Cervical Cancer Screening Guidelines Research Articles

Human papillomavirus (HPV) in pregnancy – An update

Human papilloma viruses (HPV) are small epitheliotropic DNA viruses, of which there are 200 genotypes, 40 of which are known to cause genital infections and are also oncogenic. HPV is the most common sexually transmitted infection. Clinical features vary from asymptomatic (identified at routine cervical cancer screening) to large lesions on the vulva, vagina, cervix and some extragenital sites. Its prevalence in pregnancy varies from 5.5% to 65% depending on age, geography and gestational age (increasing with gestational age). Infection in pregnancy has been associated with adverse outcomes such as spontaneous miscarriage, preterm birth, placental abnormalities and fetal growth restriction. However, the evidence for these adverse outcomes is varied. Besides being oncogenic (and thus associated with cancer of the cervix in pregnancy), vertical transmission to the fetus/neonate can cause neonatal infections, especially juvenile-onset recurrent oral and respiratory papillomatosis (JORRP). Where there are very large lesions on the vulva, delivery may be obstructed. Diagnosis in pregnancy is mainly by viral PCR or from the clinical appearance of the characteristic lesions on the vulva. Treatment is local by either surgical or laser excision or application of trichloroacetic acid. Podophyllin/podophyllotoxin is contraindicated in pregnancy. HPV Infection is not an indication for caesarean delivery as this has not been shown to prevent vertical transmission. For those diagnosed at routine cervical cancer screening, management should follow guidelines for cervical cancer screening in pregnancy. Vaccination is currently not recommended for pregnant women, although studies on those inadvertently vaccinated in pregnancy have not shown any adverse effects on either the fetus or mother.

Assessing national cervical cancer screening guidelines: Results from an HIV testing clinic also screening for cervical cancer and HPV in Soweto, South Africa.

ObjectiveA screening centre in Soweto, South Africa (SA), investigated high-risk human papillomavirus (HR-HPV), HIV, cervical cancer risk amongst women.MethodsThis cross-sectional study (June 2018-March 2019) describes screening results (Roche Linear Array HPV test and Pap smear liquid based cytology) and history of screening (known HIV status, antiretroviral therapy [ART] use, previous Pap smears). Data were stratified by age group (18–29, 30+ years), HIV status, Pap smear results and tested for statistical significance.ResultsOf 280 women, 20.4% were HIV-positive, 18.2% had abnormal Pap smears, 41.8% had HR-HPV. Of older women, 48.2% (n = 78/162) had never had a Pap smear. Of younger women, 89.0% (n = 105/118) never had a Pap smear, but had significantly more low-grade squamous intraepithelial lesions (LSIL) and other HR-HPV infection than older women (12.7%[n = 15/118] vs 4.9%[n = 8/162], p = 0.0193; and 49.2%[n = 58/118] vs 29.0%[n = 47/162], p = 0.0006; respectively). HIV-positive women had more abnormal cytology results and infection with other HR-HPV types or co-infection with other HR-HPV type(s)/HPV-16 compared to HIV-negative women (35.1%[n = 20/57] vs 13.9%[n = 31/223], p = 0.0002; 56.1%[n = 32/57] vs 32.7%[n = 73/223], p = 0.001; and 12.3%[n = 7/57] vs 4.9%[n = 11/223], p = 0.044; respectively). Of 57 HIV-positive women, 45.6% (n = 26) already knew their HIV status; of which 69.2% were on ART and 34.6% never had a Pap smear.ConclusionSouth African women have high rates of HIV, Pap smear abnormalities and HR-HPV, with low cervical cancer screening coverage. SA cervical cancer screening policy excludes (undiagnosed) HIV-positive and HIV-negative women <30 years, both populations found to have high prevalence of HR-HPV. HPV-based primary screening from 25 years could improve outcomes.

