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Tan JHJ, Neesham D, Szabo RA, Khomko N, Yap D, Wrede CDH. Colposcopy performance in the new primary HPV screening in Australia: How to determine colposcopy competency? Aust N Z J Obstet Gynaecol 2024. [PMID: 38425311 DOI: 10.1111/ajo.13807] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Accepted: 02/13/2024] [Indexed: 03/02/2024]
Abstract
AIMS To assess colposcopic performance and determine indicators for competency within the new Australian primary human papillomavirus (HPV) cervical screening program. MATERIALS AND METHODS A retrospective observational study of 4542 women seen at The Royal Women's Hospital Colposcopy Clinic in Melbourne, from 1 December 2017 to 31 July 2020 after a higher-risk cervical screening test (CST) result. RESULTS Histological CIN2+ was detected in 25.1% up to two years from first colposcopy visit (FCV). The majority (86.7%) of CIN2+ was detected early within the first six months of presentation. Biopsy rate overall was 96.1% with abnormal colposcopic impression. Of four colposcopists with a lower biopsy rate, only one was able to achieve this early detection rate. Biopsy was also taken in over 30% of cases with negative reflex cytology and normal colposcopy, with CIN2+ detected in 5.0% among positive HPV16/18 and 3.8% with non-16/18 HPV. Positive predictive value of high-grade colposcopic impression at FCV averaged 66.4% (range: 54.9-81.6% among our colposcopists) and is poorly correlated with early detection rate of CIN2+. Overall accuracy of colposcopy is 84.5% (range: 78.7-90.3%), buoyed by high true negative colposcopic predictions secondary to high rates of negative reflex cytology referral with the new screening algorithm and is also unlikely to be a useful colposcopy indicator. CONCLUSIONS Early detection rate of CIN2+ within the first six months of presentation is a useful measure of colposcopy competency and we would encourage our National Cancer Screening Register to explore this with the participating colposcopists.
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Affiliation(s)
- Jeffrey H J Tan
- Department of Oncology & Dysplasia, The Royal Women's Hospital, Melbourne, Victoria, Australia
- Department of Obstetrics and Gynaecology, University of Melbourne, Melbourne, Victoria, Australia
| | - Deborah Neesham
- Department of Oncology & Dysplasia, The Royal Women's Hospital, Melbourne, Victoria, Australia
| | - Rebecca A Szabo
- Department of Oncology & Dysplasia, The Royal Women's Hospital, Melbourne, Victoria, Australia
- Department of Obstetrics and Gynaecology, University of Melbourne, Melbourne, Victoria, Australia
| | - Natalia Khomko
- Department of Oncology & Dysplasia, The Royal Women's Hospital, Melbourne, Victoria, Australia
| | - Desiree Yap
- Department of Oncology & Dysplasia, The Royal Women's Hospital, Melbourne, Victoria, Australia
| | - C David H Wrede
- Department of Oncology & Dysplasia, The Royal Women's Hospital, Melbourne, Victoria, Australia
- Department of Obstetrics and Gynaecology, University of Melbourne, Melbourne, Victoria, Australia
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Tan JHJ, Jones A, Steele A, Vicario E, Wrede CDH. Diagnostic outcomes after colposcopy at a tertiary clinic for women aged 50-74 referred after detection of oncogenic human papillomavirus at primary screening. Aust N Z J Obstet Gynaecol 2023; 63:564-570. [PMID: 37143262 DOI: 10.1111/ajo.13684] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2022] [Accepted: 03/30/2023] [Indexed: 05/06/2023]
Abstract
AIMS To examine outcomes in women aged 50-74 years after detection of oncogenic human papillomavirus (HPV) at cervical screening. MATERIALS AND METHODS A retrospective observational study of 464 women seen in the Royal Women's Hospital Colposcopy Clinic from 1 January 2018 to 31 July 2020, 292 (62.9%) were positive for HPV16/18 and 172 (37.1%) for HPV (not 16/18). RESULTS Fifty-four women (11.6%) had histologically proven CIN2+ including seven cancers, up to two years after first colposcopy visit (FCV): 48 (88.9%) detected at FCV or at excisional treatment (Excision) arranged after no CIN2+ detected at FCV. There was no significant difference (P = 0.14) in proportion of CIN2+ detected between the two groups, 'HPV16/18' (9.9%) or 'HPV (not 16/18)' (14.5%), nor with reflex cytology types. The positive predictive value (PPV) of high-grade impression at colposcopy was 63.6%. There were 243 (52.4%) who had Type 3 transformation zone (TZ3) with 20 CIN2+ detected, 13 at FCV including all three cancers and five at Excision. There were 214 (73.3%) with positive HPV16/18 who had reflex negative cytology, of which seven had CIN2+ including one cancer but only two (1.4%) CIN2+ when their repeat cytology at colposcopy was negative. CONCLUSIONS Most CIN2+ were detected at first colposcopy or at subsequent excision. We would encourage high biopsy rates at colposcopy and vigilance in selection for excisional treatment in TZ3 cases if there is no significant suspicion of high-grade abnormality. There is a need to refine the algorithm for management of persistent HPV16/18 infections with reflex negative cytology to reduce colposcopy referrals in women aged 50 and above.
