René H.M. Verheijen

POBASCAM, a population‐based randomized controlled trial for implementation of high‐risk HPV testing in cervical screening: Design, methods and baseline data of 44,102 women

Cytological cervical screening is rather inefficient because of relatively high proportions of false negative and false positive smears. To evaluate the efficiency of high‐risk human papillomavirus (hrHPV) testing, by GP5+/6+ PCR‐enzyme immunoassay (EIA), in conjunction with cytology (Intervention Group) to that of the classical cytology (Control Group), we initiated the Population Based Screening Study Amsterdam (POBASCAM). POBASCAM is a population‐based randomized controlled trial for implementation of hrHPV testing in cervical screening. The outcome measure is the proportion of histologically confirmed ≥CIN3 lesions in each study arm up to and including the next screening round after 5 years. We present the design, methods and baseline data of POBASCAM. When, in the next 5 years, the follow‐up will be completed, the data obtained will be used in model studies, including a cost‐effectiveness study, to advise the Dutch Ministry of Public Health in deciding whether cervical screening should be based on combined hrHPV and cytology testing instead of cytology alone. Between January 1999 and September 2002, 44,102 women (mean age = 42.8 years; range = 29–61) that participated in the regular Dutch screening program were included in our study. In the Intervention Group the distribution of cytology and hrHPV by cytology class was as follows: normal cytology 96.6% (3.6% hrHPV positive); borderline and mild dyskaryosis (BMD) 2.5% (34.6% hrHPV positive); and moderate dyskaryosis or worse (>BMD) 0.8% (88.3% hrHPV positive), i.e., 0.4% moderate dyskaryosis (82.9% hrHPV positive), 0.3% severe dyskaryosis (92.5% hrHPV positive), 0.1% carcinoma in situ (95.2% hrHPV positive), <0.1% suspected for invasive cancer (hrHPV positive 100.0%). In the Control Group 96.5% of the women had normal cytology, 2.4% BMD and 0.8% >BMD, i.e., 0.4% moderate dyskaryosis, 0.3% severe dyskaryosis, 0.1% carcinoma in situ, <0.1% suspected for invasive cancer. The presence of hrHPV was age‐dependent, decreasing from 12.0% at 29–33 years to 2.4% at 59–61 years. Among women with a positive hrHPV test, the prevalence of BMD was age‐dependent ranging from 20.2% at 29–33 years to 7.8% at 54–58 years. In contrast, the risk of >BMD of 13.7% among women with a positive hrHPV test was not age‐dependent. Our study indicates that large‐scale hrHPV testing by GP5+/6+ PCR‐EIA in the setting of population‐based cervical screening is practically feasible, is accepted by both participating women and general practitioners and yields highly reproducible results.

Human papillomavirus testing on self-sampled cervicovaginal brushes: An effective alternative to protect nonresponders in cervical screening programs

Women not attending cervical screening programs are at increased risk of cervical cancer. We investigated in these nonresponders to what extent offering self‐sampling devices for cervicovaginal brushes for high‐risk human papillomavirus (hrHPV) testing would induce participation and, if so, what the yield of precursor (i.e. CIN2 or worse) lesions following self‐sampling would be. In addition, we assessed screening history of participants and costs per detected high‐grade CIN2 or worse (“CIN2+”) lesion in comparison to the regular program in the Netherlands. Nonresponders received a device for hrHPV testing (self‐sampling group, n = 2,546) or an extra recall for conventional cytology (control group, n = 284). The percentage of self‐sampling responders were compared with responders in the recall group. hrHPV positive self‐sampling responders were invited for cytology and colposcopy. CIN2+ yield and costs per detected CIN2+ were evaluated. Active response was higher in the self‐sampling than in the control group (34.2 vs. 17.6%; p < 0.001). hrHPV positive self‐sampling responders were less likely to have a prior screening history than screening participants (p < 0.001), indicating that they are regular nonresponders. hrHPV prevalence was similar (8.0 vs. 6.8%; p = 0.11), but CIN2+ yield was higher in self‐sampling responders compared to screening participants (1.67 vs. 0.97%; OR = 2.93, 95% CI 1.48–5.80; p = 0.0013). Costs per CIN2+ lesion detected via self‐sampling were in the same range as those calculated for conventional cytological screening (€8,836 vs. €7,599). Offering self‐sampling for hrHPV testing in nonresponders is an attractive adjunct to effectively increase population coverage of screening without the adverse effect of markedly increased costs per detected CIN2+ lesion.

