Comparing the performance of six human papillomavirus tests in a screening population.

BACKGROUND: Several new assays have been developed for high-risk HPV testing of cervical samples; we compare six HPV tests in a screening population. METHODS: Residual material from liquid-based PreservCyt samples was assayed. Four tests (Hybrid Capture 2, Cobas, Abbott and Becton-Dickinson (BD)) measured HPV DNA while two used RNA (APTIMA and NorChip). RESULTS: Positivity rates ranged from 13.4 to 16.3% for the DNA-based tests with a significantly lower positivity rate for the Abbott assay. The Gen-Probe APTIMA assay was positive in 10.3% of women, which was significantly lower than all the DNA tests; the NorChip PreTect HPV-Proofer test was much lower at 5.2%. 40 CIN2+ cases were identified, of which 19 were CIN3+. All CIN3+ cases were HPV positive by all tests except for one, which was negative by the Abbott assay and five which were negative by the NorChip test. CONCLUSION: All HPV tests except NorChip showed high sensitivity for high-grade lesions positive by cytology, suggesting co-testing is unnecessary when using HPV tests. Positivity rates in cytology-negative specimens were similar for the DNA-based tests, but lower for the APTIMA test suggesting this maintains the high sensitivity of DNA tests, but with better specificity.

Efficacy of the human papillomavirus (HPV)-16/18 AS04-adjuvanted vaccine in women aged 15-25 years with and without serological evidence of previous exposure to HPV-16/18.

In the Phase III PATRICIA study (NCT00122681), the human papillomavirus (HPV)-16/18 AS04-adjuvanted vaccine (Cervarix(®), GlaxoSmithKline Biologicals) was highly efficacious against HPV-16/18 infections and precancerous lesions in women HPV-16/18 deoxyribose nucleic acid (DNA) negative and seronegative at baseline. We present further data on vaccine efficacy (VE) against HPV-16/18 in the total vaccinated cohort including women who may have been exposed to HPV-16/18 infection before vaccination. In women with no evidence of current or previous HPV-16/18 infection (DNA negative and seronegative), VE was 90.3% (96.1% confidence interval: 87.3-92.6) against 6-month persistent infection (PI), 91.9% (84.6-96.2) against cervical intraepithelial neoplasia (CIN)1+ and 94.6% (86.3-98.4) against CIN2+ [97.7% (91.1-99.8) when using the HPV type assignment algorithm (TAA)]. In women HPV-16/18 DNA negative but with serological evidence of previous HPV-16/18 infection (seropositive), VE was 72.3% (53.0-84.5) against 6-month PI, 67.2% (10.9-89.9) against CIN1+, and 68.8% (-28.3-95.0) against CIN2+ [88.5% (10.8-99.8) when using TAA]. In women with no evidence of current HPV-16/18 infection (DNA negative), regardless of their baseline HPV-16/18 serological status, VE was 88.7% (85.7-91.1) against 6-month PI, 89.1% (81.6-94.0) against CIN1+ and 92.4% (84.0-97.0) against CIN2+ [97.0% (90.6-99.5) when using TAA]. In women who were DNA positive for one vaccine type, the vaccine was efficacious against the other vaccine type. The vaccine did not impact the outcome of HPV-16/18 infections present at the time of vaccination. Vaccination was generally well tolerated regardless of the woman's HPV-16/18 DNA or serological status at entry.

HPV self-sampling as an alternative strategy in non-attenders for cervical screening - a randomised controlled trial.

