Cervical Cancer Screening and Diagnosis

Number: 0443

(Replaces CPB 359)

Policy

1. Consistent with guidelines from the U.S. Preventive Services Task Force (USPSTF) and the American College of Obstetricians and Gynecologists (ACOG), Aetna considers annual cervical cancer screening with conventional or liquid-based Papanicolaou (Pap) smears a medically necessary preventive service for nonhysterectomized women age 21 years and older.

2. Aetna considers Pap screening medically necessary beginning in adolescense in HIV-infected women.  The ACOG guidelines on cervical cancer in adolescents (2010) recommend that adolescents with HIV have cervical cytology screening twice in the first year after diagnosis and annually thereafter.

3. Aetna considers Pap screening medically necessary in sexually active immunocompromised adolescent women, including those who have received an organ transplant or those with long-term steroid use.  According to ACOG guidelines (2010), sexually active immunocompromised adolescents, including those who have received an organ transplant or those with long-term steroid use, should undergo screening after the onset of sexual activity and not wait until 21 years of age.  The testing should be done at 6-month intervals during the first year of testing and then annually thereafter.

4. Aetna considers Pap screening medically necessary beginning in adolescence in women diagnosed with cervical dysplasia or cervical cancer, with testing twice in the first year after diagnosis and annually thereafter.

5. Aetna considers Pap smears medically necessary beginning in adolescence in sexually active women who have been exposed in utero to diethylstilbestrol (DES).  Testing should begin after the onset of sexual activity, and should be done at 6-month intervals during the first year of testing and then annually thereafter.

6. Aetna considers Pap smear screening experimental and investigational for all other women under 21 years of age because they have no proven value for these younger women.

7. Aetna considers Pap smear screening not medically necessary for women who have undergone complete (total) hysterectomy for benign disease (e.g., no evidence of cervical neoplasia or cancer) or have absent cervix.

   Note: Medically necessary cervical cancer screening is covered under plans that cover routine physical exams, routine gynecological exams and/or routine Pap smears.  Please check benefit plan descriptions for details.

8. Aetna considers diagnostic Pap smears medically necessary when any of the following conditions is met:

   1. Pap smear is accompanied by a diagnosis of a malignancy of the female genital tract (i.e., cervix, ovary, uterus, or vagina); or
   2. There is a description of symptoms or a disease requiring diagnosis by a Pap smear, for example:
      1. Abnormal vaginal bleeding or discharge
      2. Chronic cervicitis
      3. Vaginal tumor; or
         
   3. Following gynecological surgery for cancer; or
   4. Member has been exposed to diethylstilbestrol (DES); or
   5. Member has any of the following risk factors for cervical cancer:
      1. History of cervical, vaginal or vulvar cancer
      2. HIV infection
      3. History of genital human papillomavirus (HPV) infection
      4. Immunosuppression
      5. Multiple sexual partners
      6. Previously abnormal Pap smear
      7. Previous sexually transmitted disease.

   Aetna considers diagnostic Pap smears experimental and investigational for all other indications because its effectiveness for indications other than the ones listed above has not been established.

9. Aetna considers automated liquid-based thin-layer slide preparation methods (e.g., ThinPrep^® PapTest™, SurePrep™ Liquid Based Pap Test, AutoCyte PREP System™) medically necessary as an alternative to conventional Pap smears when the criteria for conventional Pap smears are met.

10. Aetna considers automated cervical cancer slide interpretation systems (e.g., FocalPoint Slide Profiler (formerly AutoPap), PAPNET) a medically necessary adjunct to cervical cancer screening.

11. Aetna considers testing for high-risk strains of HPV DNA using Food and Drug Administration (FDA)-approved techniques (e.g., Hybrid Capture II, cobas HPV PCR) medically necessary for women with any of the following indications:

    1. Assessment of women with atypical squamous cells of undetermined significance (ASCUS).  This is consistent with the National Cancer Institute's interim guidelines for managing abnormal cervical cytology as well as the position of the American Society for Colposcopy and Cervical Pathology (ASCCP) for the management of ASCUS.
    2. Follow-up of women with ASCUS who have a previously positive HPV DNA test and negative colposcopy results within the past 2 years.
    3. Follow-up of women with low-grade squamous intra-epithelial lesions (LSIL) who have had negative colposcopy results within the past 2 years.
    4. Follow-up of women with atypical squamous cells: Cannot exclude high-grade SIL (ASC-H) who have negative colposcopy results within the past 2 years.
    5. Use in combination with Pap smears for screening women aged 30 years and older.  If this combination is used for screening, it is not considered medically necessary to re-screen women who receive negative results on both tests more frequently than every 3 years.
    6. High-risk HPV testing alone for screening women aged 30 and older every 5 years.
    7. Assessment of women with atypical glandular cells not otherwise specified (AGC NOS).
    8. Follow-up of women with AGC NOS who have had negative colposcopy results within the past 2 years.

    Note: The medically necessary indications for HPV DNA testing are not affected by pregnancy status.

12. Aetna considers HPV testing experimental and investigational for the following indications:
    
    
    1. Use of HPV tests as a primary screening test for cervical cancer in women younger than 30 years of age.  According to evidence-based guidelines from the U.S. Preventive Services Task Force, the medical literature does not support HPV testing as a screening test for cervical cancer for younger individuals whose cervical cytology is normal or is unknown.
    2. For selecting candidates for cervical cancer vaccine.  The Centers for Disease Control and Prevention's Advisory Committee on Immunization Practices does not recommend HPV testing to select persons for cervical cancer vaccine. 
    3. For testing members with definitively positive cervical cytology, other than follow-up of women with ASC-H, LSIL or AGC NOS and negative colposcopy.
    4. Testing for low-risk HPV strains.
    5. Testing of men.
    6. Use for indications other than detection of cervical cancer, such as testing for infection following exposure to HPV.
    7. For use in girls and women less than 21 years of age unless they have had a previous abnormal Pap smear that meets criteria above.
    8. Use for all indications other than those listed in section XI above.

13. Aetna considers cervicography or speculoscopy (Pap-Sure) experimental and investigational for the screening or diagnosis of cervical cancer because of a lack of adequate clinical studies related to their use for these indications.

14. Aetna considers video colpography experimental and investigational for cervical cancer screening or diagnosis because of a lack of adequate evidence of its effectiveness for these indications.

15. Aetna considers spectroscopy/optical/optoelectric detection systems (e.g., the Luma cervical imaging system, and TruScreen) experimental and investigational for cervical cancer screening or diagnosis because of insufficient evidence of their effectiveness for these indications.

16. Aetna considers the Resolve^TM laboratory testing kit (Gynecor^TM, Glen Allen, VA) experimental and investigational for cervical cancer screening or diagnosis because of insufficient evidence of its effectiveness for these indications.

17. Aetna considers the use of methylation markers for cervical cancer screening experimental and investigational because of insufficient evidence of their effectiveness.

18. Aetna considers fluorescence in-situ hybridization (FISH) testing (e.g., the Ikonisys oncoFISH cervical test) for cervical cancer screening or diagnosis experimental and investigational because of insufficient evidence of its effectiveness.

19. Aetna considers p16/Ki-67 dual staining of women with a positive HPV screening test experimental and investigational because of insufficient evidence of its effectiveness.

20. Aetna considers self-collected / self-sampling HPV tests for screening of cervical cancer experimental and investigational because of insufficient evidence of its effectiveness.

21. Aetna considers DYSIS Smart Colposcopy experimental and investigational for screening of cervical cancer because of insufficient evidence of its effectiveness.

See also CPB 0650 - Polymerase Chain Reaction Testing: Selected Indications.

Background

Pap smears consist of cells removed from the cervix, which are specially prepared for microscopic examination.  The cells are removed by brushing or scraping the cervix during a pelvic examination and then placing the cells on one or more glass slides.  Each slide typically contains hundreds of thousands of cells.  All Pap smears should be sent to an accredited laboratory to be stained, examined under a microscope, and interpreted.  The test is used as the principal screening test to detect cervical cancer in asymptomatic women.  It can detect precancerous changes or cancer of the cervix or vagina.  A Pap test will only rarely detect cancer of the ovaries or endometrial cancer.  It can also find some infections of the cervix and vagina.

The American Academy of Family Physicians recommends that all women who are or have been sexually active, or who have reached age 18, should have annual Pap smears.  The American Cancer Society, National Cancer Institute, and American Medical Association recommend that cervical cytology screening should begin within 3 years of onset of sexual activity or age 21.  The recommendation allows less frequent Pap testing after 3 or more annual smears have been normal, at the discretion of the physician.  For women who have had repeated negative tests, the marginal gain from screening more often than every 3 years decreases sharply.  However, because of the difficulty in identifying patients at increased risk for cervical cancer, most physicians will recommend a Pap test be performed at least once-yearly.

The American College of Obstetricians and Gynecologists (ACOG, 2009) recommend that cervical cytology screening begin at age 21 regardless of age at onset of sexual activity and from age 21 to 29, testing is recommended every 2 years but should be more frequent in women who are HIV-positive, immunosuppressed, were exposed in- utero to diethylstilbestrol (DES), or have been treated for cervical intraepithelial neoplasia (CIN) grade 2, 3 or cervical cancer.  The ACOG guidelines on cervical cancer in adolescents (2010) recommend that adolescents with HIV have cervical cytology screening twice in the first year after diagnosis and annually thereafter.  Sexually active immunocompromised adolescents, including those who have received an organ transplant or those with long-term steroid use, should undergo screening after the onset of sexual activity and not wait until 21 years of age.  The testing should be done at 6-month intervals during the first year of testing and then annually thereafter.  Beginning at age 30, women who have 3 consecutive negative screens and who do not fit the criteria above for more frequent screening, may be tested every 3 years.  Co-testing with cervical cytology and high-risk human papillomavirus (HPV) typing is also appropriate and if both tests are negative, re-screening in 3 years is recommended.

Although ACOG (2013) guidelines state that women younger than 21 years should not undergo screening, they also state that "[i]f a woman younger than 21 years is inadvertently screened and has an abnormal test result, the result should not be ignored and should be managed based on the guidelines for 21–24-year-old women.” Similarly, the American Society for Colposcopy and Cervical Pathology (ASCCP) (Massad, et al, 2012) states that ”[g]uidelines for women aged 21-24 years can be extrapolated to adolescents inadvertently screened.”

After age 65, there is no clear consensus on the need for Pap smears in women who have had previous adequate screening.  The American Academy of Family Physicians recommends that at age 65, screening may be discontinued if there is documented evidence of previously negative smears; however, these recommendations are currently under review.  The ACOG (2009) recommend discontinuation of screening after age 65 or 70 in women with 3 or more negative consecutive tests and no cervical abnormalities during the previous 10 years.  Women with histories of CIN grade 2, 3 or cancer should undergo annual screening for 20 years after treatment.  The American College of Physicians (ACP) recommends Pap smears every 3 years for women aged 20 to 65, and every 2 years for women at high-risk.  The ACP also recommends screening women aged 66 to 75 every 3 years if not screened in the 10 years before age 66.

The U.S. Preventive Services Task Force (USPSTF, 2018) recommends screening for cervical cancer every 3 years with cervical cytology alone in women aged 21 to 29 years. For women aged 30 to 65 years, the USPSTF recommends screening every 3 years with cervical cytology alone, every 5 years with high-risk human papillomavirus (hrHPV) testing alone, or every 5 years with hrHPV testing in combination with cytology (cotesting). The USPSTF recommends against screening for cervical cancer in women older than 65 years who have had adequate prior screening and are not otherwise at high risk for cervical cancer.

Pap testing need not be performed for women who had a hysterectomy for benign disease; however, women who had a hysterectomy performed in which the cervix was left intact probably still require screening.  However, a recent study by Sirovich and Welch (2004) indicated that many U.S. women who have undergone hysterectomy are undergoing Pap smear screening despite the U.S. Preventive Services Task Force's recommendation that Pap smear screening is unnecessary for women who have undergone a complete hysterectomy for benign disease.

A federally funded survery of 1,100 clinicians (internists, family practitioners, or obstetrician-gynecologists) found that only about 1/5 consistently follow guidelines for Pap testing (Yabroff et al, 2009).  While over 80 % said that at least one set of screening guidelines (e.g., U.S. Preventive Services Task Force) was "very influential" in their practices, only 22 % recommended guideline-consistent care for every clinical scenario included in the survey.  Obstetrician-gynecologists were less guideline-concordant than the other specialties.  Of note, 1/3 of participants recommended annual Pap testing for an 18-year old who hadn't had sexual intercourse, while almost 1/2 continued to recommend Pap testing for a women whose cervix had been removed for benign reasons.

Repeat Pap smears may be indicated 3 to 4 months following local treatment of vaginal infection/inflammation, and 2 to 3 months following a Pap test suggestive of mild dyskaryosis or if the initial Pap smear results were unsatisfactory due to inadequate sampling.

A standardized method of reporting cytology findings was developed by the National Cancer Institute called the "Bethesda System".  In the Bethesda System, atypical squamous cells fall into 2 categories:

1. atypical squamous cells of undetermined significance (ASCUS) and
2. atypical squamous cells: cannot exclude HSIL (ASC-H). 

Cervical cancer precursors fall into 2 categories:

1. low-grade squamous intraepithelial lesions (LSIL) and
2. high-grade squamous intraepithelial lesions (HSIL). 

Low-grade squamous intraepithelial lesions include CIN 1 (mild dysplasia) and the changes of HPV, termed koilocytotic atypia.  High-grade squamous intraepithelial lesions include CIN 2 and CIN 3 (moderate dysplasia, severe dysplasia, and carcinoma in situ).  Other classification systems in use include the Dysplasia/CIN System and the Papanicolaou System.

Currently there are no formal guidelines for anal Pap smear screening.  The Centers for Disease Control and Prevention (Workowski and Bolan, 2015) stated: "Data are insufficient to recommend routine anal-cancer screening with anal cytology in persons with HIV infection or HIV-negative MSM. More evidence is needed concerning the natural history of anal intraepithelial neoplasia, the best screening methods and target populations, safety of and response to treatments, and other programmatic considerations before screening can be routinely recommended. However, some clinical centers perform anal cytology to screen for anal cancer among high-risk populations (e.g., persons with HIV infection and MSM), followed by high-resolution anoscopy for those with abnormal cytologic results (e.g., ASC-US)."  Observing that HIV-infected men and women with human papillomavirus (HPV) infection are at increased risk for anal dysplasia and cancer, the HIV medicine association of the Infectious Diseases Society of America (Aberg, et al, 2013) states that MSM, women with a history of receptive anal intercourse or abnormal cervical Pap test results, and all HIV-infected persons with genital warts should have anal Pap tests. This is a weak recommendation based upon moderate quality evidence. 

Automated Liquid-Based Thin-Layer Slide Preparation (e.g., ThinPrep, SurePath, AutoCyte PREP)

To decrease the number of false-negative Pap smears, new technologies for preparing the Pap smear have been approved by the U.S. Food and Drug Administration (FDA).

The ThinPrep^® PapTest™ (Cytyc Corp., Marlborough, MA), and SurePath (TriPath Imaging Inc., Burlington, NC) are automated liquid-based thin layer slide preparation techniques.  With the ThinPrep System, a conventional Pap smear is not performed.  Using a spatula and a brush or a cervical broom, the cervical area is sampled and the devices are rinsed in a fixative solution.  The slide is then automatically made in the laboratory, which decreases the possibility of air-drying artifacts.  It is then stained and read by a technician or a cytopathologist.  SurePath (formerly known as AutoCyte PREP) is another liquid-based thin-layer sample preparation system that uses centrifugation to separate cells from obscuring material, and automatically prepares and stains cytology slides.