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Affiliation(s)
- Jeffery H J Tan
- Department of Oncology and Dysplasia, The Royal Women's Hospital, Melbourne, Victoria, Australia
- Department of Obstetrics and Gynaecology, University of Melbourne, Melbourne, Victoria, Australia
| | - Antonia Jones
- Department of Oncology and Dysplasia, The Royal Women's Hospital, Melbourne, Victoria, Australia
| | - Angela Steele
- Department of Oncology and Dysplasia, The Royal Women's Hospital, Melbourne, Victoria, Australia
| | - Estefania Vicario
- Department of Oncology and Dysplasia, The Royal Women's Hospital, Melbourne, Victoria, Australia
| | - C David H Wrede
- Department of Oncology and Dysplasia, The Royal Women's Hospital, Melbourne, Victoria, Australia
- Department of Obstetrics and Gynaecology, University of Melbourne, Melbourne, Victoria, Australia
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Ng HYK, Tan JHJ, Marceglia AH, Bittinger S, Dundas KE, Talia KL, Wrede CDH. Outcomes of women with positive oncogenic HPV and reflex cytology showing possible high-grade squamous intraepithelial lesion. Aust N Z J Obstet Gynaecol 2021; 61:910-917. [PMID: 34287824 DOI: 10.1111/ajo.13408] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2021] [Revised: 06/23/2021] [Accepted: 06/26/2021] [Indexed: 11/26/2022]
Abstract
AIM To examine outcomes in women following cervical screening detection of oncogenic human papillomavirus (HPV), with reflex cytology showing possible high-grade squamous intraepithelial lesion (pHSIL). MATERIALS AND METHODS A retrospective observational study of 523 women seen in the Royal Women's Hospital Colposcopy Clinic from 1 January 2018 to 31 July 2020. RESULTS Two hundred eighty-two (53.9%) women had histology-confirmed HSIL, encompassing CIN2 or worse (CIN2+), including seven cancers (1.3%) and two adenocarcinoma in situ (AIS) (0.4%). In 81.2% (229/282) of women with CIN2+, this was detected on cervical biopsy at initial colposcopy, with another 8.9% (25/282) of CIN2+ detected at cervical excision following initial colposcopy and the remaining 9.9% (28/282) at follow-up colposcopy thereafter. When discordant cervical biopsy results were discussed at multidisciplinary meeting (MDM), 66.7% of women with pHSIL cytology upgraded to definite HSIL were found to have CIN2+, but only 20.8% when pHSIL cytology was retained and none when downgraded to low-grade (LSIL) or normal. No significant difference was found in the proportion of CIN2+ based on patient age above or below 40, HPV16 and/or 18 versus non 16/18, or whether discordant findings were reviewed at MDM. CONCLUSIONS We propose a pathway for management of women with positive oncogenic HPV and reflex pHSIL cytology. MDM review is recommended when CIN2+ is not identified on cervical biopsy at initial colposcopy. Conservative management is safe with low risk of CIN2+ when LBC prediction of pHSIL is confirmed or downgraded at MDM with no high-grade change on colposcopy or repeat cytology.
