Triage of HPV positive women in cervical cancer screening

Abstract

Despite HPV vaccines, screening will remain central for decades to control cervical cancer. Recently, HPV testing alone or with cytology was introduced as an alternative to cytology screening. However, most HPV infections are harmless and additional tests are required to identify women with progressing infections or precancer. With three options for primary screening, and without clear strategies for triage of screen-positive women, there is great confusion about the best approach. Also, increasing HPV vaccination coverage will lead to lower disease prevalence, and force new screening approaches. Currently recommended triage strategies for primary HPV screening include HPV genotyping for HPV16 and HPV18 and cytology. Other alternatives that are currently evaluated include p16/Ki-67 dual stain cytology, host methylation, and viral methylation testing. Clinical management of women with cervical cancer screening results is moving to use risk thresholds rather than individual test results. Specific risk thresholds have been defined for return to primary screening, repeat testing, referral to colposcopy, and immediate treatment. Choice of test algorithms is based on comparison of absolute risk estimates from triage tests with established clinical thresholds. Importantly, triage tests need to be evaluated together with the primary screening test and the downstream clinical management. An optimal integrated screening and triage strategy should reassure the vast majority of women that they are at very low risk of cervical cancer, send the women at highest risk to colposcopy at the right time, when disease can be colposcopically detected, and minimize the intermediate risk group that requires continued surveillance.

Analysis of invasive cervical cancer cases in Latvia

“…[8][9][10][11]13 Cytological triage is defined as testing HPV positive women for cytology and referring directly to colposcopy those women who show relevant cytological abnormalities. 8,11,14 There is also evidence that cytology informed of HPV positivity is more sensitive than cytology without knowing the presence of HPV infection. 8,11,14 The screening interval for women with a negative HPV primary test result should be at least five years and may be extended up to 10 years depending on the age and screening history.…”

“…8,11,14 There is also evidence that cytology informed of HPV positivity is more sensitive than cytology without knowing the presence of HPV infection. 8,11,14 The screening interval for women with a negative HPV primary test result should be at least five years and may be extended up to 10 years depending on the age and screening history. 8,14 Prolonged intervals for HPV primary screening would reduce costs and, more importantly, would reduce the probability of unnecessary colposcopy and treatment with attendant side effects.…”

“…8,11,14 The screening interval for women with a negative HPV primary test result should be at least five years and may be extended up to 10 years depending on the age and screening history. 8,14 Prolonged intervals for HPV primary screening would reduce costs and, more importantly, would reduce the probability of unnecessary colposcopy and treatment with attendant side effects. 8,14 There is good evidence from randomized trials that the low-risk period is longer after a negative HPV test than after normal cytology.…”

“…8,14 Prolonged intervals for HPV primary screening would reduce costs and, more importantly, would reduce the probability of unnecessary colposcopy and treatment with attendant side effects. 8,14 There is good evidence from randomized trials that the low-risk period is longer after a negative HPV test than after normal cytology. 8,11,14 In the implementation of HPV primary screening it is also important to keep the entire screening process in mind, including the attendant laboratory, colposcopy, cytopathology and histopathology services.…”

Management of high-risk HPV-positive women for detection of cervical (pre)cancer

“…Currently, Pap cytology is the most advocated triage strategy for hrHPV-positive women [39,40,45,46]. Due to experience with Pap cytology as a primary cervical screening test for decades, Pap cytology is a well-studied strategy embedded in the healthcare infrastructure of many developed countries.…”