An assessment of liquid-based cervical cytology systems by the Institute for Clinical Systems Improvement (ICSI, 2003) concluded that liquid-based cytology is an acceptable alternative to conventional Pap testing for cervical cancer screening.  The ICSI technology assessment made the following findings:

• For the detection of pre-invasive cervical lesions, liquid-based cytology is comparable to conventional Pap; there is no evidence of a change in the rate of cancer detection when liquid-based samples are analyzed.
• For minor grade lesions, there is evidence of a higher detection rate with liquid-based cytology.  As a result, liquid-based cytology acts to normalize the rate of detection of atypical squamous cells of undetermined significance (ASCUS) so that pathologists can reach the 3 % to 5 % ASCUS rate expected (Bethesda criteria).  More accurate detection of ASCUS helps to better identify patients who need further testing.  Inter-observer validity is higher with LBC.
• Of 11 studies cited in the ICSI technology assessment that presented test results as either satisfactory, satisfactory but limited by, or unsatisfactory, 8 found a higher rate of satisfactory samples with liquid-based cytology.  Between 75.6 % and 97.7 % of liquid-based cytology preparations were satisfactory compared with 60.5 % to 97.5 % with conventional Pap preparations.
• The ICSI report cited the results of a meta-analysis of 15 studies that reported a sensitivity of 80 % for liquid-based cytology and 72 % for conventional Pap testing predominantly for the detection of low-grade squamous intraepithelial lesions or more severe (LSIL+) by histology and/or independent pathology review of slides with a Pap test result of LSIL+.  Specificity did not differ between conventional and liquid-based cytology preparations.

A technology assessment by the Canadian Coordinating Office for Health Technology Assessment found that "[e]vidence (based primarily on results from split-sample trials) suggests that compared with Pap smears, the use of [liquid-based cytology] reduces the proportion of unsatisfactory specimens and generates fewer false negatives for ordinary populations, but not for high-risk populations" (Noorani et al, 2003).

In its updated guidelines on cervical cancer screening, the American Cancer Society has stated that liquid-based thin-layer Pap smears are an acceptable alternative to conventional Pap smears (Saslow et al, 2002).  "As an alternative to conventional cervical cytology smears, cervical screening may be performed every two years using liquid-based cytology; at or after age 30, women who have had 3 consecutive, technically satisfactory normal/negative cytology results may be screened every 2 to 3 years (unless they have a history of in utero DES exposure, are HIV+, or are immunocompromised)."

An assessment by the Danish Centre for Evaluation and Health Technology Assessment (DACEHTA, 2005) concluded that "no scientific basis has been found to suggest any difference in clinical or health economic effect between liquid based cytology (LBC) and conventional Pap smear (CPS)."  The report noted that "[i] the objective is to improve the clinical or health economic effectiveness, the report demonstrates that an increased coverage rate and an expansion of the age interval included in screening programmes for cancer of the uterine cervix from 59 to 69 years of age would be the more efficient strategy."

A recent large-scale clinical trial found that liquid-based cytology does not perform better than conventional Pap tests in terms of relative sensitivity and PPV for detection of cervical cancer precursors.  In a randomized double-blind controlled trial, Siebers and colleagues (2009) compared liquid-based cytology with conventional cytology for detection of cervical cancer precursors in women (n = 89,784) aged 30 to 60 years participating in the Dutch cervical screening program.  A total fo 122 practices were assigned to use liquid-based cytology and screened 49,222 patients and 124 practices were assigned to use the conventional Pap test and screened 40,562 patients.  Patients were followed for 18 months.  The adjusted detection rate ratios for CIN grade 1+ was 1.01 (95 % confidence interval [CI]: 0.85 to 1.19); for CIN grade 2+, 1.00 (95 % CI: 0.84 to 1.20); for CIN grade 3+, 1.05 (95 % CI: 0.86 to 1.29); and for carcinoma, 1.69 (95 % CI: 0.96 to 2.99).  The adjusted positive predictive value (PPV) ratios, considered at several cytological cut-offs and for various outcomes of CIN did not differ significantly from unity. 

Automated System (FocalPoint, PAPNET)

Automated slide analysis devices (e.g., PapNet (Neuromedical Systems Inc.), FocalPoint (formerly AutoPap) (TriPath Technologies, Inc., AutoCyte SCREEN (AutoCyte, Inc.)) are designed to partially automate screening of Pap smears.  The primary focus of current research is on use of image analysis as a primary screening device, where Pap smear slides are translated into digitalized images for automated image analysis.  Slides that are identified by automated image analysis as possibly abnormal are passed on for manual interpretation.  Slides that are identified by automated image analysis as very unlikely to contain abnormal cells may not be examined manually, or a random sample may be spot checked manually.  Automated slide analysis devices may also be used to rescreen slides that are reported as negative or inadequate.

Although it is not known whether programs employing automated slide analysis are more effective than manual screening in detecting more cervical cancers, automated slide analysis devices have become standard of care.  An Agency for Healthcare Research and Quality technology assessment of cervical cancer screening techniques (McCrory et al, 1999) concluded that there is substantial uncertainty about the estimates of sensitivity and specificity of cervical cancer screening using automated slide analysis devices compared with conventional manual screening, which in turn results in substantial uncertainty about the estimates of the effectiveness and cost-effectiveness of these techniques.  "Although it is clear that both thin-layer cytology and computerized rescreening technologies provide an improvement in effectiveness at higher cost, the imprecision in estimates of effectiveness makes drawing conclusions about the relative cost-effectiveness of thin-layer cytology and computerized rescreening technologies problematic."

A technology assessment for the Minnesota Health Technology Advisory Committee (1999) concluded: "Studies of these methods demonstrate that computer-assisted cervical cancer screening and rescreening modestly improves detection of false-negative smears as compared with conventional manual screening.  The majority of false-negative smears detected are low-grade squamous intraepithelial lesions (LGSIL), reactive or reparative changes, or atypical squamous cells of undetermined significance (ASCUS) rather than the more serious premalignant or malignant lesions.  Some studies have shown that computer-assisted Pap smear screening may marginally improve health outcome for some patients.  The net health benefits of computer-assisted screening have not been proven.  Studies examining the cost-effectiveness of the new technologies indicate that the cost-benefit of computer-assisted rescreening technologies is less favorable than any manual rescreening alternatives."

An assessment of the use of automated slide analysis devices in cervical cancer screening conducted by the Research Triangle Institute Evidence-Based Practice Center for the Agency for Healthcare Research and Quality (Hartmann et al, 2002) concluded that "[o]verall, the quality of this literature is poor for the purposes of making decisions about choice of screening systems in US populations.  No randomized trials or prospective cohort studies relate use of a screening modality over time to outcomes for individual women.  The cost-effectiveness of use of new technologies has only been estimated, not measured directly."

More recently, the U.S. Preventive Services Task Force (USPSTF, 2003) reached the following conclusions regarding cervical cancer screening using automated slide analysis devices: "The USPSTF concludes that the evidence is insufficient to recommend for or against the routine use of new technologies to screen for cervical cancer.  The USPSTF found poor evidence to determine whether new technologies, such as liquid-based cytology, computerized rescreening, and algorithm based screening, are more effective than conventional Pap smear screening in reducing incidence of or mortality from invasive cervical cancer.  Evidence to determine both sensitivity and specificity of new screening technologies is limited.  As a result, the USPSTF concludes that it cannot determine whether the potential benefits of new screening devices relative to conventional Pap tests are sufficient to justify a possible increase in potential harms or costs.

An assessment for the European Cervical Cancer Screening Network's Guidelines for Quality Assurance in Cervical Cancer Screening (Nieminen, 2003) summarized the current evidence for automated cervical cancer slide analysis devices: "There are several articles published concerning the performance of automation assisted screening.  They show generally a better sensitivity with at least same specificity than conventional screening.  Most of these articles have been retrospective (quality control) and/or relatively small numbers of smears have been studied.  However, randomized, prospective public health trials in primary screening setting have been published very few.  The show equal or slightly better performance compared to manual conventional screening …. When implementing the new methods, it is needed to carefully ascertain and evaluate the performance of the method in primary (public health) screening up to the final invasive end points with randomized prospective studies."

An assessment for the National Coordinating Centre for Health Technology Assessment (Willis et al, 2005) concluded: "As in previous health technology assessments on this subject, the conclusion is that the available evidence on test performance, impact on process and cost-effectiveness is still insufficient to recommend implementation of automated image analysis systems.  The priority for action remains further research."

Wain (1997) has commented that "[t]he performance of automated techniques in quality assurance should be assessed against other methods of quality assurance, such as random re-screening of a mandated proportion of smears, directed re-screening of 'high-risk' groups and 'rapid re-screening'."

In its updated guidelines on cervical cancer screening, the American Cancer Society expert review panel (Saslow et al, 2002) only considered screening technologies with sufficient published clinical data, and excluded cervical cancer screening with automated slide analysis devices from its consideration.

HPV Testing

Human papillomavirus (HPV) has been associated with the development of CIN and invasive cancer of the cervix.  Recent prospective studies have shown that abnormal Pap smears that are positive for oncogenic HPV strains are much more likely to be associated with abnormal colposcopic findings than abnormal Pap smears that are HPV negative.  There is no proven value for testing for additional "low-risk" strains of HPV that have not been associated with substantially elevated cancer risk.

HPV testing has been used as an adjunctive reflex test in women with ASCUS to identify those at highest risk for cervical cancer, who should go on to receive definitive colposcopy.  HPV testing of patients with ASCUS can be used to identify patients at highest risk of underlying cervical dysplasia, and minimize the number of unnecessary colposcopic examinations in women who have no disease.  Women with ASCUS who have a positive HPV and no lesions on colposcopy should be followed-up with repeat Pap testing at 6 and 12 months or with HPV testing at 12 months.  Current guidelines do not recommend reflex testing of women with squamous intraepithelial lesions (HSIL, ASC-H, or LSIL).  However, guidelines from the American Society of Colposcopy and Cervical Cytology (Wright et al, 2002; Wright et al, 2007) recommend that women with LSIL or ASC-H with no lesions on colposcopy should be followed-up with repeat Pap testing at 6 and 12 months or with HPV testing at 12 months. 

HPV testing has also been proposed as a primary screening test to be performed simultaneously with Pap smear screening.  Digene Corp. received FDA approval for a test that combines the Pap smear with a genetic exam for 13 oncogenic strains of HPV.  

The ACOG (2009) concluded, based on "good and consistent scientific evidence" that the use of a combination of cervical cytology and HPV DNA screening is appropriate for women aged 30 years and older.  According to ACOG (2009), if this combination is used, women who receive negative results on both tests should be re-screened no more frequently than every 3 years.  ACOG's recommendation was based on the results of studies that demonstrated that women aged 30 years and older who had both negative cervical cytology test results and negative high-risk type HPV-DNA test results were at extremely low-risk of developing CIN 2 or CIN 3 during the next 4 to 6 years.  ACOG guidelines explain that any woman aged 30 years or older who receives negative test results on both cervical cytology screening and HPV DNA testing should be re-screened no more frequently than every 3 years.  The ACOG guidelines state that the combined use of these modalities has been shown to increase sensitivity but also decrease specificity and increase cost.  However, ACOG estimated that the increase in screening interval will offset the cost of this new screening regimen.

The ACOG guidelines (2009) stated that the combination of cytology and HPV DNA screening should be restricted to women aged 30 years and older because transient HPV infections are common in women younger than 30 years, and a positive test result may lead to unnecessary additional evaluation and treatment.  The ACOG guidelines on cervical cancer in adolescents (2010) stated that HPV testing is not recommended at any time in adolescents because of the high prevalence of HPV infection in adolescents and there is little utility in HPV testing in this population; there are no clinical situations, screening, triage, or follow-up that require HPV testing in this population and if conducted, a positive test result should not influence management.  The guidelines stated that there is no role for HPV testing in the patient before HPV vaccination.  Furthermore, the ACOG guidelines (2010) stated that adolescents who have low- to high-grade precancerous lesions (dysplasia) – with the exception of cervical intraepithelial neoplasia 3 (CIN 3) – generally should be managed by periodic observation.  The guidelines stated that re-screening can be delayed until age 21 when the Pap test results show regression of the dysplasia, but annual screening also is an acceptable alternative.

Published studies of cervical cancer screening using a combination of cytology and HPV DNA tests have predominantly employed conventional Pap smears for assessment of cervical cytology.  Although there are no studies directly comparing the screening performance of HPV-cytology combination testing using a conventional Pap versus liquid-based cervical cytology, available indirect evidence suggests that there is no clinically significant difference in the screening performance of HPV-cytology combination testing regardless of whether conventional or liquid-based cervical cytology is used (Lorincz and Richart, 2003).

In April 2014, the FDA modified the labeling of cobas, a currently marketed HPV test, to include the additional indication of primary cervical cancer screening (HPV primary screening). Based on the HPV test’s equivalent or superior effectiveness for primary cervical cancer screening compared with cytology alone in a large U.S.-based study of HPV primary screening, known as the Addressing the Need for Advanced HPV Diagnostics trial, the FDA modified the labeling of the test to include an indication for its use for primary screening in women starting at age 25 years. In 2015, ASCCP and Society of Gynecologic Oncology (SGO) published interim guidance for the use of the cobas FDA-approved HPV test for primary cervical cancer screening (Huh, et al, 2015). The interim guidance panel concluded that because of its equivalent or superior effectiveness, in women 25 years and older, the FDA-approved primary HPV screening test can be considered as an alternative to current cytology-based cervical cancer screening methods. The ASCCP and SGO interim guidance (Huh, et al, 2015) states that the test should not be used in women younger than 25 years; these women should continue to be screened with cytology alone. Rescreening after a negative primary HPV screening result should occur no sooner than every 3 years. Positive test results should be triaged with genotyping for HPV-16 and HPV-18, and if the genotyping test results are negative, with cytology testing. If genotyping and cytology test results are negative, patients should have follow-up testing in 1 year.

ACOG (2016) states that major society guidelines currently recommend HPV testing for cervical cancer screening only for women 30 years of age and older, but indicated that use of the cobas HPV test may be considered in women age 25 years and older: "In women 25 years and older, the FDA-approved primary HPV screening test can be considered as an alternative to current cytology-based cervical cancer screening methods. Cytology alone and cotesting remain the options specifically recommended in current major society guidelines. If screening with primary HPV testing is used, it should be performed as per the ASCCP and SGO interim guidance." Guidelines on cervical cancer screening from the U.S. Preventive Services Task Force are currently under review.

The National Cancer Institute is currently sponsoring a multi-center 5-year clinical trial directed at determining the role of HPV testing in the management of cervical disease.  Interim guidelines for the management of abnormal cytologic findings in the cervix were developed at a work-shop sponsored by the NCI, which concluded that HPV testing can be used as an adjunctive test to help identify patients at low- or high-risk of developing CIN and cancer.  The American Society of Colposcopy and Cervical Pathology has also issued guidelines for the management of ASCUS which incorporated HPV testing and typing to determine which women with ASCUS should undergo colposcopy.

