Performance of Liquid Biopsy for Diagnosis and Surveillance of Human Papillomavirus–Associated Oropharyngeal Cancer

Abstract

ImportanceThere is growing interest in the use of circulating plasma tumor human papillomavirus (HPV) DNA for diagnosis and surveillance of patients with HPV-associated oropharyngeal squamous cell carcinoma (OPSCC). Recent advances in the assays, combining the identification of circulating HPV tumor DNA and tumor DNA fragment analysis (tumor tissue–modified viral [TTMV]-HPV DNA), have been shown to be highly accurate. However, use of these newer techniques has been limited to small cohort studies and clinical trials.ObjectiveTo establish the clinical efficacy of plasma TTMV-HPV DNA testing in the diagnosis and surveillance of HPV-associated OPSCC in a contemporary clinical setting.Design, Setting, and ParticipantsThis retrospective observational cohort study included patients with OPSCC who underwent TTMV-HPV DNA testing between April 2020 and September 2022 during the course of routine clinical care. For the diagnosis cohort, patients with at least 1 TTMV-HPV DNA measurement prior to initiation of primary therapy were included. Patients were included in the surveillance cohort if they had at least 1 TTMV-HPV DNA test performed after completion of definitive or salvage therapy.Main Outcomes and MeasuresPer-test performance metrics, including sensitivity, specificity, positive predictive value, and negative predictive value, for TTMV-HPV DNA testing.ResultsOf 399 patients included in the analysis, 163 were in the diagnostic cohort (median [IQR] age, 63 [56-68.5] years; 142 [87.1%] male), and 290 were in the surveillance cohort (median [IQR] age, 63 [57-70] years; 237 [81.7%] male). Of the 163 patients in the diagnostic cohort, 152 (93.3%) had HPV-associated OPSCC while 11 (6.7%) had HPV-negative OPSCC. The TTMV-HPV DNA sensitivity in pretreatment diagnosis was 91.5% (95% CI, 85.8%-95.4% [139 of 152 tests]), and the specificity was 100% (95% CI, 71.5%-100% [11 of 11 tests]). In the surveillance cohort, 591 tests conducted in 290 patients were evaluated. A total of 23 patients had molecularly confirmed pathologic recurrences. The TTMV-HPV DNA test demonstrated sensitivity of 88.4% (95% CI, 74.9%-96.1% [38 of 43 tests]) and specificity of 100% (95% CI, 99.3%-100% [548 of 548 tests]) in detecting the recurrences. Positive predictive value was 100% (95% CI, 90.7%-100% [38 of 38 tests]), and negative predictive value was 99.1% (95% CI, 97.9%-99.7% [548 of 553 tests]). The median (range) lead time from positive TTMV-HPV DNA test to pathologic confirmation was 47 (0-507) days.Conclusions and RelevanceThis cohort study demonstrated that when evaluated in a clinical setting, the TTMV-HPV DNA assay demonstrated 100% specificity in both diagnosis and surveillance. However, the sensitivity was 91.5% for the diagnosis cohort and 88.4% for the surveillance cohort, signifying that nearly 1 in 10 negative tests among patients with HPV-associated OPSCC was a false negative. Additional research is required to validate the assay’s performance and, if validated, then further research into the implementation of this assay into standard clinical practice guidelines will be required.

Circulating Tumor HPV DNA for Surveillance of HPV-Positive Oropharyngeal Squamous Cell Carcinoma

“…The ctHPVDNA assays are most often considered binary. At diagnosis, sensitivities of contemporary droplet digital polymerase chain reaction or next-generation sequencing–based assays for HPV OPSCC range from 82% to 98% . Specificity is also high (97%-100%), although less well studied because few reported cohorts include disease-free controls.…”

“…Our current knowledge of TTMV-HPV DNA assay sensitivity is based on 6 peer-reviewed studies representing 559 HPV-positive patients, whereas specificity is based on 4 studies and 226 controls . Although test sensitivity and specificity have been reassuringly consistent and high, important questions remain:…”

“…Considering only TTMV-HPV DNA testing, 4 studies have evaluated the assay for detection of preclinical recurrent disease (Table 1). In a study of 115 patients with HPV-positive OPSCC (median follow-up, 23 months; range, 6.1-54.7 months), 0 of 87 patients with undetectable TTMV-HPV DNA had disease recurrence (100% negative predictive value) compared with 15 of 28 patients with any positive test results (54% positive predictive value) and 15 of 16 patients with 2 consecutive positive test results (94% positive predictive value) .…”

“…Among 498 clinically disease-free patients, only 3 had detectable TTMV-HPV DNA, yielding a specificity of 99.4% and negative predictive value of 98.4%. Finally, a 290-patient single-institution observational retrospective cohort study conducted by Ferrandino et al found that among 22 patients with recurrent disease, 18 had detectable TTMV-HPV DNA, resulting in sensitivity of 81.8%. The positive predictive value of TTMV-HPV DNA detection was 100% because all 18 patients with positive test results developed recurrence (Table 1).…”

“…Our current knowledge of the TTMV-HPV DNA assay’s performance for detecting preclinical recurrence in surveillance is from 4 studies and approximately 220 HPV-positive OPSCC recurrences.…”