Determinants of Human Papillomavirus Vaccine Uptake by Adult Women Attending Cervical Cancer Screening in 9 European Countries

INTRODUCTION

Human papillomavirus-vaccinated cohorts, irrespective of age, will likely reduce their subsequent screening requirements, thus opening opportunities for global cost reduction and program sustainability. The determinants of uptake and completion of a 3-dose human papillomavirus vaccination program by adult women in a European context were estimated.

STUDY DESIGN

This was an intervention study.

SETTING/PARTICIPANTS

Study participants were women aged 25-45 years, attending opportunistic or population-based cervical cancer screening in Belgium, Denmark, Finland, France, Germany, Slovenia, Spain, Sweden, and the United Kingdom between April 2016 and May 2018.

INTERVENTION

Study participants completed a questionnaire on awareness and attitudes on adult female human papillomavirus vaccination and were invited to receive free human papillomavirus vaccination.

MAIN OUTCOME MEASURES

Main outcome measures were acceptance, uptake, and completion of vaccination schedule. Determinants of vaccine uptake were explored using multilevel logistic models in 2019.

RESULTS

Among 3,646 participants, 2,748 (range by country=50%-96%) accepted vaccination, and 2,151 (range=30%-93%) received the full vaccination course. The factors associated with higher vaccine acceptance were previous awareness of adult female (OR=1.22, 95% CI=1.00, 1.48) and male (OR=1.59, 95% CI=1.28, 1.97) vaccination. Women in stable relationships (OR=0.56, 95% CI=0.45, 0.69) or with higher educational level (OR=0.76, 95% CI=0.63, 0.93) were more likely to refuse vaccination. Recruitment by postal invitation versus personal invitation from a healthcare professional resulted in lower vaccine acceptance (OR=0.13, 95% CI=0.02, 0.76). Vaccination coverage of >70% of adolescent girls in national public programs was of borderline significance in predicting human papillomavirus vaccine uptake (OR=3.23, 95% CI=0.95, 10.97). The main reasons for vaccine refusal were vaccine safety concerns (range=30%-59%) and the need for more information on human papillomavirus vaccines (range=1%-72%). No safety issues were experienced by vaccinated women.

CONCLUSIONS

Acceptance and schedule completion were largely dependent on recruitment method, achieved coverage of national vaccination programs, and personal relationship status. Knowledge of benefits and safety reassurance may be critical to expanding vaccination target ages. Study results suggest that there are no major opinion barriers in adult women to human papillomavirus vaccination, especially when vaccination is offered face to face in healthcare settings.

TRIAL REGISTRATION

EudraCT Number 2014-003177-42.

A Randomized Comparison of Different Vaginal Self-sampling Devices and Urine for Human Papillomavirus Testing-Predictors 5.1

BACKGROUND

Human papillomavirus (HPV)-based screening is rapidly replacing cytology as the cervical screening modality of choice. In addition to being more sensitive than cytology, it can be done on self-collected vaginal or urine samples. This study will compare the high-risk HPV positivity rates and sensitivity of self-collected vaginal samples using four different collection devices and a urine sample.

METHODS

A total of 620 women referred for colposcopy were invited to provide an initial stream urine sample collected with the Colli-Pee device and take two vaginal self-samples, using either a dry flocked swab (DF) and a wet dacron swab (WD), or a HerSwab (HS) and Qvintip (QT) device. HPV testing was performed by the BD Onclarity HPV Assay.

RESULTS

A total of 600 vaginal sample pairs were suitable for analysis, and 505 were accompanied by a urine sample. Similar positivity rates and sensitivities for CIN2+ and CIN3+ were seen for DF, WD, and urine, but lower values were seen for QT and HS. No clear user preferences were seen between devices, but women found urine easiest to collect, and were more confident they had taken the sample correctly. The lowest confidence in collection was reported for HS.

CONCLUSIONS

Urine, a DF swab, and WD swab all performed well and were well received by the women, whereas the Qvintip and HerSwab devices were less satisfactory.

IMPACT

This is the first study to compare five self-sampling methods in the same women taken at the same time. It supports wider use of urine or vaginal self-sampling for cervical screening.

