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Human papillomavirus (HPV) immunization prevents most cases of cervical intraepithelial neoplasia, so our approach to cervical cancer screening must adapt to immunized populations. Investigators in Australia randomized some 5000 women (age range, 25–64; 22% previously offered HPV immunization) to: primary cytology screening; HPV screening followed by colposcopy for women with HPV16/18 and cytology for women with other oncogenic types; or HPV screening followed by colposcopy for women with HPV 16/18 and p16/Ki67 staining (an indicator of potential oncogenesis) for women with other oncogenic types. Women with positive p16/Ki67 staining were referred for colposcopy.
Rates of cervical intraepithelial neoplasia grade 2+ (CIN2+) detection were 0.1% in the cytology group, 0.7% in the HPV screening plus colposcopy or cytology group, and 0.8% in the HPV screening plus colposcopy or p16/Ki67 staining group. Rates of colposcopy were 41% to 44% higher among women randomized to HPV screening compared with cytology screening.
Canfell K et al. Cervical screening with primary HPV testing or cytology in a population of women in which those aged 33 years or younger had previously been offered HPV vaccination: Results of the Compass pilot randomised trial. PLoS Med 2017 Sep 19; 14:e1002388. (http://dx.doi.org/10.1371/journal.pmed.1002388)
Comment
Primary HPV testing is more sensitive than cytologic screening for detecting precancerous cervical lesions such as CIN2+, and this trial is the first to demonstrate such a finding in a population with high uptake of HPV vaccination. Not surprisingly, colposcopy referrals were more common among women who underwent HPV testing. However, this study includes only baseline screening results; subsequent follow-up may show lower colposcopy rates in HPV-screened participants. Research such as this this will pave the way for novel cervical cancer detection strategies, especially as HPV vaccination coverage increases.