Tritesting in Battor, Ghana: an integrated cervical precancer screening strategy to mitigate the challenges of multiple screening visits and loss to follow-up

Abstract

Background: Human papillomavirus (HPV) DNA testing is more sensitive than cytology for detecting cervical precancer; however, increasing reports of high-risk HPV (hr-HPV)-negative cases of cervical intraepithelial neoplasia (CIN) and even malignancy motivate the use of combined testing. We present our experience with 'tritesting', defined as the performance of HPV DNA testing, cytology and visual inspection in a single session at the Cervical Cancer Prevention and Training Centre, Ghana. We further determined the prevalence rates of hr-HPV infection, abnormal cytology and cervical lesions among women screened using tritesting.

Methods: This descriptive retrospective cross-sectional study assessed all women screened via tritesting between April 2019 to April 2023. HPV DNA testing was performed using the Sansure MA-6000, GeneXpert or AmpFire platforms. Visual inspection was performed using enhanced visual assessment mobile colposcopy or visual inspection with acetic acid. Liquid-based cytology was performed using cervical samples taken with a Cervex-Brush® and fixed in PreservCyt, while samples for conventional cytology were taken using an Ayre spatula and cytobrush.

Results: Among 236 women screened (mean age, 39.1 years (standard deviation, 10.9)), the overall prevalence rates of hr-HPV infection and cervical lesions were 17.8% (95% confidence interval (CI), 13.1-23.3) and 11.9% (95% CI, 8.0-16.7), respectively. Cytology yielded findings of atypical squamous cells of undetermined significance or worse in 2.5% (95% CI, 0.9-5.5) of women. Histopathology following loop electrosurgical excision procedure revealed CIN I (tritest positive) and CIN III (hr-HPV-positive, visual inspection 'positive', cytology-negative) in one woman each. Factors independently associated with hr-HPV infection among 'tritested' women were age ≥ 39 years, tertiary level of education and current contraceptive use. Twenty-seven out of 39 hr-HPV-positive women (69.2%; 95% CI, 52.4-83.0) showed a type 3 transformation zone and would have needed to be recalled for a cytologic sample to be taken in a 'see and triage' approach with HPV DNA testing and a visual inspection method.

Conclusion: This study brings tritesting into the spotlight, as an alternative to other methods, particularly for women who prefer this due to the advantage of a single visit to a health facility and being more cost-effective, if they have to travel long distances to access cervical screening services.

Keywords: Papanicolaou test; colposcopy; cytology; human papillomavirus DNA test; human papillomavirus infection; uterine cervical neoplasm.

Supplementary Figure 1.. Nested boxplots showing the distributions of (A–C): age and (D–F): parity by test result among women who underwent cervical precancer screening via ‘tritesting’ (combined hr-HPV DNA testing, visual inspection and cytology). hr-HPV, high-risk human papillomavirus. ^*Statistically significant.

Figure 1.. Flowchart for cervical precancer screening among women via ‘tritesting’ (hr-HPV DNA testing, visual inspection and cytology in a single visit). hr-HPV, high-risk human papillomavirus; LSIL, low-grade intraepithelial lesion; Pap, Papanicolaou test; TZ, transformation zone; LEEP, loop electrosurgical excision procedure; ASCUS, atypical squamous cells of undetermined significance; CIN, cervical squamous intraepithelial neoplasia.

Figure 2.. Flow chart for concurrent screening with hr-HPV DNA testing and visual inspection (EVA mobile colposcopy or VIA) during the study period. VIA, visual inspection with acetic acid; hr-HPV, high-risk human papillomavirus; TZ, transformation zone.