Ruifang Wu

Human papillomavirus infection in women in Shenzhen City, People's Republic of China, a population typical of recent Chinese urbanisation.

Select cancer registries report that cervical cancer is relatively rare in the Peoples Republic of China, but may not be representative of the entire country. We carried out a survey of human papillomavirus (HPV) prevalence in 3 samples of women, i.e., general population, factory workers, and tertiary sector workers, in Shenzhen City in 2004. All participants were interviewed and offered gynaecological examination. HPV detection in exfoliated cervical cells was performed using a GP5+/6+ PCR‐based assay. Overall HPV prevalence was 18.4% among the general population (n = 534), 11.2% among factory workers (n = 269) and 18.8% among tertiary sector workers (n = 224). Corresponding prevalence for high‐risk HPV types was 13.5%, 8.2% and 13.8%, respectively. The most commonly found HPV types were HPV16, 52, 58, 31 and 39. HPV prevalence significantly increased with age in the general population, whereas it was highest below age 25 years in tertiary sector workers. Associations of HPV prevalence with indicators of sexual behaviour were stronger among tertiary sector workers than in the other samples of women. High HPV prevalence in all age groups and the appearance of a ‘western‐type’ peak in HPV prevalence among young women employed in the tertiary sector raise important questions concerning the real cervical cancer burden, and its control, in urban China.

Improved sensitivity of vaginal self-collection and high-risk human papillomavirus testing

Self‐collected vaginal specimens tested for high‐risk human papillomavirus (HR‐HPV) have been shown to be less sensitive for the detection of cervical intraepithelial neoplasia or cancer (≥CIN 3) than physician‐collected endocervical specimens. To increase the sensitivity of self‐collected specimens, we studied a self‐sampling device designed to obtain a larger specimen from the upper vagina (POI/NIH self‐sampler) and a more sensitive polymerase chain reaction (PCR)‐based HR‐HPV assay. Women (10,000) were screened with cervical cytology and HR‐HPV testing of vaginal self‐collected and endocervical physician‐collected specimens. Women were randomly assigned to use either a novel self‐collection device (POI/NIH self‐sampler) or conical‐shaped brush (Qiagen). The self‐collected and clinician‐collected specimens were assayed by Cervista (Hologic) and the research only PCR‐based matrix‐assisted laser desorption/ionization time‐of‐flight (MALDI‐TOF). Women with any abnormal screening test underwent colposcopy and biopsy. Women (8,556), mean age of 38.9, had complete data; 1.6% had ≥ CIN 3. For either HR‐HPV assay, the sensitivity was similar for the two self‐collection devices. Tested with Cervista, the sensitivity for ≥CIN 3 of self‐collected specimens was 70.9% and for endocervical specimens was 95.0% (p = 0.0001). Tested with MALDI‐TOF, the sensitivity for ≥CIN 3 of self‐collected specimens was 94.3% and for endocervical specimens was also 94.3% (p = 1.0). A self‐collected sample using a PCR‐based assay with the capability of very high throughput has similar sensitivity as a direct endocervical specimen obtained by a physician. Large population‐based screening “events” in low‐resource settings could be achieved by promoting self‐collection and centralized high‐throughput, low‐cost testing by PCR‐based MALDI‐TOF.

Prevalence of human papillomavirus and cervical intraepithelial neoplasia in China: a pooled analysis of 17 population-based studies.

High‐risk (HR) human papillomavirus (HPV) prevalence has been shown to correlate well with cervical cancer incidence rates. Our study aimed to estimate the prevalence of HR‐HPV and cervical intraepithelial neoplasia (CIN) in China and indirectly informs on the cervical cancer burden in the country. A total of 30,207 women from 17 population‐based studies throughout China were included. All women received HPV DNA testing (HC2, Qiagen, Gaithersburg, MD), visual inspection with acetic acid and liquid‐based cytology. Women positive for any test received colposcopy‐directed or four‐quadrant biopsies. A total of 29,579 women had HR‐HPV testing results, of whom 28,761 had biopsy confirmed (9,019, 31.4%) or assumed (19,742, 68.6%) final diagnosis. Overall crude HR‐HPV prevalence was 17.7%. HR‐HPV prevalence was similar in rural and urban areas but showed dips in different age groups: at age 25–29 (11.3%) in rural and at age 35–39 (11.3%) in urban women. In rural and urban women, age‐standardized CIN2 prevalence was 1.5% [95% confidence interval (CI): 1.4–1.6%] and 0.7% (95% CI: 0.7–0.8%) and CIN3+ prevalence was 1.2% (95% CI: 1.2–1.3%) and 0.6% (95% CI: 0.5–0.7%), respectively. Prevalence of CIN3+ as a percentage of either all women or HR‐HPV‐positive women steadily increased with age, peaking in 45‐ to 49‐year‐old women. High prevalence of HR‐HPV and CIN3+ was detected in both rural and urban China. The steady rise of CIN3+ up to the age group of 45–49 is attributable to lack of lesion removal through screening. Our findings document the inadequacy of current screening in China while indirectly raising the possibility that the cervical cancer burden in China is underreported.