BACKGROUND: A randomised trial to ascertain whether women who do not attend for cervical screening are more likely to respond to the opportunity to collect a self-sample for human papillomavirus (HPV) testing, or to a further invitation to attend for cervical screening. METHODS: The study was carried out in a Primary Care Trust (PCT) in London between June 2009 and December 2009. In total, 3000 women were randomly selected from persistent non-responders (i.e., who had not responded to at least two invitations to attend for screening). The women were randomised on a 1 : 1 basis to either receive an HPV self-sampling kit or a further invitation to attend for cervical cytology. The main outcome measures were (1) percentage of women attending for cervical cytology compared with those returning a self-sample HPV test or attending for cytology subsequent to receiving the kit and (2) percentage of those testing positive for HPV who attended further investigation. RESULTS: The total response in the self-sampling group for screening was 10.2%. Of the 1500 women in the control group sent a further invitation for cervical screening, 4.5% attended for cytology screening. This difference is highly statistically significant (P<0.0001). Of the 8 women who tested positive for HPV, 7 attended for a cervical smear and had a concurrent colposcopy. Three of these (43%) had high-grade disease (defined as CIN 2+), with one found to have an invasive cancer (stage 1b) and one CIN 3. CONCLUSIONS: The value of this intervention relies on the detection of high-grade CIN and early stage cancer with a good prognosis. The relatively high yield of abnormalities found is consistent with that expected among a hard to reach and relatively high-risk group of women. Our study suggests that self-sampling could increase participation among non-responders in England, but further work is needed to ascertain whether the low response rate seen here is likely to be representative of the rest of the country. Other studies are needed to investigate the response to self-sampling in different demographic and geographic settings.

Long-term follow-up of cervical disease in women screened by cytology and HPV testing: results from the HART study.

BACKGROUND: Several studies have shown that testing for high-risk human papillomavirus (HPV) types results in an improved sensitivity for CIN2+, compared with cytology, although with a somewhat lower specificity. METHODS: We obtained follow-up results, with at least one smear after participation in the HART study, which compared HPV testing (HC-II) with cytology as a primary screening modality. RESULTS: With a median follow-up of 6 years, 42 additional cases of CIN2+ were identified; women who were HPV positive at baseline were more likely to develop CIN2+ than those who were HPV negative (hazard ratio (HR) 17.2; 95% confidence interval (CI) (9.3-31.6)) and the risk increased with increasing viral load. Compared with HPV-negative women (relative light unit (RLU) <1), the HR (95% CI) was 5.4 (1.6, 18.2) for 1-10 RLU and 25.5 (13.6, 47.9) for RLU > or = 10. Positive cytology (borderline or worse compared with negative) was also predictive of developing CIN2, although to a lesser extent (HR 8.7; 95% CI (4.5-17.1)). Only one case of CIN3 and three cases of CIN2 were found in women who showed a positive cytology result but were HPV negative at baseline. CONCLUSION: After 5 years of follow-up, CIN2+ occurred in 0.23% of women who were HPV negative at baseline compared with 0.48% of women who showed a negative cytology result, indicating a much longer low-risk interval for CIN2+ after HPV testing.

Efficacy of human papillomavirus (HPV)-16/18 AS04-adjuvanted vaccine against cervical infection and precancer caused by oncogenic HPV types (PATRICIA): final analysis of a double-blind, randomised study in young women.

BACKGROUND: The human papillomavirus (HPV)-16/18 AS04-adjuvanted vaccine was immunogenic, generally well tolerated, and effective against HPV-16 or HPV-18 infections, and associated precancerous lesions in an event-triggered interim analysis of the phase III randomised, double-blind, controlled PApilloma TRIal against Cancer In young Adults (PATRICIA). We now assess the vaccine efficacy in the final event-driven analysis. METHODS: Women (15-25 years) were vaccinated at months 0, 1, and 6. Analyses were done in the according-to-protocol cohort for efficacy (ATP-E; vaccine, n=8093; control, n=8069), total vaccinated cohort (TVC, included all women receiving at least one vaccine dose, regardless of their baseline HPV status; represents the general population, including those who are sexually active; vaccine, n=9319; control, n=9325), and TVC-naive (no evidence of oncogenic HPV infection at baseline; represents women before sexual debut; vaccine, n=5822; control, n=5819). The primary endpoint was to assess vaccine efficacy against cervical intraepithelial neoplasia 2+ (CIN2+) that was associated with HPV-16 or HPV-18 in women who were seronegative at baseline, and DNA negative at baseline and month 6 for the corresponding type (ATP-E). This trial is registered with ClinicalTrials.gov, number NCT00122681. FINDINGS: Mean follow-up was 34.9 months (SD 6.4) after the third dose. Vaccine efficacy against CIN2+ associated with HPV-16/18 was 92.9% (96.1% CI 79.9-98.3) in the primary analysis and 98.1% (88.4-100) in an analysis in which probable causality to HPV type was assigned in lesions infected with multiple oncogenic types (ATP-E cohort). Vaccine efficacy against CIN2+ irrespective of HPV DNA in lesions was 30.4% (16.4-42.1) in the TVC and 70.2% (54.7-80.9) in the TVC-naive. Corresponding values against CIN3+ were 33.4% (9.1-51.5) in the TVC and 87.0% (54.9-97.7) in the TVC-naive. Vaccine efficacy against CIN2+ associated with 12 non-vaccine oncogenic types was 54.0% (34.0-68.4; ATP-E). Individual cross-protection against CIN2+ associated with HPV-31, HPV-33, and HPV-45 was seen in the TVC. INTERPRETATION: The HPV-16/18 AS04-adjuvanted vaccine showed high efficacy against CIN2+ associated with HPV-16/18 and non-vaccine oncogenic HPV types and substantial overall effect in cohorts that are relevant to universal mass vaccination and catch-up programmes. FUNDING: GlaxoSmithKline Biologicals.

