HPV testing increases high-grade CIN detection following abnormal cytology
medwireNews: Human papillomavirus (HPV) testing after abnormal cytology improves detection of high-grade cervical intraepithelial neoplasia (CIN) lesions but with associated increases in biopsy and loop electrosurgical excision procedure rates, researchers report.
Cosette Wheeler (University of New Mexico Health Sciences Center, Albuquerque, USA) and co-investigators say their observational study findings “provide essential information for cervical screening guidelines and public health policy.”
Between 2008 and 2012, 457,317 women (mean age, 39.8 years) underwent cervical screening in New Mexico, USA. Of these, 20,677 (4.5%) had atypical squamous cells of undetermined significance (ASC-US cytology), including 16,648 (80.5%) who had an HPV test either as a co-test or as a triage test within 28 days of the cytology result.
The researchers report in JAMA Oncology that CIN grade 3 or more severe (CIN3+) lesions were detected in 2.5% of women with and 2.2% of women without HPV testing in the 5 years post-screening.
This difference was not statistically significant, but the median time to CIN3+ detection was significantly shorter in those with versus without HPV testing, at 103 versus 393 days.
For CIN2, women with HPV screening had a significant 27% increased likelihood for detection at 5 years compared with those without screening, at 4.3% versus 3.4%, as well as a significantly shorter median time to detection (91 vs 340 days).
The researchers point out that almost all cases of CIN2 and CIN3+ disease diagnosed in women with HPV testing occurred in the 43.1% who were HPV positive.
They say this “highlights the enormous predictive value of HPV testing for women with ASC-US cytology [and] allows colposcopy and related resources to be focused on women who need them most.”
CIN1 detection rates at 5 years were also a significant 76% higher in the women with HPV testing, at 11.6%, compared with 6.6% in those without testing.
However, the increased detection rates of CIN1, CIN2, and CIN3+ occurred “at the expense of more biopsies and loop electrosurgical excision procedures,” Wheeler et al remark.
Loop electrosurgical excision procedure rates within 5 years were a significant 20% higher in women who underwent HPV testing (4.9 vs 4.0%), while biopsy rates were a significant 56% higher (32.1 vs 20.6%) compared with women who did not receive HPV testing.
In an accompanying editorial, Chris Meijer and Peter Snijders, both from VU University Medical Center in Amsterdam, the Netherlands, say the study “provides a unique basis for further monitoring of the balance between benefits and harms in US cervical screening practice” but does not answer the question of whether the screening strategy prevents more cervical cancer because too few cases were detected.
They add that the HPV triage strategy “triggers considerable overtreatment of many women of reproductive age who will never develop cervical cancer,” and this data should be used as a basis for a critical evaluation of the current American Society for Colposcopy and Cervical Pathology management guidelines for ASC-US, CIN1, and CIN2.
Meijer and Snijders conclude that such an evaluation “may lead to recommendation of less intense screening strategies with similar benefits and less harms.”
By Laura Cowen
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