Marc Arbyn

Reproducibility of HPV Testing With Two Versions of the Papilloplex High‐Risk HPV Assay

ABSTRACT Validation of HPV tests usable in cervical cancer screening require demonstration of noninferior clinical accuracy and sufficient reproducibility. The Papilloplex HR‐HPV assay [version1] (Genefirst, UK) has been validated only for clinical accuracy. Here, we assessed its reproducibility, aiming to complete the validation process. A panel of 550 cryopreserved cervical cell samples collected from women attending the cervical cancer screening program in Belgium was used to assess the intra‐ and inter‐laboratory reproducibility of Papilloplex HR‐HPV [version1], a full genotyping assay that identifies separately 14 high‐risk HPV (hrHPV) types using multiple probe amplification technology. We assessed whether the reproducibility fulfils validation criteria (lower 95% confidence interval [CI] bound ≥ 87% and κ ≥ 0.50). Subsequently, we compared the concordance between version1 and a new version6 of the assay and between three analysis methods for PCR curve interpretation. Papilloplex HR‐HPV version1 assay showed an excellent reproducibility for hrHPV (97.5% [CI: 95.8%–98.7%], κ = 0.94 for intra‐ and 93.5% [CI: 91.0%–95.4%], κ = 0.85 for inter‐laboratory reproducibility). Concordance analyses exhibited an excellent agreement between two assay versions and between three PCR curve analysis methods. Papilloplex HR‐HPV version1 assay exhibited excellent reproducibility, completing the international validation criteria. Papilloplex HR‐HPV version6 showed excellent concordance with version1 but still lacks clinical validation.

Clinical Performance of OncoPredict HPV Screening Assay on Self‐Collected Vaginal and Urine Specimens Within the VALHUDES Framework

ABSTRACT The introduction of self‐sampling in cervical cancer screening has raised the importance of HPV test validation on self‐collected samples. This study aimed to evaluate the clinical accuracy of the OncoPredict HPV Screening (SCR) assay on self‐collected vaginal and first‐void urine (FVU) samples, relative to cervical specimens, using the VALHUDES Framework. FVU and vaginal self‐samples followed by a clinician‐collected cervical brushing were collected from 500 women referred to colposcopy and tested using OncoPredict HPV SCR assay. The assay demonstrated clinical sensitivity to detect cervical intraepithelial neoplasia grade 2 or worse (≥ CIN2) similar to cervical samples in FVU (ratio: 0.95, [95% CI: 0.88–1.02]) and vaginal self‐samples (ratio: 0.96 [95% CI: 0.90–1.02]). The clinical specificity for < CIN2 was lower in vaginal (ratio: 0.90 [95% CI: 0.84–0.96]) but not in FVU samples (ratio: 1.03 [95% CI: 0.96–1.12) when compared to cervical samples. However, the relative specificity improved following cut‐off optimization (ratio: 0.94, 95% CI: [0.88–1.01]). Moderate to excellent agreement in HPV detection between self‐collected and cervical samples was demonstrated (Kappa values: 0.53–1.00). To conclude, OncoPredict HPV SCR assay demonstrated similar accuracy on FVU and cervical samples. On vaginal compared to cervical samples sensitivity was similar with a lower specificity, which improved with cut‐off optimization.

Clinical Validation of the Venus HPV Full‐Genotyping Assay for Cervical Cancer Screening in the VALGENT‐4 Framework