Racial disparities in routine health checkup and adherence to cancer screening guidelines among women in the United States of America

Routine health checkup and cancer screening rates among women are suboptimal, partially due to the health care disparities by race/ethnicity in the USA. This study examined the previously understudied associations between routine health checkup, cervical cancer screening, and breast cancer screening by race/ethnicity using the national representative sample of women. Data were obtained from three cycles (2017, 2018, and 2019) of the Health Information National Trends Survey (HINTS) (n = 12,227). Survey-weighted logistic regressions were evaluated to assess associations between routine health checkup and cervical and breast cancer screening compliance with the established guidelines with the age criteria and frequency of screening by race/ethnicity (Black, White, Hispanic, and Other). This study included 6,941 women in the cervical cancer screening and 8,005 women for breast cancer screening, considering the age criteria. Women who had received routine health checkups were more likely to meet the cervical cancer screening guideline (Odds ratio 3.24, p < 0.05) and breast cancer screening guideline (OR 5.86, p < 0.05) compared to women who did not receive routine health checkups. While routine health checkups were associated with both types of cancer screenings in most racial/ethnic groups, analyses stratified by race/ethnicity suggest that Hispanic women and Other women did not benefit from routine health checkup in relation to cervical and breast cancer screening, respectively. Promotion of routine health checkups could promote cancer screening among women across racial/ethnic groups, although specific racial/ethnic groups may require additional support.

Global guidelines for cervical cancer screening: a systematic review

Objective: To systematically summarize and evaluate the current cervical cancer screening guidelines worldwide. Methods: "Cervical cancer/cervical intraepithelial neoplasia", "screening", and "guidelines/recommendations" were searched as keywords in PubMed, Embase, China National Knowledge Infrastructure (CNKI), Wanfang Data for cervical cancer screening guidelines. The language was limited to Chinese and English. A total of 29 guidelines were included before September 1, 2020. The basic information and recommendations of the guidelines issued were summarized. Results: Among the 29 cervical cancer screening guidelines, most guidelines targeted on the population aged 25-65 years. Cytology and human papillomavirus (HPV) testing are two commonly used methods for the cervical cancer screening, and HPV testing is increasingly recommended as the primary screening methods. Most guidelines recommended five years interval for the HPV testing-based screening or co-testing (HPV testing and cytology) based screening and three years for the cytology-based. For managing population with abnormal cervical cancer screening, triage or screening repeatedly to identify high-risk populations were more recommended. Direct colposcopy or treatment were allowed for women with higher risk of cervical intraepithelial neoplasia (CIN) during the screening procedure. Several guidelines involving HPV vaccination population recommended them the same strategy as the general population without vaccination. Conclusion: Currently, most of the cervical cancer screening guidelines applied to the population with the average risk of the CINs and were issued by the developed countries. Primary methods for the cervical cancer screening have gradually changed from the cytology to the HPV testing. There is a lack of recommendations targeting special population on cervical cancer screening in the current guidelines.

The ASCCP Cervical Cancer Screening Task Force Endorsement and Opinion on the American Cancer Society Updated Cervical Cancer Screening Guidelines

The American Cancer Society (ACS) released updated cervical cancer screening guidelines in 2020 that endorse a shift in practice to primary human papillomavirus (HPV) screening in people with a cervix, beginning at ages of 25-65 years. When access to US Food and Drug Administration-approved primary HPV testing is not available, the ACS offers cotesting or cytology as acceptable alternative strategies but suggests that these testing modalities may be excluded from future iterations of the guidelines. The ASCCP recognizes the benefits and risks of primary HPV cervical cancer screening while acknowledging the barriers to widespread adoption, including implementation issues, the impact of limited HPV vaccination in the United States, and inclusion of populations who may not be well represented on primary HPV screening trials, such as underrepresented minorities. The ASCCP endorses the 2018 US Preventive Services Task Force Recommendation Statement and supports the ACS cervical cancer screening guidelines. Most importantly, the ASCCP endorses any cervical cancer screening for secondary prevention of cervical cancer and recommends interventions that improve screening for those who are underscreened or unscreened.

Cervical cancer screening among sexual minority women: findings from a national survey.

