Practice guidelines for the early detection of cervical cancer in Korea: Korean Society of Gynecologic Oncology and the Korean Society for Cytopathology 2012 edition

Analysis of HR-HPV Infection Concordance Rates in Cervical and Urine Specimens; Proposal of Additional Cervical Screening Process for Women Who Refuse Invasive Cervical Sampling

This study aimed to provide basic data for the clinical application of urine samples to prevent cervical cancer due to persistent HR-HPV infection in women who refuse invasive cervical sampling. Pairs of cervical swabs and urine samples were collected from 210 asymptomatic women who visited the obstetrics and gynecology department from August to December 2020, and a total of 420 samples were collected. Using the PANA RealTyper™ HPV Screening Kit as a real-time PCR method, paired cervical swabs and random urine samples were tested. A total of 19 samples (9.1%) were both HPV positive and 177 (84.3%) were both negative. The concordance between the two types of samples was 93.3%, with κ = 0.69 (moderate, 95% CI 0.54-0.84). The HPV infection rate by age was highest in both cervical swabs and urine samples in women in their 30s, followed by those in their 20s. Thus, the HPV infection rate was high in young women under 40 at 69.2% in cervical swabs and 61.8% in urine samples. Urine samples are considered a valuable screening test for women who refuse invasive Pap tests to prevent cervical cancer caused by persistent HPV infection.

Clinical management of abnormal Pap tests: differences between US and Korean guidelines

Cervical cancer has been the most common gynecological cancer in Korea but has become a preventable disease with regular screening and proper vaccination. If regular screening is provided, cervical cancer does not progress to more than carcinoma in situ, due to its comparatively long precancerous duration (years to decades). In 2012, the American Society for Colposcopy and Cervical Pathology published guidelines to aid clinicians in managing women with abnormal Papanicolaou (Pap) tests, and they soon became the standard in the United States. Not long thereafter, the Korean Society of Gynecologic Oncology and the Korean Society for Cytopathology published practical guidelines to reflect the specific situation in Korea. The detailed screening guidelines and management options in the case of abnormal Pap test results are sometimes the same and sometimes different in the United States and Korean guidelines. In this article, we summarize the differences between the United States and Korean guidelines in order to facilitate physicians’ proper management of abnormal Pap test results.

Carcinogenic risk of human papillomavirus (HPV) genotypes and potential effects of HPV vaccines in Korea

This study investigated the distribution of HPV types in Korean women and evaluated the carcinogenic risk of individual HPV types and the potential effects of HPV vaccines. A total of 4,081 HPV-positive samples between 2014 and 2017 were included. The most prevalent genotypes were HPV 16, 58, 68, and 56. Among them, HPV 16 was significantly higher in high-grade squamous intraepithelial neoplasia or worse (HSIL+ ) group. In cytologically evaluating the risk for HSIL+ by individual HPV types, HPV 16 was associated with the highest risk of HSIL+ (OR = 10.82; 95% CI: 7.93–14.77), followed by HPV 33, 31, 52, 18, 58, 51, and 35, in descending order (OR = 3.50 [type 33] to 2.62 [type 35]). Among those types, HPV 16, 18, 31, 33, and 58 were also significantly associated with HSIL+ on histologic evaluation. The analysis of the HPV subgroups covered by the different vaccines revealed that the HPV types covered by the 9-valent vaccine had a high association with HSIL+ (OR = 4.09; 95% CI: 3.02–5.54). Our findings highlight the different carcinogenic risks posed by the high risk HPV genotypes and the positive potential effects of the 9-valent HPV vaccine in reducing HPV-associated cervical cancer in Korea.

Comparison of cervical cancer screening among women with and without hysterectomies: a nationwide population-based study in Korea

BACKGROUND

Cervical cancer screening is not recommended for women who underwent hysterectomy with no history of cervical intraepithelial neoplasia (CIN) of grade 2 or higher. We aimed to determine the cervical cancer screening rate in Korean women who underwent hysterectomies and compare it to that in women with intact uteri.

METHODS

We used data from the 2014-2016 Korean National Cancer Screening Survey; 6807 women aged 30-74 years were included in the study. Participants were asked about their experiences with cervical cancer screening, hysterectomy status, and other variables associated with cancer screening.