There are no current guidelines recommending HPV testing of men (CDC, 2006; Workowski and Berman, 2006).  There is no FDA-approved HPV test for men, and there are no studies demonstrating benefit of testing men for HPV infection.  Unlike with cervical ASCUS, HPV typing has not been shown to aid in predicting which patients with anal ASCUS are at risk for high-grade anal intraepithelial neoplasia (AIN) (Panther et al, 2003).

Saqi and colleagues (2006) evaluated the potential role of HPV DNA testing on atypical glandular cells (AGC) cases.  Hybrid Capture 2 (Digene Corp.) testing was performed on 144 cervical/endo-cervical AGC specimens.  A total of 103 of 144 cases had follow-up; 60/103 (58.3 %) were high-risk HPV negative and 43/103 (42.3 %) were high-risk HPV positive.  Of 43 HPV-positive patients, 37 had adenocarcinoma in situ (AIS), ASCUS, or cervical squamous intra-epithelial neoplasia, while only 1 patient without high-risk HPV had a squamous intraepithelial neoplasia.  Furthermore, most high-risk HPV positive AGC cases harbored high-grade squamous intra-epithelial lesion rather than AIS.  The authors concluded that their findings support HPV DNA testing of all AGC specimens to detect cervical, especially squamous, neoplasia.

The American Society for Colposcopy and Cervical Pathology (ASCCP)'s guidelines for the management of women with abnormal cervical cancer screening tests (Wright et al, 2007) noted that HPV testing is incorporated into the management of AGC after their initial evaluation with colposcopy and endometrial sampling.  The recommended post-colposcopy management of women with AGC is to repeat cytologic testing combined with HPV DNA testing at 6 months if they are HPV DNA positive and at 12 months if they are HPV DNA negative.  Referral to colposcopy is recommended for women who subsequently test positive for HPV DNA or who are found to have ASCUS or greater on their repeat cytologic tests.  If both tests are negative, women can return to routine cytologic testing.

In a randomized study, Mayrand et al (2007) examined if testing for DNA of oncogenic HPV is superior to the Pap test for cervical cancer screening.  These investigators compared HPV testing, using an assay approved by the FDA, with conventional Pap testing as a screening method to identify high-grade CIN in women aged 30 to 69 years.  Women with abnormal Pap test results or a positive HPV test (at least 1 pg of high-risk HPV DNA per milliliter) underwent colposcopy and biopsy, as did a random sample of women with negative tests.  Sensitivity and specificity estimates were corrected for verification bias.  A total of 10,154 women were randomly assigned to testing.  Both tests were performed on all women in a randomly assigned sequence at the same session.  The sensitivity of HPV testing for CIN of grade 2 or 3 was 94.6 % (95 % CI: 84.2 to 100), whereas the sensitivity of Pap testing was 55.4 % (95 % CI: 33.6 to 77.2; p = 0.01).  The specificity was 94.1 % (95 % CI: 93.4 to 94.8) for HPV testing and 96.8 % (95 % CI: 96.3 to 97.3; p < 0.001) for Pap testing.  Performance was unaffected by the sequence of the tests.  The sensitivity of both tests used together was 100 %, and the specificity was 92.5 %.  Triage procedures for Pap or HPV testing resulted in fewer referrals for colposcopy than did either test alone but were less sensitive.  No adverse events were reported.  The authors concluded that as compared with Pap testing, HPV testing has greater sensitivity for the detection of CIN.

An assessment by the California Technology Assessment Forum (CTAF, 2008) found HPV testing for primary cervical cancer screening did not meet CTAF criteria.  The CTAF assessment found that, although incorporation of HPV screening can lead to earlier detection of carcinoma in situ lesions, whether or not this will result in reduced cervical cancer incidence and mortality is not known.  The CTAF assessment noted, in addition, that the 2 trials that have published long term follow-up used a PCR test that is not currently available in the United States.  The CTAF assessment concluded that the evidence is insufficient to recommend for or against the incorporation of HPV testing into cervical cancer screening programs.

Thus, whether HPV testing can replace conventional Pap cytologic testing for cervical cancer screening awaits results from randomized controlled trials and/or recommendations from leading national medical organizations.

Sankaranarayanan and colleagues (2009) began to measure the effect of a single round of screening by testing for HPV, cytologic testing, or visual inspection of the cervix with acetic acid (VIA) on the incidence of cervical cancer and the associated rates of death in the Osmanabad district in India.  In this cluster-randomized trial, 52 clusters of villages, with a total of 131,746 healthy women between the ages of 30 and 59 years, were randomly assigned to 4 groups of 13 clusters each.  The groups were randomly assigned to undergo screening by HPV testing (n = 34,126), cytologic testing (n = 32,058), or VIA (n = 34,074) or to receive standard care (n = 31,488, control group).  Women who had positive results on screening underwent colposcopy and directed biopsies, and those with cervical pre-cancerous lesions or cancer received appropriate treatment.  In the HPV-testing group, cervical cancer was diagnosed in 127 subjects (of whom 39 had stage II or higher), as compared with 118 subjects (of whom 82 had advanced disease) in the control group (hazard ratio for the detection of advanced cancer in the HPV-testing group, 0.47; 95 % CI: 0.32 to 0.69).  There were 34 deaths from cancer in the HPV-testing group, as compared with 64 in the control group (hazard ratio, 0.52; 95 % CI: 0.33 to 0.83).  No significant reductions in the numbers of advanced cancers or deaths were observed in the cytologic-testing group or in the VIA group, as compared with the control group.  Mild adverse events were reported in 0.1 % of screened women.  The authors concluded that in a low-resource setting, a single round of HPV testing was associated with a significant reduction in the numbers of advanced cervical cancers and deaths from cervical cancer.

In an editorial that accompanied the afore-mentioned article, Schiffman and Wacholder (2009) stated that "[i]n developed nations, HPV testing at extended screening intervals could eventually replace repeated cytologic testing as the primary screening method.  Cytologic testing might be used to stratify risk further by identifying HPV-positive women at highest risk for cancer.  In these countries, a widespread transition from a good method (frequent cytologic testing) to a better one (less frequent HPV screening) will require high-quality testing that is widely available and properly priced, the establishment of correct screening intervals and related health messages, and the promulgation of clinical guidelines and reimbursement policies to avoid overtreatment of benign infections".  Schiffman and Wacholder also noted that, "[i]n the United States, switching to primary HPV screening will be contentious, partly because lengthening the interval between cervical screenings seriously disrupts established gynecologic clinical practice".

Davis (2009) stated that "[i]n showing that a single round of HPV screening (compared with cytologic or VIA screening) had the most marked effect on preventing cervical cancer deaths, these results have tremendous international health implications: Single rounds of HPV screening are much easier to implement than repetitive cytologic screening, particularly in resource-poor countries where cervical cancer is relatively common.  Nonetheless, we should not rush to apply such findings to populations with optimal resources.  Clinicians in the U.S. should continue to screen as recommended by the American Society for Colposcopy and Cervical Pathology".

Cervicography and Speculoscopy

Cervicography is a procedure in which the cervix is swabbed with an acetic acid solution to identify acetowhite changes in the cervix.  With cervicography, a photograph of the cervix is taken with a special camera (Cerviscope), and is sent to trained technicians for evaluation (National Testing Laboratories, St. Louis, MO).  The technicians determine whether the visual image is most compatible with normal, atypia/metaplasia, intraepithelial neoplasia, or cancer.  In contrast, speculoscopy (PapSure) uses a chemiluminescent light to aid naked-eye or minimally magnified visualization of acetowhite changes on the cervix.  Both cervicography and speculoscopy have been used as an adjunct to Pap smear for cervical cancer screening and as a triage method to identify which patients with low grade atypical Pap smears need further evaluation by colposcopy and biopsy.  According to practice guidelines from the ASCCP, "there have been insufficient large scale controlled studies related to their use in the triage of LGISL [low grade squamous intraepithelial lesion] to recommend either for or against their use" (Cox et al, 2000).  An International Academy of Cytology (IAC) Task Force (van Niekerk et al, 1998) concluded that "[t]he role of cervicography, or high resolution photography, as a screening device remains to be defined."  The IAC Task Force also noted that "[t]here are, at present, insufficient data for the evaluation of speculoscopy…."  The U.S. Preventive Services Task Force (1996) concluded that "[t]here is insufficient evidence to recommend for or against routine screening with cervicography … although recommendations against such screening can be made on other grounds."

Video Colpography

Video colpography (video colposcopy) has been used for imaging the vagina and cervix, and has been proposed for use as a method of cervical cancer screening.  In this procedure, a video camera is used to create computerized digital images of the cervix, vaginal fornices and endocervical canal; the system may be interfaced with a computer for image manipulation.  The images are evaluated by a video screener for signs of cervical cancer.  Etherington et al (1997) stated that video colpography has potential advantages as a portable and rapid method of cervical imaging.  The investigators stated that video colpography has potential of use in fields of teaching, audit and screening of women with low-grade smear abnormalities.  Etherington et al (1997) compared video colpography with colposcopy in a pilot study involving 50 women referred for colposcopy.  The investigators reported that the video colpography images were satisfactory or good in 47 (94 %) cases, and there was agreement between colposcopist and video screener in 86 % of cases.  The investigators stated that, if the technique had been used in a primary health care setting as a secondary screening method for women with low-grade cervical smear abnormalities, 61 % would have avoided referral for colposcopy.  The investigators concluded that "before the technique can be implemented as part of the screening process, it needs to be evaluated in a larger series …"  Other publications have described the technical performance of video colposcopy (e.g., Milbourne et al, 2005) and the use of video colposcopy as a research tool (Brown et al, 2005), as an educational tool (e.g., Walsh et al, 2004), in forensic investigations (e.g., Mears et al, 2003), and in colposcopy quality assurance protocols (e.g., Ferris et al, 2004).  Regarding use of video colposcopy in quality assurance, Ferris et al concluded that "[c]olposcopy quality control by review of digitized colposcopic images in clinical trials warrants further evaluation if the accuracy can be improved."

Spectroscopy / Optical / Optoelectronic Detection Systems

The Luma cervical imaging system (MediSpectra, Inc., Lexington, MA) is an optical detection system approved by the FDA in March, 2006 as an adjunct to colposcopy to identify areas of the cervix with the highest likelihood of high-grade CIN on biopsy.  The Luma system shines a light on the cervix and analyzes how different areas of the cervix respond to the light.  The system produces a color map that distinguishes between healthy and potentially diseased tissue to indicate where biopsy samples should be taken.

In a pilot study, Huh and colleagues (2004) investigated the in-vivo optical detection of high-grade CIN.  Cervical scanning devices collected intrinsic fluorescence and broadband white light spectra and video images from 604 women during routine colposcopy examinations.  A statistically significant dataset was developed of intrinsic fluorescence and white light-induced cervical tissue spectra that was correlated to histopathologic determination.  On the basis of a retrospective analysis of the acquired data, a classification algorithm was developed, validated, and optimized.  Intrinsic fluorescence, back-scattered white light, and video imaging each contributed complementary information to diagnostic algorithms for high-grade cervical neoplasia.  Over 10,000 measurements were made on colposcopically identified tissue from more than 500 subjects and were the basis for algorithm training and testing.  Algorithm performance demonstrated a sensitivity of approximately 90 %.  This performance was confirmed by various training methods.  With the use of a multi-variate classification algorithm, optical detection is predicted to detect 33 % more high-grade CIN (2/3+) than colposcopy alone.  The authors concluded that full cervix optical interrogation for the detection of high-grade CIN is feasible and appears capable of detecting more high-grade CIN than colposcopy alone. 

A multi-center controlled trial (Alvarez et al, 2007) evaluated the performance of the Luma system as an adjunct to colposcopy among women (n = 193) referred for the evaluation of an abnormal cervical cytology result.  Initial colposcopy identified 41 cases of CIN 2+ for a true positive (TP) rate of 21.2 %.  Adjunctive use of the Luma system identified an additional 9 cases of CIN 2+ which corresponds to an incremental optical detection TP rate of 4.7 % (95 % CI: 2.2 % to 8.7 %).  Adjunctive use of the Luma system resulted in a 22.0 % (95 % CI: 6.1 % to 37.8 %) relative gain in the number of women with CIN 2+ compared to colposcopy alone.  The false-positive (FP) rate for initial colposcopy was 51.8 % (100 of 193 women).  An additional 35 subjects had a Luma system-directed biopsy that was not diagnosed as CIN 2+, yielding an incremental FP rate of 18.1 % (95 % CI: 13.0 % to 24.3 %).  The authors concluded that the adjunctive use of the Luma system with colposcopy provided a significant increase in the detection of CIN 2+ in women referred for the evaluation of abnormal cytology results. 

There is insufficient evidence of the effectiveness of an optical detection system as an adjunct to colposcopy for in vivo identification and localization of cervical intraepithelial for cervical cancer screening or diagnosis.  Furthermore, there are no recommendations or guidelines for its use from any professional medical society.  Post-approval studies are currently underway to further assess the long-term efficacy of the Luma system.

A spectroscopy system may be referred to as an optical detection system.  Spectroscopy emits light from a probe onto the cervix, allowing the examiner to objectively categorize tissues as either normal or diseased.  Spectroscopy is based on the principle that epithelial tissues that are abnormal have different optical properties than normal tissues and that these optical differences can be used to determine whether a tissue is normal or abnormal.  Devices that are currently under various stages of research and development for diagnostic purposes use various approaches, including: fluorescence spectroscopy, image analysis of visible images, infrared spectroscopy, Raman spectroscopy, white light elastic backscatter spectroscopy, or combinations of the different methods (Wright et al, 2002).

Wright et al (2002) stated that visual screening techniques include both low-technology approaches, such as direct visual inspection (DVI), and high-technology approaches, such as those that utilize electro-optical detectors to identify cervical cancer precursors and invasive cervical cancer.  Simple visual screening techniques, such as DVI, consist of washing the cervix with a solution of 5 % acetic acid (e.g., vinegar) and then inspecting it using either the naked eye or with a low-power magnifying device to identify areas of aceto-whitening, which frequently correspond to cervical squamous intraepithelial lesions (SILs).  The simple visual screening methods are being evaluated as an alternative to cytology in low-resource settings where screening using cervical cytology is not feasible.  Multiple studies have shown DVI to have sensitivity similar to that of cervical cytology for identifying women with high-grade SIL but much lower specificity.  The novel high-technology visual screening methods that utilize electro-optical sensors to identify cervical abnormalities are still in the developmental phases but offer considerable potential.

In a prospective observational study, Brown et al (2005) compared cervical impedance spectroscopy n the cervical epithelium of women with CIN and normal epithelium.  A total of 87 women referred to colposcopy with a moderate or severely dyskaryotic smear were included in this study.  A pencil probe incorporating 4 gold electrodes was used to measure an electrical impedance spectrum from cervical epithelium.  Colposcopy examinations, including probe positioning, were recorded by video to allow for correlation between results obtained from colposcopic impression, histopathological examination of colposcopically directed punch biopsies and the impedance measurements.  Cervical impedance derived parameters R, S and C were assessed to see if there was a significant difference in values obtained in CIN and normal squamous epithelium.  Analysis was based upon matching the electrical components measured to those identified by cellular modeling as being most sensitive for pre-malignancy.  From normal epithelium through CIN 1 to CIN 2/3, R decreased by a factor of 4.5, S increased by a factor of 2.5, but C remained unchanged.  The authors concluded that cervical impedance spectroscopy provided a potentially promising screening tool with similar sensitivity and specificity to currently used screening tests, but with the potential advantage of providing instant results.  Moreover, they stated that further work is currently being undertaken to improve the probe in its clinical use.