A Population-Based Clinical Trial Comparing Endocervical High-Risk HPV Testing Using Hybrid Capture 2 and Cervista From the SHENCCAST II Study

Our objective was to directly compare the accuracy of the high-risk human papillomavirus (HPV) assays, Hybrid Capture 2 (hc2; Qiagen, Gaithersburg, MD) and Cervista (Hologic, Bedford, MA), in diagnosing cervical intraepithelial neoplasia (CIN) 3 or worse (cancer). A population-based, cross-sectional study (The Shenzhen Cervical Cancer Screening Trial II) was conducted in Guangdong Province in China. Three high-risk HPV assays, self and direct cervical sampling and cytology, were studied. Abnormal results on any of 6 study tests (33%) resulted in referral to colposcopy. At colposcopy, every patient had at least 5 cervical biopsy specimens obtained. For 8,556 women between the ages of 25 and 59 years (mean, 38.9 years), the rate for CIN 3 or worse was 1.6% (141/8,556). The sensitivity (confidence interval) values for CIN 3 or worse were 97.9% (94.0%-99.6%) and 95.1% (90.0%-98.0%) for hc2 and Cervista, respectively (P > .05). The specificity (confidence interval) values were 87.8% (87.1%-88.5%) and 90.3% (89.6%-90.9%), respectively (P < .05). Differences in accuracy in diagnosing CIN 3 or worse with the hc2 and Cervista tests are minor and result from the decisions made in selecting the cut points.

Development and validation of a new HPV genotyping assay based on next-generation sequencing.

OBJECTIVES We developed a new human papillomavirus (HPV) genotyping assay based on multiplex polymerase chain reaction and next-generation sequencing (NGS) methods for large-scale cervical cancer screening. METHODS We first trained the assay on 1,170 self-collected samples, balancing the cutoff points for high-risk types. Then using 4,262 separate self-collected specimens, we compared concordance, sensitivity, and specificity for cervical intraepithelial neoplasia type 2 (CIN2) or higher and CIN type 3 (CIN3) or higher of the HPV sequencing assay with that of Hybrid Capture 2 (HC2) direct samples and matrix-assisted laser desorption/ionization time-of-flight mass spectrometry assay self-samples. RESULTS All assays had a good agreement. The sensitivity for CIN2 or higher and CIN3 or higher of the self-sampling specimens tested with the sequencing assay run on both MiSeq and Ion Torrent Personal Genome Machine sequencer was similar to that of direct-sampling specimens tested with HC2 (P > .05), but the specificity of the sequencing assay for CIN2 or higher and CIN3 or higher was significantly higher than that of HC2 (P < .01). CONCLUSIONS This population-based study has demonstrated the applicability of a new NGS high-risk HPV assay for primary cervical cancer screening based on self-collection.

A New PCR-Based Mass Spectrometry System for High-Risk HPV, Part II Clinical Trial

This was a population-based clinical trial of a polymerase chain reaction-based multiplex high-risk human papillomavirus (HR-HPV) assay using mass spectrometry (MassARRAY [Sequenom, San Diego, CA] matrix-assisted laser desorption/ionization time-of-flight mass spectrometry system [MALDI-TOF]). Participants were 10,000 women between the ages of 25 and 59 years in Guangdong Province, China (SHENCCAST II Study). All women collected a self-sample (tested with Cervista [Hologic, Marlborough, MA] and MALDI-TOF) followed by a clinician-collected cervical sample (for cytology, Hybrid Capture 2 [HC2; Qiagen, Gaithersburg, MD], Cervista, and MALDI-TOF). Patients with any abnormal result were asked to return for colposcopy and biopsies. This analysis included the data for 8,556 women. The sensitivity values for cervical intraepithelial neoplasia (CIN) 3 or worse for a direct cervical sample were 97.9%, 95.1%, and 94.3 for HC2, Cervista, and MALDI-TOF, respectively (P > .05). The sensitivity for CIN 3 or worse for a self-collected sample tested with MALDI-TOF was also 94.3%, which was similar to a clinician-obtained endocervical sample assayed with the 3 HR-HPV assays. MALDI-TOF combined with a self-collected sample provides a highly sensitive, high-throughput, low-cost-per-case assay for mass screening.

The development and evaluation of a community based model for cervical cancer screening based on self-sampling

OBJECTIVE To develop and implement a community based model for cervical cancer prevention that allows the communities to manage the screening and the healthcare system to focus resources on evaluation and management of the positives. METHODS Using self-sampling and the concepts founded in Community Based Participatory Research (CBPR), we progressively developed a model to efficiently reach the women, especially rural communities; and collect the volume of samples needed to support high throughput centralized low cost per case processing. RESULTS 8382 eligible women, ages 35 to 59, in 130 rural communities participated. The screening was organized by the local government administration and conducted by the community leaders (CLs). The model used was progressively designed through detailed assessment of key elements at 6 decision points in 26 workshops that were used to train the CLs and the local promoters. The communities were able to accurately conduct the screening; in the final model a local medical worker conducted a 50-minute workshop featuring instructional posters and structured role-play. A manual and a workshop DVD were created for distribution to and implementation by local governments. The average callback rate was 84.3%, without involvement of the local doctors in the management of the positives. CONCLUSION An efficient community based model capable of massive screening events was developed. We believe that the callback rate will be further improved when local doctors are trained in the management of the positives. Many elements impact coverage and further research is needed to define the influence of the identified key variables.