Sexual minority women (SMW; lesbian, bisexual, and other women who have sex with women) are at risk for cervical cancer but less likely than non-SMW to receive regular cervical cancer screening (Pap- and/or HPV-testing). We examined factors contributing to receipt of guideline-based cervical cancer screening among SMW. During October 2019, we conducted an online survey of self-identified SMW aged 21-45years living in the United States (n = 435). We estimated risk differences (RD) in women's likelihood of being within current cervical cancer screening guidelines by sociodemographic and health-related characteristics. Overall, 75% of respondents were within current screening guidelines. Adjusting for other factors, SMW were more likely to be within guidelines if they were insured (aRD 0.26, 95% CI 0.13, 0.39), had a partner (aRD 0.18, 95% CI 0.09, 0.28), and were older (aRD 0.12, 95% CI 0.04, 0.20). Overall, the most common reasons for not being screened recently were lack of insurance/cost (42%) and perceiving it was unnecessary (28%). Many SMW are not being screened for cervical cancer according to guidelines. Findings can inform efforts to improve screening among this population.

Frequency of high-grade squamous cervical lesions among women over age 65 years living with HIV

Current US cervical cancer screening guidelines recommend screening cessation at the age of 65 years provided women have adequate previous screening and no history of precancer. Women living with HIV are at higher risk of cervical cancer than women living without HIV. Furthermore, limited data exists to quantify the risk of cervical cancer among women who otherwise would qualify for screening cessation. This study aimed to determine whether guidelines recommending women to discontinue cervical cancer screening at the age of 65 years are appropriate for women living with HIV. Semiannual Papanicolaou testing was performed as part of surveillance visits in the Women's Interagency HIV Study. Launched in October 1994, the Women's Interagency HIV Study is a federally funded US multisite cohort study that has enrolled 3678 women living with HIV and 1304 women living without HIV; we included data throughout September 2019 onward. Conventional Papanicolaou tests were collected at scheduled 6-month visits and read centrally according to the 1991 Bethesda System criteria. Results were analyzed among women at least 65 years of age. The primary endpoint was high-grade cytology, including high-grade squamous intraepithelial lesions; atypical glandular cells; atypical squamous cells, cannot exclude high-grade lesions; and malignant cytology. Wilcoxon rank-sum tests were used to compare the continuous variables, and Chi-square tests or the Fisher exact tests were used to compare the categorical variables. The Kaplan-Meier method was used to calculate the cumulative incidence. Poisson regression was used to compare 2 incidence rates. Of 169 eligible women (121 women living with HIV and 48 women living without HIV) who contributed 678.4 person-years of observation after reaching the age of 65 years, 2.2% had high-grade cytologic abnormalities. However, no cancer was found. Furthermore, 20 women had previous precancer results, and 74 women had abnormal Papanicolaou test results in the previous decade. Among 50 women (38 women living with HIV and 12 women living without HIV) with a previous hysterectomy and no history of cervical precancer, the cumulative incidence rates of high-grade squamous intraepithelial lesions were 0.6 (95% confidence interval, 0.0-3.2) per 100 person-years for women living with HIV and 0.0 (95% confidence interval, 0.0-8.1) per 100 person-years for women living without HIV (P=.61). Only 48 women (27 women living with HIV and 21 women living without HIV) had cervices and met the current guidelines to discontinue screening; their risk of experiencing high-grade squamous intraepithelial lesions was 2.2 (95% confidence interval, 0.6-5.5) per 100 person-years overall and did not vary by HIV status (2.3 [95% confidence interval, 0.5-6.8] per 100 person-years for women living with HIV and 1.8 [95% confidence interval, 0.0-9.8] per 100 person-years for women living without HIV; P=.81). Most women living with HIV do not meet the criteria for cervical cancer screening cessation and will need to continue screening over the age of 65 years; however, women who meet the criteria for screening cessation have risks of high-grade squamous lesions similar to women living without HIV and may choose to discontinue.

