Accuracy of human papillomavirus testing on self-collected versus clinician-collected samples: a meta-analysis

Smartphone-based urine colourimetric assay for home self-screening of HPV infection

Currently, producing NPSH after HPV infection of cells has been confirmed. These NPSH-containing substances accumulate around the urethral opening and are subsequently washed out with urine. Therefore, indirect detection of HPV infection by assessing NPSH levels in urine is feasible, but it has not been reported in detail so far. Here, an assay using phosphotungstic acid to oxidise and produce colour changes by NPSH in urine was developed. This assay enabled the rapid, non-invasive identification of HPV infection by detecting the metabolic byproduct NPSH produced by HPV-infected cells. Employing a smartphone-based device, developed using an ambient light sensor, reduces the cost and simplifies the operation associated with the colourimetric assay. The colourimetric assay was used to detect L-cysteine and L-ascorbic acid standard substance (as NPSH mimics), the limited of detection were 0.12 mM and 31.25 μM, respectively, with high reproducibility and stability. When this colourimetric assay was used to evaluate urine samples from individuals suspected of HPV infection, along with other at-home self-screening methods for HPV nucleic acid detection in urine, showed comparable sensitivity and specificity. Compared with nucleic acid detection in urine, this colourimetric assay is cost-effective, user-friendly, amenable to self-sampling, and enables testing at one's convenience and location of choice, which is more suitable for home self-testing or population self-screening.

Accuracy of real-time PCR assays for human papillomavirus using urine samples: a systematic review and meta-analysis

This study aims to assess the diagnostic accuracy of real-time PCR assays for detecting human papillomavirus (HPV) in urine samples through a systematic review and meta-analysis. A comprehensive search of PubMed, Embase, and Springer databases (2014-2024) was conducted. Studies comparing urine-based HPV tests with cervical samples as the reference standard were included. Diagnostic accuracy measures such as sensitivity, specificity, diagnostic odds ratio (DOR), likelihood ratios (LR+ and LR-), percent agreement, and Cohen's kappa were calculated. Heterogeneity was assessed using the Higgins' I² index, and subgroup analyses were performed based on HPV test type and urine volume. The study revealed that 15 studies met the inclusion criteria, with pooled sensitivity of urine-based HPV tests at 0.82 (95% CI, 0.78-0.86), specificity at 0.91 (95% CI, 0.87-0.94), positive LR at 9.5 (95% CI, 6.3-14.3), negative LR at 0.19 (95% CI, 0.16-0.24), DOR at 49 (95% CI, 32-75), and the area under the curve at 0.92 (95% CI, 0.90-0.94), with significant heterogeneity observed (I² >50%), particularly in sensitivity and specificity, and subgroup analysis indicating that urine volumes ≤20 mL demonstrated higher sensitivity compared to those >20 mL, despite this finding being based on a limited number of studies. Results suggest that urine-based HPV testing shows strong diagnostic accuracy and could be a viable alternative to cervical swabs, with potential benefits for increasing screening accessibility, especially in areas with limited healthcare resources, despite some variability and limitations in the data.IMPORTANCEThis study is significant as it thoroughly evaluates the diagnostic accuracy of real-time PCR assays for human papillomavirus (HPV) detection in urine samples through a rigorous systematic review and meta-analysis. By integrating data from multiple databases and comparing urine-based HPV tests with the established cervical sample reference standard, the study provides valuable insights into the effectiveness and reliability of non-invasive HPV screening methods. The findings demonstrate that urine-based tests exhibit high sensitivity and specificity, offering a promising alternative to traditional cervical swabs. This advancement has significant implications for increasing accessibility to HPV screening, particularly in under-resourced settings, thereby potentially enhancing cervical cancer prevention efforts on a broader scale. The study not only fills a critical gap in HPV screening methodologies but also supports the development of more inclusive and practical public health strategies for combating cervical cancer.

Accuracy analysis of cervical cancer screening using urine and vaginal self-sampling versus clinician-collected samples: A systematic review and meta-analysis

OBJECTIVE

The aim of the present study was to explore the differences in diagnostic performance between vaginal self-sampling, urine self-sampling, and clinician sampling in cervical cancer screening.

METHODS

Following the preferred reporting items for systematic reviews and meta-analyses (PRISMA) 2020, we searched PubMed, Cochrane Library, Web of Science, and Embase. Study quality was assessed with Cochrane Review Manager 5.3. Diagnostic performance was evaluated by pooling sensitivity, specificity, and the area under the summary receiver operating characteristic (SROC) curve using STATA 18.0.

RESULTS

The meta-analysis included 15 studies with 3665 participants, all with abnormal cervical cancer screening results. The pooled sensitivity for both self-sampling methods was 0.88 (95% confidence interval [CI]: 0.85, 0.91), the pooled specificity was 0.81 (95% CI: 0.68, 0.89), and the area under the curve (AUC) was 0.92 (95% CI: 0.89, 0.94). For high risk-human papillomavirus (HR-HPV), vaginal self-sampling showed a sensitivity of 0.92 (95% CI: 0.90, 0.94) and specificity of 0.80 (95% CI: 0.58, 0.92), and AUC was 0.93 (95% CI: 0.91, 95); urine self-sampling showed a sensitivity of 0.83 (95% CI: 0.77, 0.88) and specificity of 0.81 (95% CI: 0.65, 0.91), and AUC was 0.88 (95% CI: 0.85, 0.91). For >CIN2 lesions, vaginal self-sampling showed a sensitivity of 0.98 (95% CI: 0.96, 0.99) and specificity of 0.63 (95% CI: 0.48, 0.77), and AUC was 0.98 (95% CI: 0.96, 0.99); urine self-sampling showed a sensitivity of 0.95 (95% CI: 0.91, 0.97) and specificity of 0.62 (95% CI: 0.31, 0.86), and AUC was 0.95 (95% CI: 0.93, 0.97).

CONCLUSION

Vaginal and urine self-sampling for HPV testing show promising diagnostic potential, with vaginal sampling outperforming urine. Both methods have similar sensitivity for detecting lesions >CIN2.

Women's perceptions and preferences toward HPV self-sampling in France: A questionnaire within the French CapU4 Trial

BACKGROUND

Despite organised screening efforts since 2018 targeting under-screened women, cervical cancer (CC) screening coverage remains moderate (60 %) in France. The target age for HPV-based screening is women aged 30-65. Vaginal self-sampling (VSS) has recently been introduced for women who have not been screened. This study assesses women's perceptions and preferences toward HPV self-sampling among women enrolled in the CapU4 trial.

METHODS

CapU4 is a randomised controlled trial with two experimental arms (mailing either a urine self-sampling (USS) or VSS kit) and a control arm (mailing of a conventional invitation letter). The trial invited 15,000 women aged 30-65, who had no screening test recorded since more than four years and who did not respond to an invitation letter within 12 months before. Half of the women in each arm were randomly selected to receive a supplementary questionnaire (sent in March 2023, with responses collected until August 2023).

RESULTS

In total, 682 completed questionnaires were analysed (9.1 % response rate). Most women found self-sampling instructions clear (VSS 87.4 %, USS 90.7 %) and procedures easy (VSS 85.9 %, USS 90.3 %). About 23.5 % of VSS users and 4.9 % of USS users found the process unpleasant. Around 80 % of participants in both SS arms preferred taking a specimen at home rather than going to a health care professional for cervical screening. They also indicated a preference for using self-sampling kit to collect a sample for their next CC screening instead of visiting a health care professional (VSS 82.6 %, USS 89.1 %).

CONCLUSION

Self-sampling appears to be a well-received alternative in women not attending routine CC screening programme.

Equivalent Clinical Accuracy of Human Papillomavirus DNA Testing Using Cobas 4800 and 6800 Human Papillomavirus Systems in Paired Urine and Cervical Samples

The use of urine for cervical cancer screening is gaining international attention, although more data on the relative clinical accuracy of validated human papillomavirus (HPV) DNA tests on urine versus cervical samples are needed. This study primarily seeks to evaluate the clinical performance of Roche cobas 4800 and 6800 HPV Systems in first-void urine, collected at home, compared with clinician-collected cervical samples. Paired first-void urine (index test) and cervical samples (comparator test) from 499 females enrolled at five Belgian colposcopy clinics were analyzed with cobas HPV Systems. Colposcopy and histology of biopsies were used as reference test (trial registration number: NCT03064087). Sample processing protocols and clinical thresholds proposed by the manufacturer for cervical samples were also applied for first-void urine. In the total study population, HPV testing on first-void urine was similarly sensitive [ratioCIN2+, 0.98; 95% CI, 0.93-1.02] and specific for cobas 4800 HPV (ratio Collapse

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MESH Headings

• Adult
• Female
• Humans
• Middle Aged
• Cervix Uteri/virology
• Cervix Uteri/pathology
• Colposcopy
• DNA, Viral/genetics
• DNA, Viral/urine
• Early Detection of Cancer/methods
• Human Papillomavirus DNA Tests/methods
• Human Papillomavirus Viruses
• Papillomaviridae/genetics
• Papillomavirus Infections/diagnosis
• Papillomavirus Infections/urine
• Papillomavirus Infections/virology
• Sensitivity and Specificity
• Uterine Cervical Dysplasia/diagnosis
• Uterine Cervical Dysplasia/virology
• Uterine Cervical Neoplasms/diagnosis
• Uterine Cervical Neoplasms/virology
• Uterine Cervical Neoplasms/urine

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Affiliation(s)

Severien Van Keer Centre for the Evaluation of Vaccination, Vaccine and Infectious Disease Institute (VAXINFECTIO), Faculty of Medicine and Health Sciences, University of Antwerp, Edegem, Belgium.
Ardashel Latsuzbaia Unit of Cancer Epidemiology, Belgian Cancer Centre, Sciensano, Brussels, Belgium
Davy Vanden Broeck Laboratory of Molecular Pathology, AML Sonic Healthcare, Antwerp, Belgium; National Reference Centre for HPV, Brussels, Belgium; AMBIOR, Laboratory for Cell Biology and Histology, University of Antwerp, Wilrijk (Antwerp), Belgium; International Centre for Reproductive Health, Ghent University, Ghent, Belgium
Philippe De Sutter Department Gynaecology-Oncology, University Hospital Brussels-Vrije Universiteit Brussel, Jette (Brussels), Belgium
Gilbert Donders Department of Obstetrics and Gynaecology, General Regional Hospital Heilig Hart, Tienen, Belgium; Femicare vzw, Clinical Research for Women, Tienen, Belgium; Department of Obstetrics and Gynaecology, Antwerp University Hospital, Edegem, Belgium
Jean Doyen Department Gynaecology-Obstetrics, University Hospital Liège, Liège, Belgium
Wiebren A A Tjalma Multidisciplinary Breast Clinic, Unit Gynaecologic Oncology, Department of Obstetrics and Gynaecology, Antwerp University Hospital, Edegem, Belgium; Molecular Imaging, Pathology, Radiotherapy, Oncology, Faculty of Medicine and Health Sciences, University of Antwerp, Wilrijk (Antwerp), Belgium
Steven Weyers Department of Obstetrics and Gynecology, Ghent University Hospital, Ghent, Belgium
Marc Arbyn Unit of Cancer Epidemiology, Belgian Cancer Centre, Sciensano, Brussels, Belgium; Department of Human Structure and Repair, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
Alex Vorsters Centre for the Evaluation of Vaccination, Vaccine and Infectious Disease Institute (VAXINFECTIO), Faculty of Medicine and Health Sciences, University of Antwerp, Edegem, Belgium

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High-risk HPV prevalence in the Czech cervical cancer screening population: a comparison of clinician-collected and self-collected sampling

The prevalence of high-risk human papillomavirus (hrHPV) types varies across countries, making it essential to estimate prevalence using nationwide samples. Data on hrHPV prevalence in the Czech Republic are very limited. This study aimed to determine the prevalence of various hrHPV types in an unselected screening population of Czech women aged 30-65 years, using paired clinician-obtained cervical swab (CS) and self-collected cervicovaginal swabs (CVS). A total of 1026 eligible women were recruited into two study arms. In arm A, the digene® HC2 DNA Collection Device was used for both CS and CVS. In arm B, the Evalyn Brush was used for CVS, while the Cervex Brush was used for CS. All samples were tested for hrHPV using the digene® HC2 High-Risk HPV DNA Test and genotyped with the PapilloCheck® HPV-Screening assay. The overall hrHPV prevalence was 14.8%, based on positive results from either CVS or CS samples. hrHPV positivity was detected in 10.8% of clinician-obtained CSs and 11.8% of self-collected CVSs. A combined analysis of CS and CVS samples identified the five most prevalent hrHPV genotypes: HPV16, HPV31, HPV39, HPV56, and HPV68. The comparison of hrHPV detection in paired CS and CVS samples showed an overall concordance of 93%. These findings highlight the importance of detecting hrHPV genotypes alongside conventional Pap testing in national cervical screening programs. Furthermore, the results confirm that self-sampling kits represent a suitable alternative to clinician-collected samples.

