HPV testing and vaccination in Europe.

Current cytology-based screening has a moderate sensitivity to detect cervical intraepithelial neoplasia grade 3 (CIN 3) and cervical cancer even in those states providing rigorous quality control of their cervical screening programs. The impact of vaccination against human papillomavirus (HPV) types 16 and 18 as well as the incorporation of HPV testing on the detection of CIN 3 and cancer is discussed. HPV testing used as a triage for atypical squamous cells of undetermined significance (ASCUS) and low-grade squamous intraepithelial lesions, test of cure after treatment, and HPV-based primary screening may improve current cervical screening programs.HPV testing as a triage test for ASCUS seems to offer an improved sensitivity, with a similar specificity as compared to repeat cytology for diagnosing high-grade CIN and has been recommended throughout most EU states. HPV testing as a triage test for low-grade squamous intraepithelial lesions has a low specificity and is not recommended in most member states. HPV test of cure offers an improved sensitivity compared to cytology for women with persistent cervical precancer after treatment. HPV-based cervical cancer screening is more effective than screening with cytology. The effects of HPV-based screening depend on the organization of the program and on adherence to algorithms for screening triage. Otherwise, it is likely that HPV-based screening will increase the referral rate to colposcopy including more women with no detectable cervical lesion. HPV vaccination will require many years to evaluate any beneficial effects on cervical cancer incidence and mortality.

The future role for colposcopy in Europe.

Improvements in the performance of cervical screening may be limited by the diagnostic performance of colposcopy. Nonetheless, colposcopy remains the best available tool to assess women considered at high risk for having or developing cervical cancer. The provision and role of colposcopy across Europe is variable. Introduction of vaccination against human papillomavirus (HPV) types 16 and 18 as well as the possible switch to HPV-based screening is likely to change the profiles of women presenting to colposcopy services and provide management difficulties for the colposcopist.The standard of colposcopy in Europe can be maintained or improved despite a variable availability of screening. The prevalence of cervical intraepithelial neoplasia grade 3 may decrease for women having had HPV vaccination. The incidence of cervical intraepithelial neoplasia grade 3 and cervical cancer in second and subsequent rounds of HPV-based screening are likely to decrease compared to cytology-based screening. In HPV-based screening, the numbers of women with no detectable or minor abnormalities at colposcopy and with screen-detected glandular disease are likely to increase. We have considered how these issues will affect states that have varying implementation of organized cervical screening programs and varying degrees of implementation of HPV testing or vaccination.The development of quality assurance across Europe accompanying these program changes is discussed.

Triaging Pap cytology negative, HPV positive cervical cancer screening results with p16/Ki-67 Dual-stained cytology.

OBJECTIVE: Testing for human papillomavirus (HPV) has been shown to increase the sensitivity and negative predictive value for detection of high-grade cervical intraepithelial neoplasia (CIN2+), either when used in conjunction with Pap cytology testing or alone. However, there is no satisfying clinical management algorithm for women testing Pap negative/HPV positive. We therefore evaluated the clinical utility of a novel dual biomarker-based approach (p16/Ki-67 Dual-stained cytology) for the identification of CIN2+ in women with Pap negative/HPV positive screening results, without the need to refer all women to immediate colposcopy. METHODS: All women aged ≥30 enrolled during 2007/2008 into a regional prospective Pap/HPV co-testing screening pilot project and tested Pap negative, but positive for HPV (n=425) were included in the analysis. p16/Ki-67 Dual-stained cytology was performed from residual cellular material available from the liquid-based cytology vial collected during the initial Pap/HPV co-testing screening visit. Results were correlated to the presence of CIN2+ confirmed during preliminary follow-up. RESULTS: p16/Ki-67 Dual-stained cytology tested positive at baseline in 108 out of 425 (25.4%) Pap negative/HPV positive cases. Sensitivity of Dual-stain testing for the detection of biopsy-confirmed CIN2+ during preliminary follow-up within the group of Pap negative/HPV positive women was 91.9% for CIN2+ (34/37 cases), and 96.4% for CIN3+ (27/28 cases). Specificity was 82.1% for CIN2+ on biopsy, and 76.9% for CIN3+, respectively. CONCLUSIONS: Triaging Pap negative/HPV positive screening test results with p16/Ki-67 Dual-stained cytology may identify women with a high probability of underlying CIN2+ and may efficiently complement HPV-based screening programs to prevent cervical cancer.