ABSTRACTThe Venus HPV assay (VenusHPV) is a real‐time PCR‐based human papillomavirus (HPV) test that is widely used in China but lacks extensive clinical validation. The VALidation of HPV GENotyping Tests (VALGENT) framework is an established protocol for evaluating HPV genotyping assays against a standard comparator test. This study aimed to assess the clinical accuracy and reproducibility of the VenusHPV assay following international validation criteria. The clinical performance of VenusHPV was evaluated against the GP5+/6+ PCR‐based enzyme immunoassay (GP‐EIA) using the VALGENT‐4 panel, which included 998 consecutive routine screening samples enriched with 297 samples with abnormal cytology from the Danish cervical cancer screening program. Cases were defined as women diagnosed with histologically confirmed cervical intraepithelial neoplasia 2 or more (CIN2+), while two consecutive negative cytology results served as a proxy for nondisease. Intra‐ and interlaboratory reproducibility was assessed on 500 samples. Using the manufacturer‐recommended cutoff, VenusHPV demonstrated noninferior sensitivity for detection of CIN2+, but its specificity for ≤ CIN1 was inferior to that of GP‐EIA. Applying an optimized a posteriori cutoff improved the specificity, yielding relative specificity of 1.02 (95% CI [CI], 1.00–1.03; p noninferiority [pn.inf] < 0.0001), while maintaining a noninferior sensitivity (of 1.02; CI, 1.00–1.08; pn.inf < 0.0001). The intra‐ and interlaboratory reproducibility was excellent (95.2%, CI, 93.3–97.1%, Kappa [κ] = 0.87 and 94.0%, CI, 92.0%–96.0%, κ = 0.85, respectively). Notably, the reproducibility criteria were met consistently, regardless of whether the unadjusted or optimized cutoff was applied. The VenusHPV was as sensitive as the GP‐EIA for detecting cervical precancer using the unadjusted cutoff but less specific. However, after cutoff optimization, VenusHPV met the international accuracy criteria for cervical cancer screening. Additionally, the assay demonstrated excellent reproducibility.

Accuracy of HPV Self-Collection Compared with Clinician-Collected HPV Testing and Cytology: A Meta-analysis

Abstract Meta-analyses show comparable clinical accuracy of PCR-based human papillomavirus (HPV) assays on self- compared with clinician-collected specimens. We extended these meta-analyses by comparing HPV testing on both samples with cytology from clinician-collected specimens. Studies published in PubMed, Embase, and Cochrane Library up to September 2024 were reviewed for inclusion. Studies had to report paired HPV self-collection, clinician-collected HPV testing, and cytology. Performance measures included sensitivity and specificity of atypical squamous cells of undetermined significance or worse and high-risk HPV positivity in self- and clinician-collected samples for cervical intraepithelial neoplasia 2 or worse. Accuracy data were pooled using the bivariate normal model for logit transforms of sensitivity and specificity. Sixteen full-text articles met inclusion criteria. Studies were heterogeneous and included referral populations, which may overestimate cytology sensitivity. Cytology was less sensitive in detecting cervical intraepithelial neoplasia 2 or worse (pooled sensitivity 87%; 95% confidence interval, 76–93) compared with HPV testing on self- (90%) and clinician-collected samples (93%) when restricting to PCR-based HPV assays. Overall, HPV self-collection sensitivity surpassed clinician-collected cytology testing, demonstrating that 3-year screening intervals, which are recommended for negative cytology results, are safe to use for negative HPV results from self-collected specimens. Longitudinal data of HPV testing on self- versus clinician-collected samples are lacking.

Creating a data processing warehouse to support performance monitoring of cancer screening programmes in Europe using a common set of indicators

Abstract The CanScreen-ECIS project implemented by International Agency for Research on Cancer aimed to define indicators to monitor, breast, cervical, colorectal, and lung cancer screening and create a validated mechanism for the European screening programmes to be able to systematically collect and submit performance data for public dissemination through European Cancer Information System (ECIS). Indicators were developed through a stepwise process of literature review, Delphi survey followed by face-to-face interaction. A survey questionnaire to report policies, protocols, and organization of screening programmes and a data collection tool to estimate indicators across the screening continuum were designed. These were integrated into a data warehouse to permit programme managers to access the tools, undergo training, submit data, and estimate the indicators. The same warehouse would allow peer-reviewing of submitted information and data and will ultimately be connected to ECIS for data visualization. Functionalities of the tools and the warehouse were pilot tested through data collection from several European countries. Total 23 indicators were selected based on priority and feasibility. Programme managers from 23 European countries completed the surveys and submitted data from national/regional screening programmes. Data to estimate the indicators were obtained from 17, 13, and 15 breast, cervical, and colorectal cancer screening programmes, respectively. Major challenges identified by the participants included collecting data from opportunistic screening and data disaggregated by socio-economic status and other indicators of inequalities. The data warehouse will facilitate systematic data collection to report the status and performance of cancer screening programmes in the EU.