RESULTS

The screening rates among women who have undergone a hysterectomy vs. those who have not during the past 2 years were 61.8% (95% confidence interval [CI], 58.8-64.9) and 64.7% (95% CI, 64.1-65.3), respectively. Among younger women (30-44 years) and women with a family history of cancer, those with hysterectomies showed a higher cervical cancer screening rate than those without (77.8% vs. 57.1% and 75.0% vs. 67.1%, respectively).

CONCLUSIONS

Despite available evidence and clinical recommendations, a considerable number of Korean women who no longer have a cervix continue to undergo unnecessary cervical cancer screening. It is necessary to identify the exact underlying causes for this phenomenon, and systematic efforts are required to prevent unnecessary screening for women who have undergone a hysterectomy.

Proposal for cervical cancer screening in the era of HPV vaccination

Eradication of cervical cancer involves the expansion of human papillomavirus (HPV) vaccine coverage and the development of efficient screening guidelines that take vaccination into account. In Korea, the HPV National Immunization Program was launched in 2016 and is expected to shift the prevalence of HPV genotypes in the country, among other effects. The experiences of another countries that implement national immunization programs should be applied to Korea. If HPV vaccines spread nationwide with broader coverage, after a few decades, cervical intraepithelial lesions or invasive cancer should become a rare disease, leading to a predictable decrease in the positive predictive value of cervical screening cytology. HPV testing is the primary screening tool for cervical cancer and has replaced traditional cytology-based guidelines. The current screening strategy in Korea does not differentiate women who have received complete vaccination from those who are unvaccinated. However, in the post-vaccination era, newly revised policies will be needed. We also discuss on how to increase the vaccination rate in adolescence.

Atypical squamous cells of undetermined significance and low-grade squamous intraepithelial lesion triage in Korean women: Revisiting the 2012 American Society of Colposcopy and Cervical Pathology screening guidelines

Objective

To determine whether triage for atypical squamous cells of undetermined significance (ASC-US) and low-grade squamous intraepithelial lesion (LSIL) from the updated American Society for Colposcopy and Cervical Pathology cervical cancer screening guidelines is applicable in Korean women.

Methods

We investigated women with ASC-US or LSIL including referred from local hospitals visited for cervical cancer screening at Korea University Guro Hospital from February 2004 to December 2014. Detailed information on the results of Papanicolaou (Pap) smears, human papillomavirus (HPV) DNA tests, and cervical biopsies were collected through chart review. Cervical biopsy results were compared in eligible women according to individual Pap smear findings and HPV DNA status.

Results

Of 216,723 possible cases, 3,196 were included. There were 212 (6.6%) women with ASC-US and 500 (15.6%) with LSIL. The risk of ≥cervical intraepithelial neoplasia (CIN) 2 was significantly higher in women who were ASC-US/HPV+ than ASC-US/HPV- and LSIL/HPV+ than LSIL/HPV- (93.3% vs. 6.7% and 96.7% vs. 3.3%, P<0.001 and P<0.001, respectively). The risk of ≥CIN 3 was also significantly higher in women who were ASC-US/HPV+ than ASC-US/HPV- and LSIL/HPV+ than LSIL/HPV- (97.0% vs. 3.0% and 93.0% vs. 7.0%, P<0.001 and P<0.001, respectively). Age-stratified analysis revealed that more CIN 2 or CIN 3 was diagnosed in women aged 30 to 70 with ASC-US or LSIL when HPV DNA was present.

Conclusion

Observation with Pap and HPV DNA tests rather than immediate colposcopy is a reasonable strategy for ASC-US or LSIL when the HPV DNA test is negative, especially in women aged 30 to 70. Reflection of these results should be considered in future Korean screening guidelines.

Cervical Cancer Screening after Perimenopause: How Is Human Papillomavirus Test Performed?