Comparative cost analysis of cervical cancer screening programme based on molecular detection of HPV in Spain

BackgroundHPV cervical cancer screening (CCS) must use validated HPV tests based on the molecular detection of either viral mRNA (Aptima HPV Assay—AHPV) or DNA. AHPV has demonstrated the same cross-sectional and longitudinal sensitivity for the detection of HSIL/CIN2+ lesions but with greater specificity than HPV-DNA tests. The study aimed to estimate the total costs of a CCS with a primary HPV test based on the detection of mRNA compared to DNA in women aged 35–65 years for the National Health System.MethodsA decision-tree-based model to estimate the cost of the CCS until the first colposcopy was designed based on Spanish CCS guidelines. The total cost (€, 2019) for CCS with AHPV or DNA tests (HC2 and Cobas) was calculated, including HPV test, liquid-based cytology (LBC) and colposcopy, for a population of 7,263,529 women aged 35–65 years (assuming 70% coverage). Clinical inputs derived from a literature review were validated by a multidisciplinary expert panel. Data from head-to-head studies between different HPV tests were selected.ResultsThe use of AHPV showed reduction of 290,541 (− 35%) and 355,913 (− 40%) LBC compared to HC2 or Cobas, respectively. Furthermore, AHPV avoided 151,699 (− 47%) colposcopies versus HC2 and 151,165 (− 47%) versus Cobas. The total cost of CCS was € 282,747,877 with AHPV, € 322,587,588 with HC2 and € 324,614,490 with Cobas. Therefore, AHPV savings € − 39,839,711 versus HC2 and € − 41,866,613 versus Cobas.ConclusionsAssuming that 70% of women from 35 to 65 years attend the CCS programme, the cost of screening up to the first colposcopy using AHPV would provide cost savings of up to € 41.9 million versus DNA tests in Spain.

Who Should Decide? Decision-Making Preferences for Primary HPV Testing for Cervical Cancer Screening Among U.S. Women

Revised U.S. guidelines for cervical cancer screening provide the option of primary human papillomavirus (HPV) testing, Pap testing, or co-testing. Primary HPV testing has not yet been an option for American women, and women may be reluctant to change screening methods. The purpose of this study was to assess correlates of women’s preferences for primary HPV testing decision-making (self, provider, or shared) for cervical cancer screening. Women, aged 30-65, completed an online survey in June of 2018 (n = 812). The outcome variable was preference for decision-making for an HPV test instead of a Pap test on a scale of, healthcare provider, me, or shared. Predictor variables included testing attitudes, social norms, information seeking, previous screening, and socio-demographics. Women who disagreed that people important to them think that they should get the HPV test instead of a Pap test, who were not willing to receive an HPV test instead of a Pap test, and who did not receive HPV vaccinations were less likely to include a provider in their decision-making. In contrast, women who were not up-to-date with their cervical cancer screenings, who had some college or technical level education, or who were over 50 years of age were more likely to prefer to have a healthcare provider included in their decision-making process. While some variation was discovered, women mostly preferred a shared decision or personal decision for HPV testing. Resources to facilitate the decision-making process about this new option for cervical cancer screening are needed.

Disparities in Meeting USPSTF Breast, Cervical, and Colorectal Cancer Screening Guidelines Among Women in the United States.

IntroductionMany sociodemographic factors affect women’s ability to meet cancer screening guidelines. Our objective was to examine which sociodemographic characteristics were associated with women meeting US Preventive Services Task Force (USPSTF) guidelines for breast, cervical, and colorectal cancer screening.MethodsWe used 2018 Behavioral Risk Factor Surveillance System data to examine the association between sociodemographic variables, such as race/ethnicity, rurality, education, and insurance status, and self-reported cancer screening for breast, cervical, and colorectal cancer. We used multivariable log-binomial regression models to estimate adjusted prevalence ratios and 95% CIs.ResultsOverall, the proportion of women meeting USPSTF guidelines for breast, cervical, and colorectal cancer screening was more than 70%. The prevalence of meeting screening guidelines was 6% to 10% greater among non-Hispanic Black women than among non-Hispanic White women across all 3 types of cancer screening. Women who lacked health insurance had a 26% to 39% lower screening prevalence across screening types than women with health insurance. Compared with women with $50,000 or more in annual household income, women with less than $50,000 in annual household income had a 3% to 8% lower screening prevalence across all 3 screening types. For colorectal cancer, the prevalence of screening was 7% less among women who lived in rural counties than among women in metropolitan counties.ConclusionMany women still do not meet current USPSTF guidelines for breast, cervical, and colorectal cancer screening. Screening disparities are persistent among socioeconomically disadvantaged groups, especially women with low incomes and without health insurance. To increase the prevalence of cancer screening and reduce disparities, interventions must focus on reducing economic barriers and improving access to care.