Performance and Diagnostic Accuracy of a Urine-Based Human Papillomavirus Assay in a Referral Population

Background: Human papillomavirus (HPV) testing from clinician-collected cervical and self-collected cervico-vaginal samples is more sensitive for detecting CIN2+/CIN3+ than cytology-based screening, stimulating interest in HPV testing from urine. The objective was to determine the performance of the Trovagene HPV test for the detection of CIN2+ from urine and PreservCyt cervical samples.Methods: Women referred for colposcopy at St Mary's Hospital (London, United Kingdom), following abnormal cytology, were recruited to this diagnostic accuracy study by convenience sampling (September 2011 to April 2013). A total of 501 paired urine and cervical samples were collected. Primary outcomes were sensitivity for CIN2+/CIN3+ and specificity for Collapse

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MESH Headings

• Adult
• Aged
• Cervix Uteri/pathology
• Colposcopy
• DNA, Viral/isolation & purification
• Early Detection of Cancer/methods
• Feasibility Studies
• Female
• Humans
• Mass Screening/methods
• Middle Aged
• Papillomaviridae/isolation & purification
• Papillomavirus Infections/diagnosis
• Papillomavirus Infections/pathology
• Papillomavirus Infections/urine
• Papillomavirus Infections/virology
• Prospective Studies
• RNA, Viral/isolation & purification
• Referral and Consultation
• Sensitivity and Specificity
• Specimen Handling
• United Kingdom
• Urinalysis/methods
• Uterine Cervical Neoplasms/diagnosis
• Uterine Cervical Neoplasms/pathology
• Uterine Cervical Neoplasms/urine
• Uterine Cervical Neoplasms/virology
• Vaginal Smears
• Uterine Cervical Dysplasia/diagnosis
• Uterine Cervical Dysplasia/pathology
• Uterine Cervical Dysplasia/urine
• Uterine Cervical Dysplasia/virology

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Grants

• 16891 Cancer Research UK
• C569/A16891 Cancer Research UK

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Acceptability of unsupervised HPV self-sampling using written instructions

Objectives

The study measured the acceptability of self-sampling for human papillomavirus (HPV) testing in the context of cervical cancer screening. Women carried out self-sampling unsupervised, using a written instruction sheet.

Setting

Participants were women attending either a family planning clinic or a primary care trust for routine cervical screening.

Methods

Women (n = 902) carried out self-sampling for HPV testing and then a clinician did a routine cervical smear and HPV test. Immediately after having the two tests, participants completed a measure of acceptability for both tests, and answered questions about ease of using the instruction sheet and willingness to use self-sampling in the future.

Results

The majority of women found self-sampling more acceptable than the clinician-administered test, but there was a lack of confidence that the test had been done correctly. Significant demographic differences in attitudes were found, with married women having more favourable attitudes towards self-sampling than single women, and Asian women having more negative attitudes than women in other ethnic groups. Intention to use self-sampling in the future was very high across all demographic groups.

Conclusion

Self-sampling for HPV testing was highly acceptable in this large and demographically diverse sample, and women were able to carry out the test alone, using simple written instructions. Consistent with previous studies, women were concerned about doing the test properly and this issue will need to be addressed if self-sampling is introduced. More work is needed to see whether the demographic differences we found are robust and to identify reasons for lower acceptability among single women and those from Asian background.

Performance of a Cartridge-Based Assay for Detection of Clinically Significant Human Papillomavirus (HPV) Infection: Lessons from VALGENT (Validation of HPV Genotyping Tests)