Prophylactic HPV vaccines.

Infection with human papillomavirus (HPV), in particular HPV 16 and HPV 18, is the main cause of cervical cancer. Two prophylactic vaccines against types 6, 11, 16 and 18 have shown great promise in clinical trials, with recent results demonstrating 100% efficacy against persistent HPV infection and development of CIN up to five years of follow-up. One of these (Gardasil, recently licensed) contains all four HPV types, offering protection against genital warts (types 6 and 11) as well as cervical cancer. The other (Cervarix) contains types 16 and 18, targeting cervical cancer alone. Recent data suggest a degree of cross-protection, against types 31 and 45; this could significantly increase the level of protection afforded by the vaccines. It is envisaged that girls between 11 and 12 will be the target, and this is what has been recommended in the United States. There is still debate about the issue of vaccinating boys. A fundamental issue is the lack of education of both the public and health professionals about HPV. In theory, an HPV vaccine could prevent almost all cervical cancer, eventually removing the need for cervical smears. However, there is at least one whole generation of women for whom the vaccine will come too late, and who will continue to require screening.

Public awareness of human papillomavirus.

OBJECTIVES: The main objective of this study was to review the evidence relating to the level of awareness of human papillomavirus (HPV) in the general population and the implications for the potential introduction of HPV vaccination and HPV testing as part of screening. METHODS: PubMed search performed on terms: 'HPV education', 'HPV awareness' 'Genital Warts Awareness' Results: Public awareness of HPV is generally very low, particularly with respect to its relation to abnormal smears and cervical cancer although knowledge levels vary to some extent according to sociodemographic characteristics. There is also much confusion around which types cause warts and the types that can cause cancer. The sexually transmissible nature of the infection is of major concern and confusion to women. CONCLUSIONS: Due to the lack of current awareness of HPV, significant education initiatives will be necessary should HPV vaccination and/or HPV testing be introduced. Organized edification of health-care workers and the media, who constitute the two most preferred sources of information, will be crucial.

Acceptability of unsupervised HPV self-sampling using written instructions.

OBJECTIVES: The study measured the acceptability of self-sampling for human papillomavirus (HPV) testing in the context of cervical cancer screening. Women carried out self-sampling unsupervised, using a written instruction sheet. SETTING: Participants were women attending either a family planning clinic or a primary care trust for routine cervical screening. METHODS: Women (n = 902) carried out self-sampling for HPV testing and then a clinician did a routine cervical smear and HPV test. Immediately after having the two tests, participants completed a measure of acceptability for both tests, and answered questions about ease of using the instruction sheet and willingness to use self-sampling in the future. RESULTS: The majority of women found self-sampling more acceptable than the clinician-administered test, but there was a lack of confidence that the test had been done correctly. Significant demographic differences in attitudes were found, with married women having more favourable attitudes towards self-sampling than single women, and Asian women having more negative attitudes than women in other ethnic groups. Intention to use self-sampling in the future was very high across all demographic groups. CONCLUSION: Self-sampling for HPV testing was highly acceptable in this large and demographically diverse sample, and women were able to carry out the test alone, using simple written instructions. Consistent with previous studies, women were concerned about doing the test properly and this issue will need to be addressed if self-sampling is introduced. More work is needed to see whether the demographic differences we found are robust and to identify reasons for lower acceptability among single women and those from Asian background.