Utilizing a Multidimensional Health Literacy Framework to Assess Cervical Cancer Screening Nonadherence.

Health literacy is an amenable factor that can improve screening uptake. However, associations between the multidimensional health literacy domains and cervical cancer screening nonadherence are not known and should be considered to improve screening rates. The current quantitative study assessed the associations of multiple health literacy domains with cervical cancer screening nonadherence. Women aged 30 to 65 years without a hysterectomy were surveyed online (N = 812). Assessing, understanding, and appraising measures from the European Health Literacy Survey Questionnaire were adapted for cervical cancer screening. The outcome variable measured the application of cervical cancer information regarding adherence to the 2012 cervical cancer screening guidelines (yes/no). Adjusted logistic regression odds ratios (aORs) estimated nonadherence. Most of the women were non-Hispanic (81.4%) or White (68.1%), and aged 30 to 39 years (40%). The majority of the women (71%) were adherent to screening recommendations. The model with all domains of health literacy had the best model fit statistics compared with other models with different health literacy components. Older age and lack of insurance were statistically significant for screening nonadherence. Difficulty understanding health information (aOR = 3.15; 95% confidence interval [CI; 1.80, 5.51]) and less worry about cervical cancer (aOR = 1.74; 95% CI [1.03, 2.94]) were associated with higher odds of nonadherence. Higher cervical cancer knowledge (aOR = 0.93; 95% CI [0.87, 0.98]) and Hispanic ethnicity (aOR = 0.36; 95% CI [0.21, 0.61)] were associated with lower odds of nonadherence. Incorporating a multidimensional health literacy framework may better inform the need to develop easily understood interventions that address cervical cancer perceived vulnerability and acknowledge systemic sociodemographic influences on screening perceptions.

American Cancer Society signals transition in cervical cancer screening from cytology to HPV tests.

The 2020 American Cancer Society cervical cancer screening guidelines call for a shift to primary human papillomavirus testing every 5 years, with cotesting and cytology alone acceptable where primary testing platforms are not available. Initiation of screening is recommended at the age of 25 years instead of 21 years.

Would Women With Solid Organ Transplant Qualify for Triennial Cervical Cancer Screening as Recommended by the American College of Obstetricians and Gynecologists in 2016 and American Society for Colposcopy and Cervical Pathology in 2019?

The aim of the study was to assess the applicability and safety of cervical cancer screening guidelines recommended by the American College of Obstetricians and Gynecologists (2016) and American Society for Colposcopy and Cervical Pathology (2019) for women with solid organ transplants (SOTs). We analyzed data previously abstracted through December 2015 for 971 women (18-60 y) who received their first SOT at Mayo Clinic (Rochester, MN) from January 17, 1995, through December 31, 2011. Inclusion criteria were initial benign findings on cervical cytology after SOT and at least 1 subsequent cytologic screening. Of 415 women whose initial cytologic findings were benign, 310 met inclusion criteria. The cumulative incidence of abnormal cervical cytology among these 310 women was 4.3% (95% CI = 1.9%-6.7%) by 30 months and 11.2% (95% CI = 7.1%-15.4%) by 60 months after their initial benign results. Considering all women with SOT, 68.4% (284/415) had no documented abnormal cytologic findings within 60 months (26 had abnormality; 284 no abnormality; and 105 not assessed). In women with negative tests for human papillomavirus, high-grade squamous intraepithelial lesions were not documented on cytology with variable duration of follow-up. No cervical squamous cell carcinoma was identified. Of women with initial benign cervical cytology after SOT, more than two thirds would have been eligible for extended-interval screening. Further study is needed, particularly regarding the role of high-risk human papillomavirus testing.