In a prospective, comparative, multi-center clinical study, Tidy et al (2013) examined if electrical impedance spectroscopy (EIS) improves the diagnostic accuracy of colposcopy when used as an adjunct.  In phase-1, EIS was assessed against colposcopic impression and histopathology of the biopsies taken.  In phase-2, a probability index and cut-off value for the detection of high-grade cervical intraepithelial neoplasia (HG-CIN, i.e., grade CIN2+) was derived to indicate sites for biopsy.  Electrical impedance spectroscopy data collection and analyses were performed in real time and blinded to the clinician.  The phase-2 data were analyzed using different cut-off values to assess performance of EIS as an adjunct.  Main outcome measure was histologically confirmed HG-CIN (CIN2+).  A total of 474 women were recruited: 214 were eligible for analysis in phase-1, and 215 were eligible in phase-2.  The average age was 33.2 years (median age of 30.3 years, range of 20 to 64 years) and 48.5 % (208/429) had high-grade cytology.  Using the cut-off from phase-1 the accuracy of colposcopic impression to detect HG-CIN when using EIS as an adjunct at the time of examination improved the PPV from 78.1 % (95 % CI: 67.5 to 86.4) to 91.5 %.  Specificity was also increased from 83.5 % (95 % CI: 75.2 to 89.9) to 95.4 %, but sensitivity was significantly reduced from 73.6 % (95 % CI: 63.0 to 82.5) to 62.1 %, and the negative predictive value (NPV) was unchanged.  The positive likelihood ratio for colposcopic impression alone was 4.46.  This increased to 13.5 when EIS was used as an adjunct.  The overall accuracy of colposcopy when used with EIS as an adjunct was assessed by varying the cut-off applied to a combined test index.  Using a cut-off set to give the same sensitivity as colposcopy in phase-2, EIS increased the PPV to detect HG-CIN from 53.5 % (95 % CI: 45.0 to 61.8) to 67 %, and specificity increased from 38.5 % (95 %: CI 29.4 to 48.3) to 65.1 %.  Negative predictive value was not significantly increased.  Alternatively, applying a cut-off to give the same specificity as colposcopy alone increased EIS sensitivity from 88.5 % (95 % CI: 79.9 to 94.4) to 96.6 %, and NPV from 80.8 % (95 % CI: 67.5 to 90.4) to 93.3 %. Positive predictive value was not significantly increased.  The receiver operator characteristic (ROC) to detect HG-CIN had an area under the curve (AUC) of 0.887 (95 % CI: 0.840 to 0.934).  The authors concluded that EIS used as an adjunct to colposcopy improves colposcopic performance; and the addition of EIS could lead to more appropriate patient management with lower intervention rates.

An UpToDate review on “Cervical cancer screening tests: Evidence of effectiveness” (Sirovich et al, 2014) does not mention the use of spectroscopy/optical detection system as a screening tool.  Furthermore, the National Comprehensive Cancer Network’s clinical practice guideline on “Cervical cancer” (Version 1.2014) does not mention spectroscopy/optical detection systems as screening tools.

In a systematic review and meta-analysis, Yang and colleagues (2018) examined the diagnostic accuracy of a real-time optoelectronic device (TruScreen) for uterine cervical cancer screening.  On the basis of Preferred Reporting Items for Systematic Reviews and Meta-analyses (the PRISMA statement), these researchers searched PubMed, Embase, the Cochrane Library, CNKI, CBM, and WanFang Data using medical subject headings (MeSH) and text words.  Title/abstract screening, full text check, data extraction, and methodological quality assessment (with the QUADAS-2 tool) were performed by 2 reviewers independently.  The pooled sensitivity, specificity, positive likelihood ratio (PLR), negative likelihood ratio (NLR), diagnostic odds ratio (DOR), the summary receiver operator characteristic curve, and the area under the curve (AUC) were analyzed with Meta-DiSc software.  Statistical heterogeneity was evaluated by Cochran's Q test and I, meta-regression was conducted based on patient type, and the possibility of publication bias was evaluated using Deeks funnel plot in Stata software.  Of 293 publications, 9 met inclusion criteria.  These studies included a total of 2,730 patients and 567 cervical intra-epithelial neoplasia.  The pooled test characteristics for the TruScreen were as follows: sensitivity 76 % (95 % CI: 73 % to 80 %), specificity 69 % (95 % CI: 67 % to 71 %), PLR 2.30 (95 % CI: 1.59 to 3.33), and NLR 0.34 (95 % CI: 0.23 to 0.51).  The corresponding pooled DOR was 7.03 (95 % CI: 3.40 to 14.55).  The AUC was 0.7859 (Q = 0.7236).  The authors concluded that the diagnostic value of this real-time optoelectronic device was moderate at best.  These researchers noted that given that the number of included studies in the meta-analysis was relatively small and all studies were conducted in China, the findings of this study could not be generalized to other populations and should be interpreted with caution.

The authors stated that the findings of this meta-analysis should be interpreted in light of the following limitations.  First, these investigators only included 9 studies, all of which were conducted in China.  Second, due to the limited number of patients, these researchers did not analyze the performance of the TruScreen device for detection of cervical intraepithelial neoplasia (CIN) II or higher.  Third, these researchers did not include “gray” literature, unpublished studies, or research abstracts from meeting proceedings.  Such studies were not commonly subjected to peer-review and they provided limited data.  However, by choosing to eliminate these studies, the authors might have over-looked potentially relevant studies.  Fourth, data from the 9 studies were collected in advanced areas and hospitals where there were well-trained medical doctors.  If the study were conducted in remote mountain/village areas by a part-time medical assistant, the conclusions may have been different.  Furthermore, these investigators stated that in the process of carrying out the meta-analysis, they found that some studies only performed the gold standard test on patients with a positive cervical cytology result or a positive index test result.  This may have led to partial verification bias or work-up bias; future researchers should remain alert to this kind of bias.

Furthermore, National Comprehensive Cancer Network’s clinical practice guideline on “Cervical cancer” (Version 3.2019) does not mention the use of an optoelectronic device as a screening tool.

In summary, as a consequence of the lack of well-designed studies, there is insufficient evidence to support the use of spectroscopy/optical/optoelectronic detection systems as a primary stand-alone or as an adjunct to standard screening techniques for the detection of cervical cancer.

Resolve™

Colposcopy is a diagnostic procedure in which a colposcope is used to provide an illuminated, magnified view of the cervix, vagina, and vulva to detect malignant and pre-malignant epithelium.  Malignant and pre-malignant epithelium have specific macroscopic characteristics relating to contour, color, and vascular pattern that can be identified by the colposcopist for directed biopsy.  Colposcopy is the "gold standard" diagnostic tool in the U.S. for diagnosing cervical dysplasia following abnormal cytology.

The Resolve laboratory testing kit (Gynecor, Glen Allen, VA) is a new colposcopic method that obtains endocervical samples using cytobrushes.  The kit contains 2 cytobrushes and 2 vials of fixative.  The first cytobrush is used to clear mucus from the cervix and the second cytobrush is used to abrade cells from the endocervix.  The fixative enables both cytology and histology to be run on both vials.  HPV is also tested from the same specimen.  If HPV is detected, genotyping by PCR is also reported.

There is insufficient evidence of the effectiveness of the Resolve laboratory testing kit for cervical cancer screening or diagnosis.  How this method compares with conventional colposcopy and cytology using quantified values of sensitivity and specificity awaits results from randomized controlled trials and/or recommendations from leading national medical organizations.

Methylation Markers

Studies of cervical cancer and its immediate precursor, cervical intra-epithelial neoplasia 3, have identified genes that often show aberrant DNA methylation and thus represent candidate early detection markers.  Wentzensen et al (2009) identified the most promising methylation marker candidates for cervical cancer early detection.  A systematic literature review was performed in Medline and weighted average frequencies for methylated genes stratified by tissue source and methods used were computed.  A total of 51 studies were identified analyzing 68 different genes for methylation in 4,376 specimens across all stages of cervical carcinogenesis.  A total of 15 genes (DAPK1, RASSF1, CDH1, CDKN2A, MGMT, RARB, APC, FHIT, MLH1, TIMP3, GSTP1, CADM1, CDH13, HIC1, and TERT) have been analyzed in 5 or more studies.  The published data on these genes is highly heterogeneous; 7 genes (CDH1, FHIT, TERT, CDH13, MGMT, TIMP3, and HIC1) had a reported range of methylation frequencies in cervical cancers of greater than 60 % between studies.  Stratification by analysis method did not resolve the heterogeneity.  Three markers (DAPK1, CADM1, and RARB) showed elevated methylation in cervical cancers consistently across studies.  The authors concluded that there is currently no methylation marker that can be readily translated for use in cervical cancer screening or triage settings.  They stated that large, well-conducted methylation profiling studies of cervical carcinogenesis could yield new candidates that are more specific for HPV-related carcinogenesis.  New candidate markers need to be thoroughly validated in highly standardized assays.

The Ikonisys oncoFISH Cervical Test

According to Ikonisys Clinical Laboratories, the oncoFISH^® cervical test is a qualitative fluorescence in-situ hybridization (FISH) test for determining the acquisition of specific chromosomal aneuploidies within the 3q26 region in cytological specimens revealing LSIL.  Until now, routine testing for 3q gain was not feasible because assessment required analysis of a large number of stained, squamous cell nuclei – impractical for manual methods.  By using the Ikoniscope Digital Microscopy System to automate analysis, the oncoFISH cervical test makes testing for 3q gain a practical reality.  The test is performed on cervico-vaginal cytology specimens, identical to those used for Pap and HPV testing.  It evaluates amplification of the 3q26 region by use of 2 FISH probes, one for the 3q26 locus and a control probe.  Enumeration and comparison of the 3q26 and control probes, in conjunction with the nuclear morphology, result in a 3q copy number for each of the nuclei analyzed.  Results of the oncoFISH cervical test are intended for use with other clinical findings for further evaluation and monitoring of cervical dysplasia in women with LSIL Pap results.  The oncoFISH cervical test is a laboratory developed test and is intended to supplement, and not replace or alter the current standards of practice used for the clinical management of women undergoing evaluation for cervical dysplastic lesions.  The oncoFISH cervical test results should be considered by the clinician in the context of other testing when formulating clinical management.

Caraway et al (2008) noted that chromosomal aberrations have been documented in cervical carcinomas, especially chromosome 3q.  The human telomerase RNA gene (hTERC) is located in the chromosome 3q26 region, and its product, telomerase, is involved in the maintenance of chromosome length and stability.  Up-regulation of telomerase is in general associated with tumorigenesis.  In this study, cervico-vaginal specimens were analyzed by FISH for gain of chromosome 3q26 containing hTERC, and FISH findings were compared with the cytologic and histologic diagnoses.  Slides prepared from 66 liquid-based preparations from cervical specimens with cytologic diagnoses of negative for SIL or malignancy (NILM, n = 4), atypical squamous cells of undetermined significance (ASC-US, n = 15), LSIL (n = 20), HSIL (n = 24), or cervical squamous cell carcinoma (SCCA, n = 3) were analyzed for aberrations of 3q26 using a commercially available 2-color FISH probe.  The results of the cytologic analysis and those of concurrent or subsequent biopsies, when available, were compared with the FISH-detected 3q26 abnormalities.  The Wilcoxon rank-sum test was used to assess associations between 3q26 gains and diagnoses.  Gain of 3q26 was significantly associated with the cytologic diagnosis (p < 0.0001).  Patients with HSIL or SCCA cytology diagnoses had significantly higher percentages of cells with 3q26 gain than did patients with NILM or ASC-US cytologic diagnoses.  The authors concluded that FISH can be performed on cervico-vaginal liquid-based preparations to detect gain of 3q26; gain of 3q26 is associated with HSIL and SCCA.  They stated that this test may be an adjunct to cytology screening, especially high-risk patients.  This study did not have enough correlative data to be useful.

Seppo et al (2009) evaluated an automated FISH assay for detection of 3q gain in liquid cytology samples as a potential tool for risk stratification and triaging.  Slides prepared from 257 liquid cytology specimens (97 negative, 135 LSIL and 25 HSIL) were hybridized with a single-copy probe for the chromosome 3q26 region and a probe for the centromeric alpha-repeat sequence of chromosome 7, using standard FISH methods.  Using automated analysis, the total number of nuclei and the number of nuclei with greater than 2 signals for 3q26 were determined, using a 20x objective.  The nuclei were rank ordered based on number of 3q26 FISH signals.  The 800 nuclei with the highest number of signals were scored using both FISH probes and nuclei with increased numbers of 3q signals were enumerated.  Analysis of 257 specimens demonstrated that a fully automated FISH scoring system can detect 3q gain in liquid cytology samples.  The authors concluded that a fully automated method for determination of 3q gain in liquid cytology may be the assay necessary to implement routine testing; and they stated that additional studies to validate the utility of this technology are needed.

Policht et al (2010) evaluated 35 genomic regions associated with cervical disease and selected those which were found to have the highest frequency of aberration for use as probes in FISH.  The frequency of gains and losses using FISH were assessed in these 35 regions on 30 paraffin-embedded cervical biopsy specimens.  Based on this assessment, 6 candidate fluorescently labeled probes (8q24, Xp22, 20q13, 3p14, 3q26, CEP15) were selected for additional testing on a set of 106 cervical biopsy specimens diagnosed as normal, CIN1, CIN2, CIN3, and SCC.  The data were analyzed on the basis of signal mean, % change of signal mean between histological categories, and % positivity.  The study revealed that the chromosomal regions with the highest frequency of copy number gains and highest combined sensitivity and specificity in high-grade cervical disease were 8q24 and 3q26.  The cytological application of these 2 probes was then evaluated on 118 ThinPrep samples diagnosed as normal, ASCUS, LSIL, HSIL and cancer to determine utility as a tool for less invasive screening.  Using gains of either 8q24 or 3q26 as a positivity criterion yielded specificity (normal + LSIL + ASCUS) of 81.0 % and sensitivity (HSIL + cancer) of 92.3 % based on a threshold of 4 positive cells.  The authors concluded that the application of a FISH assay comprised of chromosomal probes 8q24 and 3q26 to cervical cytology specimens confirmed the positive correlation between increasing dysplasia and copy gains and showed promise as a marker in cervical disease progression.

Verri and colleagues (2011) stated that studies have demonstrated a correlation between the gain in 3q26 copy number and the severity and stage of cervical disease progression.  A recent study has examined the potential of using a measure of 3q26 gain as a predictor of regression, persistence, or progression of LSIL of the cervix.  The case described in this report documented a marked progression in both the severity and extent of this patient's lesion from atypical squamous cells on cytology to biopsy established CIN2-CIN3 over the span of 1 year.  The initial gain of at least 5 copies of 3q26 in only 3 nuclei in this patient's first cervical smear may be an indication of the significance and sensitivity of this degree of gain, even in a small number of cells at a low level of disease, and may suggest the potential of predicting the progression of the lesion.  The subsequent gain of at least 5 copies of 3q26 1 year later in the very large number of 264 nuclei may reflect both the severity and extent of disease progression.  Nevertheless, since it is not possible to exclude the possibility that a high-grade CIN already existed at the time of the initial cytology, the presence of the 3q26 gain, even in a small number of cells, may also serve as an indicator of the possible presence of a high-grade lesion in those cervical specimens in which a definitive cytological diagnosis is not or cannot be made.  The authors concluded that this case report supported the findings of other investigators on the potential utility of using 3q26 gain in predicting, at an early stage, the progression or non-progression of low-grade pre-neoplastic lesions of the cervix.

