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. 2021 Jun;31(6):808-816.
doi: 10.1136/ijgc-2020-002302. Epub 2021 Apr 8.

A cross-sectional study exploring triage of human papillomavirus (HPV)-positive women by visual assessment, manual and computer-interpreted cytology, and HPV-16/18-45 genotyping in Cameroon

Pierre Vassilakos  1   2 , Ania Wisniak  3 , Rosa Catarino  1 , Eveline Tincho Foguem  4 , Christine Balli  1 , Essia Saiji  5 , Jean-Christophe Tille  5 , Bruno Kenfack  4 , Patrick Petignat  1
Affiliations

A cross-sectional study exploring triage of human papillomavirus (HPV)-positive women by visual assessment, manual and computer-interpreted cytology, and HPV-16/18-45 genotyping in Cameroon

Pierre Vassilakos et al. Int J Gynecol Cancer. 2021 Jun.

Abstract

Background: High-risk human papillomavirus (HPV)-positive women require triage to identify those at higher risk of cervical intraepithelial neoplasia grade 2 or worse (CIN2+). We aimed to compare visual assessment of the cervix, manual cytology and automated cytology as triage tests to screen HPV-positive women, and to assess over-treatment rates after visual assessment and over-referral rates to colposcopy after cytology.

Methods: The present cross-sectional study is nested in a large prospective screening trial in Cameroon. Evaluations of the tests have been conducted individually and in combination with HPV-16/HPV-18/45 genotyping. For the evaluation of over-treatment and colposcopic over-referral, we simulated two screening scenarios: (1) one-visit scenario (test-triage-and-treatment); and (2) two-visit scenario (test-triage-and-colposcopy).

Results: 1582 women with a median age of 40 years (IQR 35-45) performed self-sampling for HPV testing, of which 294 (18.6%) were HPV-positive, and 12.2% had CIN2+. Sensitivities for CIN2+ detection were 77.1% for visual assessment, 80.0% for manual cytology, and 84.8% for automated cytology. Sensitivity of combined tests was higher compared with single tests. The highest sensitivity was obtained by the combination of genotyping and automated cytology (91.2%). In the one-visit scenario, the over-treatment rate was 83.9% in referred women, with a ratio of 6.2 treated women per CIN2+. In the two-visit scenario, the lowest over-referral rate would have been under manual cytology (45.0%), with a ratio of 1.8 referred women per CIN2+. Single and combined triage strategies by automated cytology gave rise to over-referral rates of 69.2% and 76.7%, respectively, and a ratio of 3.2 and 4.3 referred women per CIN2+, respectively.

Discussion: Triage of HPV-positive women using a combination of genotyping and automated cytology for CIN2+ detection may provide public benefits in low- and middle-income countries.

Keywords: cervical cancer; pathology.

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Conflict of interest statement

Competing interests: None declared.

Figures

Figure 1
Figure 1
Study flowchart showing study population, histology results, and triage tests evaluated. CIN1, cervical intraepithelial neoplasia grade 1; CIN2, cervical intraepithelial neoplasia grade 2; CIN3, cervical intraepithelial neoplasia grade 3; HPV, human papillomavirus; LBC, liquid-based cytology; n, number; VA, visual assessment.
Figure 2
Figure 2
Sensitivity (with 95% CI) versus the false positive rate (FPR=1−specificity) for CIN2+ detection among HR-HPV positive women for various triage tests (single and combined). ASC-US, atypical squamous cells of undetermined significance; CIN2+, cervical intraepithelial neoplasia grade 2 or worse; HPV, human papillomavirus; HR-HPV, high risk HPV.
See this image and copyright information in PMC

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