Prevention of Cervical Cancer: Guideline of the DGGG and the DKG (S3 Level, AWMF Register Number 015/027OL, December 2017) - Part 1 with Introduction, Screening and the Pathology of Cervical Dysplasia.

Aims Annual opportunistic screening for cervical carcinoma has been carried out in Germany since 1971. The creation of this S3 guideline meets an important need, outlined in the National Cancer Plan, with regard to screening for cervical cancer, as the guideline aims to provide important information and support for planned organized screening for cervical cancer in Germany. Methods With the financial support of German Cancer Aid, 21 professional societies developed evidence-based statements and recommendations (classified using the GRADE system) for the screening, management and treatment of precancerous conditions of the cervix. Two independent scientific institutes compiled systematic reviews for this guideline. Recommendations The first part of this short summary presents the pathological basis and considers various questions related to screening for cervical cancer. As also reported in earlier reviews, the meta-analysis by Kleijnen Systematic Reviews showed that HPV-based screening offers better protection against invasive cervical cancer compared to cytology-based screening. The authors of this guideline therefore recommend - in accordance with the guideline of the Joint National Committee of Germany (Gemeinsamer Bundesauschuss, G-BA) - that women aged 35 and above should be examined at regular intervals (at least every 3 years) and undergo HPV-based screening. Co-testing can also be carried out. Women between the ages of 20 and 35 should have cytological screening every 2 years.

Prevention of Cervical Cancer: Guideline of the DGGG and the DKG (S3 Level, AWMF Register Number 015/027OL, December 2017) - Part 2 on Triage, Treatment and Follow-up.

Aims Annual opportunistic screening for cervical carcinoma has been done in Germany since 1971. The creation of this S3 guideline meets an important need, outlined in the National Cancer Plan, with regard to screening for cervical cancer, as this guideline aims to provide important information and support for planned organized screening for cervical cancer in Germany. Methods With the financial support of German Cancer Aid, 21 professional societies developed evidence-based statements and recommendations (classified using the GRADE system) for the screening, management and treatment of precancerous conditions of the cervix. Two independent scientific institutes compiled systematic reviews for this guideline. Recommendations The second part of this short summary deals with the triage, treatment and follow-up care of cervical dysplasia. With regard to those women who do not participate in screening, the guideline authors recommend sending out repeat invitation letters or an HPV self-collection kit. Colposcopy should be carried out for further investigation if cytology findings are Pap II-p and HPV test results are positive or if the results of an HPV 16 or HPV 18 screening test are positive. A single abnormal Pap smear should be triaged and investigated using HPV testing or p16/Ki67 dual staining.

2017 update of the European Federation for Colposcopy (EFC) performance standards for the practice of colposcopy.

A refinement of quality indicators (QIs) is described whereby the quality of care can be measured across colposcopy services in different countries and healthcare settings. A five-round Delphi process was conducted at successive satellite meetings from 2011 to 2015 of leading European colposcopists to refine the most high-scoring QIs relevant to colposcopic practice. A review and refinement of the wording of the standards and their criteria was undertaken by national society representatives. Six quality indicators were identified and refined. "Documentation of whether the squamocolumnar junction (SCJ) has been visible or not" was changed into "for cervical colposcopy transformation zone (TZ) type (1, 2 or 3) should be documented". The standard "percentage of cases having a colposcopic examination prior to treatment for abnormal cytology" was changed to "percentage of cases having a colposcopic examination prior to treatment for abnormal cervical screening test". The standard "percentage of all excisional treatments/conizations containing CIN2+ (cervical intra-epithelial neoplasia grade two or worse)" was changed into "percentage of excisional treatments/conizations having a definitive histology of CIN2+. Definitive histology is highest grade from any diagnostic or therapeutic biopsies". The standard "percentage of excised lesions/conizations with clear margins" was unchanged. The remaining two QIs define the minimum caseloads required for colposcopists. However, "cytology" was replaced by "screening results" to acknowledge the introduction of human papillomavirus testing to European screening programmes. Six QIs were identified to define good practice in colposcopy.

An economic analysis of human papillomavirus triage for the management of women with atypical and abnormal Pap smear results in Germany.

