Suzanne E. Belinson

The APTIMA HPV assay versus the hybrid capture 2 test in triage of women with ASC-US or LSIL cervical cytology: A meta-analysis of the diagnostic accuracy†

Testing for DNA of 13 high‐risk HPV types with the Hybrid Capture 2 (HC2) test has consistently been shown to perform better in triage of women with cervical cytology results showing atypical squamous cells of undetermined significance (ASC‐US) but often not in triage of low‐grade squamous intraepithelial lesions (LSIL) detected in cervical cancer screening. In a meta‐analysis, we compared the accuracy of the APTIMA HPV test, which identifies RNA of 14 high‐risk HPV types, to HC2 for the triage of women with ASC‐US or LSIL. Literature search‐targeted studies where the accuracy of APTIMA HPV and HC2 for detection of underlying CIN2/3+ was assessed concomitantly including verification of all cases of ASC‐US and LSIL. HSROC (Hierarchical Summary ROC) curve regression was used to compute the pooled absolute and relative sensitivity and specificity. Eight studies, comprising 1,839 ASC‐US and 1,887 LSIL cases, were retrieved. The pooled sensitivity and specificity of APTIMA to triage ASC‐US to detect underlying CIN3 or worse was 96.2% (95% CI = 91.7–98.3%) and 54.9% (95% CI = 43.5–65.9%), respectively. APTIMA and HC2 showed similar pooled sensitivity; however, the specificity of the former was significantly higher (ratio: 1.19; 95% CI = 1.08–1.31 for CIN2+). The pooled sensitivity and specificity of APTIMA to triage LSIL were 96.7% (95% CI = 91.4–98.9%) and 38.7% (95% CI = 30.5–47.6%) for CIN3+. APTIMA was as sensitive as HC2 but more specific (ratio: 1.35; 95% CI = 1.11–1.66). Results were similar for detection of CIN2 or worse. In both triage of ASC‐US and LSIL, APTIMA is as sensitive but more specific than HC2 for detecting cervical precancer.

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.

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.

Human papillomavirus messenger rna assay for cervical cancer screening: The shenzhen cervical cancer screening trial i

Introduction: Testing for high-risk types of human papillomavirus (HPV) has been consistently more sensitive than cervical cytology for high-grade precancers and cancers of the cervix (cervical intraepithelial neoplasia grade 2 or higher) but less specific. New assays are being developed to improve on the overall accuracy of molecular testing. The Gen-Probe APTIMA HPV assay (AHPV) is a multiplex assay that qualitatively detects 14 HPV types in a single tube. Because the AHPV targets HPV-E6/E7 messenger RNA transcripts, it should theoretically have a greater specificity than HPV assays that detect HPV DNA. The objective of this study was to compare the sensitivity and the specificity of the Gen-Probe AHPV with those of the Qiagen Hybrid Capture 2 assay (HC2) and liquid-based cytologic examination for cervical cancer screening. Methods: A total of 2098 unscreened or poorly screened women 25 to 59 years of age were recruited in the city of Shenzhen, China. Two cervical specimens were collected: 1 in SurePath liquid for cytologic examination and 1 in PreservCyt for HPV testing by HC2 and the AHPV. The testing was performed by blinded technicians according to the manufacturers instructions. Women who had atypical squamous cells of undetermined significance or worse cytologic diagnosis and/or were HPV positive by either assay were asked to return for colposcopy and biopsy. Results: Overall, 2095 women had complete data. Overall, 16.5% of the women were positive on HC2, 10.1% were positive on the AHPV, 5.45% had atypical squamous cells of undetermined significance or greater on cytologic examination, and 1.4% had histologically confirmed cervical disease: cervical intraepithelial neoplasia grade 2 or higher. The sensitivity values of liquid-based cytologic examination, HC2, and the AHPV were 66.7%, 88.9%, and 100%, respectively. The specificity values were 95.5%, 84.5%, and 91.2%, respectively. The AHPV was significantly more accurate by receiver operating characteristic curve comparison (P = 0.005). Conclusions: The low false-positive rate (high specificity) and the high sensitivity of the AHPV makes this assay suitable for use as a primary assay for detecting cervical disease in a screening setting.