Clinical trials registration  ClinicalTrials.gov Identifier (NCT04133610).

Self-Collected Vaginal Specimens for HPV Testing: Recommendations From the Enduring Consensus Cervical Cancer Screening and Management Guidelines Committee

OBJECTIVE

The Enduring Consensus Cervical Cancer Screening and Management Guidelines Committee developed recommendations for the use of self-collected vaginal specimens for human papillomavirus (HPV) testing in health care settings.

METHODS

A comprehensive literature search was performed, external systematic reviews were evaluated, and HPV genotype agreement between self-collected vaginal and clinician-collected cervical specimens was summarized. Recommendations considered available data, public comments, and expert consensus. Recommendations were ratified through a vote by the Consensus Stakeholder Group.

RESULTS

Clinician-collected cervical specimens are preferred and self-collected vaginal specimens are acceptable for primary HPV screening of asymptomatic average-risk individuals. Repeat testing in 3 years is recommended following HPV-negative screens using self-collected vaginal specimens. Colposcopy with collection of cytology and biopsies is recommended following positive tests for HPV types 16 and 18. Clinician-collected cytology or dual stain for triage testing is recommended following positive tests for HPV 45, 33/58, 31, 52, 35/39/68, or 51 or for pooled HPV other types but negative for HPV 16 or 18. Repeat HPV testing in 1 year is recommended following a positive test for HPV types 56/59/66 and no other carcinogenic types. Minimal data exist on use of self-collected vaginal specimens for surveillance following abnormal screening test results, colposcopy or treatment, and therefore, clinician-collected cervical specimens are preferred.

CONCLUSIONS

Human papillomavirus testing of self-collected vaginal specimens expands cervical cancer screening options and has potential to increase access for currently underscreened individuals. Laboratory and clinical workflows will need to be modified to ensure adequate specimen processing and follow-up.

Improving the Sensitivity-Specificity Balance of Human Papillomavirus Testing on Self- and Clinician-Collected Samples in South Africa

PURPOSE

Human papillomavirus (HPV) testing on self-collected samples may increase coverage of cervical cancer screening, but previous studies have observed lower specificity of HPV testing in self- versus clinician-collected samples. Here we investigate strategies to improve the sensitivity-specificity balance of a round of HPV testing on self-collected samples.

MATERIALS AND METHODS

Women living with and without HIV, age 30-65 years, were recruited in South Africa. Self-collected vaginal samples and clinician-collected cervical samples were tested with Xpert HPV, an assay that detects the 14 high-risk HPV types in five separate channels: (P1) HPV 16; (P2) HPV 18, 45; (P3) HPV 31, 33, 35, 52, 58; (P4) HPV 51, 59; and (P5) HPV 39, 56, 66, 68. All women underwent colposcopy with histology sampling, and diagnosis of cervical intraepithelial neoplasia grade 2 or greater (CIN2+) was determined by adjudicated pathology. The AUC and related performance parameters were calculated using logistic regression with the cycle threshold (Ct) values of the channels as predictors.

RESULTS

HPV prevalence in women without and with HIV was higher in self-collected (25.1% v 61.5%) than in clinician-collected samples (16.2% v 48.4%). The optimal model to predict CIN2+ used Ct values from the three channels that detect HPV 16, 18, 45, 31, 33, 35, 52, and/or 58. AUC was superior for testing on clinician-collected (0.908) than on self-collected samples (0.878; P = .0261) in women without HIV, as well as for women living with HIV (0.868 v 0.819; clinician v self; P = .0002). Alternate approaches to handling multiple types and sequential testing approaches did not allow self-testing to achieve equivalent performance to testing on clinician-collected samples.

CONCLUSION

Using more stringent Ct cutoffs on the three channels that detect the eight highest-risk HPV types can improve the sensitivity-specificity balance of a round of screening in both self- and clinician-collected samples. Although performance of HPV testing on self-collected samples is excellent, performance parameters are better on clinician-collected samples.

Identifying Data-Driven Clinical Subgroups for Cervical Cancer Prevention With Machine Learning: Population-Based, External, and Diagnostic Validation Study

Background

Cervical cancer remains a major global health issue. Personalized, data-driven cervical cancer prevention (CCP) strategies tailored to phenotypic profiles may improve prevention and reduce disease burden.

Objective

This study aimed to identify subgroups with differential cervical precancer or cancer risks using machine learning, validate subgroup predictions across datasets, and propose a computational phenomapping strategy to enhance global CCP efforts.

Methods

We explored the data-driven CCP subgroups by applying unsupervised machine learning to a deeply phenotyped, population-based discovery cohort. We extracted CCP-specific risks of cervical intraepithelial neoplasia (CIN) and cervical cancer through weighted logistic regression analyses providing odds ratio (OR) estimates and 95% CIs. We trained a supervised machine learning model and developed pathways to classify individuals before evaluating its diagnostic validity and usability on an external cohort.

Results

This study included 551,934 women (median age, 49 years) in the discovery cohort and 47,130 women (median age, 37 years) in the external cohort. Phenotyping identified 5 CCP subgroups, with CCP4 showing the highest carcinoma prevalence. CCP2-4 had significantly higher risks of CIN2+ (CCP2: OR 2.07 [95% CI: 2.03-2.12], CCP3: 3.88 [3.78-3.97], and CCP4: 4.47 [4.33-4.63]) and CIN3+ (CCP2: 2.10 [2.05-2.14], CCP3: 3.92 [3.82-4.02], and CCP4: 4.45 [4.31-4.61]) compared to CCP1 (P<.001), consistent with the direction of results observed in the external cohort. The proposed triple strategy was validated as clinically relevant, prioritizing high-risk subgroups (CCP3-4) for colposcopies and scaling human papillomavirus screening for CCP1-2.

Conclusions

This study underscores the potential of leveraging machine learning algorithms and large-scale routine electronic health records to enhance CCP strategies. By identifying key determinants of CIN2+/CIN3+ risk and classifying 5 distinct subgroups, our study provides a robust, data-driven foundation for the proposed triple strategy. This approach prioritizes tailored prevention efforts for subgroups with varying risks, offering a novel and scalable tool to complement existing cervical cancer screening guidelines. Future work should focus on independent external and prospective validation to maximize the global impact of this strategy.

Comparison of self-collected and healthcare worker-collected rectovaginal swabs for group B streptococcus detection in pregnancy using PCR with a commercial collection-enrichment device

Introduction

Universal screening for the detection of group B streptococcus (GBS) colonization in pregnant women was recently introduced in Slovenia. The aim of our study was to determine whether self-collection of rectovaginal swabs is a valid alternative to collection by healthcare workers (HCWs).

Methods

A prospective, multicenter study was conducted between June and November 2023. A total of 227 pregnant women (aged 20 to 44 years) from the University Medical Center Ljubljana (n = 136), the Novo mesto Community Health Center (n = 48) and the Trebnje Community Health Center (n = 43) were included. Two swabs were taken: swab A by the HCWs using standard semi-solid Amies transport medium (Meus; current standard) and swab B by the pregnant woman following visual instructions using a commercial LIM Broth (Copan). Swabs were inoculated onto ChromID Strepto B (STRB) agars directly and after overnight enrichment in LIM broth. The NeuMoDx GBS assay was performed from the enrichment broth. A self-assessment questionnaire was completed after sampling. Performance characteristics were calculated and compared between different diagnostics test algorithms using McNemar's test for paired samples.

Results

Overall, GBS was detected in 18% (95% CI 13-23%; n = 40) of swabs A and 19% (95% CI 14-25%; n = 43) of swabs B. PCR was superior in both groups. In the group of swabs collected by HCWs, 4 (40 vs. 36; 11.1% difference; p = 0.046) and 3 (40 vs. 37; 8.1% difference; p = 0.083) additional positives were detected with PCR compared to direct and enrichment culture, respectively; in the group of self-collected swabs, 4 (43 vs. 39; 10.3% difference; p = 0.046) and 6 (43 vs. 36; 16.2% difference; p = 0.014) additional positives were detected with PCR compared to direct and enrichment culture, respectively. Self-collection showed a trend towards a higher diagnostic yield. PCR after enrichment from self-collected samples was found to be the most sensitive method overall. 58.5% (n = 124/212; 95% CI 52-65%) of women would prefer the swabs taken by HCWs.

Discussion

Self-collection of rectovaginal swabs during pregnancy is a good alternative to HCW-collected swabs. PCR from enrichment broth was better for the detection of GBS compared to enrichment culture. Majority of women preferred swabs taken by HCWs.

Molecular Detection of Human Papillomavirus (HPV) and Other Sexually Transmitted Pathogens in Cervical and Self-Collected Specimens

This study investigated the detection of high-risk Human Papillomavirus (hrHPV) and seven other pathogens associated with sexually transmitted infections (STIs) in matched clinician-collected cervical samples and self-taken vaginal and urine specimens collected from 342 asymptomatic women referred to colposcopy to evaluate (i) the concordance in the molecular detection of investigated pathogen in three different sample types; (ii) the analytical sensitivity and specificity of STIs detection on self-samples; and (iii) the distribution of STIs in hrHPV-positive and hrHPV-negative women. Pathogens detection was performed using Anyplex™II HR and Anyplex™II STI-7e, respectively. Good/substantial agreement was observed between cervical and self-taken samples in detecting hrHPV (κ = 0.870 and κ = 0.773 for vaginal and urine). The agreement between cervical and self-taken samples for detecting STIs was found to be significant (κ = 0.779 and κ = 0.738 for vaginal and urine), with almost perfect agreement between urine and vaginal specimens (κ = 0.899). The positivity rate for all investigated STIs was found to be higher in hrHPV-positive compared to hrHPV-negative women. In conclusion, self-sampling proved to be a valid alternative to cervical samples to detect hrHPV and STIs, but further studies are required to evaluate the role of STI coinfections in cervical lesions development and progression.