Size of sentinel-node metastasis and chances of non-sentinel-node involvement and survival in early stage vulvar cancer: results from GROINSS-V, a multicentre observational study

BACKGROUNDnCurrently, all patients with vulvar cancer with a positive sentinel node undergo inguinofemoral lymphadenectomy, irrespective of the size of sentinel-node metastases. Our study aimed to assess the association between size of sentinel-node metastasis and risk of metastases in non-sentinel nodes, and risk of disease-specific survival in early stage vulvar cancer.nnnMETHODSnIn the GROningen INternational Study on Sentinel nodes in Vulvar cancer (GROINSS-V), sentinel-node detection was done in patients with T1-T2 (<4 cm) squamous-cell vulvar cancer, followed by inguinofemoral lymphadenectomy if metastatic disease was identified in the sentinel node, either by routine examination or pathological ultrastaging. For the present study, sentinel nodes were independently reviewed by two pathologists.nnnFINDINGSnMetastatic disease was identified in one or more sentinel nodes in 135 (33%) of 403 patients, and 115 (85%) of these patients had inguinofemoral lymphadenectomy. The risk of non-sentinel-node metastases was higher when the sentinel node was found to be positive with routine pathology than with ultrastaging (23 of 85 groins vs three of 56 groins, p=0.001). For this study, 723 sentinel nodes in 260 patients (2.8 sentinel nodes per patient) were reviewed. The proportion of patients with non-sentinel-node metastases increased with size of sentinel-node metastasis: one of 24 patients with individual tumour cells had a non-sentinel-node metastasis; two of 19 with metastases 2 mm or smaller; two of 15 with metastases larger than 2 mm to 5 mm; and ten of 21 with metastases larger than 5 mm. Disease-specific survival for patients with sentinel-node metastases larger than 2 mm was lower than for those with sentinel-node metastases 2 mm or smaller (69.5%vs 94.4%, p=0.001).nnnINTERPRETATIONnOur data show that the risk of non-sentinel-node metastases increases with size of sentinel-node metastasis. No size cutoff seems to exist below which chances of non-sentinel-node metastases are close to zero. Therefore, all patients with sentinel-node metastases should have additional groin treatment. The prognosis for patients with sentinel-node metastasis larger than 2 mm is poor, and novel treatment regimens should be explored for these patients.

Cervical cancer in the Netherlands 1989–1998: Decrease of squamous cell carcinoma in older women, increase of adenocarcinoma in younger women

Cervical cancer is a preventable disease, occurring in relatively young women. In the Netherlands, population‐based cervical screening aims at women aged 30–60 years. We performed a population‐based study of the incidence of invasive cervical cancer in the Netherlands to evaluate trends, with emphasis on age at time of diagnosis. Histologic diagnosis was retrieved from the Netherlands Cancer Registry for all women residing in the Netherlands with invasive cervical cancer between January 1, 1989, and December 31, 1998. In this 10‐year period, the incidence rate of squamous cell carcinoma decreased significantly from 7.1/100,000 to 6.1/100,000 (p < 0.001), with the greatest decrease in women aged 60–74 (–5.5%). While the overall incidence rate of adenocarcinoma remained stable, it increased in women aged 15–29 (+15.8%) and in women aged 30–44 (+2.5%), though the number of cases was small. For squamous cell carcinoma, the incidence of stage II at diagnosis decreased most (–2.7%). There was no change in stage at diagnosis for adenocarcinoma. Most cases of cervical cancer, 60.5%, were detected between ages 30 and 60 years, i.e., the Dutch screening age interval. Cervical cancer in women below age 30 contributed 5.0% to the total incidence, with 3.0% occurring between ages 27 and 29. Thus, screening for cervical cancer in the Netherlands is associated with a decrease in the incidence of squamous cell carcinoma and adenocarcinoma incidence appears to be increasing in younger women.