Rodolakis and associates (2012) examined if 3q26 gain can predict which LSILs and ASC-USs will progress to HSIL.  Liquid cytology specimens of LSIL and ASC-US from 73 women were examined using FISH for the detection of 3q26 gain.  All women underwent colposcopy and biopsy at the initial visit and 40 of them with histology showing CIN 1 or HPV infection (koilocytosis) were included in the study.  They were re-evaluated with liquid cytology, colposcopy, and biopsy after a median follow-up of 17.5 months.  A total of 40 cases were analyzed (31 LSILs and 9 ASCUSs).  Of these cases, 8 (20 %; 6 LSILs and 2 ASCUSs) were positive and 32 (80 %) were negative for 3q26 gain according to FISH.  Three of the 8 positive women (38 %) progressed to HSIL/CIN 2 or worse, whereas none of the 32 negative women did so.  3q26 gain could predict progression with a negative-predictive value of 100 % (95 % confidence interval: 89.1 % to 100 %).  In addition, women positive for 3q26 gain had a significantly lower regression rate compared with negative women (p = 0.009).  The authors concluded that in this first prospective study, 3q26 gain in LSIL/ASCUS cytology exhibited an impressive negative predictive value for progression to HSIL/CIN 2 or worse.  They stated that 3q26 gain may be useful in stratifying patients' risk for progression and possibly alter management and reduce cost of follow-up.

Currently, there is insufficient evidence regarding the clinical value of the oncoFISH cervical test.  Furthermore, there are no guidelines from leading medical professional organizations or public health agencies that recommend FISH measurement of 3q26 in cervical cancer screening.

Fluorescence In-Situ Hybridization (FISH) Testing

Earley et al (2014) examined the diagnostic performance of fluorescence in-situ hybridization (FISH) tests on cervical cytology for precancerous lesions or cancer on cervical histology.  These researchers performed a search in MEDLINE, the Cochrane Central Register of Controlled Trials, and Scopus through September 3, 2013.  A total of 11 studies examined FISH tests for telomerase RNA component gene (TERC), myelocytomatosis oncogene (MYC), or HPV type 16 or 18 in samples exhibiting ASC-US or LSIL.  None examined HPV-positive, cytologically normal samples.  These investigators extracted data on the sensitivity and specificity for high-grade cervical intraepithelial neoplasia (CIN 2+ or CIN 3+).  Fluorescence in-situ hybridization test probes and thresholds varied across studies.  Included populations were convenience samples.  Only 1 study testing for TERC specified HPV status.  In meta-analysis, FISH for TERC in LSIL (9 studies, 1,082 cases) had a summary sensitivity of 0.76 (95 % CI: 0.63 to 0.85) and a summary specificity of 0.78 (95 % CI: 0.57 to 0.91) for CIN 2+.  Fluorescence in-situ hybridization for TERC in ASC-US (3 studies, 839 cases) showed sensitivities ranging from 0.75 to 1.00 and specificities from 0.87 to 0.93 for CIN 2+.  For CIN 3+, sensitivity and specificity appeared similar, although a small number of studies preclude firm conclusions.  For FISH tests for HPV, these researchers found only few studies with small sample sizes.  The authors concluded that the evidence on FISH testing is limited given the small number of studies for each cytology subgroup and the lack of studies in well-defined screening contexts stratifying participants by HPV status.

An AHRQ assessment on fluorescent in situ hybridization or other in situ hybridization of uterine cervical cells to predict precancer and cancer (Uhlig, et al, 2013) concluded: “Overall, the evidence of the analytic and clinical validity of ISH tests in screening for cervical cancer was limited. Further research is needed to standardize techniques, compare clinical validity, thresholds, and combinations across different ISH tests, and compare the clinical utility of combinations of probes as add-on tests to HPV and cytology tests.”

Furthermore, an UpToDate review on “Invasive cervical cancer: Epidemiology, risk factors, clinical manifestations, and diagnosis” (Frumovitz, 2015) and National Comprehensive Cancer Network’s clinical practice guideline on “Cervical cancer” (Version 2.2015) do not mention fluorescence in-situ hybridization/FISH as a diagnostic tool. 

p16/Ki-67 Dual Staining for Triaging High Risk HPV Strains

Ravarino and colleagues (2012) noted that cytologic findings of glandular lesions of the cervix uteri are often difficult to evaluate.  These researchers examined the usefulness of CINtec PLUS p16/Ki-67 double-stain (mtm laboratories, Heidelberg, Germany) for the diagnosis of glandular lesions.  The study included 47 abnormal results on liquid-based cytologic tests with a subsequent histologic diagnosis of adenocarcinoma in-situ or with early invasion, and 16 samples with negative results on follow-up.  All samples were stained with CINtec PLUS p16/Ki-67 double-stain.  Of the neoplastic samples, 7 were excluded because of insufficient residual cellularity or loss of neoplastic cells.  Of the samples that were adequate, 92.5 % were stained with CINtec PLUS, whereas 7.5 % were judged inconclusive.  All inconclusive cases were at least 3 years old.  Of the 16 negative samples, 15 (93.8 %) stained negative and only 1 (6.2 %) showed several positive clusters of cells.  The authors concluded that the findings of this study showed that CINtec PLUS immunocytochemistry may be a useful tool for the diagnosis of glandular lesions of the cervix uteri and may reduce the risk of false negatives as well as the number of uncertain borderline reports.  Moreover, these researchers stated that the interpretation of the immuno-stains, however, may differ slightly between squamous and glandular lesions and always needs to take into account the morphology of the stained cells.

The authors stated that this study showed that CINtec PLUS immunocytochemistry may be useful also for the cytologic diagnosis of glandular lesions of the cervix uteri.  Among neoplastic samples, 92.5 % expressed CINtec PLUS, whereas 93.8 % of the negative samples did not.  The few cases that were judged inconclusive were older samples that had been conserved for more than 2 years at room temperature.  In fact this, as well as the poor cellularity of some samples that had been used in previous studies, was a limitation of this study.  In some cases, only a few small residual neoplastic sheets were present and therefore more difficult to evaluate.

Chen and colleagues (2016) reviewed studies investigating the diagnostic performance of p16/Ki-67 dual stain for triage of women with abnormal Pap tests.  They conducted a systematic review and meta-analysis of diagnostic test accuracy studies.  These researchers followed the protocol of systematic review of diagnostic accuracy studies.  They searched PubMed, The Cochrane Library, BioMed Central, and ClinicalTrials.gov for relevant studies, and included research that assessed the accuracy of p16/Ki-67 dual stain and high-risk HPV testing for triage of abnormal Pap smears.  Review articles and studies that provided insufficient data to construct 2.2 tables were excluded.  Data synthesis was conducted using a random-effects model.  Main outcome measures were sensitivity and specificity.  In 7 studies encompassing 2,628 patients, the pooled sensitivity and specificity of p16/Ki-67 for triage of abnormal Pap smear results were 0.91 (95 % CI: 0.89 to 0.93) and 0.64 (95 % CI: 0.62 to 0.66), respectively.  No study used a case-control design.  A subgroup analysis involving liquid-based cytology showed a sensitivity of 0.91 (95 % CI: 0.89 to 0.93) and specificity of 0.64 (95 % CI: 0.61 to 0.66).  The authors concluded that this meta-analysis of p16/Ki-67 dual stain studies showed that the test achieved high sensitivity and moderate specificity for p16/Ki-67 immunocytochemistry for high-grade squamous intraepithelial lesion and cervical cancer.  They suggested that p16/Ki-67 dual stain might be a reliable ancillary method identifying high-grade squamous intraepithelial lesions in women with abnormal Pap tests.  The authors stated that a major drawback of this study was that no study in the meta-analysis examined the accuracy of the p16/Ki-67 dual stain for interpretation of glandular neoplasms.

Wright et al (2017) assessed the performance of p16/Ki-67 dual-stained cytology for triaging HPV-positive women undergoing primary HPV screening.  All women greater than or equal to 25years with valid cervical biopsy and cobas HPV Test results from the cross-sectional phase of ATHENA who were referred to colposcopy (n = 7,727) were eligible for enrolment.  p16/Ki-67 dual-stained cytology was retrospectively performed on residual cytologic material collected into a 2nd liquid-based cytology vial during the ATHENA enrolment visit.  The diagnostic performance of dual-stained cytology, with or without HPV16/18 genotyping, for the detection of biopsy-confirmed cervical intraepithelial neoplasia grade 3 or worse (CIN3+) was determined and compared to Pap cytology.  Furthermore, the number of colposcopies required per CIN3+ detected was determined.  The investigators found that dual-stained cytology was significantly more sensitive than Pap cytology (74.9 % versus 51.9 %; p < 0.0001) for triaging HPV-positive women, whereas specificity was comparable (74.1 % versus 75.0 %; p = 0.3198).  Referral of all HPV16/18 positive women combined with dual-stained cytology triage of women positive for 12 "other" HPV genotypes provided the highest sensitivity for CIN3+ (86.8 %; 95 % CI: 81.9 to 90.8).  A similar strategy but using Pap cytology for the triage of women positive for 12 "other" HPV genotypes was less sensitive (78.2 %; 95 % CI: 72.5 to 83.2; p = 0.0003), but required a similar number of colposcopies per CIN3+ detected.  The investigators concluded that 16/Ki-67 dual-stained cytology, either alone or combined with HPV16/18 genotyping, represents a promising approach as a sensitive and efficient triage for colposcopy of HPV-positive women when primary HPV screening is utilized.

Consensus Recommendations from the College of American Pathologists and the American Society for Colposcopy and Cervical Pathology (Darragh et al, 2012) stated: "On the basis of final literature review and data extractions, we concluded that only p16, a biomarker that is recognized in the context of HPV biology to reflect the activation of E6/E7–driven cell proliferation, had sufficient evidence on which to make recommendations regarding use in LAT squamous lesions. ProEx C and Ki-67 (Mib1) had similar trending data, but the literature was insufficient to make an independent recommendation for use, alone or in combination. Individual institutions might opt to use these other markers in cases with equivocal p16 IHC staining or as an adjunct, given that both have cleaner nuclear staining. However, the accumulated evidence was insufficient to make an independent recommendation for use of any additional biomarker, alone or in combination."

More recent guidelines from the French National Heath Authority (HAS, 2019) concluded: "In view of the available data, the use of p16/Ki67 dual immunostaining for primary screening or as a triage test following a positive HPV test is not recommended.

An UpToDate review on “Screening for cervical cancer” (Feldman et al, 2017 ) does not mention p16/Ki-67 dual staining as a screening/diagnostic tool. In a discussion of future directions in cervical cancer screening, In an UpToDate chapter on "Human papillomavirus testing of the cervix: Management of abnormal results", Einstein (2019) stated that: "In addition to cervical cytology and HPV testing, there are tests to evaluate cervical biopsy specimens that aid pathologists in their diagnoses, such as immunostaining for p16INK4a/Ki-67. . . . Some of these tests will likely be considered in future management guidelines."

Furthermore, National Comprehensive Cancer network’s clinical practice guideline on “Cervical cancer” (Version 1.2017) does not mention p16/Ki-67 dual staining as a screening/diagnostic tool. The NCCN guidelines panel for cervical cancer screening endorses guidelines from the ASCCP (Saslow, et al, 2012) and consensus recommendations from Massad, et al (2013).

Onyango et al (2020) noted that cervical cancer screening is slowly transitioning from Pap cytologic screening to primary visual inspection with acetic acid (VIA) or HPV testing as an effort to enhance early detection and treatment.  However, an effective triage tests needed to decide who among the VIA or HPV positive women should receive further diagnostic evaluation to avoid unnecessary colposcopy referrals is still lacking.  Evidence from experimental studies have shown potential usefulness of squamous cell carcinoma antigen (SCC Ag), macrophage colony stimulating factor (M-CSF), vascular endothelial growth factor (VEGF), microRNA, p16INKa / ki-67, HPV E6/E7/mRNA, and DNA methylation biomarkers in detecting pre-malignant cervical neoplasia.  Given the variation in performance, and scanty review studies in this field, this systematic review described the diagnostic performance of some selected assays to detect high-grade cervical intraepithelial neoplasia (CIN2+) with histology as gold standard.  These investigators searched articles published in English between 2012 and 2020 using key words from PubMed/Medline and SCOPUS with 2 reviewers evaluating study eligibility, and risk of bias.  They carried out a descriptive presentation of the performance of each of the selected assays for the detection of CIN2+.   Out of 298 citations retrieved, 58 articles were included.  Participants with cervical histology yielded CIN2+ proportion range of 13.7 % to 88.4 %.  The diagnostic performance of the assays to detect CIN2+ was:

1. SCC-Ag: range sensitivity of 78.6 % to 81.2 %, specificity of 74 % to 100 %;
2. M-CSF: sensitivity of 68 % to 87.7 %, specificity of 64.7 % to 94 %;
3. VEGF: sensitivity of 56 % to 83.5 %, specificity of 74.6 % to 96 %;
4. microRNA: sensitivity of 52.9 % to 67.3 %, specificity of 76.4 % to 94.4 %;
5. p16INKa / ki-67: sensitivity of 50 % to 100 %, specificity of 39 % to 90.4 %;
6. HPV E6/E7/mRNA: sensitivity of 65 % to 100 %, specificity of 42.7 & to 90.2 %, and
7. DNA methylation: sensitivity of 59.7 % to 92.9 %, specificity of 67 % to 9%. 

The authors concluded that the reported test performance and the receiving operating characteristics curves implied that implementation of p16ink4a/ki-67 assay as a triage for HPV positive women to be used at one visit with subsequent cryotherapy treatment is feasible.

The authors stated that this systematic review presented the latest developments in the field of SCC Ag, M-CSF, VEGF, miRNA (miR-9), p16INKa / ki-67, HPV E6/E7 mRNA and DNA methylation tests accuracy.  These researchers included relatively adequate number of articles published in different countries employing large number of study participants; however, these findings should be interpreted in light of a few shortcomings.  The main drawback was lack of studies that employed similar and well-defined population with same cervical pathology characteristics; therefore, this review suffered from heterogeneity of studies that made it difficult to pool the performance characteristics of each of the tested assays.  Furthermore, the use of histologically confirmed CIN2+ endpoint when evaluating the test accuracy represented a challenge because of the regression (false-positive) or progression (false-negative) of many confirmed lesions.  Moreover, confining the inclusion criteria to include only articles published in English would also mean missing some of the relevant studies; thus, reducing the accuracy of these findings.

