Uses of HPV Testing in Triage of cervical Screening
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The document discusses the use of HPV testing in triaging cervical cytology results, emphasizing its increased sensitivity over cytology for detecting CIN2+ lesions. It highlights the role of HPV testing in managing cases of ASC-US and LSIL cytology, as well as its utility as a test of cure after treatment for high-grade lesions. Key findings include the ability of HPV testing to allow for more effective screening and monitor the risk of recurrence post-treatment, although treatment decisions should consider individual patient histories.
Uses of HPV Testing in Triage of cervical Screening
- 1. Uses of HPV Testing in Triage of Cervical Cytology Dr Dirk Grothuesmann Cervical Cytology (Up to date, 2016) http://dg-maternalhealth.de/
- 2. Uses of HPV Testing alongside Cytology • Triage of ASC-US and/or LSIL cytology • Test of cure after treatment of high-grade CIN • Resolution of uncertainties • Primary HPV testing or co-testing
- 3. Uses of HPV Testing alongside Cytology
- 4. Principles of HPV Testing • HPV is more sensitive than cytology for CIN2+ • Early detection of CIN2 is not an end in itself because almost half of CIN2 lesions would resolve naturally without treatment • Detection of CIN2+ depends on sensitivity of colposcopy • HPV specificity is considerably lower than cytology • Most HPV-positive lesions represent transient infection • Persistent HPV-positive lesions are at risk for progression • HPV is not 100% sensitive for CIN2+, CIN3+ or cancer
- 5. Progression of CIN Categories HIGH-GRADE SQUAMOUS LESION (HSIL) — HSIL refers to moderate to severe changes in the cells of the cervix. The risk that these abnormalities reflect precancerous changes is as high as 20.8%, and the risk of cervical cancer is as high as 1.4%
- 6. HPV triage of ASC-US or LSIL cytology ASC-US atypical cells of undetermined significance LSIL Low-grade squamous intraepithelial lesion • In ASC-US Hybrid Capture 2 (HC2) to be significantly more sensitive than repeat cytology in detecting CIN2+ • no more sensitive in detecting CIN3 • 40% of CIN2 lesions had regressed • In LSIL HPV triage was not recommended for LSIL, most of which was hrHPV+
- 7. Summary of HPV ASC-US/LSIL triage • Allows about half of women with ASC-US to be returned to routine screening due to HPV negativity • Detects more CIN2+ than cytological surveillance • Detects more CIN3+ in meta-analyses but not at all centres (depending on the sensitivity of cytology)
- 8. In view of frequent regression of CIN2, immediate treatment may not be mandatory in young women and requires histology and cytology review
- 9. Test of cure after treatment of CIN • Women may be at increased risk of cancer for up to 20 years after treatment of CIN3 (Strander et al. 2007) • A four-fold increased risk of cancer has been reported after treatment of any grade of CIN and three negative cytology tests (Rebolj et al. 2012) • Among 15 studies with 2-year follow up, the risk of recurrent CIN varied between 4% and 18% (average 8%) in 15 studies (Flannelly et al. 2001)
- 10. Risk of CIN3+ within 10 years Post-treatment disease in women treated for high- grade cervical disease • 29% of HPV-positive women (i.e. 6%) • 13% of women with ASC-US+ cytology (i.e. 3%) • 22.5% of women positive for either or both (i.e. 7%) • 2.1% of HPV-negative women (i.e. 2%) • 2.8% of cytology-negative women (i.e. 2%) • 1.4% of double-negative women (i.e. 1%) Kocken et al., Gynecologic Oncology, vol. 125, no. 2, pp. 500–507, 2012
- 11. Co-testing after Treatment • Risk of CIN2+ recurrence after negative co-testing at 24 months or three negative cytology tests was similar to the risk of CIN2+ in the general population • As a result of this study the authors recommended co-testing at 6 and 24 months - or three cytology tests at 6, 12 and 24 months if HPV testing is not available.
- 12. HPV testing to resolve uncertainty (e.g. persistent CIN1) • HPV testing was positive in one-third to half of women • CIN2+ rates were higher in HPV+ women (8% vs. 0.7%) • HPV testing in this setting highlights the problem of managing HPV- positive women who do not have CIN2+
- 13. ASC-US Management using HPV Triage HPV Test with Hybrid-capture using High Risk Probe ASC-US Pap Test High Risk HPV positive High Risk HPV negative Perform Coloposcopy Repeat Pap in 12 month