Cervical cancer is the third most prevalent cancer in women around the world. Recently in Korea, the incidence of cervical cancer has decreased, but in all stages of cervical intraepithelial neoplasia (CIN), CIN has shown a 91% increase from 1999 to 2008. Persistent human papillomavirus (HPV) infection has been found to be the main cause of cervical cancer. HPV types 16 and 18 have been found in 70% of cervical cancer patients around the world. Cervical cancer screening such as cytology has limitations in terms of sensitivity and specificity. A discussion about the need for the HPV test is becoming active in order to compensate for the limitation of cytology. After the role of HPV in cervical cancer was identified, the importance of HPV detection test as a screening was emphasized. Several tests have been developed and each test has its own advantages and disadvantages, and new test method to overcome the disadvantages is still being developed. Today's guidelines and tests are those you would choose from among the large number of cervical cancer screening guidelines and tests, based on the consideration that the selected guidelines and the test are effective.

Clinical Significance of an HPV DNA Chip Test with Emphasis on HPV-16 and/or HPV-18 Detection in Korean Gynecological Patients

BACKGROUND

Human papillomavirus (HPV) is a major risk factor for cervical cancer.

METHODS

We evaluated the clinical significance of the HPV DNA chip genotyping assay (MyHPV chip, Mygene Co.) compared with the Hybrid Capture 2 (HC2) chemiluminescent nucleic acid hybridization kit (Digene Corp.) in 867 patients.

RESULTS

The concordance rate between the MyHPV chip and HC2 was 79.4% (kappa coefficient, κ = 0.55). The sensitivity and specificity of both HPV tests were very similar (approximately 85% and 50%, respectively). The addition of HPV result (either MyHPV chip or HC2) to cytology improved the sensitivity (95%, each) but reduced the specificity (approximately 30%, each) compared with the HPV test or cytology alone. Based on the MyHPV chip results, the odds ratio (OR) for ≥ high-grade squamous intraepithelial lesions (HSILs) was 9.9 in the HPV-16/18 (+) group and 3.7 in the non-16/18 high-risk (HR)-HPV (+) group. Based on the HC2 results, the OR for ≥ HSILs was 5.9 in the HR-HPV (+) group. When considering only patients with cytological diagnoses of "negative for intraepithelial lesion or malignancy" and "atypical squamous cell or atypical glandular cell," based on the MyHPV chip results, the ORs for ≥ HSILs were 6.8 and 11.7, respectively, in the HPV-16/18 (+) group.

CONCLUSIONS

The sensitivity and specificity of the MyHPV chip test are similar to the HC2. Detecting HPV-16/18 with an HPV DNA chip test, which is commonly used in many Asian countries, is useful in assessing the risk of high-grade cervical lesions.

The health beliefs of mothers about preventing cervical cancer and their intention to recommend the Pap test to their daughters: a cross-sectional survey

BACKGROUND

Mothers have a primary role in the prevention of cervical cancer in Korea. This study aimed to determine the awareness and health beliefs of mothers about preventing cervical cancer in their daughters, their intention to recommend the Pap test to their daughters, and the factors influencing this intention.

METHODS

A cross-sectional survey design was employed, and the study enrolled mothers (n = 1,581) of pubescent girls aged 13 to 18 years who were living nationwide in Korea. The six health-beliefs variables related to preventing cervical cancer in their daughters, awareness of the importance of cervical cancer prevention methods, and the intention to recommend the Pap test to daughters were investigated. The impacts of these health beliefs of the mothers and the sociodemographic factors influencing their intention to recommend the Pap test to their daughters were assessed using multiple logistic regression analysis.

RESULTS

Almost one-quarter (23.7 %) of the mothers had talked about the Pap test, 69.2 % were intending to recommend the Pap test to their daughters, and 38.5 % considered that the Pap test could be necessary if their daughters became sexually active. The significant health beliefs influencing the intention to recommend the Pap test were the perceived barriers [odds ratio (OR) = 1.47, 95 % confidence interval (95 % CI) = 1.03-2.11] and benefits (OR = 2.25, 95 % CI = 1.55-3.25). The significant sociodemographic factors of mothers were their education (OR = 1.52, 95 % CI = 1.08-2.13), their experience of talking about the Pap test with their daughters (OR = 2.11, 95 % CI = 1.23-3.64), their regularity of undergoing the Pap test themselves (OR = 1.98, 95 % CI = 1.30-3.03), and their age when they first underwent the Pap test (OR = 1.60, 95 % CI = 1.43-0.82).