Safaeian and associates (2021) noted that an increase in HPV test volumes is expected in the near future as HPV–based screening protocols are expected to become more broadly adopted.  The IMproving Primary screening And Colposcopy Triage (IMPACT) Trial, a prospective, multi-center U.S. cervical cancer screening trial, was carried out to obtain FDA approvals for the new high-throughput cobas HPV for use on the cobas 6800/8800 Systems (cobas HPV) for detecting cervical pre-cancer and cancer (cervical intraepithelial neoplasia of grade 2 or worse [greater than or equal to CIN2] and grade 3 or worse, [greater than or equal to CIN3]).  These researchers presented the baseline demographics, HPV, cervical cytology and histopathologic results.  Furthermore, the baseline and 1-years risks of greater than or equal to CIN2 and greater than or equal to CIN3 associated with HPV results were reported.  A total of 35,263 women aged 25 to 65 years undergoing routine screening were enrolled; liquid-based cytology and 2 high-risk HPV PCR-based tests were carried out.  Women with abnormal Pap cytology, women positive for high-risk HPV by either of the 2 HPV tests, and a random subset of women negative by Pap cytology and the 2 HPV tests were referred to colposcopy/cervical biopsy.  Women who did not meet the study endpoint were eligible for the 1-year follow-up study phase.  Verification bias-adjusted cervical disease prevalence and risks and 95 % CIs were computed.  The prevalence of ASC-US and greater than ASC-US cytology were 6.5 % and 3.2 %, respectively.  Prevalence of high-risk HPV, HPV16, and HPV18 base on the new cobas HPV test were 15.1 %, 3.1 %, and 1.4 %, respectively.  Both cytologic abnormalities and HPV positivity declined with increasing age.  Among women who had a colposcopy/biopsy, prevalence of greater than or equal to CIN2 and greater than or equal to CIN3 were 8.8 % and 3.6 %, respectively.  The baseline and 1-year cumulative risks for greater than or equal to CIN3 were 13.6 % and 16.9 %, respectively, in HPV16-postive women.  HPV-negative women had the lowest 1-year cumulative risk for greater than or equal to CIN3 (0.06 %).  The authors concluded that the contemporary age-specific prevalence of HPV (including HPV16 and HPV18), cytologic abnormalities, and CIN in a large U.S. cervical cancer screening population provided benchmarks for health care policy, screening programs, and for laboratories and clinicians.  These researchers stated that a drawback of the IMPACT Trial was that follow-up of women who underwent colposcopy at baseline was only 1 year, as opposed to 3 years as in the ATHENA and Onclarity Trials.

UpToDate reviews on “Screening for cervical cancer in resource-rich settings” (Feldman et al, 2021) and “Screening for cervical cancer in resource-limited settings” (Denny, 2021) do not mention p16INKa / ki-67 / dual staining as a management option.

Furthermore, National Comprehensive Cancer Network’s clinical practice guideline on “Cervical cancer” (Version 1.2021) does not mention p16INKa / ki-67 / dual staining.

Wright et al (2022) noted that triage strategies are needed for primary human papillomavirus (HPV)-based cervical cancer screening to identify women requiring colposcopy/biopsy.  In a prospective, observational study, these researchers examined the performance of p16/Ki-67 dual-stained (DS) immunocytochemistry to triage HPV-positive women and compared it to cytology, with or without HPV16/18 genotyping.  This trial enrolled 35,263 women aged 25 to 65 years at 32 U.S. sites.  Cervical samples had HPV and cytology testing, with colposcopy/biopsy for women with positive tests.  Women without cervical intraepithelial neoplasia Grade 2 or worse (greater than or equal to CIN2) at baseline (n = 3,876) were re-tested after 1 year.  A total of 4,927 HPV-positive women with valid DS results were included in this analysis.  DS sensitivity for greater than or equal to CIN2 and greater than or equal to CIN3 at baseline was 91.2 % (95 % confidence interval [CI]: 86.8 % to 94.2 %) and 91.9 % (95 % CI: 86.1 % to 95.4 %), respectively, in HPV16/18-positive women and 83.0 % (95 % CI: 78.4 % to 86.8 %) and 86.0 % (95 % CI: 77.5 % to 91.6 %) in women with 12 "other" genotypes.  Using DS alone to triage HPV-positive women showed significantly higher sensitivity and specificity than HPV16/18 genotyping with cytology triage of 12 "other" genotypes, and substantially higher sensitivity but lower specificity than using cytology alone.  The risk of greater than or equal to CIN2 was significantly lower in HPV-positive, DS-negative women (3.6 %; 95 % CI: 2.9 % to 4.4 %), compared to triage-negative women using HPV16/18 genotyping with cytology for 12 "other" genotypes (7.4 %; 95 % CI: 6.4 % to 8.5 %; p < 0.0001) or cytology alone (7.5 % ; 95 % CI: 6.7 % to 8.4 %; p < 0.0001).  DS showed better risk stratification than cytology-based strategies and provided high reassurance against pre-cancers both at baseline and at 1-year follow-up, irrespective of the HPV genotype.  DS allowed for the safe triage of primary screening HPV-positive women.  These researchers stated that the main drawback of this study was the fact that the study follow-up was limited to 1 year; thus, the assessment of the negative disease prediction of a negative DS for a period longer than 1 year could not be made.

Li et al (2022) stated that CINtec PLUS p16/Ki-67 DS cytology is an alternative test to cytology in triaging HPV-positive women.  Dalton p16/Ki-67 Dual Stain kit employs the similar immunocytochemical detection and operating procedures with CINtec PLUS; however, its accuracy and effectiveness in triaging HPV-positive women need to be examined.  A total of 717 HPV-positive specimens of cervical exfoliated cells were included.  Cytology, Dalton, and CINtec PLUS were subsequently performed, and 2 DS tests were separately completed in each of the same specimens.  The results of 2 DS tests were head-to-head compared, and their effectiveness to identify high-grade CIN were evaluated, using histopathology of biopsy as the golden standard.  The overall positive rate of 2 DS tests were 28.31 % for Dalton and 33.89 % for CINtec PLUS (p < 0.05); both rose with the increased severity of histopathological and cytological abnormalities.  Compared to CINtec PLUS, the positive rate of Dalton was significantly lower in the normal histopathology group (p < 0.05) and lower, but not significantly, in mild abnormal histopathology and cytology NILM and LSIL groups.  Two DS tests showed a good consistency (Kappa value, 0.63; 95 % CI: 0.557 to 0.688), with 100 % of consistency in the cytology HSIL group.  Inconsistency occurred mainly in the cytology NILM and LSIL groups, with more Dalton negative but CINtec PLUS positive.  Compared to CINtec PLUS, Dalton showed similar sensitivity (94.59 % versus 91.89 %), but significantly higher specificity (75.29 % versus 69.26 %, p = 0.013) and accuracy (76.29 % versus 70.43 %, p = 0.012), with a larger AUC of 0.849 (95 % CI: 0.800 to 0.899) for identifying CIN3+.  The similar results were observed when identifying CIN2+.  The author s concluded that Dalton presented the lower false positive rate and better effectiveness in identifying high-grade CIN than CINtec PLUS, suggesting that Dalton may be superior to CINtec PLUS and an alternative technique for triaging primary HPV-positive women in cervical cancer screening.

Self-Collected / Self-Sampling HPV Tests

Catarino et al (2017) compared HPV test positivity and accuracy between self-collected sample with a dry swab (s-DRY) versus physician-collected cervical sampling using a broom like brush and immediate immersion in PreservCyt (dr-WET).  In this cross-sectional study, these researchers recruited 150 women greater than or equal to 18 years old attending the colposcopy clinic in the University Hospital of Geneva.  Each participant first self-collected a vaginal sample using a dry swab and then the physician collected a cervical specimen in PreservCyt.  HPV analysis was performed with Xpert.  Part of the PreservCyt-collected sample was used for high-risk HPV (hrHPV) detection with the Cobas HPV test.  HPV test positivity and performance of the 2 collection methods was compared.  HPV positivity was 49.1 % for s-DRY, 41.8 % for dr-WET and 46.2 % for Cobas.  Good agreement was found between s-DRY and dr-WET samples (kappa ± Standard error (SE) = 0.64 ± 0.09,), particularly for low-grade squamous intraepithelial lesions (LSIL+) (kappa ± SE = 0.80 ± 0.17).  Excellent agreement was found between the 2 samples for HPV16 detection in general (kappa ± SE = 0.91 ± 0.09) and among LSIL+ lesions (kappa ± SE = 1.00 ± 0.17).  Sensitivities and specificities were, respectively, 84.2 % and 47.1 % (s-DRY), 73.1 % and 58.7 %. (dr-WET) and 77.8 % and 45.7 % (Cobas) for CIN2+ detection.  The median delay between sampling and HPV analysis was 7 days for the Xpert HPV assay and 19 days for Cobas.  There were 36 (24.0 %) invalid results among s-DRY samples and 4 (2.7 %) among dr-WET (p = 0.001).  Invalid results happened due to the long interval between collection and analysis.  The authors concluded that self-collected vaginal dry swabs were a valid alternative to collecting cervical samples in PreservCyt solution for HPV testing with the Xpert HPV assay.  They stated that HPV self-collection with dry cotton swabs might assist in the implementation of an effective screening strategy in developing countries.

Asciutto et al (2017) compared HPV DNA detection in self-collected vaginal and urine samples with clinician-taken cervical samples in relation to histology.  Self-collected vaginal, urine and clinician-taken cervical samples were analyzed from 218 women with the Cobas 4800 HPV test (Roche Molecular Diagnostics).  The sensitivity for detection of HPV in the vaginal self-sampling test was 96.4 % and in urine was 83.9 % relative to detection by clinician-taken cervical sample.  The vaginal self-sampling and the clinician-taken HPV tests had the same sensitivity of 92.8 % (95 % CI: 86.3 to 96.8 %) and specificity for detection of high-grade squamous intraepithelial lesion (HSIL) and adenocarcinoma in situ (AIS).  Detection in urine samples had a sensitivity of 76.3 % (95 % CI: 67.9 to 84.2 %) for HSIL/AIS.  The authors concluded that the Cobas 4800 HPV test detected high-grade pre-cancerous cervical lesions in self-collected vaginal samples with the same high sensitivity as in clinician-taken cervical samples.

Chatzistamatiou et al (2017) examined the feasibility of a site-of-care cervico-vaginal self-sampling methodology for HPV-based screening in 346 women residing in under-served rural areas of Northern Greece.  These women were provided self-collected cervico-vaginal sample along with a study questionnaire.  Following molecular testing, using the Cobas HPV Test, HPV-positive women, were referred to colposcopy and upon abnormal findings, to biopsy and treatment.  Participation rate was 100 %.  Regular pap-test examination was reported for 17.1 %.  Among hrHPV testing, 11.9 % were positive and colposcopy/biopsy revealed 2 CIN3 cases.  Non-compliance was the most prevalent reason for no previous attendance.  Most women reported non-difficulty and non-discomfort in self-sampling (77.6 % and 82.4 %, respectively).  They would choose self-sampling over clinician-sampling (86.2 %), and should self-sampling being available, they would test themselves more regularly (92.3 %).  The  authors concluded that self-sampling was feasible and well-accepted for HPV-based screening, and could increase population coverage in under-served areas, helping towards successful prevention.

Braz et al (2017) noted that cervical cancer is a major cause of death in adult women.  However, many women do not undergo cervical cancer screening for the following reasons: fear, shame, physical limitations, cultural or religious considerations and lack of access to health care services.  Self-collected vaginal smears maybe an alternative means of including more women in cervical cancer screening programs.  In a systematic review, these investigators evaluated the acceptability of vaginal smear self-collection for cervical cancer screening.  They selected articles from PubMed, the Cochrane Library and Embase that were published between January 1995 and April 2016.  Studies written in English, French, Italian, Portuguese or Spanish that involved women between 18 and 69 years of age who had engaged in sexual intercourse were included in this review.  The review was performed in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement.  A total of 19 studies were evaluated in this review.  Most of the included studies (n = 17) demonstrated that the self-collection method exhibited outstanding acceptability among women with respect to cervical cancer screening, and only 2 studies indicated that self-collection exhibited low acceptability among women in this context.  The acceptability of self-collection was determined subjectively (without standardized questionnaires) in 10 studies (53 %) and via structured and validated questionnaires in the remaining studies.  The authors concluded that the results of this review suggested that the self-collection method was well-accepted and may therefore encourage greater participation in cervical cancer screening programs.  Moreover, they stated that additional studies are needed to verify these findings.

Lim et al (2017) examined the feasibility and acceptability of offering self-sampling for HPV testing to cervical screening non-attenders when they consult primary care for any reason.  In a pilot implementation study, 6 general practices in London, UK, offered self-sampling kits during consultation to women aged 25 to 64 years who were at least 6 months overdue for cervical screening (no cytology test recorded in the past 3.5 years if aged 25 to 49, or 5.5 years if aged 50 to 64).  Eligible women were identified using an automated real-time search (during consultation) of the general practice electronic medical record system.  Women collected samples either in clinic or at home (dry flocked swabs analyzed using Roche Cobas 4800).  Of approximately 5,000 eligible women, 3,131 consulted primary care between January and December 2014 (mean recruitment period of 9.5 months).  Of these, 21 % (652) were offered kits, 14 % (443) accepted, and 9 % (292) returned a self-sample.  The proportion of eligible women offered kits varied markedly among practices (11 to 36 %).  Sample return rates increased with kit offered rates ( r = 0.8, p = 0.04).  Of 39 HPV-positive women 85 % (33) attended follow-up, including 2 with invasive cancers (stage 2A1 and 1A1).  The authors concluded that offering self-sampling to cervical screening non-attenders opportunistically in primary care was feasible.  They stated that return rates could be increased if more women were offered kits.  Moreover, they stated that  a large trial is needed to identify how self-sampling is best integrated into the national screening program, and to identify determinants of uptake.

Modibbo et al (2017) stated that cervical cancer incidence and mortality rates in Sub-Saharan Africa (SSA) remain high due to several factors including low levels of uptake of cervical cancer screening.  Self-collection of cervico-vaginal samples for HPV DNA testing may be an effective modality that can increase uptake of cervical cancer screening in SSA and hard to reach populations in developed countries.  These researchers examined if self-collection of cervico-vaginal samples for HPV DNA tests would be associated with increased uptake of screening compared with clinic based collection of samples.  Furthermore, these investigators compared the quality of samples collected by both approaches for use in HPV genotyping.  They conducted a community-based randomized trial in a semi-urban district of Abuja, Nigeria with 400 women, aged 30 to 65 years randomized to either hospital-collection or self-collection of cervico-vaginal samples.  These researchers compared cervical cancer screening uptake among the 2 groups and evaluated the concentration of human DNA in the samples by measuring RNase P gene levels using qPCR.  High-risk HPV DNA detection and typing was done using the GP5+/6+ Luminex system.  Most participants in the self-collection arm (93 %, 185/200) submitted their samples, while only 56 % (113/200) of those invited to the hospital for sample collection attended and were screened during the study period (p < 0.001).  Human genomic DNA was detected in all but 5 (1.7 %) participants, all of whom were in the self-collection arm.  The prevalence of high-risk HPV in the study population was 10 % with types 35, 52 and 18 being the commonest.  The authors concluded that the findings of this study showed that self-sampling significantly increased uptake of HPV DNA based test for cervical cancer screening in this population and the samples collected were adequate for HPV detection and genotyping.  They stated that cervical cancer screening programs that incorporate self-sampling and HPV DNA tests were feasible and may significantly improve uptake of cervical cancer screening in SSA; and this justified further studies that integrate this modality into cervical cancer screening programs in low and middle income countries.

The authors stated that a drawback of this study was the use of interviewer administered questionnaires that may have skewed responses to some of the sensitive questions towards what was perceived to be more socially acceptable, however studies have shown that the influence of biased responses were minor and did not affect overall results.  The demographic characteristics of the participants in this study also differed from that of the general Nigeria population and this may limit the generalizability of these results.  Some members of the community may have opted not to respond to the invitations to participate in the study and the authors could not rule out healthy volunteer bias.