We developed decision-analytic models to determine the cost effectiveness of incorporating human papillomavirus (HPV) testing into the management of atypical and abnormal Pap smear results in Germany. The models compare three management strategies: (1) repeat Pap smear, (2) triage with HPV DNA testing, or (3) immediate treatment. The primary outcome measure is incremental cost per case of cervical intraepithelial neoplasia (CIN) 2+ detected and treated. The models take the perspective of the German health system. For patients with initial PapIIw, III, and IIId results, incremental cost effectiveness ratios for HPV triage versus repeat Pap smears are 2,232 euro, 815 euro, and 487 euro per additional case of CIN2+ detected and treated. In addition, the number of cases of CIN2+ detected and treated in a hypothetical population of 1,000 women increases from 17 to 35, 61 to 130, and 157 to 332 for each population, respectively. For patients with initial PapIII and IIId results, immediate treatment of 1,000 patients detects only four and 11 additional cases of CIN2+ versus HPV triage at incremental cost effectiveness ratios of 39,684 euro and 10,716 euro per case, respectively. For each of the populations evaluated, HPV triage is the most cost-effective management strategy versus either repeat Pap smear or immediate treatment.

Prognostic value of HPV-mRNA in sentinel lymph nodes of cervical cancer patients with pN0-status.

Up to 15% of patients with cervical cancer and pN0-status develop recurrent-disease. This may be due to occult metastatic spread of tumor cells. We evaluated the use of human-papillomavirus-(HPV)-mRNA as a molecular marker for disseminated tumor cells to predict the risk of recurrence. For this prospective, multi-center prognostic study, 189 patients free of lymphnode metastases by conventional histopathology could be analyzed. All patients underwent complete lymphadenectomy. Of each sentinel node (SLN) a biopsy was taken for the detection of HPV-E6-E7-mRNA. Median follow-up time after surgery was 8.1 years. HPV-mRNA could be detected in SLN of 52 patients (27.5%). Recurrence was observed in 22 patients. Recurrence-free-survival was significantly longer for patients with HPV-negative SLN (log rank p = 0.002). By Cox regression analysis the hazard ratio (95%CI) for disease-recurrence was 3.8 (1.5 - 9.3, p = 0.004) for HPV-mRNA-positive compared to HPV-mRNA-negative patients. After adjustment for tumor size as the most influential covariate the HR was still 2.8 (1.1 - 7.0, p = 0.030). In patients with cervical cancer and tumor-free lymph nodes by conventional histopathology HPV-mRNA-positive SLN were of prognostic value independent of tumor size. Particularly, patients with tumors larger than 20mm diameter could possibly benefit from further risk stratification using HPV-mRNA as a molecular marker.

Risk-adapted primary HPV cervical cancer screening project in Wolfsburg, Germany--experience over 3 years.

BACKGROUND: Currently, the German cervical cancer screening program encompasses an annual cytological Papanicolaou (Pap) smear. However, primary screening for cervical cancer using human papillomavirus (HPV) DNA testing detects cervical pre-cancerous lesions with a significantly higher sensitivity than the Pap smear-based cytology. OBJECTIVES: In order to develop viable modalities for primary cervical screening incorporating DNA testing for high-risk (HR) types of HPV, we started a pilot project in the city of Wolfsburg, Germany, in February 2006. This program provided a risk-adapted HPV testing-based strategy with defined patient pathways and extended screening intervals for women of 30 years or older. We report here the data of a 3-year follow-up. STUDY DESIGN: In the context of the usual routine screening at their office-based gynecologists, women were offered conventional cytology plus the Hybrid Capture 2 (HC2) HPV DNA test. Women with inconspicuous cytological findings (Pap I/II) and negative HC2 test were re-tested after 5 years but continued their annual gynecological examinations. When cytology and HC2 were positive, women were immediately referred to colposcopy. In women with a negative cytology but positive HC2 test, Pap smear was repeated after 6 mo and HC2 testing after 12 mo, and women were called for colposcopy if the HC2 test was persistently positive. RESULTS: From February 2006 to December 2008, 16,724 women agreed to participate in the project. Overall, 906 (5.41%) had positive HC2 results and 338 (2.02%) showed atypical Pap smears at recruitment. There were 417 (2.48%) women referred for colposcopy, 104 of whom were diagnosed with cervical intraepithelial neoplasia (CIN) 3 or worse, including 8 invasive cancers and 8 adenocarcinoma in situ (ACIS). No case of CIN 3 or worse occurred in HC2 negative women. CONCLUSIONS: The presented risk-adapted Wolfsburg Cervical Cancer Prevention Project ("Wolfsburg Model") has been shown to be effective and feasible in identifying women at risk and for avoiding unnecessary procedures for those who are double negative, thus allowing longer screening intervals and cost savings. Acceptance rates for the program were high for both participating women and gynecologists.

