Abstract
BackgroundPoor attendance to cervical cancer (CC) screening is a major risk factor for CC. Efforts to capture underscreened women are considerable and once women agree to participate, the provision of longitudinal validity of the screening test is of paramount relevance. We evaluate the addition of high risk HPV test (HPV) to cervical cytology as a primary screening test among underscreened women in the longitudinal prediction of intraepithelial lesions grade 2 or worse (CIN2+).MethodsWomen were included in the study if they were older than 39 years and with no evidence of cervical cytology in the previous five years within the Public Primary Health Care System in Catalonia (Spain). 1,832 underscreened women from eight public primary health areas were identified during 2007–2008 and followed-up for over three years to estimate longitudinal detection of CIN2+. Accuracy of each screening test and the combination of both to detect CIN2+ was estimated. The risk of developing CIN2+ lesions according to histology data by cytology and HPV test results at baseline was estimated using the Kaplan–Meier method.ResultsAt baseline, 6.7% of participants were HPV positive, 2.2% had an abnormal cytology and 1.3% had both tests positive. At the end of follow-up, 18 out of 767 (2.3%) underscreened women had a CIN2+, two of which were invasive CC. The three-year longitudinal sensitivity and specificity estimates to detect CIN2+ were 90.5% and 93.0% for HPV test and 38.2% and 97.8% for cytology. The negative predictive value was >99.0% for each test. No additional gains in validity parameters of HPV test were observed when adding cytology as co-test. The referral to colposcopy was higher for HPV but generated 53% higher detection of CIN2+ compared to cytology.ConclusionsUnderscreened women had high burden of cervical disease. Primary HPV screening followed by cytology triage could be the optimal strategy to identify CIN2+ leading to longer and safe screen intervals.
Highlights
Poor attendance to cervical cancer (CC) screening is a major risk factor for CC
Women identified as being underscreened were offered a screening visit that included co-testing with human papillomavirus types (HPV) testing and cervical cytology in order to assure the highest accuracy of the visit
The aim of this study was to evaluate the addition of HPV test to cervical cytology as a primary screening test among the underscreened population in the longitudinal prediction of CIN2+
Summary
Poor attendance to cervical cancer (CC) screening is a major risk factor for CC. Efforts to capture underscreened women are considerable and once women agree to participate, the provision of longitudinal validity of the screening test is of paramount relevance. We evaluate the addition of high risk HPV test (HPV) to cervical cytology as a primary screening test among underscreened women in the longitudinal prediction of intraepithelial lesions grade 2 or worse (CIN2+). Absence or poor screening history remains the Primary CC screening with HPV detection has been shown in randomized controlled trials (RCTs) to have higher longitudinal sensitivity to detect cervical intraepithelial neoplasia grade 2 or worse (CIN2+) than conventional cytology, maintaining a high negative predictive value (NPV) [10,11,12,13,14]. Within the Public Health System efforts to increase CC screening coverage in underscreened women have been established [15] These activities are facilitated by raising awareness and a campaign was launched amongst midwives, gynaecologists and family practitioners to identify poorly screened women when visiting Primary Health Care services. The rationale was based on the very high sensitivity and high NPV of joint testing for an extended period of three years [10,11,12,13,14]
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