Lofters et al (2017) stated that with appropriate screening (i.e., the Pap test), cervical cancer is highly preventable, and high-income countries, including Canada, have observed significant decreases in cervical cancer mortality.  However, certain subgroups, including immigrants from countries with large Muslim populations, experience disparities in cervical cancer screening.  Little is known about the acceptability of HPV self-sampling as a screening strategy among Muslim immigrant women in Canada.  This study assessed cervical cancer screening practices, knowledge and attitudes, and acceptability of HPV self-sampling among Muslim immigrant women.  A convenience sample of 30 women was recruited over a 3-month period (June to August 2015) in the Greater Toronto Area.  All women were between 21 and 69 years old, foreign-born, and self-identified as Muslim, and had good knowledge of English.  Data were collected through a self-completed questionnaire.  More than 50 % of the participants falsely indicated that Pap tests may cause cervical infection, and 46.7 % indicated that the test is an intrusion on privacy.  The majority of women reported that they would be willing to try HPV self-sampling, and more than 50 % would prefer this method to provider-administered sampling methods.  Barriers to self-sampling included confidence in the ability to perform the test and perceived cost, and facilitators included convenience and privacy being preserved.  The authors concluded that although HPV self-sampling has been studied in a variety of other populations, this body of work was the first that these researchers knew of to examine the acceptability of this method among Muslim immigrant women in Canada.  This study added important information to the literature related to promoting cancer screening among women under or never screened for cervical cancer.  The results demonstrated that HPV self-sampling may provide a favorable alternative model of care to the traditional provider administered Pap testing.  It has the potential to increase participation in cervical cancer screening.  Potential benefits from HPV self-sampling may include removing several major barriers identified in the literature, such as modesty, access to female physicians, lack of transportation, and inconvenient hours of service.  Moreover, they stated that future larger-scale research is needed to allow women of a broad range of ages and ethnicities to trial devices to further explore acceptability and feasibility.

The authors stated that this study had several drawbacks.  First, the small sample size (n = 30) was reflective of the qualitative nature of the other component of this body of work.  Due to the small sample size and the demographics of participants, results must be interpreted with caution and cannot be generalized to the broader population of Muslim immigrant women in this setting future research will need to be conducted on a larger scale, will need to include a diversity of ages and ethnicities, and will need to allow women to try self-sampling devices to further assess acceptability and feasibility.  Second, these findings may have been affected by self-report and social desirability biases, including around reported screening status.  Third, these researchers were not able to allow women to try HPV self-sampling to provide more detailed feedback about acceptability, but as noted, planned future research will address this limitation.

In a randomized controlled trial (RCT), Viviano et al (2017) examined if self-sampling can increase screening attendance of women who do not attend regular screening in Switzerland.  Participants were proactively recruited in Geneva between September 2011 and November 2015.  Women (25 to 69 years) who had not undergone cervical cancer (CC) screening in the last 3 years were considered eligible.  Through a 1 : 1 ratio randomization, enrolled participants were invited to either undergo liquid-based cytology, which was performed by a health-care provider (control group, CG) or to take a self-sample for HPV-testing, which was mailed to their home (intervention group, IG).  A total of 331 and 336 women were randomized in the CG and in the IG, respectively.  Overall, 7.3 % (95 % CI: 4.9 to 10.6) women in the CG and 5.7 % (95 % CI: 3.6 to 8.7) women in the IG did not undergo the initial screening (p = 0.400).  There were 1.95 % (95 % CI: 0.8 to 4.3) women in the CG and 5.05 % (95 % CI: 3.1 to 8.1) women in the IG with a positive screen who did not attend triage and colposcopy (p = 0.036).  The authors concluded that the participation in CC screening in women offered self-sampling was not higher than among those offered specimen collection by a clinician.  Moreover, they stated that compliance with further follow-up for women with a positive HPV test on the self-sample requires further attention.

The authors stated that this study had several drawbacks.  First, these researchers were able to recruit fewer participants than expected by the sample size estimation.  The assumptions used to estimate the sample size were different from the actual recruitment process of the trial, thus limiting the power to obtain statistically significant difference between the 2 options for initial screening.  Second, this study was conducted in an urban setting, which limits the generalization of these findings to the population living in Switzerland.  Another reason for which the study group was not entirely representative of the population living in Geneva and its surroundings was the proportion of women with previous CC screening, which was rather high as compared with the lower rates in Geneva and its surroundings.  Third, an important pre-selection bias was likely to have occurred since these investigators selected women who had actively responded to the campaign’s advertisements, participants were possibly more willing to accept any CC screening approach than the general population.

Kobetz et al (2017) noted that under-served ethnic minority women experience significant disparities in cervical cancer incidence and mortality, mainly due to lack of cervical cancer screening.  Barriers to Pap smear screening include lack of knowledge, lack of health insurance and access, and cultural beliefs regarding disease prevention.  In the previous SUCCESS trial, these investigators demonstrated that HPV self-sampling delivered by a community health worker (CHW) is efficacious in circumventing these barriers.  This approach increased screening uptake relative to navigation to Pap smear screening.  SUCCESS trial participants, as well as community partners, provided feedback that women may prefer the HPV self-sampler to be delivered through the mail, such that they would not need to schedule an appointment with the CHW.  Thus, the current trial aims to elucidate the efficacy of the HPV self-sampling method when delivered via mail.  These researchers are conducting a RCT among 600 Haitian, Hispanic, and African-American women from the South Florida communities of Little Haiti, Hialeah, and South Dade.  Women between the ages of 30 and 65 years who have not had a Pap smear within the past 3 years are eligible for the study.  Women are recruited by CHWs and complete a structured interview to assess multi-level determinants of cervical cancer risk.  Women are then randomized to receive HPV self-sampling delivered by either the CHW (group 1) or via mail (group 2).  The primary outcome is completion of HPV self-sampling within 6 months post-enrollment.  The authors concluded that this trial is among the first to examine the efficacy of the mailed HPV self-sampling approach.  If found to be efficacious, this approach may represent a cost-effective strategy for cervical cancer screening within under-served and under-screened minority groups.

de Thurah et al (2018) undertook a systematic literature review to determine the concordance in positive test results (i.e., detection of HPV infections) between Hybrid Capture 2 (HC2) and other assays.  These investigators searched PubMed, Embase and Scopus for studies of primary screening with HC2 and one or more assays, with cross-tabulated testing results for the assays.  Two authors applied inclusion criteria and 3 authors extracted data from included studies.  For each inter-assay comparison, these researchers calculated the concordance by comparing the number of concordant samples with the number of samples that tested positive on at least 1 assay.  A total of 16 studies fulfilled inclusion criteria, comparing 9 assays to HC2, and including 392 to 9,451 patients each.  The calculated concordance varied between 48 % and 69 % for HC2 and APTIMA, Cobas, Abbott RealTime, Cervista, GP5+/6+, CLART, BD HPV test, Amplicor and Linear Array, i.e., 31 % to 52 % of all positive tests on any pair of compared assays were discordant.  Although modest variation in the degree of concordance with HC2 was suggested for particular assays, the numbers of studies per assay were generally low.  No pronounced systematic patterns were observed by study (e.g., liquid medium) or population characteristics.  The authors concluded that the 10 commercially available assays did not detect the same HPV infections.  Moreover, they stated that even in the most favorable case, the 2 assays provided discordant test results in 31 % of all detected infections.

Phoolcharoen et al (2018) studied the concordance between vaginal self- and endocervical physician-collected hrHPV testing in Thai women who attended a colposcopy clinic.  Vaginal samples were obtained by self-sampling with a dry brush before endocervical samples were obtained by physicians.  Both specimens were analyzed for hrHPV by Cobas4800 HPV test.  Of the 247 pairs of samples, overall hrHPV prevalence from self- and physician-collected samples was 41.3 % and 36.0 %, respectively.  The overall agreement between the methods was 74.5 % with κ 0.46 (p < 0.001).  This study revealed moderate agreement between self- and physician-collected methods for hrHPV testing.

The authors stated that this study had several limitations.  First, all the participants in the study did the self-collection first then underwent pelvic examination to obtain physician-collected specimens later.  This sampling order may have resulted in the self-collected specimens having more exfoliated cells than the physician-collected specimens had.  Second, the participants were women who attended a colposcopy clinic for various reasons such as abnormal cytology or positive HPV testing, so the prevalence of HPV in this group was higher than in the normal population.  The prevalence of hrHPV in this study was 41.3 % and 36.0 % from self- and physician-collected specimens, respectively.  The prevalence of hrHPV in Thai women in previous studies was 3.3 to 14.0 %.  Lastly, due to the level of agreement in this study was slightly lower than in most previous studies, more studies with larger populations are needed to explore the reliability and feasibility of self-sampling of HPV as a method for cervical cancer screening in Thai and other Asian women.  The molecular and biomarker analyses may be combined to achieve greater accuracy of the test.

Winer et al (2018) noted that women who delay or do not attend Pap screening are at increased risk for cervical cancer.  Trials in countries with organized screening programs have demonstrated that mailing hrHPV self-sampling kits to under-screened women increases participation, but U.S. data are lacking.  HOME is a pragmatic RCT set within a U.S. integrated healthcare delivery system to compare 2 programmatic approaches for increasing cervical cancer screening uptake and effectiveness in under-screened women (greater than or equal to 3.4 years since last Pap) aged 30 to 64years: First – usual care (annual patient reminders and ad-hoc outreach by clinics), and second – usual care plus mailed hrHPV self-screening kits.  Over 2.5 years, eligible women were identified through electronic medical record (EMR) data and randomized 1:1 to the intervention or control arm.  Women in the intervention arm were mailed kits with pre-paid envelopes to return samples to the central clinical laboratory for hrHPV testing.  Results were documented in the EMR to notify women's primary care providers of appropriate follow-up.  Primary outcomes are detection and treatment of cervical neoplasia.  Secondary outcomes are cervical cancer screening uptake, abnormal screening results, and women's experiences and attitudes towards hrHPV self-sampling and follow-up of hrHPV-positive results (measured through surveys and interviews).  The trial was designed to evaluate whether a programmatic strategy incorporating hrHPV self-sampling is effective in promoting adherence to the complete screening process (including follow-up of abnormal screening results and treatment).  The objective of this report is to describe the rationale and design of this pragmatic trial.

An UpToDate review on “Screening for cervical cancer” (Feldman et al, 2018) does not mention the sue of “self-collection or self-sampling” HPV testing.

Furthermore, National Comprehensive Cancer Network’s clinical practice guideline on “Cervical cancer” (Version 1.2018) does not mention “self-collection or self-sampling” HPV testing.

Human Papillomavirus (HPV) Genotyping in Cervical Cancer Screening

Bonde and colleagues (2020) stated that 13 HPV genotypes are associated with the highest risk of cervical disease/cancer; however, the risk of disease progression and cancer is genotype-dependent.  In a systematic review, these researchers examined evidence for high-grade cervical intraepithelial neoplasia (greater than or equal to CIN 3) risk discrimination using HPV genotyping.  They carried out a systematic review of English and non-English articles through Medline, Cochrane, clinicaltrials.gov, and abstracts presented at relevant professional society conferences were searched from 2000 to 2019.  Search terms included: cervical cancer screening, HPV genotyping, CIN, HPV persistence, humans, and colposcopy; prospective, controlled trials, observational studies, and retrospective studies of residual specimens; evidence included HPV genotyping (beyond genotypes 16/18/45) results.  Data were obtained independently by authors using predefined fields.  Risk of bias was evaluated with a modified Newcastle-Ottawa Scale.  The Grading of Recommendations, Assessment, Development and Evaluation (GRADE) methodology facilitated overall quality of evidence evaluation for risk estimation.  The study protocol was registered with the PROSPERO International Prospective Register of Systematic Reviews (CRD42018091093).  The primary outcome was CIN 3 or worse risk both at baseline and at different follow-up periods.  Of 236 identified sources, 60 full texts were retrieved and 16 articles/sources were included.  Risk of bias was deemed low; the overall quality of evidence for CIN 3 or worse risk with negative for intraepithelial lesions or malignancies or low-grade squamous intraepithelial cytology was assessed as moderate; that with atypical squamous cells-undetermined significance and "all cytology" was assessed as high.  Clinical and methodological heterogeneity precluded meta-analysis.  Human papillomavirus genotyping discriminated risk of CIN 3 or worse to a clinically significant degree, regardless of cytology result.  The authors concluded that the evidence supported a clinical utility for HPV genotyping in risk discrimination during cervical cancer screening.  Moreover, these researchers stated that before large-scale implementation, this use of genotype information would need formal evaluation and recommendations by groups issuing clinical testing guidelines.  Recently, the United Kingdom’s National Institute for Health Research Health Technology Assessment concluded that HPV assays identifying not only HPV 16 and 18, but in addition HPV 31, 33, 45, 52, and 58, could be useful in triage as well as in primary HPV testing.  Finally, the Danish National Health Authority Steering Committee on cervical screening has included use of genotyping and cytology as a combined triage of primary screening HPV positive women for a defined implementation period starting 2020, becoming the first country to use not just HPV screening, but HPV genotype information in an advanced screening algorithm poised at reducing over-treatment while maintaining the sensitivity of HPV-based screening.

The authors stated that a limitation of this analysis was that across the published literature, researchers have developed different methods for assigning genotype in the case of mixed infections.  For useful genotype risk assessment, genotypes must be included in order from most discriminatory to least.  To determine this order, variations of 3 different approaches may be used.  In this analysis, the hierarchical method was preferred, where possible.  The models for iterative attribution of risk rank were as follows: multi-variate analysis, descending positive predictive values, and higher risk by single-genotype analysis.  An alternative technique was to exclude all multiple infections and rank order risk for single genotype results only.  The simple proportional method of according equal risk to each genotype found in mixed infection results in totals exceeding 100 %, and over-estimation of risk for genotypes of lesser rank order.  An underlying assumption for all the hierarchical models was that mixed infections do not involve synergism that led to risk greater than that associated with either individual genotype.  The period over which risk was estimated differed for many studies; 5 reported baseline risks, 6 reported risks between of 16 months and 4 years, and the remaining studies reported cumulative risks for a range of 4 to 14 years.  Rare cases of pre-malignant and invasive cervical lesions are related to non-high-risk HPV genotypes; these cases were not a focus of this systematic review but have been a confounding factor in some to the studies included in this synthesis.  Another drawback of this analysis was that cervical cancer screening in the studies that constitute the data sources for this review were performed on different patient populations, which included differences in age, race, screening history, HPV genotype prevalence, disease prevalence, time to follow-up (from 16 months to 14 years), and clinical management at baseline screening and follow-up testing.  Study populations also varied by size and cytology result, both of which impacted the interpretation of results when considering the most appropriate risk thresholds for clinical management.  In addition, HPV genotyping information was obtained from different methodology including PCR and sequencing – allowing for differences in sensitivity/specificity due to the intrinsic differences in the clinical cutoff values for respective assays.

The U.S. Preventive Services Task Force (USPSTF)’s Recommendation Statement on “Screening for Cervical Cancer” (No authors listed, 2019) did not mention HPV genotyping.