Utility of Random Cervical Biopsy and Endocervical Curettage in a Low-Risk Population

Objective The study aimed to determine the increase in the yield of cervical intraepithelial neoplasia 3 (CIN 3) or cancer (CIN 3+) from random cervical biopsy in quadrants without visible lesions and endocervical curettage (ECC) in a low-prevalence setting. Materials and Methods Random biopsy and ECC (unless pregnant) have been obtained in the colposcopy clinic of the Southern California Permanente Medical Group (SCPMG)-Fontana since 2004. We reviewed the colposcopy experience of SCPMG-Fontana for January 1, 2007, to December 31, 2009, to determine the method of diagnosis of CIN 3+. Results Between January 1, 2007, and December 31, 2009, 4677 women with median age 32 years had 4932 colposcopies in the SCPMG-Fontana colposcopy clinics. Cervical intraepithelial neoplasia 3+ was diagnosed in 295 women. Cervical biopsy detected 64.4% of CIN 3+; ECC diagnosed 5.1%; loop electrocautery excision procedure (LEEP) or cervical conization for cervical biopsy and/or ECC of CIN 2 diagnosed 27.8%; LEEP for the cytology of high-grade squamous intraepithelial lesion with cervical biopsy result of negative or CIN 1 diagnosed 1.4%; and LEEP, cervical conization, or biopsy in follow-up of CIN 2 diagnosed 1.4%. Sixty-one of the 295 cases of CIN 3+ (20.7%) were diagnosed after evaluation of random cervical biopsy and/or ECC of CIN 2+. Conclusions Random biopsy in cervical quadrants without visible lesions and ECC increased the yield of CIN 3+ in this low-risk colposcopy setting. Endocervical curettage can be omitted in women younger than 25 years.

Primary cervical cancer screening and triage using an mRNA human papillomavirus assay and visual inspection

Objective Mexican Cervical Cancer Screening Study II (MECCS II) seeks to develop a highly sensitive and highly specific screening program able to be adapted to all socioeconomic levels in Mexico. The objectives of MECCS II are (1) to compare the sensitivity and specificity for cervical intraepithelial neoplasia (CIN) 3 or cancer of self-collected vaginal specimens tested for high-risk types of the human papillomavirus (HR-HPV) by APTIMA with those tested for HR-HPV by Hybrid Capture 2 (HC2); and (2) determine the efficacy of cryotherapy in the treatment of HR-HPV–positive and acetic acid–aided visual inspection (VIA)–positive and -negative women after VIA triage. Methods The study was conducted in rural Mexico. Women aged 30 to 50 years, nonpregnant, with no history of hysterectomy or pelvic irradiation and varied histories of screening, participated. A direct endocervical sample was tested for cytology, HC2, and APTIMA assay (AHPV). Subjects positive on any test were recalled for triage VIA, biopsies, and immediate cryotherapy. Tests were compared using McNemar test. Results Two thousand forty-nine patients have complete results. Mean age of the patients was 39.2 years; 7.7% presented with ≥atypical squamous cells of uncertain significance (ASCUS), 1.8% ≥low-grade squamous intraepithelial neoplasia, and 0.5% ≥high-grade squamous intraepithelial neoplasia. Two percent of patients had ≥CIN2, and 0.78% had ≥CIN3 (including 2 with invasive disease). The sensitivity of ThinPrep (>ASCUS), HC2, and AHPV for >CIN3 for direct endocervical collection was 87.5%, 100%, and 100%, respectively. The specificity of ThinPrep (>ASCUS), HC2, and AHPV for >CIN3 was 94.1%, 92.2%, and 93.5%, respectively. Specificities of HC2 and AHPV differed significantly. The overall percentage of agreement among HPV assays (HC2 vs APTIMA) is 97%. Four hundred sixty-nine women returned for VIA. Two hundred ninety-one women were treated with cryotherapy. Conclusions The specificity of the APTIMA assay along with high sensitivity is an advantage for primary screening. Follow-up evaluation will be important to determine the true impact of potential undertreatment in the screening algorithm. Self-sampling applications are explored.

The Peru cervical cancer prevention study (PERCAPS): community-based participatory research in Manchay, Peru.