Effect of 2 Interventions on Cervical Cancer Screening Guideline Adherence

This study sought to determine whether a provider mobile phone application, used with or without a patient educational tool accessed on a computer tablet, would promote adherence to guidelines for cervical cancer screening and management of abnormal cytology in young women. The study was conducted as a prospective cohort study in which 14 Family Planning, Access, Care, and Treatment provider clinics were randomized to 1 of 2 arms: (1) provider mobile phone application only or (2) provider mobile phone application plus patient educational tool. The provider mobile phone application gave information to providers regarding cervical cancer screening and management of abnormal cytology. The patient educational tool accessed on a computer tablet was a patient-centered educational tool. Each arm was compared with clinic control groups (no intervention) in a 2:1 ratio (control:intervention). Claims data were used to calculate and compare 18-month cytology (Pap) and colposcopy rates before the intervention and during the 18 months using the Poisson mixed-effect regression model. A sensitivity analysis examined the differences in the rate of change between each arm and controls. The study took place between July 2015 and December 2016, and analysis was performed in 2019. The clinics randomized to the provider mobile phone application plus patient educational tool arm and their control group achieved similar 18-month Pap rates (0.52, 95% CI=0.37, 0.74 and 0.68, 95% CI=0.53, 0.86, respectively) as well as the provider mobile phone application arm and their control group (0.44, 95% CI=0.33, 0.58 and 0.41, 95% CI=0.34, 0.51; p-values >0.1). In the sensitivity analysis, the difference in the rate of change in Pap rates for the provider mobile phone application plus patient educational tool arm and their control group before and during the intervention was -0.22 and -0.09, respectively (p=0.02), but no differences were seen between the provider mobile phone application arm and their control group. No significant changes were observed for colposcopy rates. Providing clinicians and patients with information on guidelines had no demonstrable effect on 18-month Pap and colposcopy rates in the regression model; however, results from the sensitivity analysis for the patient educational tool were encouraging. This study is registered at www.clinicaltrials.gov NCT02270021.

Increased Risk of High-grade Cervical Neoplasia in Women with Inflammatory Bowel Disease: A Case-controlled Cohort Study

Background and AimsWomen with inflammatory bowel disease [IBD] may be at higher risk for cervical intraepithelial neoplasia [CIN]. However, data are conflicting. The aim of this study was to assess the risk of high-grade dysplasia and cancer [CIN2+] in IBD women and identify risk factors.MethodsClinical data from adult IBD women in a multicentre Dutch IBD prospective cohort [PSI] from 2007 onwards were linked to cervical cytology and histology records from the Dutch nationwide cytology and pathology database [PALGA], from 2000 to 2016. Patients were frequency-matched 1:4 to a general population cohort. Standardised detection rates [SDR] were calculated for CIN2+. Longitudinal data were assessed to calculate CIN2+ risk during follow-up using incidence rate ratios [IRR] and risk factors were identified in multivariable analysis.ResultsCervical records were available from 2098 IBD women [77%] and 8379 in the matched cohort; median follow-up was 13 years. CIN2+ detection rate was higher in the IBD cohort than in the matched cohort (SDR 1.27, 95% confidence interval [CI] 1.05–1.52). Women with IBD had an increased risk of CIN2+ [IRR 1.66, 95% CI 1.21–2.25] and persistent or recurrent CIN during follow-up (odds ratio [OR] 1.89, 95% CI 1.06–3.38). Risk factors for CIN2+ in IBD women were smoking and disease location (ileocolonic [L3] or upper gastrointestinal [GI] [L4]). CIN2+ risk was not associated with exposure to immunosuppressants.ConclusionsWomen with IBD are at increased risk for CIN2+ lesions. These results underline the importance of human papillomavirus [HPV] vaccination and adherence to cervical cancer screening guidelines in IBD women, regardless of exposure to immunosuppressants.