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Affiliation(s)
- Hamon Y K Ng
- Department of Oncology & Dysplasia, The Royal Women's Hospital, Parkville, Victoria, Australia
| | - Jeffrey H J Tan
- Department of Oncology & Dysplasia, The Royal Women's Hospital, Parkville, Victoria, Australia.,Department of Obstetrics and Gynaecology, University of Melbourne, Melbourne, Victoria, Australia
| | - Alexandra H Marceglia
- Department of Oncology & Dysplasia, The Royal Women's Hospital, Parkville, Victoria, Australia.,Department of Obstetrics and Gynaecology, University of Melbourne, Melbourne, Victoria, Australia
| | - Sophie Bittinger
- Department of Pathology, The Royal Women's Hospital, Parkville, Victoria, Australia
| | | | - Karen L Talia
- Department of Pathology, The Royal Women's Hospital, Parkville, Victoria, Australia.,VCS Pathology, VCS Foundation, Carlton, Victoria, Australia
| | - C David H Wrede
- Department of Oncology & Dysplasia, The Royal Women's Hospital, Parkville, Victoria, Australia.,Department of Obstetrics and Gynaecology, University of Melbourne, Melbourne, Victoria, Australia
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Chin FHX, Wrede CDH, Richards A, Steele A, Vicario E, McNally OM, Tan JHJ. Primary HPV cervical screening: Clinical audit of outcomes of women seen at a tertiary referral centre for colposcopy in Australia. Aust N Z J Obstet Gynaecol 2021; 61:750-758. [PMID: 33963546 DOI: 10.1111/ajo.13367] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Revised: 03/27/2021] [Accepted: 04/09/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Primary human papillomavirus (HPV) screening was introduced in Australia in December 2017. AIMS Outcomes for women after positive HPV in their cervical screening test (CST). MATERIALS AND METHODS A retrospective observational study of 4458 women seen at the Royal Women's Hospital Colposcopy Clinic from 1 January 2018 to 31 July 2020. RESULTS HPV16/18 was positive (considered higher-risk CST) in 42.2% of women in the study, 16.6% with reflex possible with high-grade squamous intraepithelial lesions (pHSIL) or worse and 54.9% with normal cytology. There were 24.8% of women with positive HPV16/18 who had histological confirmed cervical intraepithelial neoplasia grade 2 or worse (CIN2+), 10.3% CIN2+ (including six cancers) among women with reflex negative cytology and 87.7% CIN2+ among women with reflex HSIL cytology. In women with positive HPV (not 16/18), CIN2+ was found in 60.2% with reflex pHSIL or worse cytology (higher risk) and 10.2% with reflex low-grade SIL (LSIL) or normal cytology (intermediate risk). Median waiting time to colposcopy with the intermediate-risk group went up to 181 days. Our colposcopists were able to achieve a positive predictive value (PPV) for CIN2+ of 69.9%, higher than 57.8% PPV in the National Cervical Screening Program (NCSP) 2020 monitoring report. Women with type 3 transformation zone on colposcopy could be followed up with CST if no HSIL was suspected on screening or at colposcopy as their risk of CIN2+ was only 2.5%. CONCLUSIONS Our findings support direct referral to colposcopy for women with higher-risk CST, with all cancers confined to this group. The NCSP recommendation to refer for colposcopy only after three intermediate-risk CST will need monitoring with the LSIL triage group.