The Validation of Human Papillomavirus (HPV) Genotyping Tests (VALGENT) studies offer an opportunity to clinically validate HPV assays for use in primary screening for cervical cancer and also provide a framework for the comparison of analytical and type-specific performance. Through VALGENT, we assessed the performance of the cartridge-based Xpert HPV assay (Xpert HPV), which detects 14 high-risk (HR) types and resolves HPV16 and HPV18/45. Samples from women attending the United Kingdom cervical screening program enriched with cytologically abnormal samples were collated. All had been previously tested by a clinically validated standard comparator test (SCT), the GP5+/6+ enzyme immunoassay (EIA). The clinical sensitivity and specificity of the Xpert HPV for the detection of cervical intraepithelial neoplasia grade 2 or higher (CIN2+) and CIN3+ relative to those of the SCT were assessed as were the inter- and intralaboratory reproducibilities according to international criteria for test validation. Type concordance for HPV16 and HPV18/45 between the Xpert HPV and the SCT was also analyzed. The Xpert HPV detected 94% of CIN2+ and 98% of CIN3+ lesions among all screened women and 90% of CIN2+ and 96% of CIN3+ lesions in women 30 years and older. The specificity for CIN1 or less (≤CIN1) was 83% (95% confidence interval [CI], 80 to 85%) in all women and 88% (95% CI, 86 to 91%) in women 30 years and older. Inter- and intralaboratory agreements for the Xpert HPV were 98% and 97%, respectively. The kappa agreements for HPV16 and HPV18/45 between the clinically validated reference test (GP5+/6+ LMNX) and the Xpert HPV were 0.92 and 0.91, respectively. The clinical performance and reproducibility of the Xpert HPV are comparable to those of well-established HPV assays and fulfill the criteria for use in primary cervical cancer screening.

A comparison of different human papillomavirus tests in PreservCyt versus SurePath in a referral population-PREDICTORS 4

BACKGROUND

Two transport media, PreservCyt and SurePath, are widely used for cervical cytology screening. There are concerns that they may perform differently for HPV testing.

OBJECTIVES

A comparison of the performance of six different HPV tests in SurePath and PreservCyt in a referral population using two samples from each woman. The primary goal was to compare the performance of each test in the two media. Comparisons between assays and viral load comparisons between media were secondary aims.

STUDY DESIGN

Two cervical samples were collected in random order at the same visit in women with abnormal cytology. One sample was placed in 20ml of PreservCyt and the other in 10ml of SurePath. Aliquots were taken for 4 DNA based tests: digene HC2 High-Risk HPV DNA Test, Abbott Realtime, BD Onclarity and Genera PapType, an RNA based test-: Hologic Aptima and a protein test: OncoHealth.

RESULTS

630 sample pairs were included in the analyses. For all tests except the protein test sensitivities were in excess of 90% for CIN2+ and 95% for CIN3+ for both media and with no significant differences except for a lower sensitivity for CIN2+ of Aptima in SurePath (93% vs 98%, P=0.005). Specificity for

CONCLUSIONS

We found similar sensitivity for CIN3+ in PreservCyt and SurePath for 5 nucleic acid tests in the two media in a referral population, but signal strength and positivity rates were lower in SurePath except for the Onclarity test. These results need to be replicated in a screening population.

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Key Words

• Cervical screening
• Human papillomavirus testing
• PreservCyt
• SurePath
• ThinPrep

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MESH Headings

• Adult
• Diagnostic Tests, Routine/methods
• Early Detection of Cancer/methods
• Female
• Humans
• Papillomaviridae/classification
• Papillomaviridae/genetics
• Papillomaviridae/isolation & purification
• Papillomavirus Infections/diagnosis
• Prospective Studies
• Sensitivity and Specificity
• Specimen Handling/methods
• Viral Load/methods

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Grants

• 16891 Cancer Research UK
• C569/A16891 Cancer Research UK

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Validation of a DNA methylation HPV triage classifier in a screening sample

High-risk human papillomavirus (hrHPV) DNA tests have excellent sensitivity for detection of cervical intraepithelial neoplasia 2 or higher (CIN2+). A drawback of hrHPV screening, however, is modest specificity. Therefore, hrHPV-positive women might need triage to reduce adverse events and costs associated with unnecessary colposcopy. We compared the performance of HPV16/18 genotyping with a predefined DNA methylation triage test (S5) based on target regions of the human gene EPB41L3, and viral late gene regions of HPV16, HPV18, HPV31 and HPV33. Assays were run using exfoliated cervical specimens from 710 women attending routine screening, of whom 38 were diagnosed with CIN2+ within a year after triage to colposcopy based on cytology and 341 were hrHPV positive. Sensitivity and specificity of the investigated triage methods were compared by McNemar's test. At the predefined cutoff, S5 showed better sensitivity than HPV16/18 genotyping (74% vs 54%, P = 0.04) in identifying CIN2+ in hrHPV-positive women, and similar specificity (65% vs 71%, P = 0.07). When the S5 cutoff was altered to allow equal sensitivity to that of genotyping, a significantly higher specificity of 91% was reached (P < 0.0001). Thus, a DNA methylation test for the triage of hrHPV-positive women on original screening specimens might be a valid approach with better performance than genotyping.