Clinical and Analytical Evaluation of the Abbott Alinity m HR HPV Assay in a New Generation First-Void Urine Collector

Urine-based self-sampling approaches can simplify cervical screening programs whilst increasing response. This study reports on the performance of Abbott Alinity m HR HPV on urine, self-collected at home using a new generation first-void urination device that is suitable for postal delivery (Novosanis Colli-Pee Small Volumes). First-void urine and paired cervical samples from 297 females attending colposcopy (age 25-65, NCT04530201) were analysed for the presence of Human Papillomavirus (HPV) DNA. Cervical disease was confirmed by colposcopy and/or histology. HPV testing on first-void urine was less sensitive for high-grade cervical intraepithelial neoplasia (CIN2 +; ratio 0.91; 95% CI: 0.83-0.99), though equally specific (< CIN2; ratio 1.04; 95% CI: 0.92-1.19) compared to cervical samples at the manufacturer established cut-off for cervical samples. Adjusting the cut-off for first-void urine improved sensitivity for CIN2+ (ratio 0.96; 95% CI: 0.90-1.03), whilst maintaining equal specificity compared to cervical samples (ratio 1.00; 95% CI: 0.88-1.14). Cohen's kappa agreements of HPV outcomes between sample pairs were good to excellent at both cut-offs (range: 0.64-0.85). Using the HPV test's adjusted cutoff for first-void urine, no difference in clinical sensitivity or specificity was observed between first-void urine and cervical samples. These data highlight the importance of evaluating self-sample-specific cut-offs for HPV assays, previously validated on cervical samples.

Beliefs and Perceptions in Attending the Cervical Screening: The COMUNISS Project Experience

BACKGROUND

Several studies highlighted that tailored health communication interventions improve cervical screening participation, vaccination coverage, and awareness about self-sampling benefits. The "COMUNISS" project was aimed at increasing awareness about cervical cancer prevention, identifying barriers to screening, and promoting screening uptake in under-screened women.

METHODS

A dedicated website with a Q&A session regarding HPV-associated diseases has been set up. Participants were invited to complete a questionnaire to gather demographic information, knowledge about HPV and cervical cancer, and attitudes toward screening based on the Health Beliefs Model (HBM). Women can also require a vaginal self-sampling kit at your home to perform the HPV-DNA analysis.

RESULTS

The website registered over 1000 users over 6 months, and 256 women completed the survey. Nearly half were under-screened. The HBM revealed a high susceptibility and severity perception of diseases, regardless of screening participation, whereas older women declared a high perception of barriers. One-quarter of the women who had requested the self-collection kit returned it for the HPV-DNA testing.

CONCLUSIONS

The project found significant gaps in knowledge regarding extra-cervical HPV-related cancers, interpretation of screening results, and effectiveness of self-collection. These findings highlight the need to plan targeted information campaigns to enhance awareness and adherence to screening programs.

A Mail-Based HPV Self-Collection Program to Increase Cervical Cancer Screening in Appalachia: Results of a Group Randomized Trial

BACKGROUND

Despite the promise of mail-based human papillomavirus (HPV) self-collection programs for increasing cervical cancer screening, few have been evaluated in the United States. We report the results of a mail-based HPV self-collection program for underscreened women living in Appalachia.

METHODS

We conducted a group randomized trial from 2021 to 2022 in the Appalachian regions of Kentucky, Ohio, Virginia, and West Virgnia. Participants were women of ages 30 to 64 years who were underscreened for cervical cancer and from a participating health system. Participants in the intervention group (n = 464) were mailed an HPV self-collection kit followed by telephone-based patient navigation (if needed), and participants in the usual care group (n = 338) were mailed a reminder letter to get a clinic-based cervical cancer screening test. Generalized linear mixed models compared cervical cancer screening between the study groups.

RESULTS

Overall, 14.9% of participants in the intervention group and 5.0% of participants in the usual care group were screened for cervical cancer. The mail-based HPV self-collection intervention increased cervical cancer screening compared with the usual care group (OR, 3.30; 95% confidence interval, 1.90-5.72; P = 0.005). One or more high-risk HPV types were detected in 10.5% of the returned HPV self-collection kits. Among the participants in the intervention group whom patient navigators attempted to contact, 44.2% were successfully reached.

CONCLUSIONS

HPV self-collection increased cervical cancer screening, and future efforts are needed to determine how to optimize such programs, including the delivery of patient navigation services.

IMPACT

Mail-based HPV self-collection programs are a viable strategy for increasing cervical cancer screening among underscreened women living in Appalachia.

Evaluation of a Self-collected Device for Human Papillomavirus Screening to Increase Cervical Cancer Screening

OBJECTIVE

The authors compared the performance of a novel self-collect device with clinician-collected samples for detection of high-risk human papillomavirus (hrHPV).

MATERIALS AND METHODS

Eighty-two (82) participants were recruited from 5 clinical sites in the United States. Each participant performed self-collect sampling using the self-collect device followed by a standard of care clinician-collected sample. Both samples were evaluated for hrHPV using polymerase chain reaction (PCR)-based HPV assays. A subset of HPV-positive samples underwent dual staining (p16/Ki-67), and concordance was evaluated. Biopsy results collected per standard of care were recorded.

RESULTS

On the Roche cobas assay, the preliminary positive percent agreement (PPA) and negative percent agreement (NPA) was 91%. Agreement for hrHPV using the BD OnClarity in PreservCyt was 100% PPA (n = 10), and 100% PPA, 93% NPA in SurePath. Dual-stain concordance was 93% (n = 16) overall, and 100% for HPV other genotypes. Seventy-one participants (n = 71; 89%) indicated they would feel confident using the self-collect device for screening if they knew they could get equal results, and 86% (n = 69) indicated that they would be more likely to get screened with this option.

CONCLUSIONS

The self-collect device shows high (>92%) positive and negative agreement for detection of HPV when compared with reference clinician-collected samples, with very high acceptability and preference. Furthermore, the self-samples collected with the self-collect device showed highly concordant results by dual stain, which is a novel and emerging application for a self-collected sampling device, thus enabling potential triage from 1 sample.

General Practitioners' Needs and Preferences Regarding the Provision of Self-sampling Tests for Cervical Cancer Screening in Flanders, Belgium

BACKGROUND

Screening coverage for cervical cancer remains suboptimal in Flanders, Belgium. The upcoming transition to primary HPV screening in January 2025 presents an opportunity to offer self-sampling kits (SSKs) as an alternative to conventional Pap smears, with the potential to increase participation rates. General practitioners (GPs) can play a crucial role in reaching under-screened populations. Hereto it is essential to understand the needs and preferences of GPs regarding the integration of SSKs into their routine practice.

METHODS

Semi-structured interviews were conducted with GPs participating in an implementation study on the added value of SSKs for long-term non-screened women, focusing on their experiences, challenges, and suggestions regarding the provision of SSKs to these patients.

RESULTS

The interviewed GPs recognized the potential of SSKs to increase participation, particularly due to their less invasive nature, which makes them more acceptable to underscreened women. Time constraints, technical software challenges, limited knowledge and doubt about SSK accuracy were identified as key barriers to implement SSKs in routine practice. GPs emphasized the need for adaptability in the distribution methods of SSKs, with many preferring a combination of mailing the SSKs and providing them in person. Personalized communication and tailored explanations were considered as crucial to ensure patient acceptance and the correct use of the tests.

CONCLUSION

This study shows that while GPs recognize the potential of SSKs to enhance cervical cancer screening, several challenges need to be addressed for their effective integration into primary care. A successful approach should incorporate streamlined support systems, tailored approaches to implement reminders for GPs and improved education for GPs. Future research should consider quantitative data on the effectiveness and cost-efficiency of SSKs in the specific context of Flanders and the perspectives of a broader range of stakeholders, including patients, practice nurses, gynecologists and policymakers, to develop more comprehensive strategies for the successful implementation of SSKs.

Self-Collection for HPV-Based Cervical Screening: Knowledge and Attitudes of Australian Health Care Workers in an Area With Low Screening Rates, July-November 2023

Cervical screening is crucial for early detection of and ultimately eliminating cervical cancer. Conventional methods for cervical screening that rely on clinician collection of specimens encounter barriers, including embarrassment, discomfort, accessibility, and cultural concerns. Self-collection offers a promising solution to promote cervical screening among underscreened populations. Both methods are available to screen eligible patients since changes to the Australian screening program in 2022. We surveyed Australian health care workers at medical practices in an area with low screening rates on their views about self-collection from July through November 2023. Findings revealed gaps in knowledge about appropriate test use and test accuracy. In addition, findings showed a preference for clinician collection and perceptions that their patients lack confidence in self-collection and lack the willingness to learn about self-collection for cervical screening. Lack of up-to-date information on self-collection logistics and accuracy and pessimistic views on the ability of patients to perform self-collection can hinder the use of self-collection for cervical screening. Addressing these concerns through comprehensive education, easy-to-access guidelines, and interventions designed to support self-collection as part of routine practice is essential, especially for improved participation among under- or never-screened patients.

Clinical accuracy of OncoPredict HPV Quantitative Typing (QT) assay on self-samples

BACKGROUND

The VALHUDES initiative was established to assess the clinical accuracy of HPV assays to detect cervical precancers using urine and vaginal self-samples compared to cervical clinician-collected samples. Here, the clinical performance of OncoPredict HPV Quantitative Typing (QT) assay (OncoPredict QT) was evaluated.

METHODS

490 women referred to colposcopy self-collected a urine and a vaginal specimen using Colli-Pee and FLOQSwab, respectively. Subsequently, a colposcopy was performed, and a cervical sample was collected with Cervex-Brush, followed by biopsy if clinically indicated. Vaginal samples were transported dry and resuspended in 5 mL of eNAT medium, whilst cervical brushings were immediately transferred in 20 mL ThinPrep.

RESULTS

The clinical sensitivity of OncoPredict HPV QT testing for CIN2+ in urine and vaginal self-samples was similar to cervical samples (ratios of 0.99 [95 % CI 0.94-1.05] and 1.00 [95 % CI 0.96-1.04]), respectively, when manufacturer's cut-offs were applied. The specificity for

CONCLUSION

Following cut-off optimisation OncoPredict HPV QT assay demonstrated similar accuracy on self-collected versus cervical samples.

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Key Words

• Cervical cancer prevention
• Diagnostic accuracy study
• HPV
• OncoPredict
• Self-sampling
• VALHUDES

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MESH Headings

• Humans
• Female
• Papillomavirus Infections/diagnosis
• Papillomavirus Infections/virology
• Sensitivity and Specificity
• Adult
• Papillomaviridae/genetics
• Papillomaviridae/isolation & purification
• Papillomaviridae/classification
• Middle Aged
• Uterine Cervical Neoplasms/virology
• Uterine Cervical Neoplasms/diagnosis
• Vagina/virology
• Uterine Cervical Dysplasia/virology
• Uterine Cervical Dysplasia/diagnosis
• Specimen Handling/methods
• Cervix Uteri/virology
• Cervix Uteri/pathology
• Viral Load
• Colposcopy
• Young Adult
• Early Detection of Cancer/methods

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Affiliation(s)

Ardashel Latsuzbaia Unit of Cancer Epidemiology, Belgian Cancer Centre, Sciensano, Brussels, Belgium
Marianna Martinelli School of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
Chiara Giubbi School of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
Kate Cuschieri Scottish HPV Reference Laboratory, Dept of Lab Medicine Royal Infirmary of Edinburgh, NHS Lothian, Edinburgh, UK; HPV Research Group, Centre for Reproductive Health, University of Edinburgh, UK
Hana Elasifer Scottish HPV Reference Laboratory, Dept of Lab Medicine Royal Infirmary of Edinburgh, NHS Lothian, Edinburgh, UK; HPV Research Group, Centre for Reproductive Health, University of Edinburgh, UK
Anna D Iacobone Preventive Gynecology Unit, European Institute of Oncology IRCCS, Milan, Italy
Fabio Bottari General Clinical Laboratory with Specialized Areas Clinical Pathology - Microbiology and Virology, European Institute of Oncology IRCCS, Milan, Italy
Andrea F Piana Department of Medicine, Surgery and Pharmacy, University of Sassari, Sassari, Italy
Roberto Pietri U.O. Coordinamento Consultori Familiari, ASSL Sassari - ATS Sardegna, Sassari, Italy
Giancarlo Tisi Gynecologic and Obstetrical Division, University of Brescia-Spedali Civili di Brescia, Brescia, Italy
Franco Odicino Gynecologic and Obstetrical Division, University of Brescia-Spedali Civili di Brescia, Brescia, Italy
Clementina E Cocuzza School of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy.
Marc Arbyn Unit of Cancer Epidemiology, Belgian Cancer Centre, Sciensano, Brussels, Belgium; Department of Human Structure and Repair, Faculty of Medicine and Health Sciences, University Ghent, Ghent, Belgium

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Human papillomavirus self-sampling versus provider-sampling in low- and middle-income countries: a scoping review of accuracy, acceptability, cost, uptake, and equity

Introduction

HPV self-sampling is a relatively new, cost-effective and widely accepted method, however, uptake in LMICs remains limited. We aimed to map out the evidence and identify gaps in accuracy, acceptability, cost, equity and uptake of self-sampling vs. provider-sampling in LMICs.

Methods

We searched: MEDLINE, EMBASE, CINAHL, SCOPUS, Web of Science, and Global Index Medicus, from 1946 to July 2023. Inclusion criteria entailed studies focusing on self-sampling alone or compared to provider-sampling for HPV testing and reporting on at least one outcome of interest (accuracy, acceptability, cost, equity, or uptake). Two authors independently screened titles, abstracts, and full texts, resolving disagreements through discussion. Data was extracted by one reviewer independently, with quality checks by senior authors, and results were synthesised narratively.

Results

Our search yielded 3,739 records, with 124 studies conducted on 164,165 women aged 15-88 years between 2000 and 2023 included. Most studies were from the African region (n = 61, 49.2%). Designs included cross-sectional (n = 90, 81.1%), randomised (n = 5, 4.5%), modelling (n = 4, 3.6%), micro-costing (n = 2, 1.8%), and non-randomised crossover (n = 1, 0.9%) studies. Outcomes included; acceptability (n = 79, 63.7%), accuracy (n = 51, 41.1%), cost (n = 7, 5.6%), and uptake (n = 7, 5.6%). Most studies reported that participants preferred self-sampling, with only a few studies (n = 7, 8.9%) studies favouring provider-sampling. The sensitivity and specificity of self-sampling ranged from 37.5-96.8% and 41.6-100.0%, respectively. One study directly compared the sensitivity and specificity of dry self-collected vs. wet provider-collected sample transportation. Laboratory costs were similar, but overall costs were lower for self-sampling. Uptake was higher for self-sampling in five of the seven studies. Most studies (n = 106) mentioned equity factors like age (n = 69, 65.1%), education (n = 68, 64.2%) and place of residence (n = 59, 55.6%) but no analysis of their impact was provided.

Conclusion

HPV self-sampling is acceptable and cost-effective but, evidence of its accuracy shows varying sensitivity and specificity. Evidence on the accuracy of dry self-collected vs. wet provider-collected sample transportation is limited. Research evaluating HPV self-sampling's accuracy, including comparisons of transportation modes, uptake, the impact of equity factors in LMICs and comparisons with high-income countries is essential to inform cervical cancer screening uptake.

Systematic review registration

https://doi.org/10.17605/OSF.IO/34TUY.

Prevalence of vaginal and cervical HPV infection among 35-year age cohort ever-married women in Kalutara district of Sri Lanka and the validity of vaginal HPV/DNA specimen as a cervical cancer screening tool: a cross-sectional study

BACKGROUND

Cervical cancer is the 2nd most common female cancer among Sri Lankan females and is almost associated with sexually transmitted cervicovaginal human papillomavirus (HPV) infection. The study objectives were to determine the prevalence of vaginal and cervical HPV infection among 35year old ever-married women and assess the validity of primary healthcare provider-collected vaginal HPV/DNA specimens as a cervical cancer screening tool to improve the coverage of the programme.

METHOD

A descriptive cross-sectional study was carried out from the 1st of September 2018 to the 31st of January 2019. Ever-married women 35 years of age in Kalutara district were the study population. Two women from each Public Health Midwife area (n = 413) were selected randomly from the relevant area eligible families register/s. HPV/DNA cervical specimen and vaginal specimen collection (n = 621) were carried out. Specimens were screened by the Cobas 4800 HPV/DNA automated Polymerase Chain Reaction (PCR) machine. Participants' profiles were recorded by the research assistants using an interviewer-administered questionnaire.

RESULTS

The overall prevalence of vaginal and cervical HPV infection was 7.08% (95% CI; 5.2-9.4%) and 6.12% (95% CI; 4.26-8.3%) respectively. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), diagnostic accuracy, and the kappa coefficient of the vaginal HPV/DNA screening method vs. cervical HPV/DNA screening method were 100%, 98.9%, 86.4%, 100%, 99% and 0.92 respectively.

CONCLUSIONS

Vaginal HPV/DNA specimen screening method can be used as a cervical cancer screening tool due to its high validity. Pilots of the feasibility should be set up before the regional or national rollout of vaginal sampling strategies.

Clinical Performance of OncoPredict HPV Screening Assay on Self-Collected Vaginal and Urine Specimens Within the VALHUDES Framework

The introduction of self-sampling in cervical cancer screening has raised the importance of HPV test validation on self-collected samples. This study aimed to evaluate the clinical accuracy of the OncoPredict HPV Screening (SCR) assay on self-collected vaginal and first-void urine (FVU) samples, relative to cervical specimens, using the VALHUDES Framework. FVU and vaginal self-samples followed by a clinician-collected cervical brushing were collected from 500 women referred to colposcopy and tested using OncoPredict HPV SCR assay. The assay demonstrated clinical sensitivity to detect cervical intraepithelial neoplasia grade 2 or worse (≥ CIN2) similar to cervical samples in FVU (ratio: 0.95, [95% CI: 0.88-1.02]) and vaginal self-samples (ratio: 0.96 [95% CI: 0.90-1.02]). The clinical specificity for < CIN2 was lower in vaginal (ratio: 0.90 [95% CI: 0.84-0.96]) but not in FVU samples (ratio: 1.03 [95% CI: 0.96-1.12) when compared to cervical samples. However, the relative specificity improved following cut-off optimization (ratio: 0.94, 95% CI: [0.88-1.01]). Moderate to excellent agreement in HPV detection between self-collected and cervical samples was demonstrated (Kappa values: 0.53-1.00). To conclude, OncoPredict HPV SCR assay demonstrated similar accuracy on FVU and cervical samples. On vaginal compared to cervical samples sensitivity was similar with a lower specificity, which improved with cut-off optimization.

Navigating the landscape of HPV-associated cancers: From epidemiology to prevention

Human Papillomavirus (HPV) is a widespread infection associated with various cancers, including cervical, oropharyngeal, anal, and genital cancers. This infection contributes to 5 % of global cancer cases annually, affecting approximately 625,600 women and 69,400 men. Cervical cancer remains the most prevalent HPV-linked cancer among females, with the highest incidence seen in low and middle-income countries (LMICs). While most HPV infections are transient, factors such as HPV variants, age, gender, and socioeconomic status influence transmission risks. HPV is categorized into high-risk (HR-HPV) and low-risk types, with strains like HPV 16 and 18 displaying distinct demographic patterns. The intricate pathogenesis of HPV involves genetic and epigenetic interactions, with HPV oncogenes (E6 and E7) and integration into host DNA playing a pivotal role in driving malignancies. Early diagnostics, utilizing HPV DNA testing with surrogate markers such as p16, and advanced molecular techniques like PCR, liquid biopsy, and NGS, significantly impact the management of HPV-induced cancers. Effectively managing HPV-related cancers demands a multidisciplinary approach, including immunotherapy, integrating current therapies, ongoing trials, and evolving treatments. Prevention via HPV vaccination and the inclusion of cervical cancer screening in national immunization programs by conventional Pap smear examination and HPV DNA testing remains fundamental.Despite the preventability of HPV-related cancers, uncertainties persist in testing, vaccination, and treatment. This review article covers epidemiology, pathogenesis, diagnostics, management, prevention strategies, challenges, and future directions. Addressing issues like vaccine hesitancy, healthcare disparities, and advancing therapies requires collaboration among researchers, healthcare providers, policymakers, and the public. Advancements in understanding the disease's molecular basis and clinical progression are crucial for early detection, proper management, and improved outcomes.

An Injection Molded SlipChip with Self-Sampling for Integrated Point-of-Care Testing of Human Papilloma Virus

High-risk human papillomavirus (HPV) screening is crucial for cervical cancer prevention. However, laboratory-based nucleic acid amplification tests (NAATs) require costly equipment, designated lab space, and skilled personnel. Additionally, cervical swabs collected by healthcare professionals can be inconvenient, uncomfortable, and reduce privacy, limiting broader application and patient compliance. A SlipChip-based Integrated Point-of-Care (SIPOC) system featuring an injection-molded SlipChip is presented with preloaded reagents for nucleic acid extraction and a portable four-channel real-time quantitative PCR instrument for detection. This system incorporates a self-sampling method that allows participants to collect their own vaginal swabs, with the β-Globin gene as a control. After testing 130 participants for HPV-16 and HPV-18, 97.7% of the self-collected samples are valid. Among valid samples, 25 tested positive for HPV-16 and 9 for HPV-18. Compared to Roche's standard HPV PCR test, the SIPOC system shows 100% positive predictive value (PPV) for both HPV-16 and HPV-18 and negative predictive values (NPVs) of 99.0% and 99.1%, respectively. This system is promising for HPV screening in resource-limited settings and adaptable for other point-of-care NAAT applications, including home testing.

Human Papillomavirus Self-Sampling for Unscreened Women Aged 24 Years During the COVID-19 Pandemic

BACKGROUND

The increasing trend of cervical cancer in women in their 20s in Japan is largely attributable to the low rate of cervical cancer screening. This study aimed to assess the usefulness of human papillomavirus (HPV) self-sampling among 24-year-old Japanese women who had never previously been screened for cervical cancer during the coronavirus disease (COVID-19) pandemic.

METHODS

In August 2021, consenting eligible women received HPV self-sampling kits. An Evalyn brush was used for self-sampling, and a Cobas 4800 PCR-based HPV DNA test was used to detect high-risk HPV genotypes. We analyzed the return rates of self-sampling kits and conducted a survey on the acceptability of the self-sampling method.

RESULTS

Of the total 1997 eligible women, 13.4% (268/1997) agreed to participate. The return rate of the kits was 72.4% (194/268), corresponding to 9.7% of the eligible population. Among the participants who returned the kits, 14.9% (29/194) tested positive for HPV, and 41.4% (12/29) of these underwent subsequent cytological testing. The questionnaire results indicated that 57.8% of participants reported no pain during self-sampling, and 72.9% expressed a willingness to continue using the self-sampling method in the future.

CONCLUSION

This study demonstrated that opt-in HPV self-sampling among 24-year-old women who had never been screened for cervical cancer had a favorable kit return rate and was well accepted by the participants, especially during the COVID-19 pandemic. However, the follow-up cytology test rates were low, highlighting the need for improved post-screening management.

Evidence from Europe on implementation, participation and performance of self-collection for cervical cancer screening

Cervical cancer screening programs reduce the number of cervical cancer cases and deaths, but the success of any screening program is dependent on high participant uptake and coverage and many European countries are observing declining cervical cancer screening coverage to below national targets. Self-collection of vaginal samples for human papillomavirus testing, also termed self-sampling, is one strategy which is being introduced to try to increase screening coverage by removing barriers to participation and it has attracted growing interest and support globally. Informed by peer-reviewed and gray literature, this narrative review starts with a case study from the Netherlands and outlines the self-collection landscape in Europe within the themes of program implementation and relative test performance. It highlights some of the current evidence gaps needed to inform policy decisions on the use of self-collection within screening programs.

The Utility of an Human Papillomavirus Genotype Assay for Cancer Screening in Self-Collected Urine and Vaginal Samples from Japanese Women

OBJECTIVES

The high incidence of invasive cervical cancer among those who have not undergone cancer screening is a serious problem. This study aimed to investigate the utility of human papillomavirus (HPV) test results from self-collected urine and vaginal samples as screening tools.

DESIGN

The study was conducted in two steps. First, the appropriate storage container, temperature, and time until urine HPV assay performance were verified. Second, the results of spot urine testing under those conditions and of gynecologist-collected cervical and self-collected vaginal samples were compared to verify the feasibility of using the BD Onclarity® HPV assay for individuals with abnormal cervical cytology.

PARTICIPANTS/MATERIALS, SETTING, METHODS

The participants were 121 women with abnormal cervical cytology. Self-collected urine and vaginal samples, along with gynecologist-collected cervical samples, were tested for HPV using the BD Onclarity® HPV assay. The optimal conditions for urine sample storage were identified by comparing the HPV detection rates under various conditions.

RESULTS

Urine stored in a BD Probe Tec™ (QxUPT) for less than 72 h at room temperature was found to have the highest HPV positivity rate. Under these conditions, the detection rates of HPV in urine, cervical, and vaginal samples were examined. HPV type 16 was detected in 41.7% of the cervical samples, type 18 in 10%, and types 31 and 52 in 12.6% each. The concordance rate for HPV testing between clinician-collected cervical and urine samples was 63.9% (kappa: 0.34; 95% CI: 0.21-0.47), and that between clinician-collected cervical and self-collected vaginal samples was 77.8% (kappa: 0.68; 95% CI: 0.53-0.83), indicating good concordance. In a population with an HPV-related lesion/tumor prevalence of approximately 70%, the sensitivity of HPV testing was 82.7% for the cervix, 46.4% for urine, and 75.7% for vaginal samples.

LIMITATIONS

The primary limitation is the lower detection rate of HPV in spot urine samples than in other sample types, indicating room for methodological improvement. The study's findings are based on a specific population, which may limit generalizability.

CONCLUSIONS

We investigated the optimal self-collected urine-to-testing time and temperature. Self-collected vaginal and urine HPV tests show moderate-high concordance with clinician-collected cervical HPV tests, suggesting their potential utility for women who do not undergo regular cancer screening. However, the sensitivity was not high in spot urine. Therefore, further large-scale studies are needed to verify these findings and optimize testing methods to encourage broader participation in cancer screening programs.

OBJECTIVES

The high incidence of invasive cervical cancer among those who have not undergone cancer screening is a serious problem. This study aimed to investigate the utility of human papillomavirus (HPV) test results from self-collected urine and vaginal samples as screening tools.

DESIGN

The study was conducted in two steps. First, the appropriate storage container, temperature, and time until urine HPV assay performance were verified. Second, the results of spot urine testing under those conditions and of gynecologist-collected cervical and self-collected vaginal samples were compared to verify the feasibility of using the BD Onclarity® HPV assay for individuals with abnormal cervical cytology.

PARTICIPANTS/MATERIALS, SETTING, METHODS

The participants were 121 women with abnormal cervical cytology. Self-collected urine and vaginal samples, along with gynecologist-collected cervical samples, were tested for HPV using the BD Onclarity® HPV assay. The optimal conditions for urine sample storage were identified by comparing the HPV detection rates under various conditions.

RESULTS

Urine stored in a BD Probe Tec™ (QxUPT) for less than 72 h at room temperature was found to have the highest HPV positivity rate. Under these conditions, the detection rates of HPV in urine, cervical, and vaginal samples were examined. HPV type 16 was detected in 41.7% of the cervical samples, type 18 in 10%, and types 31 and 52 in 12.6% each. The concordance rate for HPV testing between clinician-collected cervical and urine samples was 63.9% (kappa: 0.34; 95% CI: 0.21-0.47), and that between clinician-collected cervical and self-collected vaginal samples was 77.8% (kappa: 0.68; 95% CI: 0.53-0.83), indicating good concordance. In a population with an HPV-related lesion/tumor prevalence of approximately 70%, the sensitivity of HPV testing was 82.7% for the cervix, 46.4% for urine, and 75.7% for vaginal samples.

LIMITATIONS

The primary limitation is the lower detection rate of HPV in spot urine samples than in other sample types, indicating room for methodological improvement. The study's findings are based on a specific population, which may limit generalizability.

CONCLUSIONS

We investigated the optimal self-collected urine-to-testing time and temperature. Self-collected vaginal and urine HPV tests show moderate-high concordance with clinician-collected cervical HPV tests, suggesting their potential utility for women who do not undergo regular cancer screening. However, the sensitivity was not high in spot urine. Therefore, further large-scale studies are needed to verify these findings and optimize testing methods to encourage broader participation in cancer screening programs.

A health decision analytical model to evaluate the cost-effectiveness of female genital schistosomiasis screening strategies: The female genital schistosomiasis SCREEN framework

Female genital schistosomiasis is a chronic gynaecological disease caused by the waterborne parasite Schistosoma (S.) haematobium. It affects an estimated 30-56 million girls and women globally, mostly in sub-Saharan Africa where it is endemic, and negatively impacts their sexual and reproductive life. Recent studies found evidence of an association between female genital schistosomiasis and increased prevalence of HIV and cervical precancer lesions. Despite the large population at risk, the burden and impact of female genital schistosomiasis are scarcely documented, resulting in neglect and insufficient resource allocation. There is currently no standardised method for individual or population-based female genital schistosomiasis screening and diagnosis which hinders accurate assessment of disease burden in endemic countries. To optimise financial allocations for female genital schistosomiasis screening, it is necessary to explore the cost-effectiveness of different strategies by combining cost and impact estimates. Yet, no economic evaluation has explored the value for money of alternative screening methods. This paper describes a novel application of health decision analytical modelling to evaluate the cost-effectiveness of different female genital schistosomiasis screening strategies across endemic settings. The model combines a decision tree for female genital schistosomiasis screening strategies, and a Markov model for the natural history of cervical cancer to estimate the cost per disability-adjusted life-years averted for different screening strategies, stratified by HIV status. It is a starting point for discussion and for supporting priority setting in a data-sparse environment.

FOXP3 serum concentration; a likely predictor of CIN and cervical cancer: Secondary analysis from a case control study at a clinic in South western Uganda

Biomarkers including Forkhead/winged-helix transcription factor box P3 have been proposed in immunohistochemical techniques to diagnose cervical lesions, but can be objectively quantified and measured in blood using methods that can be standardised. In this study we quantified the serum FOXP3 concentrations and assessed their association with cervical lesions at the cervical cancer clinic of Mbarara Regional Hospital (MRRH) Southwestern Uganda. We performed secondary analysis on archived serum samples from a previous unmatched case control study in which we recruited 90 cervical cancer (CC) cases, 90 cervical intraepithelial neoplasia (CIN) cases before any form of treatment and 90 controls. Clinical and demographic data were recorded. We measured FOXP3 concentrations using quantitative ELISA. We performed descriptive statistics and logistic regression in STATA 17 and took P-values of < 0.05 as statistically significant. The mean concentration of FOXP3 was higher in serum samples from CC cases compared with CIN cases and controls, and this difference was statistically significant (P value < 0.001). More than half (52/90,58 %) of serum samples from CC cases had FOXP3 concentrations greater than 0.0545 ng/ml (P value < 0.001). Increase serum FOXP3 expression was not associated with CIN. Increase in serum FOXP3 concentrations were observed to increase the chances of CC by 2 times (OR: 2.094, P value 0.038, 95 % CI: 1.042---4.209). Serum FOXP3 is likely associated with cervical lesions especially CC in our study population. Serum FOXP3 testing may be useful in resource limited settings to aid detection of such lesions given the challenges associated with cytology and VIA. We recommend diagnostic utility studies for circulating FOXP3 as a biomarker for detection of cervical cancer.

HPV self-collection for cervical cancer screening among survivors of sexual trauma: a qualitative study

Intimate partner violence affects 20-30% of women in the United States. Disparities in routine cervical cancer surveillance have been demonstrated in certain populations, including victims of intimate partner violence (IPV). This study examined and assessed the acceptability of high-risk HPV (hrHPV) self-collection among individuals who have experienced IPV. We conducted an observational study using qualitative data collection and analysis. We interviewed individuals with a history of IPV and who currently reside in Oregon. This study identified key themes describing knowledge and attitudes towards cervical cancer screening for individuals who have experienced IPV. They include: guideline knowledge, prior office-based cervical cancer screening experience, barriers to cervical cancer screening, at-home hrHPV self-collection experience, and testing confidence. Participants experienced fewer barriers and expressed increased comfort and control with hrHPV self-collection process. Individuals with a history of IPV have lower rates of cervical cancer screening adherence and higher rates of cervical dysplasia and cancer than other populations. The patient-centered approach of hrHPV self-collection for cervical cancer screening can reduce barriers related to the pelvic exam and empower patients to reduce their risks of developing cervical cancer by enabling greater control of the testing process.

Early adoption of innovation in HPV prevention strategies: closing the gap in cervical cancer

Cervical cancer (CC) is one of the highest prevailing causes of female cancer-related mortality globally. A significant discrepancy in incidence has been noted between high and low-middle-income countries. The origins of CC have been accredited to the human papillomavirus (HPV) with serotypes 16 and 18 being the most prevalent. HPV vaccines, with 90%-97% efficacy, have proven safe and currently function as the primary prevention method. In addition, secondary prevention by timely screening can potentially increase the 5-year survival rate by >90%. High-precision HPV DNA testing has proven to be both highly sensitive and specific for early detection and is advocated by the WHO. Lack of public awareness, poor screening infrastructure and access to vaccines, socio-cultural concerns, along with economic, workforce-associated barriers and the presence of marginalised communities unable to access services have contributed to a continued high incidence. This article comprehensively analyses the efficacy, coverage, benefits and cost-effectiveness of CC vaccines and screening strategies including the transition from cytological screening to HPV self-sampling, while simultaneously exploring the real-world disparities in their feasibility. Furthermore, it calls for the implementation of population-based approaches that address the obstacles faced in approaching the WHO 2030 targets for CC elimination.

Invitation strategy of vaginal HPV self-sampling to improve participation in cervical cancer screening: a systematic review and meta-analysis of randomized trials

BACKGROUND

Human papillomavirus (HPV) self-sampling is recognized as a feasible option for enhancing screening for cervical cancer, particularly among hard-to-reach women. The magnitude of the effectiveness of screening participation under different invitation strategies was reported. This review seeks to compare the effectiveness of invitation strategies in increasing screening participation of HPV self-sampling across diverse study settings.