Human papillomavirus-type persistence patterns predict the clinical outcome of cervical intraepithelial neoplasia.

BACKGROUND: Persistent infection with high-risk (HR) human papillomavirus (HPV) genotypes is required for the development of cervical carcinoma, and integration of HPV testing into cervical screening programs is under investigation. For the clinical value of HPV testing to be fully established, genotyping studies are needed to identify HR HPV persistence in samples of known cytology and histology, and to determine the relationship with clinical outcome. To date, methods for genotyping have been research-based, and subject to variation. The availability of the Roche prototype line blot assay (LBA) offers a PCR-based, reproducible genotyping method, with a 37-type target spectrum and many potential applications. METHODS: We applied the LBA to determine persistence of HR HPV in 54 women with low-grade histology. Median interval between genotyping was 12.5 months (range 5-48). RESULTS: All 15 lesions that progressed to CIN3 (PD) were associated with HR HPV persistence. Regression of lesions (REM) was observed in 31 HPV+ women, of whom nine had clearance of existing HPV infections, with one patient then acquiring additional types. Eight HPV+ patients had no change in lesions observed (NC). Persistence of HPV type 16 was more common in the PD group (60%), compared with the REM group (27%) and the NC group (38%). CONCLUSION: Our results show that the LBA is a useful tool to identify HPV persistence patterns under anonymized conditions, with potential for research and clinical studies.

Clinical trials in cervical intraepithelial neoplasia: balancing the need for efficacy data with patient safety.

OBJECTIVE.: Trial designs for novel nonsurgical, nonablative therapies for cervical intraepithelial neoplasia grades 2 and 3 (CIN 2,3) must ensure patient safety while providing sufficient time to show clinical effects. We propose an observation period based on literature and current practice. MATERIALS AND METHODS.: We reviewed 3 types of literature regarding observation of untreated CIN 2,3: 1) the management of CIN in pregnancy, perhaps the best existing model of observation; 2) the natural history of untreated CIN 2,3; and 3) the optimal means of protecting patient safety during longer-term follow-up of untreated CIN 2,3 lesions. RESULTS.: Data from both the pregnant and nonpregnant patient populations indicate that delaying treatment of CIN for periods of several weeks to several months is rarely associated with clinically significant disease progression. Screening and follow-up criteria that promote patient safety have been suggested and seem adaptable to clinical trials. CONCLUSIONS.: Careful screening and follow-up of patients with CIN 2,3 allows an observation period of at least 6 months after nonsurgical, nonablative therapy in clinical trials.

Factors associated with an increased risk of prevalent and incident grade III cervical intraepithelial neoplasia and invasive cervical cancer among women with Papanicolaou tests classified as grades I or II cervical intraepithelial neoplasia.

OBJECTIVE: Women with Papanicolaou tests classified as cervical intraepithelial neoplasia grade I or II are treated conservatively in many countries. However, these women are at an increased risk of having underlying prevalent and incident grade III cervical intraepithelial neoplasia and invasive cancer. This study was undertaken to identify factors that could predict these clinically important disease states. STUDY DESIGN: Five hundred women with Papanicolaou tests classified as persistent grade I or II cervical intraepithelial neoplasia underwent a repeat test, human papillomavirus testing with Hybrid Capture assay (Digene, Silver Spring, Md) and polymerase chain reaction, and colposcopy with histologic assessment. One hundred fifty-seven women with histologically proven grade I or II cervical intraepithelial neoplasia were monitored conservatively for a minimum of 9 months to assess predictors of incident grade III cervical intraepithelial neoplasia. RESULTS: One hundred fifty-one women with prevalent grade III cervical intraepithelial neoplasia and 5 women with prevalent invasive cancer were identified at the first colposcopy. A repeated Papanicolaou test classified as higher than grade II cervical intraepithelial neoplasia and detection of oncogenic human papillomavirus types were significant predictors of underlying grade III cervical intraepithelial neoplasia and cancer in the multivariate analysis. Seventeen of 157 women (10.8%) with grade I or II cervical intraepithelial neoplasia progressed to grade III cervical intraepithelial neoplasia. Age >30 years and detection of oncogenic human papillomavirus were significantly correlated with progression in the multivariate analysis. No progression was observed in women who were negative for human papillomavirus. CONCLUSION: The high rate of underlying prevalent grade III cervical intraepithelial neoplasia and cancer found in our study (31.2%) indicates that conservative management of women with persistent grade I or II cervical intraepithelial neoplasia should be discouraged. Colposcopy with histologic assessment should be recommended as the standard of care. However, for women with histologically proven grade I or II cervical intraepithelial neoplasia, subsequent conservative management was safe in our study for those who were negative for human papillomavirus by type-specific polymerase chain reaction.