Performance of the Xpert HPV assay in women attending for cervical screening

Objectives

This study evaluated the Xpert HPV Assay in women attending screening in general practice by comparing Xpert with two established HPV tests, cytology and histology.

Methods

A prospective study in women aged 20–60 years attending screening in Bristol, Edinburgh and London using residual Preservcyt cytology samples. Sample order was randomised between Roche cobas4800 and Cepheid Xpert assays with Qiagen hc2 third.

Results

3408 cases were included in the primary analysis. Positivity for Xpert was 19.6%, cobas 19.2% and hc2 19.9% with high concordance (kappa=86.8% vs cobas, 81.55 vs hc2). Xpert, cobas and hc2 showed similar sensitivity (98.7%, 97.5%, 98.7%) for CIN2+. All pairwise comparisons had high concordance (Kappa ≥0.78 with any abnormal cytology. Xpert and hc2 were positive for all cases of ≥moderate dyskaryosis (N=63)), cobas was negative in two. Histology was available for 172 participants. 79 reported CIN2+, 47 CIN3+. All CIN3+ was positive on Xpert and hc2 and one case negative for cobas. One case of CIN2 was negative for all assays.

Conclusions

The performance of Xpert HPV Assay in a general screening population is comparable to established HPV tests. It offers simplicity of testing, flexibility with non-batching of individual samples and rapid turnaround time.

•

This is the first study to report on the performance of the Xpert HPV Assay in a screening population.

•

Xpert HPV Assay׳s performance in detecting HPV is comparable to two clinically validated HPV tests.

•

Xpert HPV Assay showed a relative sensitivity of 98.73% for CIN 2 or higher and 100% for CIN3 or higher.

HPV33 DNA methylation measurement improves cervical pre-cancer risk estimation of an HPV16, HPV18, HPV31 and \textit{EPB41L3} methylation classifier

BACKGROUND

Persistent infection %by with high risk human papillomavirus (hrHPV) types causes cervical cancer but most women who test positive are at very low risk of neoplasia. Strategies are needed which can retain high sensitivity of hrHPV testing but reduce the number of false-positives. We showed previously that a combination DNA methylation triage assay for HPV types 16, 18 and 31 and human gene EPB41L3 was useful to identify high grade cervical lesions.

OBJECTIVE

Assess whether measurement of DNA methylation in HPV type 33 can improve the previous classifier.

METHODS

A London colposcopy referral group of 1493 women of whom 556 (37%) had histologically-confirmed CIN (cervical intraepithelial neoplasia) 2 or 3 that included 114 HPV33 positive women with methylation measured for three L2 CpGs 5557, 5560 and 5566. Discrimination performance was assessed for the new classifier S5, built by adding HPV33 to the earlier classifier.

RESULTS

HPV33 methylation measurement improved prediction among HPV33 positive women. Receiver operating characteristic analyses showed an area under the curve (AUC) for HPV33 methylation of 0.68 (95% CI 0.57-0.78). The earlier risk score was significantly improved by HPV33 methytlation (AUC = 0.82 vs 0.80; P < 0.001). For 90% sensitivity the specificity for CIN2/3 was 49% (95% CI 46-52%).

CONCLUSIONS

Measurement of HPV33 DNA methylation contributes independent diagnostic information to EPB41L3 and HPV16, HPV18 and HPV31, and is superior to genotyping. Other HPV and human methylation target regions might be useful to further improve S5.

A randomized controlled trial in non-responders from Newcastle upon Tyne invited to return a self-sample for Human Papillomavirus testing versus repeat invitation for cervical screening

BACKGROUND

Non-attenders for cervical screening are at increased risk of cervical cancer. Studies offering self-sampling for high-risk Human Papillomavirus (HrHPV) testing have shown greater uptake than sending another invitation for cytology.

OBJECTIVES

To explore whether uptake would increase in a less diverse, more stable population than the previous English study, which demonstrated a lower response rate than other studies. The primary objective was whether non-attenders were more likely to respond to a postal invitation, including kit, to collect a self-sample compared with a further invitation for cytology screening. The secondary objective was whether women with an abnormal result would attend for follow-up.

