Immediate referral to colposcopy versus cytological surveillance for minor cervical cytological abnormalities in the absence of HPV test

Cervical Cytology and Histology Correlation as an Analytic Quality Assurance Exercise: Experience from an Accredited Cytology Laboratory

Context

The performance parameters of cervical cytology in any accredited cytology laboratory requires implementation of quality control exercise, which ensures acceptable performance by a laboratory. This study aims to assess the analytical aspect of quality control measures by evaluating the frequency and accuracy of epithelial abnormalities as detected in cervical Pap smears using histopathologic diagnosis as the gold standard.

Methods

A retrospective diagnostic test study from 2018 to 2020 was conducted. Out of the total 6000 Pap smears, histopathologic correlation was available in 150 cases in the form of colposcopic-directed biopsy (CDB) and loop electrosurgical excision procedure (LEEP) tissue in 105 cases. The quality control measures analyzed were Atypical Squamous Cell: Squamous Intraepithelial Lesion (ASC: SIL) ratio, cyto-histo correlation, and study parameters like sensitivity, specificity, positive predictive value, and negative predictive value of Pap smears as against CDB and LEEP.

Results

4.5% smears were reported as inadequate, 92.3% as Negative for intraepithelial lesion or malignancy (NILM), followed by epithelial abnormality found in 3.21%. The ASC: SIL ratio was 1.3:1. Concordance rate against CDB was 100% in Squamous cell carcinoma (SCC), 82.35% in high-grade squamous intraepithelial lesion (HSIL), 82% in atypical squamous cells of undetermined significance (ASCUS), 65.6% in low-grade squamous intraepithelial lesion (LSIL), and 50% in Atypical Squamous Cell ,High grade Squamous Intraepithelial Lesion can not be ruled out (ASC-H). Total concordance rate was 84.15%. Sensitivity of Pap smear was 65% for LSIL and 82% for HSIL. Specificity, positive predictive value, and negative predictive value were 63.63%, 90%, and 75%, respectively. Concordance rate was 96% with LEEP.

Conclusion

Quality control measures give an insight of performance of any accredited cytology laboratory. This exercise needs to be conducted on a regular basis, so that relevant steps can be taken in case of major discrepancy.

Proposal for a descriptive and differentiated presentation of the longitudinal impact of the new organized cancer screening guideline and HPV vaccination in Germany

INTRODUCTION

Since 01/01/2020, the cervical cancer screening in Germany has been carried out due to the organized early cancer diagnosis guideline (oKFE-RL). In 2007, HPV vaccination was initiated in Germany. The main goal of both initiatives is to further reduce the incidence of invasive cervical cancer. To assess the effect of the new screening strategy in a timely manner, monitoring of short-term changes need to be considered. Ideally, the effects of both prevention methods would be presented together in one model.

MATERIALS AND METHODS

Because no change in the incidence of invasive cervical cancer is initially expected, the incidence of CIN 3 is used as a surrogate parameter to assess the effects of the prevention efforts. Based on expected additional effects of vaccination and co-testing, a model-based estimation of the expected CIN 3 incidence during the evaluation of the screening program is performed using the CIN 3 incidence in the Saarland population.

MODELING RESULTS

The oKFE-RL provides for two groups: Primary cytodiagnosis continues until 35 years of age. Here, in the next few years, CIN 3 incidence will be reduced not by the oKFE-RL but by the increasing proportion of vaccinated women. In the group over 35 years, co-testing was introduced with a stringent algorithm. Due to the higher sensitivity of the HPV test, significantly more CIN 3 are detected in the first round of 3 years and thus, the CIN 3 incidence initially increases. As these CIN 3 are absent in the second round, significantly fewer CIN 3 cases will be detected then. These effects suggest a global decrease in CIN 3 incidence of 25.8% after 6 years.

CONCLUSION

Observation of the age distribution curve of CIN 3 allows both effects of prevention to be assessed in a timely manner and separately. In the future, data from epidemiologic cancer registries should be incorporated into the model to replace modeling with real data.

Predictors of depressive symptoms before and after diagnostic procedures in women with abnormal Pap smear attending cervical cancer screening programme in Serbia

OBJECTIVES

Receipt of a positive Papanicolaou screening result and subsequent referral for diagnostic tests can cause psychological stress. Still, not enough is known about depression before and after the diagnostic test in these women. The aim of this study was to determine the burden and predictors of depressive symptoms prior to and after diagnostic investigations in women who had received a positive Papanicolaou screening result.