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Affiliation(s)
- Felicia H X Chin
- Department of Oncology & Dysplasia, The Royal Women's Hospital, Melbourne, Victoria, Australia
| | - C David H Wrede
- Department of Oncology & Dysplasia, The Royal Women's Hospital, Melbourne, Victoria, Australia.,Department of Obstetrics and Gynaecology, University of Melbourne, Melbourne, Victoria, Australia
| | - Anthony Richards
- Department of Oncology & Dysplasia, The Royal Women's Hospital, Melbourne, Victoria, Australia
| | - Angela Steele
- Department of Oncology & Dysplasia, The Royal Women's Hospital, Melbourne, Victoria, Australia
| | - Estefania Vicario
- Department of Oncology & Dysplasia, The Royal Women's Hospital, Melbourne, Victoria, Australia
| | - Orla M McNally
- Department of Oncology & Dysplasia, The Royal Women's Hospital, Melbourne, Victoria, Australia.,Department of Obstetrics and Gynaecology, University of Melbourne, Melbourne, Victoria, Australia
| | - Jeffrey H J Tan
- Department of Oncology & Dysplasia, The Royal Women's Hospital, Melbourne, Victoria, Australia.,Department of Obstetrics and Gynaecology, University of Melbourne, Melbourne, Victoria, Australia
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Tan JHJ, Jayasinghe YL, Osinski MJ, Brotherton JML, Wrede CDH. Recurrent post-coital bleeding: Should colposcopy still be mandatory? Aust N Z J Obstet Gynaecol 2020; 60:952-958. [PMID: 32914426 DOI: 10.1111/ajo.13247] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Accepted: 08/11/2020] [Indexed: 12/27/2022]
Abstract
BACKGROUND Colposcopy has been recommended for all women with recurrent post-coital bleeding (PCB) even if their cervical cytology or co-test (involving oncogenic human papillomavirus (HPV) DNA testing and cytology) are negative. AIMS To determine the risk of cervical cancer and its precursors among women with recurrent PCB with negative cytology or co-test. MATERIALS AND METHODS A retrospective analysis of two cohorts of women with PCB referred to a tertiary colposcopy clinic. Cohort (1) (n = 1846) between 1 January 2000 and 31 December 2016 (cytology-based screening) and Cohort (2) (n = 215) from 1 January 2018 to 31 December 2019 after introduction of primary HPV screening. RESULTS In 1217 (65.9%) women in Cohort (1) referred with negative cytology, there was one cancer (0.08%) and 22 high-grade squamous intraepithelial lesions (HSIL (cervical intraepithelial neoplasia 2/3)) on histopathology. In Cohort (2), there was no cancer or HSIL in 83 women with negative co-tests (negative for oncogenic HPV and cytology). False-negative cytology after a negative referral cytology or co-test was low with 2% of repeat cytology at initial colposcopy showing possible HSIL or worse. CONCLUSIONS Women presenting with PCB and negative cytology alone have a low risk of cancer and could have HPV testing before being triaged to colposcopy. We showed that with the assurance of a negative co-test and the low likelihood of false-negative cytology, these women could avoid colposcopy unless cervical cancer is clinically suspected. There is a need for a larger cohort study to substantiate our findings with more precision.
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Affiliation(s)
- Jeffrey H J Tan
- Oncology and Dysplasia Unit, The Royal Women's Hospital, Melbourne, Victoria, Australia.,Department of Obstetrics and Gynaecology, University of Melbourne, Melbourne, Victoria, Australia
| | - Yasmin L Jayasinghe
- Oncology and Dysplasia Unit, The Royal Women's Hospital, Melbourne, Victoria, Australia.,Department of Obstetrics and Gynaecology, University of Melbourne, Melbourne, Victoria, Australia
| | - Margot J Osinski
- Oncology and Dysplasia Unit, The Royal Women's Hospital, Melbourne, Victoria, Australia
| | | | - C David H Wrede
- Oncology and Dysplasia Unit, The Royal Women's Hospital, Melbourne, Victoria, Australia.,Department of Obstetrics and Gynaecology, University of Melbourne, Melbourne, Victoria, Australia
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Foster E, Malloy MJ, Jokubaitis VG, Wrede CDH, Butzkueven H, Sasadeusz J, Van Doornum S, Macrae F, Unglik G, Brotherton JML, van der Walt A. Increased risk of cervical dysplasia in females with autoimmune conditions-Results from an Australia database linkage study. PLoS One 2020; 15:e0234813. [PMID: 32555638 PMCID: PMC7302686 DOI: 10.1371/journal.pone.0234813] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2020] [Accepted: 06/02/2020] [Indexed: 12/29/2022] Open
