Uses of HPV Testing in Triage of cervical Screening
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Transcript of Uses of HPV Testing in Triage of cervical Screening
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Uses of HPV Testing in Triage of Cervical
Cytology
Dr Dirk GrothuesmannCervical Cytology (Up to date, 2016)
http://dg-maternalhealth.de/
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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
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Uses of HPV Testing alongside Cytology
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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
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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%
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HPV triage of ASC-US or LSIL cytology
ASC-US atypical cells of undetermined significanceLSIL 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+
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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)
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In view of frequent regression of CIN2, immediate treatment may not be mandatory in
young women and requires histology and cytology review
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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)
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Risk of CIN3+ within 10 yearsPost-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
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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.
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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+
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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
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http://dg-maternalhealth.de/
Dr Dirk Grothuesmann Consultancy