MMP-1 and MMP-2 in the cervix uteri in different steps of malignant transformation--an immunohistochemical study.

OBJECTIVES: Enzymatic degradation of the extracellular matrix (ECM) represents a key element in the multistage process of tumor invasion and metastasis. This process requires extensive degradation of ECM components such as basement membrane collagen (type IV) and interstitial collagen (type I, II, III). Matrix metalloproteinase-2 (MMP-2) specifically cleaves collagen type IV, the major collagen of the basement membrane. MMP-1 digests interstitial collagen type I and III, the main collagen types of the stromal extracellular matrix. We investigated protein levels of MMP-1 and MMP-2 in different stages of malignant transformation. METHODS: Using the APAAP method we analyzed 10 normal cervical tissues, 11 cervical intraepithelial neoplasia 1 (CIN 1), 8 CIN 2 and 10 CIN 3 lesions, and 15 invasive squamous cell carcinomas. These data were compared with the HPV DNA status tested by hybrid capture II. RESULTS: Only a few isolated epithelial cells stained positively for MMP-1 and MMP-2 in normal cervical tissue and CIN 1 lesions. The CIN 2 and CIN 3 group displayed a heterogeneous distribution of MMP expression. 3 CIN 2 and 8 CIN 3 lesions showed strong MMP-2 and weak MMP-1 expression in the dysplastic epithelial cells. 5 CIN 2 and 2 CIN 3 lesions stained negatively. Invasive carcinomas showed a coexpression for MMP-1 and MMP-2 in malignant epithelial cells and peritumoral stroma cells. All MMP-2-positive cases tested positive for the HPV high-risk group. CONCLUSIONS: The expression of MMP-2 protein in preinvasive lesions of the cervix uteri and a consecutive coexpression of MMP-1 and MMP-2 in invasive cancer suggest a gradually increasing invasive potential. MMP-2 expression, when focally observed in high-grade squamous intraepithelial lesions of the cervix, may indicate tumor areas with an increased risk for invasive growth.

No confirmed case of human papillomavirus DNA-negative cervical intraepithelial neoplasia grade 3 or invasive primary cancer of the uterine cervix among 511 patients.

OBJECTIVE: This study was undertaken to analyze the prevalence and peculiarities of high-grade cervical neoplasias that are not associated with human papillomavirus (HPV) DNA. STUDY DESIGN: Four hundred nineteen women with a first-time diagnosis of cervical intraepithelial neoplasia grade 3 and 92 women with cervical cancer were examined prospectively with a commercially available HPV DNA test. Negative samples were re-tested by polymerase chain reaction (PCR) with general and type-specific primers while the corresponding histology specimens were evaluated by immunohistochemistry. RESULTS: Of the 511 cases examined, 14 were HPV DNA negative on initial analysis. Of these, 7 were found not to be high-grade cervical neoplasia on histologic review, 3 cases were found to contain high-risk HPV types by PCR, and 2 samples were found to be inadequate for analysis. The 2 remaining HPV-negative cases were FIGO stage III and IV tumors. Immunohistochemistry was consistent with a primary adenocarcinoma of the ovary in 1 case and a primary bladder tumor in the other, although a primary cancer of the cervix could not be ruled out completely. CONCLUSION: After exclusion of inadequate samples and erroneous diagnoses, HPV DNA was associated with all confirmed cervical intraepithelial neoplasia grade 3 and primary cervical cancers.