Risk of high-grade cervical intra-epithelial neoplasia based on cytology and high-risk HPV testing at baseline and at 6-months†

Adding a test for high‐risk human papillomavirus (hrHPV) to cytological screening enhances the detection of high‐grade cervical intraepithelial neoplasia (≥CIN2), but data are required that enable long‐term evaluation of screening. We investigated the ≥CIN2 risk for women participating in population‐based screening as a function of hrHPV and cytology testing results at baseline and at 6 months. We included 2,193 women aged 30–60 years participating in a population‐based screening trial who received colposcopy or a repeat testing advice at baseline. The main endpoint was histologically confirmed ≥CIN2 diagnosed within 36 months. hrHPV testing was more sensitive than cytology for ≥CIN2 (relative sensitivity 1.4, 95%CI: 1.3–1.5; absolute sensitivity 94.1 and 68.0%, respectively). The 18‐month ≥CIN2 risks in women with a hrHPV‐positive smear and in women with abnormal cytology were similar (relative risk 0.9, 95%CI: 0.8–1.1). Women with HPV16 and/or HPV18 had a higher ≥CIN2 risk than other hrHPV‐positive women irrespective of the cytological grade. Repeat testing showed that both cytological regression and viral clearance were strongly associated with a decrease in ≥CIN2 risk. Notably, women who had a double negative repeat test at 6 months had a ≥CIN2 risk of only 0.2% (95%CI: 0.0–1.1) and hrHPV‐negative women with baseline borderline or mild dyskaryosis and normal cytology at 6 months had a ≥CIN2 risk of 0% (95%CI: 0.0–0.8). Using hrHPV and/or cytology testing, risk of ≥CIN2 can be assessed more accurately by repeat testing than single visit testing. Hence, when hrHPV testing is implemented, patient management with repeat testing is a promising strategy to control the number of referrals for colposcopy.

Histopathological characteristics of BRCA1- and BRCA2-associated intraperitoneal cancer: a clinic-based study

The aim of the research was to assess possible histopathological differences between BRCA1- and BRCA2-associated malignant intraperitoneal (ovarian/fallopian tube/peritoneal) tumors and their sporadic counterparts. Dutch families harboring pathogenic BRCA1 or BRCA2 mutations were selected. Included were patients who had had malignant primary ovarian, fallopian tube or peritoneal tumors. Histopathological data was compared with data obtained from the Dutch cancer registry between 1989 and 1993 (reference group). A total of 63 with primary intraperitoneal malignant tumors were identified in 41 families. Non-epithelial malignant tumors were not observed in the study group versus 6% (n = 404) in the reference group (n = 6,789, P = 0.04). These tumors were excluded from further analysis, as were ovarian adenocarcinomas not otherwise specified, since these were detected in 22% of the study group, and in 19% of the reference group (P = 0.76). Serous carcinomas were detected in 94% (47/50) of the women in the study group in contrast to 62% (3,145/5,088) of the reference group (P < 0.01). In the study group, mucinous and endometrioid ovarian adenocarcinomas and serous ovarian borderline tumors each comprised 2.0% of the tumors. Clear cell ovarian carcinomas were not detected. In contrast, these percentages were 16% (P < 0.01), 10% (P = 0.07), 7% (P = 0.16) and 5% (P = 0.12), respectively, in the reference group. In the study group, 6.0% of the carcinomas arose in the fallopian tube versus 1.9% in the reference group (P = 0.03). Four percent of the study group developed primary serous peritoneal carcinomas, versus six percent in the reference group (P = 0.57). Serous carcinoma is the predominant type of intraperitoneal malignancy occurring in women harboring BRCA1 or BRCA2 mutations. Non-epithelial cancer does not seem to be part of the tumor spectrum of BRCA mutation carriers. This suggests, therefore, that serous tumors may be the only subtype related to a BRCA1 or BRCA2 mutation. Furthermore, fallopian tube carcinoma occurred more often in BRCA mutation carriers than in the reference population.

Comparison of hybrid capture 2 with in situ hybridization for the detection of high‐risk human papillomavirus in liquid‐based cervical samples

The performance of two commercially available detection systems for high‐risk HPV (hrHPV), Hybrid Capture 2 (HC2) and in situ hybridization (ISH), were compared on cervical scrapings.