METHODS

This was a cross-sectional study. Study cohort comprised women who received an abnormal Papanicolaou screening result. Women completed the socio-demographic questionnaire and 'The Center for Epidemiologic Studies Depression, CES-D' questionnaire before and after diagnostic tests (colposcopy/biopsy/endocervical curettage) to assess factors related to depression.

RESULTS

No significant difference was noted in the frequency of depressive symptoms (CES-D score ≥ 16) before and after diagnostic investigations, but the mean score on CES-D scale showed a significant difference before and after diagnostic investigations (13.98 ± 9.56 and 12.74 ± 9.15, respectively). A significant predictor of depression before diagnostic investigations was spontaneous abortion, whereas family history of other gynaecological cancers was a predictor of depression after diagnostic investigations.

CONCLUSIONS

Our findings could contribute to improving the rates of cervical cancer screening, by identifying women at risk for depression before and after investigations.

Real-world effectiveness of primary screening with high-risk human papillomavirus testing in the cervical cancer screening programme in China: a nationwide, population-based study

BACKGROUND

Randomized controlled trials have shown a higher sensitivity and longer negative predictive value of high-risk human papillomavirus (HPV) testing than cytology for cervical cancer screening; however, little is known about the effectiveness of HPV testing in middle-income countries. Understanding the characteristics of HPV testing may increase the priority of HPV testing in health policies. The study aims to evaluate the effectiveness of HPV testing in the national cervical cancer screening programme in China.

METHODS

We performed a nationwide, population-based study using individual data from the national cervical cancer screening programme in rural China between 2015 and 2017. The analyses included 1,160,981 women aged 35-64 years who underwent cytology alone or high-risk HPV testing with cytology or genotyping triage. The main outcome was cervical intraepithelial neoplasia 2 or worse (CIN2+). We used multivariate logistic regressions and performed sensitivity analyses with propensity score matching to compare the screening positive, colposcopy referral, detection rate, and positive predictive value (PPV).

RESULTS

The screening positive rates for HPV testing and cytology were 10.1% and 4.0%, respectively. The per protocol colposcopy referral rate of HPV testing was significantly lower than that of cytology (3.5% vs 4.0%), and this difference was mostly due to the low referral threshold of cytology (≥ASC-US). Overall, HPV testing detected more CIN2+ (5.5 vs. 4.4 per 1000, adjusted odds ratio [aOR]=1.18, 95% confidence interval 1.11-1.25) and had a higher PPV (13.8% vs 10.9%, aOR 1.29, 95% CI 1.21-1.37) than cytology. The colposcopy referrals of HPV testing in comparison to cytology differed by income status; it significantly increased in lower-middle-income areas (3.7% vs 3.1%, aOR 1.21, 95% CI 1.17-1.25) and significantly decreased in upper-middle-income areas (3.4% vs 4.9%, aOR 0.69, 95% CI 0.67-0.71). Sensitivity analyses demonstrated the reliability and robustness of the results.

CONCLUSIONS

The introduction of HPV testing could improve both the CIN2+ detection rate and efficiency of cervical cancer screening programme, supporting the introduction of primary screening with high-risk HPV testing in China. Further study is needed to investigate the long-term effect of this change.

The Triage Effectiveness of an Extended High-Risk Human Papillomavirus Genotyping Assay for Women with Cytology Showing Atypical Squamous Cells of Undetermined Significance in China

Purpose

Little is known about the performance of extended high-risk human papillomavirus (HR-HPV) genotyping triage of cytology showing atypical squamous cells of undetermined significance (ASC-US). This study aims to evaluate the effectiveness of triage with different HR-HPV genotype models among women with ASC-US.

Materials and Methods

In this study, all women who underwent cervical cytology and HR-HPV genotyping were enrolled from 2014 to 2017 in China, and those with cytology showing ASC-US were referred for colposcopy and/or biopsy. The endpoint was histological detection of cervical intraepithelial neoplasia grade 2 or worse (CIN2+). The outcome indicators were the sensitivity, specificity, positive predictive values (PPVs), negative predictive values (NPVs) and colposcopy referral rates.