CONCLUSIONS

The mothers perceived HPV vaccination as the most important of the five methods for preventing cervical cancer in their daughters. Mothers perceived the importance of their daughters undergoing the Pap test regardless of the presence of HPV vaccination, and most of the mothers had an intention of recommending the Pap test to their daughters. Strategies for increasing the intention of mothers to recommend the Pap test to their adolescent daughters could be promoted by increasing their perceptions of the benefits while reducing their perceptions of barriers toward their daughters undergoing the Pap test, and by empowering active communication about the Pap test between mothers and daughters.

Comparison of the Cobas 4800 HPV and HPV 9G DNA Chip Tests for Detection of High-Risk Human Papillomavirus in Cervical Specimens of Women with Consecutive Positive HPV Tests But Negative Pap Smears

Detecting high-risk (HR) HPV is important for clinical management of women with persistent HPV-positive and Pap-negative results. The Cobas 4800 HPV test is the first FDA-approved HPV DNA test that can be used alone as a first-line screening tool. The HPV 9G DNA chip test is a PCR-based DNA microarray assay. We evaluated the patients of consecutive HPV-positivity on HPV 9G DNA chip test without cytologic abnormalities. We then compared the performances of HPV 9G DNA chip and the Cobas 4800 HPV tests for detecting HR HPV with each other and confirmed HPV genotyping using direct sequencing. All 214 liquid-based cytology specimens were collected from 100 women with consecutive HPV-positive and Pap-negative results on the HPV 9G DNA chip test between May 2012 and Dec 2013, but only 180 specimens were available for comparing HPV test results. The HPV 9G DNA chip and the Cobas 4800 HPV tests agreed with each other in 81.7% of the samples, and the concordance rate was greater than 97.2% for detecting HPV-16 or -18. For HR genotypes other than HPV types 16 and 18, the two tests agreed for 81.1% of the samples. The sensitivity of both assays for detecting HR HPV was 100%, regardless of HR genotypes. The HPV 9G DNA chip test may be as effective as the Cobas 4800 HPV test in detecting HR HPV, and has a similar ability to identify HPV-16 and -18.

The Korean guideline for cervical cancer screening

The incidence rate of cervical cancer in Korea is still higher than in other developed countries, notwithstanding the national mass-screening program. Furthermore, a new method has been introduced in cervical cancer screening. Therefore, the committee for cervical cancer screening in Korea updated the recommendation statement established in 2002. The new version of the guideline was developed by the committee using evidence-based methods. The committee reviewed the evidence for the benefits and harms of the Papanicolaou test, liquid-based cytology, and human papillomavirus (HPV) testing, and reached conclusions after deliberation. The committee recommends screening for cervical cancer with cytology (Papanicolaou test or liquid-based cytology) every three years in women older than 20 years of age (recommendation A). The cervical cytology combined with HPV test is optionally recommended after taking into consideration individual risk or preference (recommendation C). The current evidence for primary HPV screening is insufficient to assess the benefits and harms of cervical cancer screening (recommendation I). Cervical cancer screening can be terminated at the age of 74 years if more than three consecutive negative cytology reports have been confirmed within 10 years (recommendation D).

The Korean guideline for cervical cancer screening

The incidence rate of cervical cancer in Korea is still higher than in other developed countries, notwithstanding the national mass-screening program. Furthermore, a new method has been introduced in cervical cancer screening. Therefore, the committee for cervical cancer screening in Korea updated the recommendation statement established in 2002. The new version of the guideline was developed by the committee using evidence-based methods. The committee reviewed the evidence for the benefits and harms of the Papanicolaou test, liquid-based cytology, and human papillomavirus (HPV) testing, and reached conclusions after deliberation. The committee recommends screening for cervical cancer with cytology (Papanicolaou test or liquid-based cytology) every three years in women older than 20 years of age (recommendation A). The cervical cytology combined with HPV test is optionally recommended after taking into consideration individual risk or preference (recommendation C). The current evidence for primary HPV screening is insufficient to assess the benefits and harms of cervical cancer screening (recommendation I). Cervical cancer screening can be terminated at the age of 74 years if more than three consecutive negative cytology reports have been confirmed within 10 years (recommendation D).