The sentinel node in cervical cancer: scintigraphy and laparoscopic gamma probe-guided biopsy

The sentinel node (SN) procedure has been proven to be a valuable technique in the staging and treatment of a number of solid tumours. We evaluated the feasibility of SN biopsy with a laparoscopic gamma probe and dye guidance in 34 patients with clinically localised cervical cancer. After peritumoural injection of 140xa0MBq 99mTc colloidal albumin, dynamic and late static images were obtained. Just before the laparoscopic procedure, blue dye was injected. Blue and radioactive lymph nodes were excised followed by a regular lymphadenectomy. Lymphoscintigraphy revealed 70 SNs in 50 basins during dynamic imaging and 83 SNs in 63 basins at late imaging. SNs were visualised in 97% of the patients, bilaterally in 30 and unilaterally in three. Seventy-four of the 105 radioactive lymph nodes that were excised laparoscopically were considered to be SNs, 53 being blue as well, and were sent for frozen section. Nine foci that had been seen on scintigraphy could not be found either intraoperatively or in the remaining lymphadenectomy specimen. Four blue nodes were excised in three of five basins that had shown no foci during scintigraphy. In 17 basins of 12 patients, tumour-positive lymph nodes were found. In one of them a micrometastasis was found in the hysterectomy specimen while the lymphadenectomy did not contain any metastases (sensitivity 92%). Based on SN histology, the treatment was altered in nine patients (26%). We conclude that laparoscopic SN biopsy is feasible in cervical cancer and may result in custom-designed treatment strategies with a reduction in morbidity.

Incidence and survival rate of women with cervical cancer in the greater Amsterdam area.

To evaluate the effect of population-based cervical cancer screening on the occurrence of cervical cancer in The Netherlands, we investigated the incidence and survival of cervical cancer registered by a cancer registry in the Greater Amsterdam area. The incidence rate of squamous cell carcinoma decreased significantly from 9.2/100u2009000 women in 1988 to 5.9/100u2009000 in 2000 (P<0.001). The incidence rate of adenocarcinomas remained stable. After adjustment for age, stage and lymph node involvement, the relative risk of death was 1.6 times higher for patients with adenocarcinomas than for patients with squamous cell carcinoma (95% CI 1.2–2.1). The decreased survival was related to histological type, as the effect remained significant after correction for confounding factors. Over time, the prognosis of women with squamous cell carcinoma improved significantly. No significant change was observed for women diagnosed with adenocarcinoma. These results suggest that the screening programme in The Netherlands as executed in the Greater Amsterdam area is associated with a decreased incidence and increased survival of patients with squamous cell carcinoma, but fails to detect (pre)malignant lesions of adenocarcinoma. Since more than 92% of adenocarcinomas and its precursors contain high-risk HPV, adding HPV testing to cytologic screening might improve the present screening programme in detecting adenocarcinoma and its precursor lesions.

Triage using HPV-testing in persistent borderline and mildly dyskaryotic smears: proposal for new guidelines

In the Netherlands 2% of cervical smears in the cervical cancer screening program are read as borderline or mildly dyskaryotic cytology (BMD smear). Only in about 10% of these women a high‐grade CIN lesion (CIN II–III) is present; therefore referral is for the majority unnecessary. In our study triage with high‐risk HPV (hrHPV) testing was used to identify women at risk for development of high‐grade CIN lesions after a repeat BMD smear. A “wait‐and‐see” period was incorporated allowing clearance of HPV and regression of the lesion. Women with a low‐grade lesion, irrespective of their HPV status, were monitored at 12 months; women with a high‐grade lesion were monitored at 6 and 12 months. Fifty‐one of the 105 women (49%) were hrHPV negative at baseline; none of them showed progression of the lesion within the first year of follow‐up (NPV 100%). High‐grade CIN was present in 1 patient who was HPV negative at baseline (2%); she demonstrated regression after 12 months. Nineteen of the hrHPV positive women (35%) demonstrated a high‐grade CIN lesion at baseline and 3 cleared hrHPV after 6 months, with a subsequent regression of CIN. Ten women remained hrHPV positive with persistence of high‐grade CIN and were eventually treated. At baseline, 35 hrHPV positive women demonstrated a low‐grade lesion, 19 remained hrHPV positive after 12 months and 5 developed high‐grade CIN. Sixteen out of the 35 cleared the hrHPV infection without progression of the lesion. In conclusion, triage, using hrHPV testing for women with persistent BMD cytology, can select women who are not at risk for development of high‐grade CIN. We recommend return to the screening program without referral for colposcopic examination if hrHPV is absent. For hrHPV positive women, a repeat hrHPV test after another 6 months is suggested. Referral is only required if persistence of hrHPV is established.