Reply to: Comments on cumulative risk of cervical intraepithelial neoplasia for women with normal cytology but positive for human papillomavirus: Systematic review and meta‐analysis

In their letter to the editor, Jayaraj et al have raised several points regarding our recent systematic review and meta-analysis on the risk of progression to precancer for human papillomavirus (HPV) positive but cytology normal women.1 We welcome the opportunity to further address these points, which may have been less clear in our original paper. We start with their most relevant point, and the last in their letter, about our adherence with PRISMA guidelines. Although we did not specifically mention the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines in our publication, we assure readers that we did use PRISMA reporting guidelines when drafting the article.2 Readers will find that all PRISMA items are reported in the publication and its appendix.1 Jayaraj et al stated that the categorisation of high-risk (HR) HPV types was not detailed for readers. This reflects the fact that we used each individual study's definition of what it considered to be HR-HPV types, which differed slightly between studies due to differences in the HPV assays used. However, the vast majority of studies in our review considered the same 13 to 14 HPV types as HR (HPV types 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 66 and 68). These are the types detected by commercial DNA assays approved for cervical cancer screening by the Food and Drug Administration,3 and HPV-DNA tests have generally been found to have comparable sensitivity and specificity in a screening population.4 Therefore, our analysis for grouped HR-HPV types is an accurate reflection of the risk associated with these 14 HPV types at the time the studies were performed. It is likely that much of the heterogeneity in cervical precancer risk between populations is due to differences in HPV-type distribution between populations, rather than differences in types detectable between assays. This is an issue that affects not just our study, but all observational and clinical trials of HPV tests, and screening in general: the underlying predictive value of a positive test result for grouped HPV types will always depend on the underlying distribution of these types in a population. This is why our type-specific HPV results are likely to be very important going forward as HPV-16 and HPV-18 prevalence is declining in many populations due to HPV vaccination.5 We disagree with Jayaraj et al that HPV type-specific progression risks are not useful for informing risk-based cervical cancer screening guidelines, given the numerous studies which found that HPV type is a strong predictor of cervical precancer risk, and which we cited in our review. Recently updated cervical cancer screening guidelines for the United States6 and Australia7 integrate HPV genotyping as a tool to stratify HPV-positive women based on their risk of high-grade cervical lesions. We expect that more countries will follow suit as they adopt HPV testing and revise their approaches to cervical cancer screening. The current perspective espoused by many scientists is that extended HPV genotyping is a promising molecular biomarker for further risk stratification of women with positive HPV test results,8 especially in the context of HPV self-sampling.9 Finally, Jayaraj et al's inappropriate argument that only 5% of all cancers are caused by HPV is not relevant here; we examined risk for women who are HPV positive in the context of cervical cancer screening, where it is established that HPV is a necessary cause of this disease; virtually all cervical cancers worldwide are caused by infection with HPV.10 ELF has served as occasional consultant to Merck and GSK on HPV vaccines, to Roche and to BD on HPV diagnostics. His institution has received unrestricted grants from Merck. ELF holds a patent related to the discovery “DNA methylation markers for early detection of cervical cancer”, registered at the Office of Innovation and Partnerships, McGill University, Montreal, Quebec, Canada (October, 2018). A provisional utility patent application before the United States Patent & Trademark Office was also filed (November, 2018).

American Society of Clinical Oncology (ASCO) Cervical Cancer Prevention Program: A Hands-On Training Course in Nepal.