Objective Cervical cancer is a preventable disease which causes significant morbidity and mortality, particularly in developing countries. Although technology for early detection continues to improve, prevention programs suffer from significant barriers. Community-based participatory research is an approach to research which focuses on collaboration with the community to surmount these barriers. The objective of this study was to evaluate the utility of community-based participatory research techniques in a mother-child screen/treat and vaccinate program for cervical cancer prevention in Manchay, Peru. Materials and Methods Human papillomavirus (HPV) self-sampling and cryotherapy were used for the screen/treat intervention, and the Gardasil vaccine was used for the vaccine intervention. Community health workers from Manchay participated in a 3-day educational course, designed by the research team. The community health workers then decided how to implement the interventions in their community. The success of the program was measured by (1) the ability of the community health workers to determine an implementation plan, (2) the successful use of research forms provided, (3) participation and retention rates, and (4) satisfaction of the participants. Results (1) The community health workers used a door-to-door approach through which participants were successfully registered and both interventions were successfully carried out; (2) registration forms, consent forms, and result forms were used correctly with minimal error; (3) screen/treat intervention: 97% of registered participants gave an HPV sample, 94% of HPV-positive women were treated, and 90% returned for 6-month follow-up; vaccine intervention: 95% of registered girls received the first vaccine, 97% of those received the second vaccine, and 93% the third; (4) 96% of participants in the screen/treat intervention reported high satisfaction. Conclusions Community-based participatory research techniques successfully helped to implement a screen/treat and vaccinate cervical cancer prevention program in Manchay, Peru. These techniques may help overcome barriers to large-scale preventive health-care interventions.

The Mexican cervical cancer screening trial: self-sampling for human papillomavirus with unaided visual inspection as a secondary screen.

The Mexican Cervical Cancer Screening (MECCS) study took place in the State of Michoacán. Primary screening was by self-sampling for high-risk human papillomavirus (HR-HPV). The objectives were to increase the specificity of primary HPV screening by requiring 2 positive HPV tests 1 year apart in women whose secondary screen was negative according to an acetic acid-aided visual inspection (VIA). In addition, we postulated that the sensitivity of VIA would be sufficient to identify large preinvasive lesions and cancers unsuitable for cryotherapy if applied in a see-and-treat algorithm. A total of 8621 women (aged 30-50 years) were screened, and 14.3% were positive for HR-HPV. In phase 1, 11.9% of the HPV-positive women were VIA-positive and were referred for colposcopy with directed and random biopsies. If VIA-negative, women repeated the self-sample 1 year later to detect persistent HR-HPV (25.2% were positive). If persistently HR-HPV-positive in phase 2, patients again had VIA, then all women (both VIA-positive and -negative) received directed and random biopsies. If cryotherapy had been used to treat HPV- and VIA-positive women in phase 1 or persistent HR-HPV-positive (phase 2), the potential risk of undertreatment would have been 4.1%, and 66.4% of the treated patients would have had normal or cervical intraepithelial neoplasia I on biopsy. The VIA triage would refer 0.73% of the patients to colposcopy owing to the lesion size, location, or the presence of a cancer. On the basis of this pilot study, we are encouraged to explore and evaluate a rapid, more sensitive, and more specific self-test.

Descriptive Evidence That Risk Profiles for Cervical Intraepithelial Neoplasia 1, 2, and 3 Are Unique

Objective: This study aimed to estimate if risk factor profiles for histologically confirmed cervical intraepithelial neoplasia (CIN) 2 lesions differ from those for CIN 1 or 3. Methods: A total of 2,055 women positive for high-risk human papillomavirus, with a minimum of five cervical biopsies, were enrolled in the Shanxi Province Cervical Cancer Screening Study II. We evaluated risk factor profiles for CIN 2 in comparison with CIN 1 and 3. Polytomous logistic regression was used to generate odds ratios and corresponding 95% confidence intervals and to test for differences in odds ratios across histologic grades. Results: The risk for CIN 3 associated with three or more pregnancies and sexual intercourse within 4 months of childbirth was higher than that for CIN 2 (Pdifference = 0.02 and 0.0007, respectively). Significant differences in the associations of age groups with CIN 1 and 2 were observed, such that there were positive associations with CIN 2 but none for CIN 1. There was no difference in the association of number of sexual partners or reported number of abortions between CIN 1 and 2 or between CIN 3 and 2. Conclusions: In our study, the patterns of risk factor profiles for CIN 1, 2, and 3 were unique. Conventional grouping of CIN 2 with 3 for analysis of risk factors may need revisiting. (Cancer Epidemiol Biomarkers Prev 2008;17(9):2350–5)

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.