METHODS

6000 non-attenders for screening in this pragmatic, randomized (1:1) controlled trial in Newcastle-upon-Tyne were sent an HPV self-sample kit (intervention) or a further invitation for cytology screening (comparator).

RESULTS

411(13%) responded to the intervention, returning a self-sample (247(8%)) or attending for cytology (164(5%)), compared with 183(6%) attending for cytology, relative risk 2.25 (95% CI 1.90-2.65) (comparator arm). Of those testing hrHPV positive (32(13%)), 19(59%) subsequently attended cytology screening. Of those in the intervention group who attended for cytology screening without returning an hrHPV self-sample (n = 164), 5% (n = 8) were referred for colposcopy - all attended. In the comparator group eight of the nine referred for colposcopy attended.

CONCLUSION

Persistent non-responders to invitations for cervical screening are significantly more likely to respond to a postal invitation to return a self-collected sample for HPV testing than a further invitation for cytology screening. However, just over half followed up on this positive HPV result.

A DNA methylation classifier of cervical precancer based on human papillomavirus and human genes

Testing for high-risk (hr) types of human papillomavirus (HPV) is highly sensitive as a screening test of high-grade cervical intraepithelial neoplastic (CIN2/3) disease, the precursor of cervical cancer. However, it has a relatively low specificity. Our objective was to develop a prediction rule with a higher specificity, using combinations of human and HPV DNA methylation. Exfoliated cervical specimens from colposcopy-referral cohorts in London were analyzed for DNA methylation levels by pyrosequencing in the L1 and L2 regions of HPV16, HPV18, HPV31 and human genes EPB41L3, DPYS and MAL. Samples from 1,493 hrHPV-positive women were assessed and of these 556 were found to have CIN2/3 at biopsy; 556 tested positive for HPV16 (323 CIN2/3), 201 for HPV18 (73 CIN2/3) and 202 for HPV31 (98 CIN2/3). The prediction rule included EPB41L3 and HPV and had area under curve 0.80 (95% CI 0.78-0.82). For 90% sensitivity, specificity was 36% (33-40) and positive predictive value (PPV) was 46% (43-48). By HPV type, 90% sensitivity corresponded to the following specificities and PPV, respectively: HPV16, 38% (32-45) and 67% (63-71); HPV18, 53% (45-62) and 52% (45-59); HPV31, 39% (31-49) and 58% (51-65); HPV16, 18 or 31, 44% (40-49) and 62% (59-65) and other hrHPV 17% (14-21) and 21% (18-24). We conclude that a methylation assay in hrHPV-positive women might improve PPV with minimal sensitivity loss.

Individual detection of 14 high risk human papilloma virus genotypes by the PapType test for the prediction of high grade cervical lesions

Background

HR HPV genotypes when assayed collectively, achieve high sensitivity but low specificity for the prediction of CIN2+. Knowledge of the specific genotypes in an infection may facilitate the use of HR HPV detection in routine clinical practice.

Objectives

To compare the rate of HR HPV detection and the accuracy of CIN2+ prediction between PapType test (Genera Biosystems) and other commercially available HR HPV assays, and to examine the value of full HPV genotyping.

Study design

PreservCyt samples from 1099 women referred for abnormal cervical cytology were used. CIN2+ was chosen as the primary end-point but CIN3+ was also evaluated. A hierarchy of HR HPV genotypes was created using PPV and this was used to create 3 groups of genotypes with potentially different management.

Results

The PapType assay has a specificity of 22.4% and a sensitivity of 94.6% for CIN2+ prediction. Classification into Groups A (HPV33 and HPV16, very highly predictive), B (HPV31, 18, 52, 35, 58, 51 highly predictive) and C (HPV68, 45, 39, 66, 56, 59, intermediate predictive) could double the specificity (44.5%) but only slightly reduce the sensitivity for CIN2+ (91.5%) and CIN3+ (94.0%).

Conclusions

The PapType assay is a simple, reproducible and effective test for HR HPV detection and genotyping. HPV 33 was found to have a very high PPV and should therefore be managed as for HPV16.

