Impact of HPV testing in opportunistic cervical screening: Support for primary HPV screening in the United States

Abstract

Human papillomavirus (HPV) testing for cervical screening increases diagnosis of precancer and reduces the incidence of cervical cancer more than cytology alone. However, real-world evidence from diverse practice settings is lacking for the United States (U.S.) to support clinician adoption of primary HPV screening. Using a population-based registry, which captures all cervical cytology (with or without HPV testing) and all cervical biopsies, we conducted a real-world evidence study of screening in women aged 30 to 64 years across the entire state of New Mexico. Negative cytology was used to distinguish cotests from reflex HPV tests. A total of 264 198 cervical screening tests (with exclusions based on clinical history) were recorded as the first screening test between 2014 and 2017. Diagnoses of cervical intraepithelial neoplasia grades 2 or 3 or greater (CIN2+, CIN3+) from 2014 to 2019 were the main outcomes. Of cytology-negative screens, 165 595 (67.1%) were cotests and 4.8% of these led to biopsy within 2 years vs 3.2% in the cytology-only group. Among cytology-negative, HPV tested women, 347 of 398 (87.2%) CIN2+ cases were diagnosed in HPV-positive women, as were 147 of 164 (89.6%) CIN3+ cases. Only 29/921 (3.2%) CIN3+ and 67/1964 (3.4%) CIN2+ cases were diagnosed in HPV-negative, cytology-positive women with biopsies. Under U.S. opportunistic screening, across a diversity of health care delivery practices, and in a population suffering multiple disparities, we show adding HPV testing to cytology substantially increased the yield of CIN2+ and CIN3+. CIN3+ was rarely diagnosed in HPV-negative women with abnormal cytology, supporting U.S. primary HPV-only screening.

Keywords: cervical cancer prevention; cervical cancer screening; cotesting vs cytology; opportunistic cervical screening; primary HPV screening.

Figure 1:

Sample selection for women aged 30–64 years attending cervical cancer screening in New Mexico between 2014 and 2017 ^aHPV test within −5 and +28 days of cytology, regardless of test result HPV: human papillomavirus, LEEP: Loop Electrosurgical Excision Procedure, ASC-H: Atypical Squamous Cells cannot exclude HSIL, AGC: Atypical Glandular Cells, HSIL+: High-grade Squamous Intraepithelial Lesion (HSIL) and worse (HSIL+), ASC-US: Atypical Squamous Cells of Undetermined Significance, LSIL: Low-grade Squamous Intraepithelial Lesion, CIN1: Cervical Intraepithelial Neoplasia grade 1, CIN2: Cervical Intraepithelial Neoplasia grade 2, CIN3: Cervical Intraepithelial Neoplasia grade 3