Results

In all, 56,788 women were enrolled in this study, and 2658 (4.97%) women were reported to have ASC-US; 10.1% (242/2393) of women with ASC-US were identified as having CIN2+. The HR-HPV infection rate was 95.0% among all women with ASC-US who were identified as CIN2+, and the top five genotypes with prevalence and risk of CIN2+ were HPV16 (OR=26.38), HPV58 (OR=7.04), HPV18 (OR=4.44), HPV33 (OR=3.38), HPV31 (OR=2.97) and HPV52 (OR=2.96). The HPV16/18/31/33/52/58 model achieved higher sensitivity [91.3 (87.8-94.9)], specificity [70.0 (68.1-72.0)], PPV [25.5 (22.4-28.2)] and NPV [98.6 (97.3-98.7)] for the triage of ASC-US patients than the other HR-HPV-type combination models, but the colposcopy referral rate (36.2%) was significantly lower than that of the recommended HR-HPV nongenotyping model (47.6%).

Conclusion

This study confirms that the specific HR-HPV genotype HPV16/18/31/33/52/58 is an alternative strategy for ASC-US triage and can effectively reduce the high burden of colposcopy referrals in China.

The Efficiency of Type-Specific High-Risk Human Papillomavirus Models in the Triage of Women with Atypical Squamous Cells of Undetermined Significance

Purpose

To evaluate the performance of different high-risk human papillomavirus (HR-HPV) genotype models in triaging women with cytological diagnosis of atypical squamous cells of undetermined significance (ASCUS).

Patients and Methods

A total of 36,679 Chinese women who underwent cytology and HR-HPV genotyping assessments during cervical cancer screening were enrolled in this study. Women with cytology-proven ASCUS were referred for further screening by colposcopy and biopsy. The study endpoint was histological detection of cervical intraepithelial neoplasia grade 2 or worse (CIN2+) at any of the follow-up visits. The sensitivity, specificity, positive predictive values (PPVs), negative predictive values (NPVs), positive likelihood ratio (PLR) and negative likelihood ratio (NLR) of different HR-HPV genotype combination models were estimated.

Results

In all, 1675 (4.9%) women were identified as having ASCUS, 1454 women underwent colposcopy and biopsy, and 6.0% (87/1454) women were identified as having CIN2+ lesions. Among those with ASCUS who were identified as having CIN2+, the HR-HPV infection rate was 97.7%, and the prevalence rates of HPV-16, −18, −31, −33, −35, −39, −45, −51, −52, −56, −58, −59, −66 and −68 were 48.3%, 8.0%, 6.9%, 4.6%, 1.1%, 2.3%, 3.4%, 3.4%, 26.4%, 1.1%, 17.2%, 2.3%, 0.0% and 0.0%, respectively. Compared to other HR-HPV-type combination models, the HPV16/18/31/33/52/58 model achieved a higher sensitivity [93.1 (87.8–98.4)], specificity [73.0 (70.7–75.4)], PPV [18.0 (14.5–21.5)], NPV [99.4 (98.9–99.9)], PLR [3.7 (3.1–3.8)] and NLR [0.06 (0.03–0.18)] for the triage of ASCUS patients, but the colposcopy referral rate (30.9%) was significantly lower than that of the recommended HR-HPV model (44.0%).

Conclusion

This study confirms that the specific HR-HPV genotype HPV16/18/31/33/52/58 is an alternative strategy for ASCUS triage and can effectively reduce the high burden of colposcopy referrals in China.

Risikobewertung von Zytologiebefunden im Zervixkarzinom-Screening

Zielstellung

Das CIN2+-/CIN3+(zervikale intraepitheliale Neoplasie)-Risiko plattenepithelialer zytologischer Befunde (Gruppe II‑p, IIID1, III‑p, IIID2 der Münchner Nomenklatur [MN] III) soll bewertet und mit Empfehlungen für das Patienten-Management korreliert werden.

Material und Methoden

Alle 4321 Frauen mit einer Gruppe II‑p, IIID1, III‑p, IIID2, IVa‑p, IVb-p und V‑p von Januar 2014 bis Dezember 2016 wurden in einer Praxis für Pathologie erfasst. Zytologische Vorbefunde, alle zytologischen und histologischen Folgebefunde bis Juli 2019 wurden dokumentiert. Für die Erstbefunde wurde pro Befundgruppe mittels Kaplan-Meier-Schätzung das Risiko für CIN2+/CIN3+ ermittelt. Das Risiko bei persistierenden Befunden und der Einfluss des Alters wurden untersucht.