Attitudes towards cytology and human papillomavirus self-sample collection for cervical screening among Hindu women in London, UK: a mixed methods study

Objectives

To explore the attitudes, views and understanding of women attending a Hindu temple in London, UK towards cervical screening, human papillomavirus (HPV) testing and two HPV self-sample collection devices: the Dacron swab and Evalyn^® brush.

Methods

A mixed methods design comprising a survey and four focus groups was adopted. Focus group discussions were recorded and transcribed verbatim and explored using thematic framework analysis.

Results

A total of 185 Hindu women completed surveys and 23 attended focus groups. Of the respondents 75% aged 25–64 years reported having cervical screening within the last 5 years; 85% had attended college or university. Familiar barriers to attendance for screening were identified: fear of pain and the test result, embarrassment, screener's attitude, inconvenient appointment times and difficulty with child care. Additional barriers cited included age and country of birth, with older and Indian-born women thought to be less likely to attend for screening. Self-collected sampling had a mixed reception. Women were not confident that their sample would be as good as a clinician sample and expressed concern about the impact that a positive HPV result might have on their relationships.

Conclusions

Screening attendance in this highly educated group of Hindu women was slightly lower than in the general population (75% of women aged 25–64 years had been screened in the last 5 years compared with 79% in England as a whole). Familiar barriers to screening were identified. Women felt able to collect their own sample for HPV testing with a Dacron swab but lacked confidence that it would be as good as that obtained by a clinician.

Barriers to cervical screening in women who have experienced sexual abuse: an exploratory study

OBJECTIVES

To explore self-reported cervical screening history and barriers to attendance among women who have been sexually abused and to identify measures to improve the experience of cervical screening for these women.

METHODS

Women visiting the website of the National Association for People Abused in Childhood (NAPAC), who had been sexually abused, were invited to complete a survey of their views and experiences of cervical screening. This included closed questions on demographic characteristics and cervical screening attendance, open questions on barriers to screening, and the opportunity to submit suggestions to improve this experience for women who have been sexually abused. Content analysis was used to code responses to the open questions. Four women also participated in a discussion group.

RESULTS

Overall, 135 women completed the closed questions and 124 provided open-ended responses. 77.5% of responding women who were eligible for cervical screening in England had ever attended, 48.5% at least once in the previous 5&emsp14;years, but 42.1% of women aged 25-49 within 3&emsp14;years. A total of nine higher order themes were identified related to barriers to screening, one related to intention to attend screening and five related to suggestions to improve screening.

CONCLUSIONS

This study supports the idea that women who have experienced sexual abuse are less likely to attend for regular cervical screening, with under half screened in the last 5&emsp14;years compared to the National Health Service Cervical Screening Programme figure of 78.6%. Suggestions to improve the experience for abused women focused on communication, safety, trust and sharing control. Further research in this area is warranted to ensure that this at-risk population is appropriately served by cervical screening.

Exploring the acceptability of two self-sampling devices for human papillomavirus testing in the cervical screening context: a qualitative study of Muslim women in London

Objectives

We explored Muslim women's attitudes to self-sampling for human papillomavirus (HPV) in the context of cervical cancer screening and their responses to two self-sampling devices.

Setting

A Muslim community centre in north-east London.

Methods

Following a talk given on the subject of cervical cancer and HPV at the community centre, 28 women were recruited to take part in three focus group discussions. The discussion covered cervical screening, self-sampling and HPV testing. Women were also asked for their responses to a swab self-sampling kit and a cervico-vaginal lavage device. Discussions were recorded and transcribed verbatim and the qualitative data were analysed using Framework Analysis.

Results

Participants were generally positive about cervical screening but acknowledged that some women in their community were reluctant to attend because of embarrassment, language difficulties, fear or because they were unmarried and did not want to communicate implicit messages about being sexually active. Self-sampling met a mixed response – women were concerned about not doing the test correctly, but thought that it might overcome barriers to screening for some women. HPV testing itself was thought to raise potentially difficult issues relating to trust and fidelity within marriages. Although most women said they would prefer to continue to have screening by a health professional, if they were to perform self-sampling, there was overwhelming preference for the swab over the lavage kit.

Conclusions

There was limited enthusiasm for self-sampling in this group of Muslim women who had mostly attended for cervical screening, but a clear preference for a swab rather than a cervico-vaginal lavage.

