVDNA genotyping in circumcised heterosexual men. This study aimed to determine the diagnostic efficacy of 6 different anatomic sampling sites in HPV DNA polymerase chain reaction (PCR) testing of circumcised heterosexual men with genital warts.

METHODS

The study included circumcised heterosexual men who presented to our clinic with complaints of genital warts. Swab samples were obtained from the penile shaft (PS), scrotum, coronal sulcus (CS), and external urethral meatus (EUM). First-void urine (FVU) and genital wart biopsy (GWB) were also tested for HPV DNA by PCR.

RESULTS

A total of 32 patients (mean age: 36.9 ± 6.9 years) were included. None of the six samples studied was sufficient on its own to reveal all HPV types detected in a patient. When the samples were analyzed individually, GWB detected an average of 49.5% of total HPV types in a patient. This rate was 50.5% for PS, 40.4% for CS, 31.6% for scrotum, 26.3% for EUM, and 15.8% for FVU samples. The detection rate increased to 75.8% with combined testing of GWB and PS samples, 83.2% with GWB/PS/CS, 90.5% with GWB/PS/CS/scrotum, and 98.9% with GWB/PS/CS/scrotum/EUM samples.

CONCLUSION

No single anatomic region or sample type can detect all HPV types present in circumcised heterosexual men by PCR assay. The detection rate approaches 99% when wart biopsy is combined with swab sampling of the penile shaft, coronal sulcus, scrotum, and external urethral meatus.

Study to Determine Concordance between High-Risk Human Papilloma Virus DNA Detection in Self Collected First Voided Urine Samples and Health-Care Worker Collected Cervical Samples in a Subset of Women with Proven Histopathological Precancerous and Cancerous Lesions of the Cervix

Objective

The objective of our study was to assess whether urinary samples for human papilloma virus (HPV) detection are a good predictive marker of cervical cancerous and precancerous lesions, by comparing against results from cervical scrapings as the gold standard test.

Materials and Methods

The study is a hospital-based cross-sectional study wherein symptomatic women were screened at the colposcopy clinic. Paired samples-cervical scrapings/washings and urine samples were tested for hr-HPV for women who were found to harbor premalignant and malignant lesions of the cervix in histopathological lesions, by multiplex real-time polymerase chain reaction and HPV genotyping. Diagnostic accuracy was tested by calculating concordance with Cohen's kappa with hr-HPV detection in cervical samples as the gold standard.

Results

A total of 295 patients undergoing colposcopy were recruited in the study, out of which 54 had histopathological-proven premalignant and malignant lesions of the cervix. Overall, positivity rate in urinary samples for both HPV 16 and 18 combined is 64.81%, whereas for cervical samples is 68.51%. HPV 16 was seen in 30 (55.5%) and 32 (59.3%) cervical and urinary samples, respectively, whereas HPV 18 was seen in 7 (12.9%) and 6 (11.1%) samples, respectively. There was substantial concordance between the cervical samples and first-void urinary samples results with Cohen's k: 0.6988 (95% confidence interval: From 0.507 to 0.891). There was 85.96% agreement among all the tests that were performed with only 14.04% disagreement.

Conclusions

The study showed that HPV DNA detection from the urine and cervical samples showed significant agreeability for the detection of precancerous and cancerous lesions of the cervix among women with abnormal histology results. Thus, urinary sampling can be done as a potential replacement for cervical sampling methods with the added benefit as it can be used in females reluctant to provide cervical samples, if there is no availability of skilled workforce for collecting samples, for mass screening, and for the follow-up of vaccination programs.

Current Resources for Evidence-Based Practice, March 2022

An extensive review of new resources to support the provision of evidence-based care for women and infants. The current column includes a discussion of systemic racism and its effect on maternal health in the United States and commentaries on reviews focused on barriers and facilitators to HPV vaccination and delayed cord clamping in preterm infants.