Ergebnisse

Für die Erstbefunde der Gruppen II‑p, IIID1, III‑p und IIID2 beträgt das Risiko für CIN2+ nach 12, 24 und 60 Monaten 1,0/3,3/11,8; 3,1/9,4/22,7; 33,4/38,4/55,5 bzw. 35,1/46,2/64,4 (%). Das Risiko für CIN3+ beträgt für die gleichen Zeiträume 0,6/2,7/9,7; 1,9/5,2/14,3; 28,8/32,4/44,0 bzw. 28,5/36,7/52,4 (%). Bei persistierenden Befunden derselben Gruppe steigt das Risiko für CIN2+ und CIN3+ signifikant vom ersten zum zweiten II-p‑, IIID1-, III-p- und IIID2-Befund. Bei den Gruppen II‑p, IIID1 und IIID2 finden sich keine signifikanten Altersunterschiede, bei III-p-Befunden ist das Risiko für Frauen <30 und <35 signifikant größer als für ältere Frauen.

Schlussfolgerung

Die MN III mit 3‑gliedriger Dysplasiegraduierung klassifiziert die zytologischen Befunde risikoorientiert. Ihre Befundgruppen eignen sich als Basis für ein risikoadaptiertes Management, um insbesondere Überdiagnostik und -therapie zu vermeiden.

Performance of Different Combination Models of High-Risk HPV Genotyping in Triaging Chinese Women With Atypical Squamous Cells of Undetermined Significance

Objective: The purpose of this study was to evaluate the effect of different combination models of high-risk human papilloma viruses (HPV) genotyping in triaging Chinese women with atypical squamous cells of undetermined significance (ASCUS). Methods: We established a screening cohort of 3,997 Chinese women who underwent cervical cytology and HPV genotyping test. Women with ASCUS cytology underwent punch biopsy under colposcopy/endocervical curettage. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of different combination models of HR-HPV genotyping calculated that cervical intraepithelial neoplasia 2 or higher (CIN2+) on histology were endpoints. Results: Of the full sample, 393 women had ASCUS. Among ASCUS women with a CIN2 lesion, the prevalence for HPV were 40.0% (type 16), 10.0% (type 18), 0.0% (type 33), 30.0% (type 52), 40.0% (type 58), and 30.0% (other nine types). For ASCUS women with a CIN3 lesion, the prevalence for HPV were 68.4% (type 16), 15.8% (type 18), 10.5% (type 33), 31.6% (type 52), 15.8% (type 58), and 36.8% (other nine types). Combination model including HPV16/18/33/52/58 for predicting CIN2+ lesion in women with ASCUS had relatively higher sensitivity [93.1% (78.0, 98.1)], specificity [75.8% (71.2, 79.9)], PPV [23.5% (16.7, 32.0)], and NPV [99.3% (97.4, 99.8)] than other combination models. Moreover, the referral rate of HPV16/18/33/52/58 (29.3%) was lower than HR-HPV (36.1%). Conclusions: The study demonstrates that specific HR-HPV types HPV16/18/33/52/58 may be an effective strategy in ASCUS triage. This improves the subsequent selection of ASCUS patients.

Targeted immunotherapy of high-grade cervical intra-epithelial neoplasia: Expectations from clinical trials

Targeted immunotherapy of high-grade cervical intra-epithelial neoplasia (CIN) has been developed as an alternative to conization, to preserve future reproductive outcomes and avoid human papillomavirus (HPV) persistence. The objectives of the review are to present drugs according to their process of development and to examine their potential future use. A search for key words associated with CIN and targeted immunotherapy was carried out in the Cochrane library, Pubmed, Embase, and ClinicalTrials.gov from 1990 to 2016. Publications (randomized, prospective and retrospective studies) in any language were eligible for inclusion, as well as ongoing trials registered on the ClinicalTrials.gov website. Targeted immunotherapy includes peptide/protein-based vaccines, nucleic acid-based vaccines (DNA), and live vector-based vaccines (bacterial or viral). A total of 18 vaccines were identified for treatment of CIN at various stages of development, and the majority were well-tolerated. Adverse effects were primarily injection site reactions and flu-like symptoms under grade 2. The efficacy of vaccines defined by regression of CIN2/3 to no CIN or CIN1 ranged from 17 to 59% following a minimum of a 12-week follow-up. In the majority of studies, there was no association demonstrated between histological response and HPV clearance, or between histological or virological response and immune T cell response. Given that the spontaneous regression of CIN2/3 is 20-25% at 6 months, targeted immunotherapy occurs an additional value, which never reaches 50%, with one trial an exception to this. However, research and development on HPV eradication drugs needs to be encouraged, due to HPV-associated disease burden.