Comparison of predictors for high-grade cervical intraepithelial neoplasia in women with abnormal smears

BACKGROUND

The detection of high-risk human papillomavirus (HPV) DNA provides higher sensitivity but lower specificity than cytology for the identification of high-grade cervical intraepithelial neoplasia (CIN). This study compared the sensitivity and specificity of several adjunctive tests for the detection of high-grade CIN in a population referred to colposcopy because of abnormal cytology.

METHODS

953 women participated in the study. Up to seven tests were carried out on a liquid PreservCyt sample: Hybrid Capture II (Digene), Amplicor (Roche), PreTect HPV-Proofer (NorChip), APTIMA HPV assay (Gen-Probe), Linear Array (Roche), Clinical-Arrays (Genomica), and CINtec p16INK4a Cytology (mtm Laboratories) immunocytochemistry. Sensitivity, specificity, and positive predictive value (PPV) were based on the worst histology seen on either the biopsy or the treatment specimen after central review.

RESULTS

273 (28.6%) women had high-grade disease (CIN2+) on worst histology, with 193 (20.2%) having CIN3+. For the detection of CIN2+, Hybrid Capture II had a sensitivity of 99.6%, specificity of 28.4%, and PPV of 36.1%. Amplicor had a sensitivity of 98.9%, specificity of 21.7%, and PPV of 33.5%. PreTect HPV-Proofer had a sensitivity of 73.6%, specificity of 73.1%, and PPV of 52.0%. APTIMA had a sensitivity of 95.2%, specificity of 42.2%, and PPV of 39.9%. CINtec p16INK4a Cytology had a sensitivity of 83.0%, specificity of 68.7%, and PPV of 52.3%. Linear Array had a sensitivity of 98.2%, specificity of 32.8%, and PPV of 37.7%. Clinical-Arrays had a sensitivity of 80.9%, specificity of 37.1%, and PPV of 33.0%.

The future of cervical cancer prevention: human papillomavirus vaccines

Human papillomavirus is recognised as the main cause of cervical cancer. Vaccines to protect against specific HPV types have been developed and a national HPV vaccination programme is due to begin in the UK in September 2008. Girls aged 12 to 13 years of age will be offered one of the vaccines, Cervarix, and it is hoped that it will offer them protection against over 70% of cervical cancer.

Human papillomavirus testing by self-sampling: assessment of accuracy in an unsupervised clinical setting

Objectives: To compare the performance and acceptability of unsupervised self-sampling with clinician sampling for high-risk human papillomavirus (HPV) types for the first time in a UK screening setting.

Setting: Nine hundred and twenty women, from two demographically different centres, attending for routine cervical smear testing

Methods: Women performed an unsupervised HPV self-test. Immediately afterwards, a doctor or nurse took an HPV test and cervical smear. Women with an abnormality on any test were offered colposcopy.

Results: Twenty-one high-grade and 39 low-grade cervical intraepithelial neoplasias (CINs) were detected. The sensitivity for high-grade disease (CIN2+) for the self HPV test was 81% (95% confidence interval [CI] 60–92), clinician HPV test 100% (95% CI 85–100), cytology 81% (95% CI 60–92). The sensitivity of both HPV tests to detect high- and low-grade cervical neoplasia was much higher than that of cytology (self-test 77% [95%CI 65–86], clinician test 80% [95% CI 68–88], cytology 48% [95% CI 36–61]). For both high-grade alone, and high and low grades together, the specificity was significantly higher for cytology (greater than 95%) than either HPV test (between 82% and 87%). The self-test proved highly acceptable to women and they reported that the instructions were easy to understand irrespective of educational level.

Conclusions: Our results suggest that it would be reasonable to offer HPV self-testing to women who are reluctant to attend for cervical smears. This approach should now be directly evaluated among women who have been non-attenders in a cervical screening programme.

Know the facts

Vaccines to protect women against cervical cancer are already being licensed. An RCN leaflet gives nurses some of the facts about the links between HPV and cervical cancer.

Testing positive for human papillomavirus in routine cervical screening: examination of psychosocial impact

OBJECTIVE

To examine the psychosocial impact of testing positive for high risk human papillomavirus (HPV) among women attending primary cervical screening.

DESIGN

Cross sectional survey. Measures were taken at baseline and one week after the receipt of HPV and cytology screening results.