Abstract
Background Autoimmune conditions (AICs) and/or their treatment may alter risk of human papilloma virus (HPV) infection and females with AICs are therefore at an increased risk of cervical dysplasia. However, inclusion of these at-risk populations in cervical cancer screening and HPV-vaccination guidelines, are mostly lacking. This study aimed to determine the prevalence of cervical dysplasia in a wide range of AICs and compare that to HIV and immunocompetent controls to support the optimisation of cervical cancer preventive health measures. Methods Data linkage was used to match cervical screening episodes to emergency department records of females with AICs or HIV to immunocompetent controls over a 14-year period. The primary outcome was histologically confirmed high-grade cervical disease. Results, measured as rates by cytology and histology classification per 1,000 females screened, were analysed per disease group, and intergroup comparisons were performed. Results Females with inflammatory bowel disease (2,683), psoriatic and enteropathic arthropathies (1,848), multiple sclerosis (MS) (1,426), rheumatoid arthritis (1,246), systemic lupus erythematosus and/or mixed connective tissue disease (SLE/MCTD) (702), HIV (44), and 985,383 immunocompetent controls were included. SLE/MCTD and HIV groups had greater rates of high-grade histological and cytological abnormalities compared to controls. Increased rates of low-grade cytological abnormalities were detected in all females with AICs, with the exception of the MS group. Conclusions Females with SLE/MCTD or HIV have increased rates of high-grade cervical abnormalities. The increased low-grade dysplasia rate seen in most females with AICs is consistent with increased HPV infection. These findings support expansion of cervical cancer preventative programs to include these at-risk females.
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Affiliation(s)
- Emma Foster
- Department of Neurology, MS and Neuroimmunology Service, Alfred Health, Melbourne, Australia
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Australia
- Department of Neurology, Royal Melbourne Hospital, Melbourne, Australia
| | - Michael J. Malloy
- Victorian Cervical Screening Registry, VCS Population Health, VCS Foundation, Melbourne, Australia
- Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Australia
| | - Vilija G. Jokubaitis
- Department of Neurology, MS and Neuroimmunology Service, Alfred Health, Melbourne, Australia
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Australia
| | - C. David H. Wrede
- Department of Oncology and Dysplasia, Royal Women’s Hospital, Melbourne, Australia
- Department of Obstetrics and Gynaecology, The University of Melbourne, Melbourne, Australia
| | - Helmut Butzkueven
- Department of Neurology, MS and Neuroimmunology Service, Alfred Health, Melbourne, Australia
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Australia
| | - Joe Sasadeusz
- Victorian Infectious Diseases Service, The Royal Melbourne Hospital, Melbourne, Australia
| | - Sharon Van Doornum
- Rheumatology Department, The Royal Melbourne Hospital, Melbourne, Australia
- Department of Medicine, The University of Melbourne, Melbourne, Australia
| | - Finlay Macrae
- Colorectal Medicine and Genetics, The Royal Melbourne Hospital, Melbourne, Australia
| | - Gary Unglik
- Department of Clinical Immunology and Allergy, The Royal Melbourne Hospital, Melbourne, Australia
| | - Julia M. L. Brotherton
- Victorian Cervical Screening Registry, VCS Population Health, VCS Foundation, Melbourne, Australia
- Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Australia
- * E-mail: (AVDW); (JMLB)
| | - Anneke van der Walt
- Department of Neurology, MS and Neuroimmunology Service, Alfred Health, Melbourne, Australia
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Australia
- Department of Neurology, Royal Melbourne Hospital, Melbourne, Australia
- * E-mail: (AVDW); (JMLB)
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Yap D, Liang X, Garland SM, Hartley S, Gorelik A, Ogilvie G, Tan J, Wrede CDH, Jayasinghe Y. Clinicians' attitude towards changes in Australian National Cervical Screening Program. J Clin Virol 2016; 76 Suppl 1:S81-S87. [DOI: 10.1016/j.jcv.2015.11.018] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2015] [Revised: 11/13/2015] [Accepted: 11/15/2015] [Indexed: 10/22/2022]
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