Histological outcomes in HPV-screened elderly women in Denmark

Abstract

Introduction Danish women exit cervical cancer screening at age 65 years, but 23% of cervical cancer cases occur beyond this age. In addition, due to gradual implementation of cervical cancer screening, older women are underscreened by today´s standards. A one-time screening with HPV test was therefore offered to Danish women born before 1948. Methods Register based study reporting histology diagnoses and conizations in women found HPV positive in the one-time screening. Number and proportion of women with severe or non-severe histology results were calculated for screened and HPV-positive women by age group or region of residence. Number of women with biopsy and/or conization per case of cervical intraepithelial neoplasia (CIN) grade 2 or worse (CIN2+) or CIN3+ were also calculated by age groups and region. Results 4,479 (4.1% of screened women) had positive HPV test. 94% of these had one or more additional tests. 2,785 (62%) of HPV-positive women had histology results, and conization was performed in 1,076 (24% of HPV-positive and 1% of all screened women). HPV positivity and CIN3+ detection varied little between regions, but the proportions of HPV positive women undergoing histology varied between regions from 40% to 86% and the proportion with conization from 13% to 36%. Correspondingly, the number of histologies and conizations per CIN3+ detected varied from 5.9 to 11.2 and 1.8 to 4.7, respectively. In total, 514 CIN2+ (0.47% of screened women, 11% of HPV-positive) and 337 CIN3+ (0.31% of screened women, 7.5% of HPV-positive) were diagnosed, including 37 cervical cancer cases. Discussion HPV screening of insufficiently screened birth cohorts can potentially prevent morbidity and mortality from cervical cancer but longer follow-up is needed to see if cancer incidence declines in the screened women in the coming years. Management strategies differed among regions which influenced the proportions undergoing biopsy/conization.

Adherence to follow‐up after the exit cervical cancer screening test at age 60–64: A nationwide register‐based study

“…Recently published results from a study in which Danish women older than 70 were invited for a single HPV screen showed that 4.1% of the women were HPV‐positive and 7.5% of those had CIN3+. 17 …”

“…The last region to implement the new guidelines did so about 2 years after the first region (Appendix A , Figure A1), while one region (Capital) referred all HPV‐positive women to colposcopy, regardless of the infecting genotype. 17 …”

“…We categorized women depending on the follow‐up that they were recommended for. This resulted in three groups: (1) inadequate screening tests and samples positive for other HPV genotypes either without cytological triage or with inadequate triage cytology, recommended for a new test in 3 months; (2) screening tests positive for HPV16/18 or for other high‐risk HPV genotypes combined with abnormal cytology in four out of five regions and all HPV‐positive women in the Capital region, recommended for colposcopy due to local guidelines 17 ; and (3) screening tests positive for other high‐risk HPV genotypes with normal cytology, recommended for a new HPV test in 1 year.…”

“…Recently published results from a study in which Danish women older than 70 were invited for a single HPV screen showed that 4.1% of the women were HPV-positive and 7.5% of those had CIN3+. 17 The revised guidelines for the management of HPVpositive women aged 60 and over published in 2019 36 recommend "considering an immediate conisation" in case of poor visibility of the transformation zone. This might result in fewer long surveillance pathways in the future.…”

Evidence of latent HPV infection in older Danish women with a previous history of cervical dysplasia

“…We emphasize that, although incident detection of HPV is often lower at older ages in well-screened populations, the proportion of newly HPV-positive women ultimately diagnosed with high-grade lesions or cancer is similar across all ages. 23 In fact, recent studies performing diagnostic excision in older women with persistent HPV infection in the absence of cytological abnormalities found a significant prevalence of underlying CIN2+, 24 suggesting that the risk of precancer in older women may be underestimated. The persistent risk of precancer and cancer across the lifespan described is particularly concerning given evidence that older women are screened less frequently, 26 may be more likely to actively decide not to screen, 26 and are more likely to perceive a lower risk of cervical cancer because of their current sexual activity.…”