SETTING

Well women's clinic in London, UK. Population or Sample Four hundred and twenty-eight women aged 20-64 years.

METHODS

Postal questionnaire survey.

MAIN OUTCOME MEASURES

Psychosocial and psychosexual outcomes were anxiety, distress and feelings about current, past and future sexual relationships.

RESULTS

Women with normal cytology who tested positive for HPV (HPV+) were significantly more anxious and distressed than women who were negative (HPV-) using both a state anxiety measure [F(1,267) = 29, P < 0.0001] and a screening specific measure of psychological distress [F(1,267) = 69, P < 0.0001]. Women with an abnormal or unsatisfactory smear result, who tested HPV+, were significantly more distressed than HPV- women with the same smear result [F(1,267) = 8.8, P = 0.002], but there was no significant difference in state anxiety. Irrespective of cytology result, HPV+ women reported feeling significantly worse about their sexual relationships. Approximately one-third of women who tested positive reported feeling worse about past and future sexual relationships compared with less than 2% of HPV- women.

CONCLUSION

The findings suggest that testing positive for HPV may have an adverse psychosocial impact, with increased anxiety, distress and concern about sexual relationships. Psychosocial outcomes of HPV testing need further investigation and must be considered alongside clinical and economic decisions to include HPV testing in routine cervical screening.

Attitudes to self-sampling for HPV among Indian, Pakistani, African-Caribbean and white British women in Manchester, UK

Objective: To examine attitudes to self-sampling for human papillomavirus (HPV) testing among women from contrasting ethnic groups.

Setting: Manchester, UK.

Methods: Two hundred women of Indian, Pakistani, African-Caribbean and white British origin were recruited from social and community groups to participate in a questionnaire survey. The questionnaire included items on attitudes to self-sampling and intention to use the test.

Results: Willingness to try to use the test was high, and women did not foresee religious or cultural barriers to self-sampling; however, a large proportion of women were concerned about doing the test properly. This concern was greatest in the Indian and African-Caribbean groups.

Conclusions: Although women's willingness to try self-sampling for HPV is encouraging, worries about carrying out the procedure correctly must be addressed if women are to feel confident about the results of self-sampling methods and reassured by a negative result.

Awareness of human papillomavirus among women attending a well woman clinic

OBJECTIVES

To assess the level and accuracy of public understanding of human papillomavirus (HPV) in the United Kingdom.

METHODS

Women attending a well woman clinic were asked to complete a questionnaire assessing HPV awareness and specific knowledge about the virus.

RESULTS

Questionnaires were completed by 1032 women, of whom 30% had heard of HPV. Older women, non-smokers, and those with a history of candida, genital warts, or an abnormal smear result were more likely to have heard of HPV. Even among those who had heard of HPV, knowledge was generally poor, and fewer than half were aware of the link with cervical cancer. There was also confusion about whether condoms or oral contraceptives could protect against HPV infection.

CONCLUSIONS

In this relatively well educated sample, awareness and knowledge of HPV were poor. Public education is urgently needed so that women participating in cervical cancer screening are fully informed about the meaning of their results, especially if HPV testing is soon to be introduced.

Assessing practice nurses' change in nutrition knowledge following training from a primary care dietitian

The expanding role of the Primary Health Care Team (PHCT) has led to more opportunities to offer dietary advice to patients. However, members of the PHCT appear to lack nutritional knowledge and confidence when giving dietary advice. This work assesses the changes in Practice Nurses' (PNs) nutrition knowledge and confidence when giving dietary advice to patients, following training from a dietitian. Base line nutrition knowledge of PNs and their confidence when giving dietary advice was assessed in 30 GP Practices by questionnaire. Following Practice-based training from a dietitian, change in knowledge and confidence was assessed using the same questionnaire. Paired and unpaired analysis was carried out on the PN's knowledge and confidence scores respectively. Nutrition knowledge increased significantly after training. The mean difference (95% confidence interval) pre- and post-training was 11.6 (7.8, 15.4). After training 88% of PNs reported having good or excellent confidence compared with 27% before training (chi-squared test p < 0.001). Nutrition training from a dietitian improves nutrition knowledge of PNs. It also improves their confidence and is recommended to support their role in providing accurate and consistent dietary advice to patients.