Advances in human papillomavirus detection for cervical cancer screening and diagnosis: challenges of conventional methods and opportunities for emergent tools

Abstract

Human papillomavirus (HPV) infection is the main cause of cervical cancer and other cancers such as anogenital and oropharyngeal cancers. The prevention screening and treatment of cervical cancer has remained one of the top priorities of the World Health Organization (WHO). In 2020, the WHO came up with the 90-70-90 strategy aimed at eliminating cervical cancers as a public health problem by the year 2030. One of the key priorities of this strategy is the recommendation for countries to ensure that 70% of their women are screened using a high-performance test by the age of 35, and again by the age of 45. Over the years, several traditional methods (notably, Pap smear and nucleic acid-based techniques) have been used for the detection of cervical cancer. While these methods have significantly reduced the incidence of cervical cancer and death, they still come short of excellence for the total eradication of HPV infection. The challenges include low sensitivity, low specificity, poor reproducibility, the need for high-level specialists, and the high cost of access to the facilities, to mention a few. Interestingly, however, several efforts are being made today to mitigate these challenges. In this review, we discussed the pros and cons of the traditional screening and testing of HPV infections, the efforts being made to improve their performances, and the emergent tools (especially, the electrochemical methods) that promise to revolutionize the screening and testing of HPV infections. The main aim of the review is to provide some novel clues to researchers that would allow for the development of high-performance, affordable, and triage-suitable electrochemical-based diagnostic tools for HPV and cervical cancer.

Fig. 1. (A) Pictorial depiction of the cervix anatomy (B) schematic illustration of the cervical changes caused by HPV infection.

Fig. 2. Conventional methods from the detection of HPV and their clinical sensitivity and specificity for CIN 2/3 lesions and cervical cancer.

Fig. 3. Common Fourier transforms infrared (FTIR) bands for biomolecules.

Fig. 4. Normalized mean FT-IR spectra of HR-HPV positive patients and normal people (the red solid line (A) is the FT-IR spectra of cervical exfoliated cells of 50 HR-HPV positive patients, and the black solid line (B) is the FT-IR spectra of cervical exfoliated cells of 50 normal people).

Fig. 5. (A) Raman spectrum of cervical cancer CaSki cell line. The variation of Raman shift wavelength is expressed in wavenumbers (cm⁻¹) and can be observed along the X-axis whilst the intensity is represented along the Y-axis. The fingerprint and the high wavenumber (HW) regions of the spectrum are indicated by the arrows. (B) Fingerprint region of the Raman spectrum of cervical cancer CaSki cell line. The major assignments related to glycogen, proteins, lipids, and nucleic acids are highlighted.

Fig. 6. Schematic diagram of advantages, component parts, and various measurement methods of electrochemical biosensor.

Fig. 7. Percentages of papers published on electrochemical detection of cervical cancer/HPV from 2019 to 2023 (Google Scholar database, keywords “electrochemical analysis of cervical cancer, electrochemical detection of HPV”).

Fig. 8. Electrochemical sensors – three electrodes system (A) electrochemical cell (B) screen printed electrode (SPE).

Fig. 9. Schematic illustration of (A) electrode modification and (B) immobilization and hybridization steps of paper-based electrochemical DNA biosensor. (C) Square-wave voltammograms of immobilized AQ-PNA probe on G-PANI/SPCE before and after hybridization with an equimolar concentration of target DNA.

Fig. 10. Stepwise representation of the encapsulation onto the ITO surface with GONR/Ag@AuNPs and probe DNA (PDNA) for electrochemical detection of the HPV target DNA (TDNA).

Fig. 11. Stepwise encapsulation of Ag@AuNPs-GO, SPA and anti-HPV-16 L1 antibody onto the gold electrode surface for the electrochemical detection of the target antigenic HPV-16 L1 protein.

Fig. 12. Experimental illustration of a nanoscale FET biosensor.

Fig. 13. Overview and working mechanisms of IMEAC. Side view (a) and top view (b) of the IMEAC device that integrates two main modules: PPS for plasma isolation and an electrochemical biosensor. (c) Working principle of the electrochemical sensor for hr-HPV16 cDNA detection. (d) A sample graph extracted from IMEAC showing the presence of hr-HPV cDNA in the extracted plasma sample.

Fig. 14. PPMC fabrication and characterization. (a) Fabrication of PPMC system using the screen-printing protocol coupled with layer-by-layer assembly. (b) Digital images of PPMC developed with interdigitated four-finger electrodes for single plex detection and two-semi-circular electrodes for multiplex detection. HPV nucleic acid detection and genotyping using PPMC with semi-circular electrodes (c) Schematic presentation of the developed PMMC-based nucleic acid assay for HPV DNA detection. Loop-mediated isothermal amplification (LAMP) technique was used to amplify the target HPV DNA using a set of four specific primers for each tested genotype by independent reactions and the formed amplicons were loaded on PPMC for impedance measurements. (d and e) Gel electrophoresis of LAMP amplification products generated from different concentrations of HPV DNA template. LAMP reaction was performed using tenfold serial dilutions of HPV DNA template (1 × 100 copies per microliter to 1 × 106 copies per microliter). M: 1-kb DNA ladder marker; NC: negative control (without target DNA template). (f) Impedance magnitude of LAMP amplicons prepared from different concentrations of target HPV templates at 8000 Hz and 1 V. For each concentration, the impedance magnitude was initially measured for LAMP amplicons of HPV-16 loaded on one of the testing zones and then for LAMP amplicons of HPV-18 loaded on the other testing zone. (g) Impedance magnitude of LAMP amplicons prepared from the target HPV-16 and nontarget viruses and genotype of human immunodeficiency virus-1 (HIV-1), herpes simplex virus-1 (HSV-1), and cytomegalovirus (CMV). Error bars represent the standard error of the mean calculated of at least three independent trials.

Fig. 15. Smartphone-based imaging (SBI) SBI for various biomedical imaging applications grouped into four clinical workflows.

Fig. 16. Schematic representation of the applicability of electrochemical methods for the detection of HPV infection and cancer through the detection of HPV genomes, anti-HPV antibodies, and HPV proteins.

Fig. 17. Schematic representation of the multi-disciplinary activities proposed for the prevention and control of HPV infection in the healthcare sector of resource-limited countries. The point-of-care diagnostic devices could be deployed for HPV infection and drug-monitoring, with dynamic spectrum broadband technology for an e-health that relies on secure data transmission from decentralized clinical benches (anywhere in the remote area) to the centralized laboratory, clinics, or hospitals.