HPV as a primary test in cervical screening

Human papillomavirus (HPV)

• high risk (HR) HPV is associated with cervical intraepithelial neoplasia (CIN) and is found in 99.7%(1) of cervical cancer cases
  • high risk HPV (HR-HPV), some subtypes can cause cervical cancer. In particular HPV16 and HPV18
    
    
• persistent infection with HR-HPV is a necessary but insufficient cause of cervical cancer
  
  
• persistent HR-HPV infection increases the risk of women developing cervical cancer
  
  
• transient HR-HPV infection is common

HPV in cervical screening

• high risk (HR)-HPV testing picks up more cervical abnormalities (more sensitive) than cytology, but more women without abnormalities test positive for HR-HPV (not as specific)
  
  
• women who test negative for HR-HPV have no significant cervical abnormalities (CIN2+) in 99.8% (2) of cases
  
  
• most women with high-grade abnormalities will be identified by HR-HPV testing
  
  
• as the HR-HPV test is more sensitive but less specific than cytology, primary HR-HPV testing coupled with cytology triage offers a more appropriate screening strategy, especially in an HPV-vaccinated population

Primary HR-HPV testing

• all women aged between 25 and 64 (on routine and early recall) are eligible
  
  
• the cervical sample will be taken as normal
  
  
• the sample will be tested for HR-HPV first
  
  
• samples that are positive for HR-HPV will then be processed for cytological examination (cytology triage)
  
  
• women who are HIV+ will be screened annually with the HR-HPV test in accordance with programme guidelines

Possible results

• HR-HPV not detected: return to normal recall (3 or 5 years)
  
  
• HR-HPV detected, cytology negative (no abnormal cells): recall 12 months
  
  
• HR-HPV detected, cytology positive (abnormal cells found): refer for colposcopy
  
  
• Inadequate result: repeat in 3 months

Women in follow up

• Women in follow up for treatment of CIN will be given a 3-year recall if HR-HPV negative 6 months after treatment, and will be referred to colposcopy if HR-HPV positive/any grade of cytology
  
  
• Women in follow up after adequate treatment for CGIN/SMILE will be given a 3-year recall if HR-HPV negative at both 6 and 18 months after treatment
  
  
• Women in follow up for cervical cancer (still with cervix) and CGIN/SMILE (without complete excision margins) will be screened annually with the HR-HPV test (instead of cytology) for 10 years

Reference:

• Reference:
  • WalboomersJM(1), Jacobs MV, Manos MM, Bosch FX. J Pathol. 1999 Sep;189(1):12-9. Human papillomavirus is a necessary cause of invasive cervical cancer worldwide.
  • Kitchener et al. Lancet Oncol 2009, Ronco et al. Lancet Oncol 2006, Ronco et al. JNCI 2006, Rijkaart et al. Lancet Oncol 2012
  • Public Health England (PHE). Primary High Risk HPV Testing with Cytology Triage. NHS Cervical Screening Programme (Accessed March 5th 2019)