National Comprehensive Cancer Network’s clinical practice guideline on “Cervical cancer” (Version 1.2020) does not mention HPV genotyping as a management tool.  Moreover, the NCCN Guidelines Panel for Cervical Cancer Screening endorses the following guidelines: For the prevention and early detection of cervical cancer: American Cancer Society, American Society for Colposcopy and Cervical Pathology, and American Society for Clinical Pathology screening guidelines for the prevention and early detection of cervical cancer (Saslow et al, 2012), which stated that “Other strategies have aimed to improve specificity and reduce harm by interposing secondary testing for management decisions between a positive HPV test and colposcopy.  Potential secondary biomarkers included HPV genotyping (for HPV16 or HPV16/18), HPV mRNA testing, and/or the detection of other non-HPV biomarkers (e.g., p16INK4A).  Although promising, there are limited data regarding the test performance of these markers.  Specifically, the cross-sectional and archival nature of most available molecular marker studies as well as the heterogeneity of clinical endpoints examined (CIN2+ vs CIN3+) limits the current usefulness of these data.  Finally, there are no direct comparisons of these various triage strategies and the specificity of such an approach, and the consequential potential harms (or benefits) have not yet been well defined”.

DYSIS Smart Colposcopy

DYSIS Smart Colposcopy entails computer-aided mapping of cervix uteri during colposcopy, including optical dynamic spectral imaging and algorithmic quantification of the aceto-whitening effect.  The DYSIS Colposcope measures the reaction of the cervical epithelium using a proprietary technology called Dynamic Spectral Imaging.  The cervical mapping technology helps draw attention to any additional areas of the cervix that may need further examination.

Rahatgaonkar and colleagues (2020) noted that cervical cancer is a major contributor to mortality and morbidity in women.  Naked eye visual screening (NE test) and Pap test are commonly used for cervical cancer screening.  Both tests have inherent limitations like low sensitivity (Pap test) and subjectivity in interpretation, lack of permanent record and over-estimation (NE test).  In a prospective, observational study, these researchers compared Smart Scope visual screening test (SS test) with NE and Pap tests.  Smart Scope is a small, hand-held device that captures cervical images attached to a tablet to store data.  This trial was carried out at a tertiary care hospital in India, over 16 months.  A total of 509 women aged 25 to 65 years were included in the study as per the inclusion criteria.  All subjects underwent Pap test, NE test and SS test.  Screen positives on any 1 test were advised colposcopy and biopsy.  Of the 154 screen-positive women, 49 visited for follow-up colposcopy-guided biopsy; 9 incidental biopsies of screen-negative women were included in the data.  Therefore, statistical analysis was conducted based on 58 available histopathology results.  Of the 58 biopsies, 8 were normal, 30 were benign lesions, 18 were pre-cancerous, and 2 were cancerous lesions.  SS test was found to have a sensitivity and NPV of 100 % each, PPV of 45.4 % and a specificity of 36.8 %.  Sensitivity and specificity of NE test was 90 % and 39.5 % respectively, PPV was 43.9 % and NPV was 88.2 %.  Pap smear had a sensitivity of 25 % and specificity of 84.2 %, PPV of 45.5 % and NPV of 68.08 %.  The authors concluded that SS test has great potential to be a primary screening test in low-resource settings due to its better sensitivity and NPV as compared to NE and Pap tests.  Moreover, these researchers also stated that a machine learning model is being developed for auto-assessment of lesions; and further efforts are in place to improve the image quality and magnification of the camera.

The authors stated that this study had 2 main drawbacks. First, SS test showed a very low specificity and PPV.  Second, this study was carried out in the out-patient department of a tertiary care hospital and all the screening and interpretations were performed by a single expert.  These researchers plan to involve the expertise of more than 1 observer in future trials; and they also plan to carry out a similar study in rural settings where the device will be used by a primary health care worker.

UpToDate reviews on “Screening for cervical cancer in resource-rich settings” (Feldman et al, 2021), “” (, 2020) and “Cervical cancer screening tests: Techniques for cervical cytology and human papillomavirus testing” (Feldman and Crum, 2021) do not mention computer-aid mapping/optical dynamic spectral imaging as a screening tool.

Furthermore, National Comprehensive Cancer Network’s clinical practice guideline on “Cervical cancer” (Version 1.2021) does not mention computer-aid mapping/optical dynamic spectral imaging as a management tool.

Table: CPT Codes / HCPCS Codes / ICD-10 Codes

Code	Code Description
Information in the [brackets] below has been added for clarification purposes.   Codes requiring a 7th character are represented by "+":
Annual cervical cancer screening with Papanicolaou (Pap) smears (21 years of age and older):
CPT codes covered if selection criteria are met:
88141	Cytopathology, cervical or vaginal (any reporting system), requiring interpretation by physician
88142	Cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation; manual screening under physician supervision
88143	with manual screening and rescreening under physician supervision
88147	Cytopathology smears, cervical or vaginal; screening by automated system under physician supervision
88148	screening by automated system with manual rescreening under physician supervision
88150	Cytopathology, slides, cervical or vaginal; manual screening under physician supervision
88152	with manual screening and computer-assisted rescreening under physician supervision
88153	with manual screening and rescreening under physician supervision
88154	with manual screening and computer-assisted rescreening using cell selection and review under physician supervision
+ 88155	Cytopathology, slides, cervical or vaginal, definitive hormonal evaluation (e.g., maturation index, karyopyknotic index, estrogenic index) (List separately in addition to code(s) for other technical and interpretation services)
88164	Cytopathology, slides, cervical or vaginal (the Bethesda System); manual screening under physician supervision
88165	with manual screening and rescreening under physician supervision
88166	with manual screening and computer-assisted rescreening under physician supervision
88167	with manual screening and computer-assisted rescreening using cell selection and review under physician supervision
88174	Cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation; screening by automated system, under physician supervision
88175	with screening by automated system and manual rescreening or review, under physician supervision
HCPCS codes covered if selection criteria are met:
G0101	Cervical or vaginal cancer screening; pelvic and clinical breast examination
G0123	Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation; screening by cytotechnologist under physician supervision
G0124	requiring interpretation by physician
G0141	Screening cytopathology smears, cervical or vaginal, performed by automated system, with manual rescreening, requiring interpretation by physician
G0143	Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation; with manual screening and rescreening by cytotechnologist under physician supervision,
G0144	with screening by automated system, under physician supervision
G0145	Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation, with screening by automated system and manual rescreening under physician supervision
G0147	Screening cytopathology smears, cervical or vaginal; performed by automated system under physician supervision
G0148	performed by automated system with manual rescreening
G0476	Infectious agent detection by nucleic acid (dna or rna); human papillomavirus (hpv), high-risk types (eg, 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 68) for cervical cancer screening, must be performed in addition to pap test
P3000	Screening papanicolaou smear, cervical or vaginal, up to three smears; by technician under physician supervision
P3001	requiring interpretation by physician
Q0091	Screening papanicolaou smear; obtaining, preparing and conveyance of cervical or vaginal smear to laboratory
ICD-10 codes covered if selection criteria are met:
A50.01 - A64	Infections with a predominantly sexual mode of transmission
A59.00 - A59.09	Urogenital trichomoniasis
B20	Human immunodeficiency virus [HIV] disease
B97.7	Papillomavirus as the cause of diseases classified elsewhere
C51.0 - C58	Malignant neoplasm of female genital organs
C79.60 - C79.63	Secondary malignant neoplasm of ovary
C79.82	Secondary malignant neoplasm of genital organs
D06.0 - D07.39	Carcinoma in situ of cervix uteri and other and unspecified genital organs
D39.8 - D39.9	Neoplasm of uncertain behavior of female genital organs
D80.1 - D80.9 D83.0 - D83.9	Certain disorders involving the immune mechanism [immunosuppression]
N72	Inflammatory disease of cervix uteri
N76.81	Mucositis (ulcerative) of vagina and vulva
N87.0 - N87.9	Dysplasia of cervix uteri
N89.7 - N89.8	Other specified noninflammatory disorders of vagina [abnormal bleeding]
N92.5, N93.8	Other disorders of menstruation and other abnormal bleeding from female genital tract
R87.610 - R87.619 R87.810, R87.820	Abnormal cytological findings in specimens from cervix
Z01.411 - Z01.419	Encounter for gynecological examination
Z12.4	Encounter for screening for malignant neoplasm of cervix
Z21	Asymptomatic human immunodeficiency virus [HIV] infection status
Z72.51 - Z72.53	High-risk sexual behavior [multiple sexual partners]
Z85.40 - Z85.44	Personal history of malignant neoplasm of female genital organs
Z87.42	Personal history of other diseases of the female genital tract
Z87.59	Personal history of other complications of pregnancy, childbirth and the puerperium
ICD-10 codes not covered for indications listed in the CPB:
Q51.5	Agenesis and aplasia of cervix [congenital absence of cervix]
Z90.710	Acquired absence of cervix and uterus
Z90.712	Acquired absence of cervix with remaining uterus
Annual cervical cancer screening with Papanicolaou (Pap) smears (under 21 years of age):
CPT codes covered if selection criteria are met:
88141	Cytopathology, cervical or vaginal (any reporting system), requiring interpretation by physician
88142	Cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation; manual screening under physician supervision
88143	with manual screening and rescreening under physician supervision
88147	Cytopathology smears, cervical or vaginal; screening by automated system under physician supervision
88148	screening by automated system with manual rescreening under physician supervision
88150	Cytopathology, slides, cervical or vaginal; manual screening under physician supervision
88152	with manual screening and computer-assisted rescreening under physician supervision
88153	with manual screening and rescreening under physician supervision
88154	with manual screening and computer-assisted rescreening using cell selection and review under physician supervision
+88155	Cytopathology, slides, cervical or vaginal, definitive hormonal evaluation (e.g., maturation index, karyopyknotic index, estrogenic index) (List separately in addition to code(s) for other technical and interpretation services)
88164	Cytopathology, slides, cervical or vaginal (the Bethesda System); manual screening under physician supervision
88165	with manual screening and rescreening under physician supervision
88166	with manual screening and computer-assisted rescreening under physician supervision
88167	with manual screening and computer-assisted rescreening using cell selection and review under physician supervision
88174	Cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation; screening by automated system, under physician supervision
88175	with screening by automated system and manual rescreening or review, under physician supervision
HCPCS codes covered if selection criteria are met:
P3000	Screening papanicolaou smear, cervical or vaginal, up to three smears; by technician under physician supervision
P3001	requiring interpretation by physician
HCPCS codes not covered for indications listed in the CPB (routine/preventive):
G0123	Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation; screening by cytotechnologist under physician supervision
G0124	requiring interpretation by physician
G0141	Screening cytopathology smears, cervical or vaginal, performed by automated system, with manual rescreening, requiring interpretation by physician
G0143	Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation; with manual screening and rescreening by cytotechnologist under physician supervision
G0144	with screening by automated system, under physician supervision
G0145	Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation, with screening by automated system and manual rescreening under physician supervision
G0147	Screening cytopathology smears, cervical or vaginal; performed by automated system under physician supervision
G0148	performed by automated system with manual rescreening
Q0091	Screening papanicolaou smear; obtaining, preparing and conveyance of cervical or vaginal smear to laboratory
ICD-10 codes covered if selection criteria are met:
B20	Human immunodeficiency virus (HIV) disease
B97.35	Human immunodeficiency virus, type 2 [HIV 2] as the cause of diseases classified elsewhere
C53.0 - C53.9	Malignant neoplasm of cervix uteri
D06.0 - D06.9	Carcinoma in situ of cervix uteri
N87.0 - N87.9	Dysplasia of cervix uteri
O98.511 - O98.53	Other viral diseases complicating pregnancy, childbirth, or the puerperium
R75	Inconclusive laboratory evidence of human immunodeficiency virus [HIV]
R87.610 - R87.619	Abnormal cytological findings in specimens from cervix uteri
Z20.828	Contact with and (suspected) exposure to other viral communicable diseases
Z21	Asymptomatic human immunodeficiency virus [HIV] infection status
Z85.41	Personal history of malignant neoplasm of cervix uteri
Z87.410	Personal history of cervical dysplasia
Z94.0 - Z94.9	Transplanted organ and tissue status
ICD-10 codes not covered for indications listed in the CPB:
Z01.419	Encounter for gynecological examination (general) (routine) without abnormal findings
Z12.4	Encounter for gynecological examination (general) (routine) without abnormal findings
HPV testing in women under 30 years of age:
CPT codes covered if selection criteria are met:
0500T	Infectious agent detection by nucleic acid (DNA or RNA), human papillomavirus (HPV) for five or more separately reported high-risk HPV types (eg, 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 68) (ie, genotyping)
87624	Infectious agent detection by nucleic acid (DNA or RNA); Human Papillomavirus (HPV), high-risk types (eg, 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 68)
87625	Infectious agent detection by nucleic acid (DNA or RNA); Human Papillomavirus (HPV), types 16 and 18 only, includes type 45, if performed
CPT codes not covered for indications listed in the CPB:
Self-collected / self-sampling HPV tests for screening of cervical cancer - no specific code:
87623	Infectious agent detection by nucleic acid (DNA or RNA); Human Papillomavirus (HPV), low-risk types (eg, 6, 11, 42, 43, 44)
ICD-10 codes covered if selection criteria are met (all-inclusive):
R87.610 - R87.613 R87.619, R87.810	Abnormal cytological findings in specimens from cervix
Z01.42	Encounter for cervical smear to confirm findings of recent normal smear following initial abnormal smear
HPV testing for men:
CPT codes not covered for indications listed in the CPB:
0096U	Human papillomavirus (HPV), high-risk types (ie, 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 66, 68), male urine
Cervicography or speculoscopy (Pap-Sure), Spectroscopy/optical/optoelectric detection systems (Luma cervical imaging system, TruScreen) - no specific code:
ICD-10 codes not covered for indications listed in the CPB (not all-inclusive):
C53.0 - C53.9	Malignant neoplasm of cervix uteri
D06.0 - D06.9	Carcinoma in situ of cervix uteri
Z12.4	Encounter for screening for malignant neoplasm of cervix
Methylation markers for cervical cancer screening - no specific code:
ICD-10 codes not covered for indications listed in the CPB (not all-inclusive):
C53.0 - C53.9	Malignant neoplasm of cervix uteri
D06.0 - D06.9	Carcinoma in situ of cervix uteri
Z12.4	Encounter for screening for malignant neoplasm of cervix
Ikonisys oncoFISH cervical test:
CPT codes not covered for indications listed in the CPB:
88271 - 88275	Molecular cytogenetics
88291	Cytogenetics and molecular cytogenetics, interpretation and report
88364 - 88366	In situ hybridization (eg, FISH), per specimen
88367 - 88377	Morphometric analysis, in situ hybridization (quantitative or semi-quantitative), using computer-assisted technology, per specimen
ICD-10 codes not covered for indications listed in the CPB:
C53.0 - C53.9	Malignant neoplasm of cervix uteri
D06.0 - D06.9	Carcinoma in situ of cervix uteri
Z12.4	Encounter for screening for malignant neoplasm of cervix
p16/Ki-67 dual staining - no specific code:
ICD-10 codes not covered for indications listed in the CPB:
C53.0 - C53.9	Malignant neoplasm of cervix uteri
D06.0 - D06.9	Carcinoma in situ of cervix uteri
Z12.4	Encounter for screening for malignant neoplasm of cervix
DYSIS Smart Colposcopy:
CPT codes not covered for indications listed in the CPB:
57465	Computer-aided mapping of cervix uteri during colposcopy, including optical dynamic spectral imaging and algorithmic quantification of the acetowhitening effect
ICD-10 codes not covered for indications listed in the CPB:
Z12.4	Encounter for screening for malignant neoplasm of cervix

The above policy is based on the following references: