Agreement between Self- and Physician‑Sampling for Detection of High‑Risk Human Papillomavirus Infections in Women Attending Cervical Screening at National Cancer Institute, Thailand

BACKGROUND

We determined testing of self-sampling vagina swabs for Human Papilloma Virus (HPV) can be used to screen for cervical disease in outpatient clinics.

METHODS

In this study, women attending cervical cancer screening clinic and gynecology clinic of the National Cancer Institute were invited to take a vaginal self-sampling and physician-collected cervical sampling.

RESULTS

Of 268 participants, 20 (7.5%) were HPV-positive on the physician-collected samples. Among these screen-positive women, only two (0.7%) had HPV 18 and/or 45 and none had HPV 16 infections. For the self-collected samples, 4 participants had invalid HPV test results. Of the remaining 264 women with valid test results on self-collected samples, 29 (11.0 %) were HPV-positive, of whom, two (0.8%) were infected with HPV 16 and one (0.4%) with HPV 18 and/or 45 infections. The agreement between self-sampling and physician-sampling HPV test results (when two HPV results categories were considered) was 92. 8% with a moderate Kappa value of 0.57.

CONCLUSION

Overall, self-sampling seems to be a reliable alternative to health-provider collection. However, instructions on proper procedures for sample collection to the women are important step before general roll out.

13-Type HPV DNA Test versus 5-Type HPV mRNA Test in Triage of Women Aged 25-33 Years with Minor Cytological Abnormalities-6 Years of Follow-Up

BACKGROUND

A specific, cost-effective triage test for minor cytological abnormalities is essential for cervical cancer screening among younger women to reduce overmanagement and unnecessary healthcare utilization. We compared the triage performance of one 13-type human papillomavirus (HPV) DNA test and one 5-type HPV mRNA test.

METHODS

We included 4115 women aged 25-33 years with a screening result of atypical squamous cells of undetermined significance (ASC-US) or low-grade squamous intraepithelial lesions (LSIL) recorded in the Norwegian Cancer Registry during 2005-2010. According to Norwegian guidelines, these women went to triage (HPV testing and repeat cytology: 2556 were tested with the Hybrid Capture 2 HPV DNA test, which detects the HPV types 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, and 68; and 1559 were tested with the PreTect HPV-Proofer HPV mRNA test, which detects HPV types 16, 18, 31, 33, and 45). Women were followed through December 2013.

RESULTS

HPV positivity rates at triage were 52.8% and 23.3% among DNA- and mRNA-tested women (p < 0.001), respectively. Referral rates for colposcopy and biopsy and repeat testing (HPV + cytology) after triage were significantly higher among DNA-tested (24.9% and 27.9%) compared to mRNA-tested women (18.3% and 5.1%), as were cervical intraepithelial neoplasia grade 3 or worse (CIN3+) detection rates (13.1% vs. 8.3%; p < 0.001). Ten cancer cases were diagnosed during follow-up; eight were in DNA-tested women.

CONCLUSION

We observed significantly higher referral rates and CIN3+ detection rates in young women with ASC-US/LSIL when the HPV DNA test was used at triage. The mRNA test was as functional in cancer prevention, with considerably less healthcare utilization.

"I am not a Good Woman?" Exploring the Views and Challenges of Nurses When Discussing HPV Testing and Associated Cervical Screening with Women in Iraq

Introduction

Cervical cancer is mostly caused by high-risk Human papillomavirus HPV, with an estimation prevalence of HPV of 99.7% worldwide. The US Food and Drug Administration (FDA) approved an HPV test for primary cervical screening in 2014. An HPV-DNA test, which provides higher protection against invasive cervical carcinomas, is replacing the long-standing Pap smear as the primary method of cervical cancer screening.

Objective

To explore nurses' experience and knowledge of HPV DNA testing and how screening impacts on women's health through increasing awareness and proposing actions for health education strategies.

Method

A qualitative exploratory study was conducted on a purposeful sample of 25 qualified nurses, who were all employed in regional hospitals within a gynecological department in Kirkuk, Iraq. The nurses were interviewed with a semi-structured topic guide between November 2021 and February 2022. Responses were transcribed verbatim, translated into English and analysed using a content thematic analysis approach.

Results

Four themes with associated sub-themes emerged following coding and peer review. Participants had lack of experience and fragmented knowledge of HPV DNA testing/screening. Culturally sensitive resources for patients and training for nurses was identified key requirements.

Conclusions

Currently, there are no facilities for a HPV testing/screening services available in Iraq. The role of nurses undertaking HPV screening is not established and yet nurses represent the largest sector of health professionals. The dissemination of a collaborative HPV screening training programme to include clinical competence and knowledge for nurses and gynaecologists may improve knowledge, and could also be effective in improving patient awareness and engagement with cervical health.

HPV and Cytology Testing in Women Undergoing 9-Valent HPV Opportunistic Vaccination: A Single-Cohort Follow Up Study

Background: This study evaluates the possible effect of 9-valent (9vHPV) vaccination on the results of HPV and cytological tests in a cohort of adult women. Methods: This study is a retrospective, single-cohort, monocentric study. Sexually active women aged 14-70 years, who underwent 9vHPV vaccination, were enrolled. Dose administration dates, side effects and data on Pap smears and HPV tests performed before and after the first vaccine dose were collected. Subjects were considered "unexposed" to the vaccine for all time intervals before the first dose administration, and "exposed" to the first, second and third vaccine doses in all time intervals following each specific dose. Results: A total of 512 women underwent the first 9vHPV dose administration and were enrolled in the study. Median age at vaccination was 30.5 (14-70). Log-rank tests and Cox regression analyses showed a highly statistically significant (p < 0.0001) difference in the time to negativization after the exposure to the third vaccine dose in the 207 women starting with a Pap+ smear (HR (95% C.I.), 2.66 (1.83-3.86)) and in the 198 women starting with an HPV HR+ test (HR (95% C.I.), 7.80 (4.83-12.60)). Conclusions: 9vHPV vaccination may play a role in shortening the clearance time of HPV HR+ or Pap positivity in sexually active adult women.

HPV-Negative Cervical Cancer: A Narrative Review

Cervical cancer (CC) is the fourth most frequent cancer in women worldwide. HPV infection is associated with the majority of CC cases, but a small proportion of CCs actually test negative for HPV. The prevalence of HPV among CC histotypes is very different. It has been suggested that HPV-negative CC may represent a biologically distinct subset of tumors, relying on a distinct pathogenetic pathway and carrying a poorer prognosis, than HPV-positive CCs. Although, the discordance in terms of sensitivity and specificity between different HPV tests as well as the potential errors in sampling and storing tissues may be considered as causes of false-negative results. The identification of HPV-negative CCs is essential for their correct management. The aim of this narrative review is to summarize the clinical and pathological features of this variant. We also discuss the pitfalls of different HPV tests possibly leading to classification errors.

Current Status and Future Perspectives of Molecular Prevention Strategies for Cervical Cancers

Cervical cancer continues to be a global health problem; despite the potential for prevention through organised screening programmes that can detect and treat pre-cancerous lesions and also more recently, the availability of HPV (Human Papilloma Virus) vaccines. While routine screening with Pap smear testing has reduced the burden of cervical cancer in the high-income countries, the implementation of organised Pap-based screening programmes has not been found feasible in low-resource settings due to a lack of health care delivery infrastructure and limited health budgets. The well-established causal relationship between cervical cancer development and high-risk-HPV (HR-HPV) infection and the subsequent appreciation of the greater sensitivity of HPV testing over Pap smear cytology eventually lead to HPV testing being incorporated in the primary cervical cancer prevention programmes. An organised cervical cancer screening programme incorporating HR-HPV testing and HPV vaccine administration are currently considered to be the two major interventions for a comprehensive cervical cancer control programme worldwide. However, there are concerns that the requirement of a sophisticated infrastructure with its associated costs may make cervical cancer screening using molecular prevention by HPV testing impracticable to be implemented, especially in resource-poor, low-income countries. Visual Inspection with Acetic acid (VIA) represents one of the alternative methods for cervical cancer screening proposed for the countries with low- to middle-income resources and has gained popularity in India following the successful completion of two randomised controlled trials, but this method but has low sensitivity to detect cervical pre-cancers. More recently, the cost-effectiveness analysis of many studies including randomised controlled trials, even from the low-resource settings, has found that HPV testing is followed by treatment for HPV-positive women to be an effective and cost-effective screening strategy as compared to other screening methods including VIA. The incorporation of self-sampling and HPV testing by partial genotyping has the potential to significantly add to the effectiveness and the cost-effectiveness. The current status and future perspectives of molecular prevention strategies for cervical cancer prevention is further discussed.

Evaluation of the SureX HPV genotyping test for the detection of high-risk HPV in cervical cancer screening

BACKGROUND

The SureX HPV genotyping test (SureX HPV test), which targets the human papillomavirus (HPV) E6/E7 genes was compared with the Cobas 4800 and Venus HPV tests for detecting 14 high-risk HPV (HR-HPV) types in clinical referral and follow-up patients to evaluate its value for cervical cancer screening.

METHODS

Two different populations were enrolled in the study. The first population comprised 185 cases and was used for comparing the SureX HPV test (Health, China) with the Cobas 4800 test (Roche, USA). The second population comprised 290 cases and was used for comparing the SureX HPV test (Health, China) with the Venus HPV test (Zhijiang, China). Polymerase chain reaction (PCR) sequencing was performed for further confirmation of discordant results.

RESULTS

In the first population, the overall agreement rate was 95.6% for 14 high-risk HPV types. Eight discordant cases were confirmed by PCR sequencing, which showed that the agreement rates were 75.0% between the SureX HPV test and PCR sequencing and 25.0% between the Cobas 4800 test and PCR sequencing (P < 0.01). In the second population, the overall agreement rate was 95.5%. Thirteen discordant cases were confirmed by PCR sequencing, which showed that the agreement rates were 76.9% between the SureX HPV test and PCR sequencing and 23.1% between the Venus HPV test and PCR sequencing (P < 0.01). With cervical intraepithelial neoplasia grade 2+ (CIN2+) as the reference standard, the sensitivity values of the SureX HPV test and the Venus HPV test were 93.5% and 92.0%, (P > 0.05), while the specificity values were 43.3% and 46.7%, respectively (P > 0.05).

CONCLUSION

The SureX HPV test had good consistency with both the Cobas 4800 and Venus HPV tests for 14 HR-HPV types. In addition, it avoided some false negatives and false positives. Therefore, the SureX HPV test can be used for cervical cancer screening.

Cervical cancer screening program based on primary DNA-HPV testing in a Brazilian city: a cost-effectiveness study protocol

BACKGROUND

The causal relationship between high-risk (hr) HPV infection and precancerous lesions or cervical cancer has led to the development of strategies to increase screening performance and prevent this cancer. The increased sensitivity of DNA-HPV testing compared to cervical cytology favors DNA-HPV testing as a primary screening test. Cervical cancer screening in Brazil is opportunistic, and this cancer remains a considerable health problem with a high proportion of diagnoses in advanced stages. This paper aims to describe the design and implementation of the Cervical Cancer Screening Program with primary DNA-HPV testing (CCSP-HPV) planned for Indaiatuba City (SP), Brazil; the strategies to achieve higher population coverage; and a study protocol for cost-effectiveness analyses.

METHODS

The CCSP-HPV was designed based on successful guidelines that replaced cervical cytology-based screening by the DNA-HPV test performed at 5-year intervals. The screening will be performed for the female population aged 25-64 years cared for by the public health system and aim to reach 80% coverage after completing the first round. The chosen DNA-HPV test detects 14 hr-HPV types and genotypes HPV-16 and 18. All women with a negative test will be reassessed after five years. Women showing a positive test for HPV-16 and/or 18 will be referred for colposcopy. Those showing the other 12 hr-HPV types will be tested by cytology, and if any abnormality is detected, they will also be referred for colposcopy. The histopathologic evaluation will be reviewed by a pathologist panel and aided by p16 immunohistochemistry. A cost-effectiveness analysis will be performed by a Markov model comparing the cost of the new program and the screening performed by conventional cytology five years prior (2011-2016).

DISCUSSION

The new screening program is considered a breakthrough for public health regarding cervical cancer, which is the third leading cause of cancer death among Brazilian women. Achieving at least 80% coverage will have the possibility to change this scenario. The proposed program will provide a modern cervical cancer screening method for women, and information about cost-effectiveness will help other similar places support the decision of implementing cervical cancer screening using the DNA-HPV test.

HPV screening performance indicators in women who previously tested HPV-negative: The second round of Vallecamonica screening programme, Northern Italy

OBJECTIVE

To present performance indicators from the second round of the Vallecamonica-Sebino HPV screening programme in women who had tested negative about four years earlier (mean 45 months).

METHODS

From 2010 to 2012, the target female population (aged 25-64) was invited to the first HPV screening round. In 2013-2017, women were rescreened for the second round. HPV-negative women at the first round were initially rescreened after three years. The interval was gradually increased to five years. HPV-positive women underwent cytology triage: positives were referred to colposcopy and negatives to repeat testing after one year. If HPV was persistently positive, women were referred to colposcopy, if negative, to normal interval rescreening.

RESULTS

In the second round, of 13,824 previously HPV-negative women, 598 were HPV-positive (4.3%), of whom 297 were positive at cytology triage. Of those referred to one-year HPV test, 291 complied (98.0%), 133 (50.2%) of whom were persistently positive. Total referral was 3.1% compared with 6.6% in the first round (age-adjusted relative referral 0.59, 95% CI: 0.53-0.65). There were 24 cervical intraepithelial neoplasia 2+ (three cervical intraepithelial neoplasia 3+). Detection was 0.17%, compared with 0.9% in the first round. Age-adjusted relative detections were 0.25 (95% CI: 0.16-0.39) and 0.18 (95% CI: 0.05-0.61) for cervical intraepithelial neoplasia 2+ and cervical intraepithelial neoplasia 3+, respectively. Positive predictive value was 5.7%, compared with 14.6% in the first round.

CONCLUSIONS

At second round, referral was half that at first round, while cervical intraepithelial neoplasia 2+ detection decreased nine-fold. Consequently, positive predictive value decreased dramatically. Rescreening four years after an HPV-negative test makes the process inefficient due to the low prevalence of lesions.

[The new S3 guideline "Prevention of cervical carcinoma" : What is important for pathology?]

Of the numerous aspects involved in the diagnosis, treatment, and follow-up of cervical uterine precursor lesions, epidemiology, virology, cytology, human papillomavirus (HPV) testing, and diagnostic algorithms for equivocal and HPV-positive findings are important for pathologists. Cytology will continue to be used as a preventive medical check-up in young women, while HPV-based screening is suggested for older women. HPV screening has yielded a significant reduction in cancer precursors and invasive cervical carcinoma in numerous studies. In contrast to the sensitivity, the specificity of the HPV test is inferior to that of cytology and the morphological biomarker p16/Ki-67, so that they are suitable as methods in the triage of HPV-positive findings. Cytological abnormalities and mildly dysplastic changes could be further clarified by an HPV test or the p16/Ki-67 test. The HPV test should also be used in the follow-up of patients after conization.

Validation of a Human Papillomavirus (HPV) DNA Cervical Screening Test That Provides Expanded HPV Typing

As cervical cancer screening shifts from cytology to human papillomavirus (HPV) testing, a major question is the clinical value of identifying individual HPV types. We aimed to validate Onclarity (Becton Dickinson Diagnostics, Sparks, MD), a nine-channel HPV test recently approved by the FDA, by assessing (i) the association of Onclarity types/channels with precancer/cancer; (ii) HPV type/channel agreement between the results of Onclarity and cobas (Roche Molecular Systems, Pleasanton, CA), another FDA-approved test; and (iii) Onclarity typing for all types/channels compared to typing results from a research assay (linear array [LA]; Roche). We compared Onclarity to histopathology, cobas, and LA. We tested a stratified random sample (n = 9,701) of discarded routine clinical specimens that had tested positive by Hybrid Capture 2 (HC2; Qiagen, Germantown, MD). A subset had already been tested by cobas and LA (n = 1,965). Cervical histopathology was ascertained from electronic health records. Hierarchical Onclarity channels showed a significant linear association with histological severity. Onclarity and cobas had excellent agreement on partial typing of HPV16, HPV18, and the other 12 types as a pool (sample-weighted kappa value of 0.83); cobas was slightly more sensitive for HPV18 and slightly less sensitive for the pooled high-risk types. Typing by Onclarity showed excellent agreement with types and groups of types identified by LA (kappa values from 0.80 for HPV39/68/35 to 0.97 for HPV16). Onclarity typing results corresponded well to histopathology and to an already validated HPV DNA test and could provide additional clinical typing if such discrimination is determined to be clinically desirable.

Evidence-based policy choices for efficient and equitable cervical cancer screening programs in low-resource settings

Women in developing countries disproportionately bear the burden of cervical cancer. The availability of prophylactic vaccines against human papillomavirus (HPV) types 16 and 18, which cause approximately 70% of cervical cancers, provides reason for optimism as roll‐out begins with support from Gavi, the Vaccine Alliance. However, for the hundreds of millions of women beyond the target age for HPV vaccination, cervical cancer screening to detect and treat precancerous lesions remains the only form of prevention. Here we describe the challenges that confront screening programs in low‐resource settings, including (1) optimizing screening test effectiveness; (2) achieving high screening coverage of the target population; and (3) managing screen‐positive women. For each of these challenges, we summarize the tradeoffs between resource utilization and programmatic attributes. We then highlight opportunities for efficient and equitable programming, with supporting evidence from recent mathematical modeling analyses informed by data from the PATH demonstration projects in India, Nicaragua, and Uganda.

National assessment of HPV and Pap tests: Changes in cervical cancer screening, National Health Interview Survey

BACKGROUND

Major organizations recommend cytology screening (Pap test) every 3years for women aged 21-65; women aged 30 to 65 have the option of adding the HPV test (co-test) every 5years. We examined national percentages of cervical cancer screening, and we examined use of co-testing as an option for screening.

METHODS

We used 2015 U.S. National Health Interview Survey (NHIS) data to examine recent cervical cancer screening (Pap test within 3years among women aged 21-65 without a hysterectomy; N=10,596) and co-testing (N=9,125). We also conducted a multivariable analysis to determine odds of having had a Pap test or co-test by demographic variables. To evaluate changes in screening over time, we examined Pap testing during the years 2000, 2005, 2008, 2010, 2013 and 2015. Analysis completed in Atlanta, GA during 2016.

RESULTS

Overall, 81.1% of eligible women reported having a Pap test within 3years; percentages declined over time among all age groups. An estimated 14 million women aged 21-65 had not been screened within the past 3years. Recent immigrants to the United States, women without insurance, and women without a usual source of healthcare had lower odds of being up to date with screening. About 1/3 of women up to date on Pap testing reported having a co-test with their most recent Pap test.

CONCLUSIONS

Declines in screening among women aged 21-65 are cause for concern. More research is needed on co-testing practices. Provider and patient education efforts may be needed to clarify recommended use of HPV tests.

To expand coverage, or increase frequency: Quantifying the tradeoffs between equity and efficiency facing cervical cancer screening programs in low-resource settings

Cervical cancer is a leading cause of cancer death worldwide, with 85% of the disease burden residing in less developed regions. To inform evidence‐based decision‐making as cervical cancer screening programs are planned, implemented, and scaled in low‐ and middle‐income countries, we used cost and test performance data from the START‐UP demonstration project in Uganda and a microsimulation model of HPV infection and cervical carcinogenesis to quantify the health benefits, distributional equity, cost‐effectiveness, and financial impact of either (1) improving access to cervical cancer screening or (2) increasing the number of lifetime screening opportunities for women who already have access. We found that when baseline screening coverage was low (i.e., 30%), expanding coverage of screening once in a lifetime to 50% can yield comparable reductions in cancer risk to screening two or three times in a lifetime at 30% coverage, lead to greater reductions in health disparities, and cost 150 international dollars (I$) per year of life saved (YLS). At higher baseline screening coverage levels (i.e., 70%), screening three times in a lifetime yielded greater health benefits than expanding screening once in a lifetime to 90% coverage, and would have a cost‐effectiveness ratio (I$590 per YLS) below Uganda's per capita GDP. Given very low baseline coverage at present, we conclude that a policy focus on increasing access for previously unscreened women appears to be more compatible with improving both equity and efficiency than a focus on increasing frequency for a small subset of women.

What's new?

Most cervical cancer cases and deaths occur in less‐developed countries, where resource constraints challenge the planning and implementation of screening programs. The present report examines tradeoffs between equity and efficiency in cervical cancer screening approaches specifically in Uganda, where current baseline screening coverage is low. Analyses indicate that the expansion of access to once‐in‐a lifetime cervical cancer screening in areas with initially low baseline coverage is likely to yield greater benefits for health, distributional equity and cost‐effectiveness than increasing the number of screening opportunities per woman in low‐resource settings. Improving access for previously unscreened women should be a priority in such areas.

High performance of combined HPV testing and genotyping for HPV16/18/52/58 in triaging women with minor cervical cytological abnormalities in northern Thailand

Human papillomavirus (HPV) infection is an important cause of cervical cancer. Screening with cytology or combined cytology and HPV testing helps to detect early cervical cancers and precancerous lesions (high-grade squamous intraepithelial lesion or worse [HSIL+]). Minor cytological abnormalities (atypical squamous cells of undetermined significance and low-grade squamous intraepithelial lesion) account for the majority of abnormal cervical cytology results, but only 10-20% of women with minor cytological abnormalities have histologic HSIL+. Triage tests are useful to identify the high-risk patients and reduce the colposcopy burden. This study was aimed to evaluate the triage performance of combined HPV DNA testing and genotyping. Cervical samples from women with minor cytological abnormalities, who underwent colposcopy at Chiang Mai University Hospital in northern Thailand between October 2010 and February 2014, were tested for HPV DNA using Hybrid Capture 2 (HC2). Genotyping was performed using Linear Array assay. Of 223 women with cervical histology confirmation, histologic HSIL+ was detected in 25 women (11.2%). The sensitivity, specificity, positive predictive value, and negative predictive value of 3 triage methods for histologic HSIL+ were; 100%, 47.5%, 19.4%, and 100% by HC2 only; 40.0%, 88.4%, 30.3%, and 92.1% by combined HC2 and genotypes HPV16/18; and 96.0%, 75.8%, 33.3%, and 99.3% by combined HC2 and genotypes HPV16/18/52/58. Triage using combined HC2 and genotypes HPV16/18/52/58 showed significantly greater area under the receiver operating curve than the other 2 methods (P < 0.001). Combined HPV DNA testing and genotyping for HPV16/18/52/58 is useful for triaging women with minor cervical cytological abnormalities in northern Thailand.

Cervical cancer screening with HPV testing in the Valcamonica (Italy) screening programme

OBJECTIVE

We present the results of the first screening round and the first year of the second round of the Valcamonica Human Papillomavirus (HPV) pilot screening project.

SETTING

From 2010 to 2012, the entire target female population (aged 25-64) was invited to the first HPV screening round in an area where Pap test screening had been active since 2002.

METHODS

For HPV-negative women, the interval was three years. For HPV-positive women, a cytological smear was stained and interpreted. Positive cytologies were referred to colposcopy; negatives were referred to repeat HPV after one year. If HPV was persistently positive, women were referred to colposcopy; if negative, to normal screening.

RESULTS

In 2010-12 18728 women were screened, slightly higher participation than with Pap test (18233 64.7%); 1633 were HPV-positive (8.7%); 843 were positive at cytology triage (referral rate at baseline 4.5%). Of those referred at the one year HPV test, 84% complied (660/780); 356 were persistently positive (1.9%). The total referral rate was 6.4% compared with 3.7% for the Pap test. The detection rate was 9.2/1000 compared with 5.0% for the Pap test. The HPV positivity rate during the second round in women previously negative was 3.9% and the detection rate in HPV-positive cytology-positive women was 0.8/1000.

CONCLUSIONS

HPV-based screening increases colposcopies at the first round, but also strongly increases the detection rate. At the second round, HPV prevalence was much lower and the detection rate also fell, corroborating the need for longer screening intervals in HPV-negative women.

Is HPV DNA testing specificity comparable to that of cytological testing in primary cervical cancer screening? Results of a meta-analysis of randomized controlled trials

Human-papillomavirus (HPV) DNA testing has been proposed as an alternative to primary cervical cancer screening using cytological testing. Review of the evidence shows that available data are conflicting for some aspects. The overall goal of the study is to update the performance of HPV DNA as stand-alone testing in primary cervical cancer screening, focusing particularly on the aspects related to the specificity profile of the HPV DNA testing in respect to cytology. We performed a meta-analysis of randomized controlled clinical trials. Eight articles were included in the meta-analysis. Three outcomes have been investigated: relative detection, relative specificity, and relative positive predictive value (PPV) of HPV DNA testing versus cytology. Overall evaluation of relative detection showed a significantly higher detection of CIN2+ and CIN3+ for HPV DNA testing versus cytology. Meta-analyses that considered all age groups showed a relative specificity that favored the cytology in detecting both CIN2+ and CIN3+ lesions whereas, in the ≥30 years' group, specificity of HPV DNA and cytology tests was similar in detecting both CIN2+ and CIN3+ lesions. Results of the pooled analysis on relative PPV showed a not significantly lower PPV of HPV DNA test over cytology. A main key finding of the study is that in women aged ≥30, has been found an almost overlapping specificity between the two screening tests in detecting CIN2 and above-grade lesions. Therefore, primary screening of cervical cancer by HPV DNA testing appears to offer the right balance between maximum detection of CIN2+ and adequate specificity, if performed in the age group ≥30 years.