Management of women who test positive for high-risk types of human papillomavirus: the HART study.

BACKGROUND: Certain types of human papillomavirus (HPV) are the primary cause of almost all cervical cancers. HPV testing of cervical smears is more sensitive but less specific than cytology for detecting high-grade cervical intraepithelial neoplasia (CIN2+). HPV testing as a primary screening approach requires efficient management of HPV-positive women with negative or borderline cytology. We aimed to compare the detection rate and positive predictive values of HPV assay with cytology and to determine the best management strategy for HPV-positive women. METHODS: We did a multicentre screening study of 11085 women aged 30-60 years. Women with borderline cytology and women positive for high-risk HPV with negative cytology were randomised to immediate colposcopy or to surveillance by repeat HPV testing, cytology, and colposcopy at 12 months. FINDINGS: HPV testing was more sensitive than borderline or worse cytology (97.1% vs 76.6%, p=0.002) but less specific (93.3% vs 95.8%, p<0.0001) for detecting CIN2+. Of 825 randomised women, surveillance at 12 months was as effective as immediate colposcopy. In women positive for HPV at baseline, who had surveillance, 73 (45%) of 164 women with negative cytology and eight (35%) of 23 women with borderline cytology were HPV negative at 6-12 months. No CIN2+ was found in these women, nor in women with an initial negative HPV test with borderline (n=211) or mild (32) cytology. INTERPRETATION: HPV testing could be used for primary screening in women older than 30 years, with cytology used to triage HPV-positive women. HPV-positive women with normal or borderline cytology (about 6% of screened women) could be managed by repeat testing after 12 months. This approach could potentially improve detection rates of CIN2+ without increasing the colposcopy referral rate.

Cytokeratin expression and acetowhite change in cervical epithelium.

AIM: To investigate the distribution of cytokeratins 10, 13, 14 and 19 in biopsy specimens taken from acetowhite and non-acetowhite areas of the cervix. METHOD: Cervical biopsy specimens were taken from both acetowhite and non-acetowhite areas from 44 patients who presented with abnormal cervical cytology. The specimens were snap frozen in liquid nitrogen and multiple sections taken from each specimen. Staining was performed for cytokeratins 10, 13, 14, 19 and NADPH diaphorase enzyme. The areas of each section positive for the various markers were measured. RESULTS: Cytokeratin 10 positive cells were greatly increased in number in acetowhite biopsy specimens compared with non-acetowhite samples (45.1% v 2.8%; p < 0.0001). Cytokeratin 19 was also increased, but to a lesser extent (17.8% v 5.5%; p < 0.0001). In contrast, the almost universal expression of cytokeratin 13 was reduced in acetowhite biopsy specimens (86.2% v 96.9%; p < 0.0001). Cytokeratin 14 was found diffusely in the basal region of the stratified squamous epithelium and was marginally more apparent in the acetowhite biopsy specimens (p = 0.04). CONCLUSION: It is suggested that the presence of cytokeratin 10 may be an essential requirement for the formation of acetowhite change in association with the cellular swelling caused by acetic acid.

Differential expression of keratins 10, 17, and 19 in normal cervical epithelium, cervical intraepithelial neoplasia, and cervical carcinoma.

AIM: To examine the value of immunohistochemistry in defining a keratin profile to aid cervical histopathological diagnosis. METHODS: Immunohistochemical localisation of keratins 17, 10, and 19 was studied in 268 cervical biopsies from 216 women including normal epithelia (with and without human papilloma virus), low and high grade cervical intraepithelial neoplasia, and invasive carcinoma. The percentage of positive immunostaining was scored using a Kontron MOP videoplan image analyser. RESULTS: All major categories of cervical epithelia expressed these keratins to varying degrees. The median percentage of immunostaining for keratin 10 was 40% in normal tissue compared with just 1% in invasive carcinoma (p < 0.0001). The medians for keratin 17 were 0% in the normal group and 80% in carcinomas (p < 0.0001). By contrast, there was no significant difference in staining for keratin 19. Using a combination of the keratin 10 and 17 percentages, it was possible to separate the carcinomas from the benign conditions with a sensitivity of 100% and a specificity of 93%. Further analyses within the groups revealed more extensive staining for keratins 10 and 19 in reserve cell hyperplasia, immature squamous metaplasia, and congenital transformation zone. CONCLUSIONS: The morphological variety within the cervix is reflected, in part, by distinct keratin patterns. There are striking differences in the patterns of keratins 10 and 17 between infiltrating squamous carcinoma and normal cervical epithelia.

Attitudes to self-sampling for HPV among Indian, Pakistani, African-Caribbean and white British women in Manchester, UK.

OBJECTIVE: To examine attitudes to self-sampling for human papillomavirus (HPV) testing among women from contrasting ethnic groups. SETTING: Manchester, UK. METHODS: Two hundred women of Indian, Pakistani, African-Caribbean and white British origin were recruited from social and community groups to participate in a questionnaire survey. The questionnaire included items on attitudes to self-sampling and intention to use the test. RESULTS: Willingness to try to use the test was high, and women did not foresee religious or cultural barriers to self-sampling; however, a large proportion of women were concerned about doing the test properly. This concern was greatest in the Indian and African-Caribbean groups. CONCLUSIONS: Although women's willingness to try self-sampling for HPV is encouraging, worries about carrying out the procedure correctly must be addressed if women are to feel confident about the results of self-sampling methods and reassured by a negative result.

Use of the Cytobrush for concurrent cytology and chlamydia sampling: a comparison of immunofluorescence and culture for detection of chlamydia.

Five hundred and thirty-three women attending a genitourinary medicine clinic underwent concurrent cytology and Chlamydia trachomatis screening using a Cytobrush (Medscand AB). In each case, the same Cytobrush was used to give a sample for direct immunofluorescence and culture. 11.1% of samples were positive by immunofluorescence, while 10.6% were positive by culture. This was a close agreement (Kappa = 0.875). The ability of the same instrument to be used for both cytology and chlamydial screening, where direct immunofluorescence is used for detection of chlamydiae, may allow more widespread screening for chlamydia to be practical.

Preliminary report of unexpected local reactions to a progestogen-releasing contraceptive vaginal ring.

This is the first report of vaginal erythematous areas associated with the use of a levonorgestrel-releasing contraceptive ring. Of 139 female subjects, 48 developed lesions of varying size and degrees of redness. Sixteen of these have undergone serial colposcopy and thirteen have also had biopsy examinations, which revealed acetowhite areas and, histologically, chronic inflammation with widely dilated vessels and frequently with thinning of the epithelium. The cause remains uncertain but hormonal, chemical and physical effects might all have a role.

PIP: Between August 1990 and May 1992 in London, England, researchers enrolled 139 women aged 18-40 years in a clinical trial of a levonorgestrel-releasing contraceptive vaginal ring. All the women had a negative cervical smear. They underwent a thorough initial gynecological examination (i.e., visualization of entire vaginal area and the cervix). Clinicians reexamined them at 6 weeks, 3 months, and a 3-month intervals thereafter. 48 women (34.5%) had erythematous lesions on at least 1 occasion. They were at the vaginal vault, and sometimes on the cervix, where the vaginal ring usually lies. Most women had no symptoms. All the women were unaware that they had lesions. The lesions disappeared spontaneously in 16 women (33.3%) with the vaginal ring still in place. During colposcopy with vaginal ring in place, a clinician took vaginal/cervical swabs in 16 women to test for common sexually transmitted diseases (STDs). All but 1 woman tested negative for STDs. The erythematous lesion responded to 5% acetic acid in 14 of the 16 women, indicating an abnormality. Clinicians took biopsies in 13 of these women and did repeat colposcopy at 3-4 week intervals. Histological examination showed congestion with considerable dilated vessels, chronic inflammatory changes of varying severity, and frequent intracellular edema of the squamous mucosa. The mucosa was abnormally thin in some women, while in others it was entirely missing. Changes in 4 women were caused by HPV. 1 woman had grade 1 cervical intraepithelial neoplasia (CIN). The researchers could not conclude that the HPV-induced changes or CIN occurred during vaginal use because the women were not colposcoped before entry into the study. All of the study's findings prompted the ethics committee to halt the study in May 1992. In July 1992, the manufacturer shut down the entire UK study, stating that accumulation of enough data on efficacy and acceptability had been achieved. Further research is needed to determine what caused the lesions.

Cervical smears following laser treatment. Comparison of Cervex brush versus Cytobrush-Ayre spatula sampling.

For 802 women at initial follow-up after laser treatment of cervical lesions, 421 smears prepared using the Cervex brush were compared with 381 smears prepared using the combination of a Cytobrush plus an Ayre spatula. The smears were graded for adequacy, the presence of endocervical or metaplastic cells and the presence and degree of epithelial abnormalities. Endocervical or metaplastic cells were seen more often in Cytobrush-Ayre spatula smears (94.5%) as compared with Cervex brush smears (88.8%; P = .004). Also, the number of samples classed as inadequate was significantly greater with Cervex brush smears (4.0%) than with Cytobrush-Ayre spatula smears (0.3%; P = .0003). The number of smears showing dysplasia was too small to detect realistic differences between the two sampling methods. These findings suggest that, in women who have had laser treatment of the cervix, Cytobrush plus Ayre spatula sampling produces better-quality smears than does Cervex brush sampling, with regard to both adequacy and the presence of endocervical cells.

Comparison of four cytologic sampling techniques in a large family planning center.

In recent years, several new cervical sampling techniques have been introduced to try to improve the accuracy of the cervical smear. In the present study four such techniques were compared: the Aylesbury spatula, Rolon spatula, Cervex device and Aylesbury spatula used in conjunction with a Cytobrush. The total number of smears collected was 14,172, 80% of which were from women under age 35. Despite large differences between the techniques with regard to the presence of endocervical cells in smears, no differences were found in the detection of dysplasia. Endocervical cells were seen significantly more often in dysplastic smears than in negative smears. There was little difference in the rate of unsatisfactory samples. It appears that in a young population, the instruments used for cervical sampling are not likely to significantly influence the detection of dysplasia if skilled personnel take the smears.

High acceptability and satisfaction with NuvaRing use.

NuvaRing is a combined contraceptive vaginal ring that releases constant low doses of ethinylestradiol and etonogestrel. One cycle consists of 3 weeks of ring use followed by a 1-week ring-free period and the ring can easily be inserted and removed by the women themselves. Acceptability and satisfaction were determined by a questionnaire in two large, multicenter, open, 1-year studies conducted in a total of 2393 women, of whom 1950 (82%) completed cycle 3 questionnaires. Overall, 53% of participants switched to NuvaRing from other hormonal contraception; the main reason given for deciding to use NuvaRing (47%) was that it appeared to be a new and attractive method of contraception. Nearly all users considered the ring easy to insert and remove. Although 15% of women and 30% of their partners reported feeling the ring at least occasionally during intercourse, very few partners objected to women using the ring and the majority of women felt comfortable with it during intercourse. Reductions in menstrual pain and the length of the menstrual period were reported during ring use. More than 90% of women were satisfied or very satisfied with the ring at each assessment and 97% of those who completed the studies said they would recommend the method to others. At baseline, the preferred contraceptive method was the pill (66% of users). However, more than 80% of women at each assessment said they would use NuvaRing as their first-choice method. High satisfaction at cycle 3 was a good predictor of low subsequent discontinuation risk. In conclusion, this analysis shows that users express good acceptability and a high level of satisfaction with NuvaRing.