Are We Facing a New Colposcopic Practice in the HPV Vaccination Era? Opportunities, Challenges, and New Perspectives

Abstract

The combination of primary and secondary prevention has already influenced the colposcopic practice by reduction in HPV (human papillomavirus) vaccine-type HSIL (HIGH-GRADE SIL), colposcopy referral numbers, colposcopic positive predictive value (PPV) for CIN2+, and by modification of referral pattern, colposcopic performance, and procedures. Different strategies, both isolated and combined, have been proposed in order to maintain the diagnostic accuracy of colposcopy: patient risk stratification based on immediate or future risk of CIN3+ or on HPV genotyping after a positive screening test. Data are needed to support alternative colposcopic strategies based on vaccination status and on the application of artificial intelligence where the patient’s risk stratification is implicit in precision medicine which involves the transition from an operator-dependent morphology-based to a less-operator dependent, more biomolecular management. The patient’s risk stratification based on any combination of “history” and “test results” to decrease colposcopy workload further reduce colposcopic and histologic morphological approaches, while adding genotyping to the risk stratification paradigm means less cytologic morphologic diagnosis. In Italy, there is a strong colposcopic tradition and there is currently no immediate need to reduce the number of colposcopies. Instead, there is a need for more accredited colposcopists to maintain the diagnostic accuracy of colposcopy in the vaccination era.

Improving colposcopic accuracy for cervical precancer detection: a retrospective multicenter study in China

“…Of course, HPV vaccinations will surely help as will the move from operator-dependent cytology to less operator-dependent HPV detection. Although, the practice of colposcopy faces a number of unpredictable challenges [ 27 ]. Therefore, guidelines should be regularly updated (according to best evidence) to meet the needs of real-world clinical practice.…”

Increased detection of high grade CIN, when using electrical impedance spectroscopy as an adjunct to routine colposcopy, is maintained when used across international boundaries: Prospective data from nine European countries

“…Colposcopy is becoming more challenging given the impact of HPV vaccination on the prevalence of HG-CIN with fewer young women being referred to colposcopy and treatment [12][13][14]. As a consequence many organised screening programme or national guidance documents recommend primary HPV because of the lower prevalence of HG-CIN [2].…”

Cost-Effectiveness Analysis of HPV Extended versus Partial Genotyping for Cervical Cancer Screening in Singapore

“…Furthermore, CIN2+ attributable to non-vaccine genotypes may increase with vaccinations, as previously observed in the Costa Rica vaccine trial [ 16 ]. Hence, with the growing public health efforts on HPV vaccination, risk stratification for immediate or future risk of the disease using XGT should continue to guide decisions on colposcopies [ 63 , 64 ].…”