Reflex Human Papillomavirus Test Results as an Option for the Management of Korean Women With Atypical Squamous Cells Cannot Exclude High-Grade Squamous Intraepithelial Lesion

BACKGROUND

Current guidelines recommend initial colposcopy with biopsy regardless of human papillomavirus (HPV) test results in women with atypical squamous cells, cannot exclude high-grade squamous intraepithelial lesion (ASC-H). The purpose of this study was to evaluate the value of HPV testing in women with ASC-H based on colposcopic pathology results.

MATERIALS AND METHODS

A multicenter cross-sectional study was carried out at three academic hospitals and involved 40,847 Korean women who underwent cervical cancer screening with cytology and HPV tests with or without subsequent colposcopic biopsies between January 2007 and December 2013.

RESULTS

ASC-H was diagnosed in 276 women (0.7%). Only 6 of 68 (8.8%) women with ASC-H who were HPV negative had cervical intraepithelial neoplasia grade ≥2 (CIN ≥2) lesions, whereas 47.4% of the women with ASC-H who were HPV positive had CIN ≥2 lesions. No cases of invasive cervical cancer were diagnosed among women with ASC-H who were HPV negative. Logistic regression analysis was performed using the group with normal Papanicolaou test results and HPV-negative status as the reference group. Women with ASC-H who were HPV positive had a significantly increased risk of CIN ≥2 lesions, whereas no significant increase was observed in patients with ASC-H and HPV-negative status.

CONCLUSION

If the result of the HPV test was negative, the risk of CIN ≥2 lesions in Korean women with ASC-H cytology was low. Reflex HPV testing should be an option for the management of women with cytology showing ASC-H to decrease unnecessary colposcopic biopsies, which are expensive and invasive.

IMPLICATIONS FOR PRACTICE

Current American Society for Colposcopy and Cervical Pathology guidelines recommend universal colposcopy for the management of women with atypical squamous cells, cannot exclude high-grade squamous intraepithelial lesion (ASC-H) on cytology, regardless of human papillomavirus (HPV) test results. The present study suggested that HPV cotesting in patients with ASC-H cytology can provide more detailed and useful information regarding the risk of high-grade cervical intraepithelial neoplasia (CIN) lesions and the need for further treatment. When the result of the HPV test was negative, the risk of CIN lesions of grade ≥2 in women with ASC-H cytology was low. Consequently, reflex HPV testing, rather than immediately performance of invasive and expensive colposcopy with biopsy, should be an option for the management of women with ASC-H.

Clinical significance of HPV DNA cotesting in Korean women with ASCUS or ASC-H

The purpose of this study was to evaluate the clinical significance of Human papillomavirus (HPV) DNA cotesting in Korean women with abnormal Papanicolaou (Pap) smear results based on colposcopic pathology. A total of 1012 women underwent liquid-based Pap smears and hybrid capture II HPV DNA tests followed by colposcopy at the Korea University Hospital from January 2007 to May 2012. Of these women, 832 women were included in this retrospective study. The mean patient age was 45.4 ± 13.7 years (range:15-80). The distribution of Pap smear results was normal (4.7%), atypical squamous cells of uncertain significance (ASCUS) (42.1%), low-grade squamous intraepithelial lesion (26.8%), ASC-H (7.0%), and high-grade squamous intraepithelial lesion (HSIL) (19.5%). In women with ASCUS, none of the 87 HPV-negative had ≥cervical intraepithelial neoplasia (CIN2) (P < 0.001). In women with ASC-H, only one out of 17 HPV-negative vs. 14 out of 41 HPV-positive had ≥CIN2 (P = 0.025). In patients with HSIL, 54.5% of HPV-negative had ≥CIN2, as compared to 80.8% of HPV-positive with ≥CIN2 (P = 0.039). Patients were further analyzed by age groups: <30 and ≥30 years. In HPV-negative women, there was a significant difference in the ratio of ≥CIN2 (30.8% <30 vs. 4.5% ≥30, P = 0.005). When the HPV DNA test was negative in women ≥30, the risk of ≥CIN2 was significantly lower (P < 0.001). HPV DNA cotesting in women with ASCUS and ASC-H furnish healthcare providers with informative data. There is a lower proportion of ≥CIN2 in HPV-negative women and a higher proportion of ≥CIN2 in HPV-positive. When HPV data were further evaluated by age group, the risk of ≥CIN2 was lower in HPV-negative women, especially in women ≥30.