METHODS

A systematic literature search was conducted in Embase, MEDLINE, and PubMed in April 2023. Articles were included if (1) their target participants were aged between 25 and 70 years; (2) participants in the intervention arm were randomized to receive HPV self-sampling devices through various invitation strategies; (3) participants in the control arm who either received invitations for cervical cancer screening other than HPV self-sampling or opportunistic screening as usual care; (4) studies that provided sufficient data on screening participation in HPV self-sampling as outcome measured. The study design of the included articles was limited to randomized controlled trials.

RESULTS

A total of 15 articles were included in this review. Invitation strategies of disseminating HPV self-sampling devices included opt-out and opt-in. Meta-analysis revealed screening participation in the self-sampling group was significantly greater than control arm (OR 3.43, 95% CI 1.59-7.38), irrespective of the invitation strategy employed. Among invitation strategies, opt-out appeared to be more effective on increasing screening participation, compared to control and opt-in strategy (opt-out vs. control OR 3.91, 95% CI 1.82-8.42; opt-in vs. control OR 1.34, 95% CI 0.28-6.39).

CONCLUSIONS

Opt-out strategy is more successful at improving screening participation compared to opt-in and routine invitation to cervical screening. It is therefore a promising way to improve participation in cervical cancer screening. The findings of this review provide important inputs to optimize strategies for inviting women to participate in vaginal HPV self-sampling across the study setting, thus improving participation in cervical cancer screening.

Epidemiology Characteristics and Potential Cervical Cancer Screening Value of Vulvar Human Papillomavirus in Chinese Women: A Multicenter Cross-Sectional Study

CONTEXT.—

Noninvasive self-sampling is a convenient option that may be highly accepted by women for home-based detection, which could increase the screening rate for cervical cancer (CC) and reduce its incidence and mortality.

OBJECTIVE.—

To compare the distribution of high-risk human papillomavirus (hr-HPV) between the vulva and cervix and to explore the clinical value of vulvar HPV detection in CC screening.

DESIGN.—

The study was nested within a clinical trial on a recombinant HPV 9-valent vaccine for women ages 20 to 45 years. Women with paired vulvar and cervical specimens were included and underwent cytology and HPV detection. The consistency of HPV detection between vulvar and cervical specimens was evaluated using Cohen κ statistics. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were used to evaluate the diagnostic accuracy of primary CC screening. The primary end points were cervical intraepithelial neoplasia (CIN) grade 2/3 or worse (CIN2+/3+).

RESULTS.—

A total of 7999 women were enrolled, and 83/33 cases were diagnosed as CIN2+/CIN3+. The HPV-positive rate in vulvar specimens (1785 of 7999; 22.32%) was higher than that in cervical specimens (1390 of 7999; 17.38%), and there were no significant differences in the distribution of hr-HPV genotypes between the vulva and cervix in patients with CIN2+/CIN3+. Vulva-based HPV primary screening showed sensitivity, specificity, PPV, and NPV comparable to those for cervix-based HPV primary CC screening in the detection of CIN3+.

CONCLUSIONS.—

The distribution of vulvar and cervical HPV was similar in patients with CIN2+/CIN3+. Vulva-based HPV primary CC screening had acceptable diagnostic efficacy and might be used as a modality for primary CC screening.

The ESSAG-trial protocol: A randomized controlled trial evaluating the efficacy of offering a self-sampling kit by the GP to reach women underscreened in the routine cervical cancer screening program

BACKGROUND

In Flanders (Belgium), women not screened for cervical cancer (CC) within the last three years receive an invitation letter from the regional screening organization, the Centre for Cancer Detection (CCD), encouraging them to have a cervical specimen taken by their general practitioner (GP) or gynecologist. However, the coverage for CC screening remains suboptimal (63%). The offer of a self-sampling kit (SSK, for HPV testing) by a GP may trigger participation among women who do not attend regular screening.

METHODS

The ESSAG-trial is a cluster-randomized controlled trial with three arms, each including 1125 women aged 31-64 years, who were not screened for CC in the last 6 years. In arm A, GPs offer a SSK when eligible women consult for any reason. In arm B, women receive a personal GP signed invitation letter including an SSK at their home address. In the control arm, women receive the standard invitation letter from the CCD. The primary outcome is the response rate at three months after inclusion. Secondary outcomes are: screen test positivity; compliance with foreseen follow-up among screen-positives; costs per invited and per screened women; as well as contrasts between trial arms and between socio-demographic categories.

CONCLUSION

The ESSAG-trial will assess the effect of GP-based interventions using SSKs on CC screening participation among hard-to-reach populations. Findings will inform policymakers about feasible strategies on increasing CC screening that may be rolled-out throughout the whole region.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT05656976.

Self-Collection for HPV Testing: Potential Issues Related to Performance Measures and Quality Improvement Among Federally Qualified Health Centers

CONTEXT

Most incident cases of cervical cancer in the United States are attributable to inadequate screening. Federally qualified health centers (FQHCs) serve a large proportion of women who are low-income, have no insurance, and are underserved-risk factors for insufficient cervical cancer screening. FQHCs must maintain quality measures to preserve their accreditation, address financial reimbursements, and provide quality care. Implementation of human papillomavirus (HPV) self-collection can improve cervical cancer screening coverage within FQHCs.

OBJECTIVES

To understand perspectives from clinical personnel on current cervical cancer screening rates at FQHCs in North Carolina and the impact of implementing HPV self-collection among underscreened patients on screening rates and performance measures.

DESIGN

The study used focus groups and key informant interviews. Coding-based thematic analysis was applied to both focus group and interview transcripts. Emergent themes regarding perspectives on self-collection implementation were mapped onto Consolidated Framework for Implementation Research (CFIR) constructs to identify future barriers and facilitators to implementation.

SETTING

Two FQHCs in North Carolina and a cloud-based videoconferencing platform.

PARTICIPANTS

Six FQHCs in North Carolina; 45 clinical and administrative staff from the 6 FQHCs; 1 chief executive officer (n = 6), 1 senior-level administrator (n = 6), 1 chief medical officer (n = 6), and 1 clinical data manager (n = 6) from each FQHC.

MAIN OUTCOME MEASURE

Achievement of clinical perspectives.

RESULTS

Societal-, practice-, and patient-level factors currently contribute to subpar cervical cancer screening rates. HPV self-collection was expected to improve screening uptake among underscreened women at FQHCs, and thus quality and performance measures, by offering an alternative screening approach for in-clinic or at-home use. Implementation barriers include financial uncertainties and HPV self-collection not yet a Food and Drug Administration-approved test.

CONCLUSION

HPV self-collection has potential to improve cervical cancer screening quality and performance measures of FQHCs. For a successful implementation, multilevel factors that are currently affecting low screening uptake need to be addressed. Furthermore, the financial implications of implementation and approval of HPV self-collection as a test for cervical cancer screening quality measures need to be resolved.

Effectiveness of self-sampling human papillomavirus test on precancer detection and screening uptake in Japan: The ACCESS randomized controlled trial

Japan is lagging in cervical cancer prevention. The effectiveness of a self-sampling human papillomavirus (HPV) test, a possible measure to overcome this situation, has not yet been evaluated. A randomized controlled trial was performed to evaluate the effectiveness of a self-sampling HPV test on detection of cervical intraepithelial neoplasia grade 2 or worse (CIN2+) and screening uptake. Women between 30 and 58 years old who did not participate in the cervical cancer screening program for ≥3 years were eligible and assigned to the intervention group (cytology or self-sampling HPV test) or control group (cytology). Participants assigned to the intervention group were sent a self-sampling kit according to their ordering (opt-in strategy). A total of 7337 and 7772 women were assigned to the intervention and control groups, respectively. Screening uptake in the intervention group was significantly higher than that in the control group (20.0% vs. 6.4%; risk ratio: 3.10; 95% confidence interval [CI]: 2.82, 3.42). The compliance rate with cytology triage for HPV-positive women was 46.8% (95% CI: 35.5%, 58.4%). CIN2+ was detected in five and four participants in the intervention and control groups, respectively; there was no difference for intention-to-screen analysis (risk ratio: 1.32; 95% CI: 0.36, 4.93). Self-sampling of HPV test increased screening uptake; however, no difference was observed in the detection of CIN2+, probably due to the low compliance rate for cytology triage in HPV-positive women. Efforts to increase cytology triage are essential to maximize precancer detections.

Cost-utility analysis of primary HPV testing through home-based self-sampling in comparison to visual inspection using acetic acid for cervical cancer screening in East district, Sikkim, India, 2023

INTRODUCTION

Primary Human Papilloma Virus (HPV) testing offers higher sensitivity and specificity over Visual Inspection using Acetic acid (VIA) in cervical cancer screening. Self-sampling is a promising strategy to boost participation and reduce disparities. However, concerns about the initial costs hinder HPV testing adoption in low and middle-income countries. This study assesses the cost-utility of home-based HPV self-sampling versus VIA for cervical cancer screening in India.

METHODS

A cross-sectional study was conducted in East district, Sikkim, India, comparing the costs and utility outcomes of population-based cervical cancer screening through VIA and primary HPV screening through self-sampling. Cost-related data were collected from April 2021 to March 2022 using the bottom-up micro-costing method, while utility measures were collected prospectively using the EuroQoL-5D-5L questionnaire. The utility values were converted into quality-adjusted life days (QALDs) for an 8-day period. The willingness to pay threshold (WTP) was based on per capita GDP for 2022. If the calculated Incremental Cost-Effectiveness Ratio (ICER) value is lower than the WTP threshold, it signifies that the intervention is cost-effective.

RESULTS

The study included 95 women in each group of cervical cancer screening with VIA & HPV self-sampling. For eight days, the QALD was found to be 7.977 for the VIA group and 8.0 for the HPV group. The unit cost per woman screened by VIA and HPV self-testing was ₹1,597 (US$ 19.2) and ₹1,271(US$ 15.3), respectively. The ICER was ₹-14,459 (US$ -173.6), which was much below the WTP threshold for eight QALDs, i.e. ₹ 4,193 (US$ 50.4).

CONCLUSION

The findings support HPV self-sampling as a cost-effective alternative to VIA. This informs policymakers and healthcare providers for better resource allocation in cervical cancer screening in Sikkim.

Questionnaire-Based Study on the Knowledge of Cervical Cancer and Attitude and Perception Toward Self-Sampling Method of Screening, Among Women in Sikkim, India

Background

Cervical cancer (CC) is the second most common cancer among women in India and in Sikkim. Screening helps in prevention and early detection of the disease; however, pelvic examination for smear collection is not preferred by many. Self-sampling method can be a good alternative for collection of smears, thus increasing screening uptake. Therefore, a study was conducted to evaluate perception about self-sampling method of screening among women in Sikkim.

Methodology

A total of 210 women who consented for this study were screened for cervical cancer using Pap smear and HPV DNA. Women were taught to collect their self-sample for HPV DNA test. Questionnaires were used to assess their attitude toward self-sampling prior to collection of samples and perception, post-collection.

Results

Seventy-percent women knew that CC is the most common cancer among women in Sikkim. 73% knew that it could be prevented, but only 57% had knowledge about screening facilities in Sikkim. 50% women knew about HPV vaccination program in Sikkim. 96% women had never done a self-sampling, while 67% had never heard about it. There was a significant change (p value < 0.00001) in perception toward self-sampling after the procedure. Comparative analysis showed that women found self-collection easier than expected. If they had a choice, they would prefer self-sampling over physician sampling; however, due to their trust in physicians they still believed physician collected sample would be better.