Cervical cancer is the leading cause of death among women in Nepal. The American Society of Clinical Oncology (ASCO) and The University of Texas MD Anderson Cancer Center collaborated with international and local experts to hold a cervical cancer prevention course in Nepal in November 2019. The course included didactic lectures and a hands-on workshop. The didactic lectures included the epidemiology of cervical cancer globally and locally, cervical cancer screening guidelines, human papillomavirus vaccination, colposcopy and visual inspection with acetic acid (VIA), cervical dysplasia, and cervical cancer treatment. The hands-on workshop consisted of four stations: (1) VIA; (2) colposcopy, cervical biopsy, and endocervical curettage; (3) thermal ablation; and (4) loop electrosurgical excision procedure (LEEP). A train-the-trainer model short course was held by the international faculty to assist six local faculty to become familiar with the instruments, procedures, and models used in the hands-on training stations. Forty-two people (84% gynecologist, 8% radiation oncologist, and 8% other) attended the course. Following the course, the international faculty visited the regional hospitals for additional educational activities. Increased knowledge in cervical cancer screening guidelines and ability in performing VIA, colposcopy and cervical biopsy, thermal ablation, and LEEP were reported by 89%, 84%, 84%, 87%, and 84% of participants, respectively, from the postcourse on-site evaluations. From the 6-month follow-up survey, all respondents reported that they had made practice changes based on what they learned in the course and had implemented or tried to implement the cervical cancer screening guidelines presented at the course. In conclusion, the course evaluations suggested an improvement in participants' ability to perform cervical cancer screening and diagnostic procedures and reported the changes in practices after training.

Cervical cancer prevention: Review of the past, present, and future

The purpose of this article is to summarize the history of cervical cancer research supporting current practice guidelines used today. Recent updates to the human papillomavirus vaccination schedule, in addition to the latest cervical cancer screening and management guidelines, are highlighted. Future changes on the horizon are also discussed.

Cervical Papanicolaou tests in the female-to-male transgender population: should the adequacy criteria be revised in this population? An Institutional Experience

It is recommended that female-to-male (FTM) transgender patients with a cervix follow the same cervical cancer screening guidelines as cisgender women. This study analyzes Papanicolaou tests, HPV results, and follow-up histology in FTM patients, and compares those results to other atrophic populations at our institution. A cohort of FTM patients receiving androgen therapy was identified through our institution's translational research database. We collected data on Papanicolaou tests, human papillomavirus (HPV) results, follow-up surgical procedures, and duration of androgen therapy. ThinPrep slides were reviewed for cellularity and cytomorphology. The results of these tests were compared with those of an atrophic control group consisting of postpartum and postmenopausal cisgender women. We identified 71 FTM patients with 77 Papanicolaou tests collected over 6 years. Papanicolaou interpretations included: negative for intraepithelial lesion (69%), atypical cells of undermined significance (5%), low grade squamous intraepithelial lesion (1%), atypical glandular cells (1%), and unsatisfactory due to inadequate cellularity (23%). Five of 27 (18.5%) HPV tests were positive. Follow-up surgical specimens did not identify high-grade lesions. Unsatisfactory rates among FTM patients differed significantly from the atrophic group (P < 0.05), while epithelial abnormality rates and HPV positivity did not (P > 0.05). Most FTM Papanicolaou tests reviewed showed features of atrophy. FTM patients receiving androgen have high Papanicolaou test unsatisfactory rates secondary to atrophy. Epithelial abnormality and HPV rates do not differ significantly from atrophic cisgender patients. Lowering the cellularity threshold for this population to 2000 like that of other atrophic groups should be considered.

Summary of Current Guidelines for Cervical Cancer Screening and Management of Abnormal Test Results: 2016-2020.

Cervical cancer can be prevented through routine screening and follow-up of abnormal results. Several guidelines have been published in the last 4 years from various medical societies and organizations. These guidelines aim to personalize screening and management, reducing unnecessary testing in low-risk patients and managing high-risk patients with more intensive follow-up. However, the resulting complexity can lead to confusion among providers. The CDC, NCI, and obstetrician-gynecologists involved in guideline development summarized current screening and management guidelines. For screening, guidelines for average-risk and high-risk populations are summarized and presented. For management, differences between the 2012 and 2019 consensus guidelines for managing abnormal cervical cancer screening tests and cancer precursors are summarized. Current screening guidelines for average-risk individuals have minor differences, but are evolving toward an HPV-based strategy. For management, HPV testing is preferred to cytology because it is a more sensitive test for cancer precursor detection and also allows for precise risk stratification. Current risk-based screening and management strategies can improve care by reducing unnecessary tests and procedures in low-risk patients and focusing resources on high-risk patients. Knowledge of screening and management guidelines is important to improve adherence and avoid both over- and under-use of screening and colposcopy.