High-Grade Cervical Intraepithelial Neoplasia Detected by Colposcopy-Directed or Random Biopsy Relative to Age, Cytology, Human Papillomavirus 16, and Lesion Size

Objective The aim of the study was to determine whether p16 positive/cervical intraepithelial neoplasia (CIN) 2, 3, and cancer (p16 + CIN 2/3+) detected by colposcopy-directed or random biopsy differ by age, referral cytology, human papillomavirus (HPV) 16, and lesion size. Materials and Methods Data from the Shenzhen Cervical Cancer Screening Trial II where, at colposcopy, women who had directed and random cervical biopsies were reviewed to find women with CIN 2, 3, or cancer; 227 such women identified had their paraffin-embedded tissue blocks recut, reviewed, and then immune stained for p16. Data were analyzed by &khgr;2, Fisher exact test, and linear regression. Results After histopathologic review and p16 staining of CIN 2, 175 women were diagnosed with p16 + CIN 2/3+. When compared with those diagnosed by colposcopy-directed biopsy (n = 138), those diagnosed by random biopsy (n = 37) were more likely to have Cytology-Lo (cytology of negative, atypical squamous cells of undetermined significance, or low-grade squamous intraepithelial lesion; p = .07), less likely to have HPV 16 (p = .041), more likely to be 51 years or older (p = .022), and more likely to have 1 quadrant lesions (p < .001). Logistic regression analysis showed p16 + CIN 2/3+ diagnosed by random biopsy was predicted by 1 quadrant lesions (p < .0001) and age of 51 years or older (p = .03) but not by Cytology-Lo (p = .71) nor HPV 16 (p = .26). Conclusions Women with p16 + CIN 2/3+ diagnosed by random biopsy are older and less likely to have HPV 16; hence, CIN diagnosed by random biopsy may not be as virulent as CIN diagnosed by colposcopy-directed biopsy. Regardless, we advise that CIN diagnosed by random biopsy be viewed like CIN diagnosed by colposcopy-directed biopsy.

Cervical Epithelial Brightness by Optical Coherence Tomography Can Determine Histological Grades of Cervical Neoplasia

Objective The study aimed to determine if the difference in cervical epithelium brightness, as measured by optical coherence tomography (OCT), has potential as a distinguishing characteristic of normal, low-grade, high-grade (cervical intraepithelial neoplasia 2+), and cancer histological findings. Materials and Methods Information from 476 women was available for analysis. Demographic information was collected through in-person interview. All participants were human papillomavirus positive and/or had abnormal cytological finding and underwent colposcopy or unaided visual inspection and examination by OCT by quadrant. All women had a minimum of 4 OCT-matched cervical biopsies and endocervical curettage. Two sample t tests were used to measure differences in OCT image brightness by histological grades. Results Mean OCT image brightness differed significantly between each preinvasive histological grade and invasive cancer (p < .01 for all comparisons). Brightness as measured by OCT was also able to differentiate between squamous metaplasia and cervical intraepithelial neoplasia 3/cancer; p values were .004 and .003, respectively. Conclusions Epithelial brightness is an important component of cervical epithelium diagnosis by OCT, and we plan to add it to our diagnostic mathematical algorithm in all future versions of OCT software.

Secondary screening after primary self-sampling for human papillomavirus from SHENCCAST II.

Objective We recently demonstrated that a selfcollected sample tested with a high-throughput polymerase chain reaction–based high-risk human papillomavirus (HR-HPV) assay is equal in sensitivity to a physician-obtained direct endocervical sample. We now explore some secondary screening options to improve specificity. Methods The Shenzhen Cervical Cancer Screening Trial II is a multisite, population-based cross-sectional cervical cancer screening study conducted in Guangdong Province, China. Two HR-HPV assays were used for self-collected specimens, and 3 assays were used for directly collected specimens along with cytology. The polymerase chain reaction–based matrix-assisted laser desorption/ionization time-of-flight mass spectrometry assay reported 14 HR-HPV types. Any patient with a positive lesion on any assay or cytology underwent colposcopy and biopsy. Results A total of 8,556 women with a mean age of 38.9 years (range = 25–54 years) were included in the analysis. Primary self-collection had a sensitivity of 94.3% and a specificity of 87.5% (for cervical intraepithelial neoplasia grade 3 or cancer). Secondary cervical cytology had a sensitivity and specificity of 83.0% and 95.2%, respectively, which would require a pelvic examination and sacrifice some sensitivity. Secondary genotyping for HPV types 16 or 18 had a sensitivity and specificity of 53.9% and 97.7%, respectively; and HPV types 16, 18, 31, 33, 45, 52, and 58 had a sensitivity and specificity of 92.2% and 90.4%, respectively. Conclusions Genotyping is efficient if it is part of theprimary test result. It potentially identifies a high percentage of the cancers (types 16/18 = 84.5% in China).