Conclusion

Self-sampling is a socially acceptable screening technique and can increase compliance among socially shy community.

Empowering the on-site detection of nucleic acids by integrating CRISPR and digital signal processing

Addressing the global disparity in cancer care necessitates the development of rapid and affordable nucleic acid (NA) testing technologies. This need is particularly critical for cervical cancer, where molecular detection of human papillomavirus (HPV) has emerged as an accurate screening method. However, implementing this transition in low- and middle-income countries has been challenging due to the high costs and centralized facilities required for current NA tests. Here, we present CreDiT (CRISPR Enhanced Digital Testing) for on-site NA detection. The CreDiT platform integrates i) a one-pot CRISPR strategy that simultaneously amplifies both target NAs and analytical signals and ii) a robust fluorescent detection based on digital communication (encoding/decoding) technology. These features enable a rapid assay (<35 minutes) in a single streamlined workflow. We demonstrate the sensitive detection of cell-derived HPV DNA targets down to single copies and accurate identification of HPV types in clinical cervical brushing specimens (n = 121).

Rationale and design of the Self-TI Study protocol: a cross-sectional human papillomavirus self-testing pilot study among transgender adults in England

INTRODUCTION

Persistent infection with high-risk human papillomavirus (HPV) is the causal agent of several cancers including cervical, anal and oropharyngeal cancer. Transgender men and transmasculine non-binary (TMNB) people with a cervix are much less likely to undergo cervical cancer screening than cisgender women. Transgender women and transfeminine non-binary (TWNB) people assigned male at birth may be at increased risk of HPV. Both TMNB and TWNB people face many barriers to HPV testing including medical mistrust due to stigma and discrimination.

METHODS AND ANALYSIS

The Self-TI Study (Self-TI) is a pilot study designed to measure acceptability and feasibility of HPV self-testing among transgender and non-binary people in England. TMNB people aged 25-65 years, with at least 1 year of testosterone, and TWNB people, aged 18 years and over, are eligible to participate. Participants self-collect up to four samples: an oral rinse, a first void urine sample, a vaginal swab (if applicable) and an anal swab. TMNB participants are asked to have an additional clinician-collected cervical swab taken following their routine Cervical Screening Programme sample. TWNB people are asked to take a self-collection kit to perform additional self-collection at home and mail the samples back to the clinic. Acceptability is assessed by a self-administered online survey and feasibility is measured as the proportion of samples returned in the clinic and from home.

ETHICS AND DISSEMINATION

Self-TI received ethical approval from the Research Ethics Committee of Wales 4 and ethical review panel within the Division of Cancer Epidemiology and Genetics at the US National Cancer Institute. Self-TI was coproduced by members of the transgender and non-binary community, who served as authors, collaborators and members of the patient and public involvement (PPI) group. Results of this study will be shared with the community prior to being published in peer-reviewed journals and the PPI group will help to design the results dissemination strategy. The evidence generated from this pilot study could be used to inform a larger, international study of HPV self-testing in the transgender and non-binary community.

TRIAL REGISTRATION NUMBER

NCT05883111.

Evaluation of a novel vaginal cells self-sampling device for human papillomavirus testing in cervical cancer screening: A clinical trial assessing reliability and acceptability

Cervical cancer is a significant public health concern, particularly in low- and middle-income countries where resources for prevention and treatment are limited. Routine screening, such as the Papanicolaou test (Pap smears) and human papillomavirus (HPV) testing, plays a crucial role in the early detection and prevention of cervical cancer. However, the participation rate in cervical cancer screening programs remains below optimal levels due to various factors. This study aimed to evaluate the reliability and acceptability of the HygeiaTouch Self Sampling Kit for Women in collecting vaginal samples for HPV typing, comparing the results with samples collected by physicians. The study included 1210 women aged 21-65 from three medical centers in Taiwan. The findings indicated that the self-sampling kit was as effective as physician-collected specimens in terms of obtaining valid samples and identifying HPV. The agreement between the two methods was 88%, with a κ value of 0.75. Furthermore, the study assessed the mechanical characteristics of the self-sampling applicator through tensile, bending, and torque tests, and determined that it was safe for intravaginal use. Additionally, the study evaluated the safety and satisfaction of self-sampling and found a low rate of adverse events (0.7%) and high levels of satisfaction (over 90%) among participants. Overall, we demonstrated that the HygeiaTouch Self Sampling Kit for Women is a reliable and acceptable device for HPV testing and cervical screening, providing a convenient, safe, and effective alternative for women.

Findings and Challenges in Replacing Traditional Uterine Cervical Cancer Diagnosis with Molecular Tools in Private Gynecological Practice in Mexico

We have been encouraging practicing gynecologists to adopt molecular diagnostics tests, PCR, and cancer biomarkers, as alternatives enabled by these platforms, to traditional Papanicolaou and colposcopy tests, respectively. An aliquot of liquid-based cytology was used for the molecular test [high-risk HPV types, (HR HPV)], another for the PAP test, and one more for p16/Ki67 dual-stain cytology. A total of 4499 laboratory samples were evaluated, and we found that 25.1% of low-grade samples and 47.9% of high-grade samples after PAP testing had a negative HR HPV-PCR result. In those cases, reported as Pap-negative, 22.1% had a positive HR HPV-PCR result. Dual staining with p16/Ki67 biomarkers in samples was positive for HR HPV, and 31.7% were also positive for these markers. Out of the PCR results that were positive for any of these HR HPV subtypes, n 68.3%, we did not find evidence for the presence of cancerous cells, highlighting the importance of performing dual staining with p16/Ki67 after PCR to avoid unnecessary colposcopies. The encountered challenges are a deep-rooted social reluctance in Mexico to abandon traditional Pap smears and the opinion of many specialists. Therefore, we still believe that colposcopy continues to be a preferred procedure over the dual-staining protocol.

High-Risk Genotypes of Human Papillomavirus at Diverse Anogenital Sites among Chinese Women: Infection Features and Potential Correlation with Cervical Intraepithelial Neoplasia

BACKGROUND

Both cervical cancer and cervical intraepithelial neoplasia (CIN) are associated with human papillomavirus (HPV) infection at different anogenital sites, but the infection features of high-risk (HR) HPVs at these sites and their association with cervical lesions have not been well characterized. Given the limitation of cervical HPV 16/18 test in screening patients with high-grade CIN (CIN 2+), studies on whether non-16/18 HR-HPV subtype(s) have potential as additional indicator(s) to improve CIN 2+ screening are needed.

METHODS

The infection of 15 HR-HPVs in vulva, anus, vagina, and cervix of 499 Chinese women was analyzed, and CIN lesion-associated HR-HPV subtypes were revealed.

RESULTS

In addition to the well-known cervical-cancer-associated HPV 16, 52, and 58, HPV 51, 53, and 56 were also identified as high-frequency detected subtypes prevalently and consistently present at the anogenital sites studied, preferentially in multi-infection patterns. HPV 16, 52, 58, 56, and 53 were the top five prevalent subtypes in patients with CIN 2+. In addition, we found that cervical HPV 33/35/52/53/56/58 co-testing with HPV 16/18 might improve CIN 2+ screening performance.

CONCLUSION

This study provided a new insight into HR-HPV screening strategy based on different subtype combinations, which might be used in risk stratification clinically.

Evaluation of two alternative non-alcohol-based media for the suspension of self-collected vaginal swabs for HPV testing in cervical cancer screening

The introduction of Human Papillomavirus (HPV) testing in cervical cancer screening enhanced the opportunity to introduce self-collection as an innovative approach to improve coverage rates. Validation and standardization of the pre-analytical and analytical procedures are crucial for the quality assurance of HPV tests on self-collected samples. This study evaluated the analytical performance and the stability of self-collected vaginal samples resuspended in 5 mL of two non-alcohol-based media, eNat® and MSwab® compared to a professionally collected cervical sample, resuspended in 20 mL ThinPrep®, for the detection of high-risk HPV (hrHPV). The impact of the suspension volumes on analytical performance was also evaluated (2 and 5 ml). A good analytical concordance in hrHPV detection in cervical and vaginal self-collected swabs suspended in 5 ml of both non-alcohol-based media was demonstrated (eNat®: 91.2 %, k = 0.821; MSwab®: 91.4 %; k = 0.798). A similar analytical performance was found for samples resuspended in 2 mL (eNat®: 92.9 %, k = 0.811; MSwab®: 92.9 %, k = 0.811) compared to cervical samples. Good nucleic acid stability was demonstrated for vaginal samples stored at 20-25 °C and 37 °C for up to 4 weeks. Results of this preliminary study support the introduction of these media for vaginal self-sampling-based prevention programs. Nevertheless, further research is necessary to evaluate clinical accuracy in larger settings.

Comparison of the ScreenFire and Xpert HPV assays for the detection of human papillomavirus and cervical precancer among women living with HIV in Malawi

BACKGROUND

The World Health Organization recommends human papillomavirus (HPV) testing for primary cervical cancer screening, including among women living with HIV (WLWH). Low-and-middle-income countries account for 85% of the cervical cancer burden globally, yet have limited access to HPV-based screening, largely due to cost. This study aims to compare the performance of a rapid, isothermal amplification HPV assay (ScreenFire) to that of the Xpert HPV assay for the detection of HPV and cervical precancer among WLWH in Malawi.

METHODS

We utilized stored self- and provider-collected specimens from a prospective cohort study of WLWH in Malawi from July 2020 to February 2022. Specimens were tested with both Xpert and ScreenFire HPV assays. The overall and within-channel non-hierarchical agreement between ScreenFire and Xpert was determined for both self- and provider-collected specimens. Hierarchical ScreenFire HPV positivity by channel was compared to Xpert for each histological diagnosis-cervical intraepithelial neoplasia grade 2 or worse (CIN2+) compared to

RESULTS

315 matched self- and provider-collected specimens had valid results from both Xpert and ScreenFire testing and were included in analyses, of which 279 and 36 were HPV positive and HPV negative, respectively, on Xpert self-collection. Of the 315, 245 (78%) had normal pathology, 21 CIN1 (7%), 14 CIN2 (4%), and 35 CIN3 (11%). Of the 245 with normal pathology, 213 (87%) and 188 (77%) were HPV-positive on Xpert and ScreenFire self-collected specimens, respectively. Among provider-collected specimens, the assays had 80% agreement on overall HPV positivity (unweighted kappa 0.59, 95% 0.50-0.69). ScreenFire was HPV-positive in 90% of self-collected specimens that were HPV-positive on Xpert. Channel agreement between the assays was high for both self- and provider-collected specimens, but slightly lower for HPV18/45. In hierarchical analysis, ScreenFire demonstrated high concordance with Xpert testing for detecting CIN2+ cases in all channels, missing no HPV 16 or HPV 18/45 positive CIN2+ case that was positive on Xpert, in both self- and provider-collected specimens.

CONCLUSION

In this study of stored specimens, the ScreenFire HPV assay performed well in the detection of HPV and CIN2+ among WLWH compared to the Xpert HPV assay. If supported by larger validation studies, ScreenFire could be an affordable alternative point-of-care HPV assay for use in LMICs.

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Grants

• K12 HD103085 NICHD NIH HHS
• K12HD103085 Eunice Kennedy Shriver National Institute of Child Health & Human Development of the National Institutes of Health
• Eunice Kennedy Shriver National Institute of Child Health & Human Development of the National Institutes of Health

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Affiliation(s)

Chemtai Mungo Department of Obstetrics and Gynecology, University of North Carolina-Chapel Hill, Chapel Hill, NC, USA.
Anagha Guliam Barnard College of Columbia University, New York City, NY, USA
Lameck Chinula Department of Obstetrics and Gynecology, University of North Carolina-Chapel Hill, Chapel Hill, NC, USA University of North Carolina Project-Malawi, Lilongwe, Malawi
Federica Inturrisi Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Rockville, MD, USA
Lizzie Msowoya University of North Carolina Project-Malawi, Lilongwe, Malawi
Tawonga Mkochi University of North Carolina Project-Malawi, Lilongwe, Malawi
Siniya Jawadu University of North Carolina Project-Malawi, Lilongwe, Malawi
Silvia de Sanjosé Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Rockville, MD, USA ISGlobal, Barcelona, Spain
Mark Schiffman Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Rockville, MD, USA
Jennifer H Tang Department of Obstetrics and Gynecology, University of North Carolina-Chapel Hill, Chapel Hill, NC, USA University of North Carolina Project-Malawi, Lilongwe, Malawi
Jennifer S Smith Gillings School of Global Public Health, University of North Carolina-Chapel Hill, Chapel Hill, NC, USA

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Culturally Competent Education and Human Papillomavirus Self-Sampling Achieves Healthy People 2030 Cervical Screening Target Among Low-Income Non-Hispanic Black and Hispanic Women

PURPOSE

Disparities in cervical cancer screening, incidence, and mortality exist in the United States. Cervical cancer incidence and mortality rates in Texas are 20% and 32% higher, respectively, than national averages. Within Texas, these rates are significantly higher among non-Hispanic (NH) Black and Hispanic women. Cervical cancer screening uptake is lower among NH Black and Hispanic women (72.9% and 75.9%, respectively) compared with White women (85.5%) in Texas.

METHODS

During March-August 2023, we conducted a pilot study that offered culturally competent education and human papillomavirus (HPV) self-sampling kits to women in two public housing projects in Houston, TX, that have predominantly NH Black or Hispanic residents. Among those eligible for cervical cancer screening, 35% (n = 24) of the NH Black and 34% (n = 16) of the Hispanic women were found to be underscreened per the US Preventive Services Task Force Guideline. We recruited 40 (24 NH Black and 16 Hispanic) eligible women for our study. The study was approved by the MD Anderson institutional review board and registered with ClinicalTrials.gov (NCT04614155-March 11, 2020).

RESULTS

Seventy-five percent of the NH Black and 87% of the Hispanic participants completed the HPV self-sampling procedures per protocol. Samples of 17% NH Black and 12% Hispanic participants showed a performance error. Overall, cervical cancer screening uptake improved from 65% to 91% among NH Black and from 66% to 96% among Hispanic participants.

CONCLUSION

Culturally competent education and HPV self-sampling resulted in remarkable improvement in cervical cancer screening uptake among underscreened NH Black and Hispanic women residents of Houston public housing projects. Implementing this strategy could significantly reduce cervical cancer incidence and mortality among similar populations in the United States and globally.

Attitude toward human papillomavirus self-sampling and associated factors among Thai women undergoing colposcopy

OBJECTIVE

To compare attitudes toward self-sampling for human papillomavirus (HPV) testing before and after specimen collection in women undergoing colposcopy. The factors associated with the pre-sampling attitude were also studied.

METHODS

This prospective study enrolled women with abnormal cervical cytology and/or positive high-risk HPV who attended colposcopy clinics at 10 cancer centers in Thailand between October 2021 and May 2022. Prior to colposcopy, the attitudes of the women toward self-sampling were surveyed through a questionnaire. Written and verbal instructions for self-sampling were provided before the process and subsequent colposcopy. The attitudes toward self-sampling were reassessed after the actual self-sampling. Factors associated with the attitudes were analyzed.

RESULTS

A total of 499 women were included in this study. The mean age was 39.28±11.36 years. A total of 85.3% were premenopause, and 98.8% had sexual experience. With the full score of 45, the attitude score after self-sampling was significantly higher than the attitude score before self-sampling (39.69±5.16 vs. 37.76±5.71; P<0.001). On univariate analysis, the factors associated with attitude before HPV self-sampling were age, menopausal status, sexual activity, education level, income, knowledge regarding HPV, and prior high-grade squamous intraepithelial lesion histology. The remaining significant factor on multivariate analysis was sexual activity within the past year (B=0.105, 95% confidence interval, 0.014-2.870; P=0.048).

CONCLUSION

Attitudes toward self-sampling improved after the actual self-sampling process, as evidenced by higher attitude scores. Sexual activity was the only independent factor related to the attitude before self-sampling.

Practitioners support and intention to adopt universal access to self-collection in Australia's National Cervical Screening Program

OBJECTIVE

Primary care practitioners are crucial to engaging people in Australia's national cervical screening program. From July 2022, practitioners have been able to offer all screen-eligible people the choice to collect their own self-collected sample; an option introduced to increase equity. This study explored how practitioners are intending to incorporate universal access to self-collection into their clinical care.

METHODS

Semi-structed interviews with 27 general practitioners, nurses, and practice managers from 10 practices in Victoria, Australia conducted between May and August 2022. Interviews were deductively coded, informed by the Consolidated Framework for Implementation Research. The Diffusion of Innovations theory was used to categorise intention to provide self-collection.

RESULTS

Participants were supportive of universal access to self-collection, citing benefits for screen-eligible people and that it overcame the limited adaptability of the previous policy. Most participants' practices (n = 7, 70%) had implemented or had plans to offer the option for self-collection to all. Participants deliberating whether to provide universal access to self-collection held concerns about the correct performance of the self-test and the perceived loss of opportunity to perform a pelvic examination. Limited time to change practice-level processes and competing demands within consultations were anticipated as implementation barriers.

CONCLUSIONS

The extent to which self-collection can promote equity within the program will be limited without wide-spread adoption by practitioners. Communication and education that addresses concerns of practitioners, along with targeted implementation support, will be critical to ensuring that self-collection can increase participation and Australia's progression towards elimination of cervical cancer.

Acceptability of self-collected vaginal samples for human papillomavirus testing for primary cervical cancer screening: comparison of face-to-face and online recruitment modes

BACKGROUND

This study aimed to assess the acceptability and attitudes of women towards human papillomavirus (HPV) self-sampling and compare the effectiveness of two delivery modes utilising face-to-face and online website for cervical cancer screening in Hong Kong.

METHODS

Women aged 30-65 years were invited to participate by distributing the study information pamphlets at the specialist clinics of a regional acute hospital. Those who were interested in participating were given the option to join directly face-to-face or through an online website. All participants provided informed consent and received self-sampling kits and acceptability questionnaires either immediately (face-to-face) or through the post after registering at the website (online). All participants were requested to collect their own vaginal samples using a swab which was then brushed on a DNA sample storage card and returned to the hospital either in person or by post. The self-collected samples were tested for high-risk HPV using the Sentis™ HPV assay, a validated isothermal nucleic acid amplification real-time fluorescent detection assay. The primary outcome was the uptake rate of HPV self-sampling.

RESULTS

Of the 1998 women recruited (1200 face-to-face, 798 online), 1377 returned their samples, giving an overall uptake rate of 68.9%. The uptake rate was significantly greater in the face-to-face mode than in the online mode (74.6% vs. 60.4%, p < 0.001). The median age of the participants was 49 years, 43.7% were never or under-screened, and 7.1% had high-risk HPV detected. Overall, 82.1% of the participants reported self-sampling convenient, and 79.3% were not embarrassed when collecting self-samples. However, only 49.8% were confident that they had collected the self-samples correctly. Most (91.1%) of the participants expressed willingness to perform self-sampling again, mostly because it was simple (79.2%) and quick (56.3%).

CONCLUSIONS

HPV self-sampling can serve as an alternative primary screening method for cervical cancer in Hong Kong, especially for individuals who have not been adequately screened in the past. Both face-to-face and online website recruitment were associated with high acceptability, emphasising the potential benefits of utilising different platforms and strategies for reaching diverse populations.

Direct mailing of HPV self-sampling kits to women aged 50-65 non-participating in cervical screening in the Czech Republic

BACKGROUND

A population-based cervical cancer screening programme is implemented in the Czech Republic. However, participation is insufficient among women over 50 years. This study aimed to estimate the potential improvement in participation through directly mailed HPV self-sampling kits (HPVssk) compared with standard invitation letters in women aged 50-65 non-participating in screening.

METHODS

The study recruited 1564 eligible women (no cervical cancer screening in the last 3 years or more, no previous treatment associated with cervical lesions or cervical cancer). Eight hundred women were mailed with an HPVssk (HPVssk group), and 764 women were sent a standard invitation letter (control group) inviting them to a routine screening (Pap test). The primary outcome was a comparison of the overall participation rate between study groups using a binominal regression model.

RESULTS

The participation rate in the HPVssk group was 13.4% [95% confidence interval (CI) 11.2-15.9%; 7.4% of women returned the HPVssk and 6.0% attended gynaecological examination] and 5.0% (95% CI 3.6-6.8%) in the control group. Using the binominal regression model, the difference between the groups was estimated as 7.6% (95% CI 5.0-10.2%; P < 0.001). In the HPVssk group, 22% of women who returned HPVssk had a positive result and 70% of them underwent a follow-up examination.

CONCLUSIONS

Compared with traditional invitation letters, the direct mailing of the HPVssk achieved a significantly higher participation rate, along with a notable HPV positivity rate among HPVssk responders. This approach offers a potentially viable method for engaging women who have not yet attended a cervical screening programme.

Validation of the clinical performance and reproducibility of the NeuMoDx HPV assay self-sample workflow

BACKGROUND

Human papillomavirus (HPV) testing on self-samples is a valid tool for cervical cancer screening. HPV self-sample workflows need to be clinically validated to ensure safe use in screening.

OBJECTIVE

This study evaluated the fully automated NeuMoDx HPV Assay self-sample workflow that is compiled of the NeuMoDx HPV assay and the NeuMoDx 96/288 Molecular Systems, for clinical performance and reproducibility on Evalyn Brush-collected self-samples.

METHODS

The clinical performance of the NeuMoDx HPV Assay self-sample workflow for cervical intraepithelial neoplasia grade 2 or worse (CIN2+) and CIN3+ was evaluated on 987 self-samples obtained from women attending national organized HPV-based cervical cancer screening by a noninferiority analysis relative to reference workflows using either HPV-Risk Assay or high-risk HPV GP5+/6+-PCR. Intra- and inter-laboratory reproducibility of the NeuMoDx HPV Assay self-sample workflow using both NeuMoDx 96 and 288 Molecular Systems was assessed on 520 self-samples in three laboratories.

RESULTS

The clinical sensitivity and specificity of the NeuMoDx HPV Assay self-sample workflow for the detection of CIN2+ and CIN3+ were found to be non-inferior to the reference workflows using either HPV-Risk Assay or high-risk HPV GP5+/6+-PCR, with all p-values <0.034. The NeuMoDx HPV Assay self-sample workflow exhibited an intra-laboratory reproducibility of 94.4 % (95 %CI:92.5-96.1 %) with kappa value 0.86 (95 %CI:0.81-0.91). Inter-laboratory agreement was high (all ≥93.4 % and all kappa values ≥0.83).

CONCLUSIONS

The NeuMoDx HPV Assay self-sample workflow demonstrated high clinical accuracy for CIN2+/3+ and high reproducibility. The NeuMoDx HPV Assay self-sample workflow can be considered suitable for cervical cancer screening purposes.