Technical, legal and ethical framework of cancer audit in cervical screening – Summary of best practices for organised programmes delineated through an expert group consultation

AbstractEfficient and well‐organised cervical screening programmes have significantly reduced both the incidence and mortality rates of cervical cancer in the population. For optimal performance, such programmes need to incorporate essential quality assurance measures. The International Agency for Research on Cancer (IARC/WHO) organised an expert consultation to delineate best practices in auditing cancers in a cervical screening programme, the legal and ethical frameworks governing such audits, and communicating audit outcomes. As a best practice, every programme should have a well‐documented policy and process framework for cancer audits. The TWGs agreed that the primary goal of programmatic cancer audits is to assess the programme's effectiveness in lowering cervical cancer incidence and minimising screening‐related risks. Using audit results, informed decisions can be made to enhance service delivery, including professional training, adopting improved screening tests, strengthening fail‐safe mechanisms, reducing delays, and minimising inequalities. Legal complexities in cervical screening stem from its inherent limitations and risks, and differentiating cases of negligence from inevitable and non‐negligent errors where an abnormality is not detected but actually exists is crucial. TWGs suggested that determining whether a screening error was serious enough to be categorised as negligent and/or to entitle the patient to compensation should reflect the inherent limitations of cervical screening. Data obtained while performing screening tests and subsequent diagnostic tests or treatments are sensitive and need to be safeguarded. The best practice document drafted through expert consultation will help cervical screening programmes standardise practices related to cancer audits and address associated legal and ethical issues.

The Sansure® Human Papillomavirus DNA Diagnostic Kit offers excellent reproducibility performance for the detection of high‐risk HPV

AbstractCervical cancer screening is a cornerstone of cervical cancer elimination. Detection of high‐risk human papillomavirus (hrHPV) is recommended as the first step in screening provided that the assay used has been adequately validated. The Sansure® Human Papillomavirus DNA Diagnostic Kit is a new assay designed to detect HPV16, HPV18 and 13 other HPV in aggregate. The study aimed to evaluate the intra‐ and interlaboratory reproducibility of the assay according to international guidelines. Five hundred and fifty cervical residual cell samples from women attending cervical cancer screening were selected from the biobank of the HPV National Reference Centre in Belgium and used in this study. After DNA extraction, HPV was tested using the Sansure® Human Papillomavirus DNA Diagnostic Kit. The lower 95% confidence limit around the general reproducibility of this assay should be greater than or equal to 87%, with κ ≥ 0.50. Five hundred and thirty‐three samples had valid results. The Sansure® Human Papillomavirus DNA Diagnostic Kit demonstrated an excellent intra‐laboratory reproducibility of 93.8% (95% confidence interval [CI]: 91.4–95.7, κ = 0.85). The interlaboratory reproducibility was 93.4 (95% CI: 91.0–95.4, κ = 0.84). Intra and interlaboratory reproducibility were also excellent at the genotype level. Excluding HPV53 single infection samples from the analyses also resulted in excellent agreement. These data show that the Sansure® Human Papillomavirus DNA Diagnostic Kit is highly reproducible.

Accuracy of Liferiver HarmoniaHPV and VenusHPV Assays on Urine and Vaginal Self‐Samples

ABSTRACT In this report, the clinical performance of Liferiver HarmoniaHPV and Liferiver VenusHPV was evaluated under the VALHUDES framework. Five hundred and twenty‐three women collected first‐void urine (FVU) with Colli‐Pee and vaginal samples with Evalyn Brush or Qvintip. Cervical samples were taken with the Cervex Brush by a clinician. Both vaginal and cervical samples were resuspended in 20 mL ThinPrep. Triplet samples from 499 women were tested with HarmoniaHPV and VenusHPV tests. The clinical accuracy of HarmoniaHPV did not differ in FVU and vaginal self‐samples versus cervical samples. The relative sensitivity for CIN2+ on FVU and vaginal samples was 0.95 [95% CI 0.89–1.02] and 0.95 [95% CI 0.88–1.02], respectively. Relative specificity for < CIN2 was 0.95 [0.86–1.04] on FVU and 0.93 [0.86–1.01] on vaginal samples. VenusHPV demonstrated lower sensitivity on both self‐sample types, whereas the specificity was similar to cervical samples. Post‐hoc adjustment of the VenusHPV C t ‐values improved sensitivity (ratio FVU/cervical = 0.94 [95% CI 0.88–1.00]; ratio vaginal/cervical = 0.96 [95% CI 0.92–1.01]) without compromising specificity (ratio FVU/cervical = 1.00 [0.92–1.09]; ratio vaginal/cervical = 0.95 [95% CI 0.88–1.02]) on both self‐samples. In conclusion, HarmoniaHPV and VenusHPV tests demonstrated similar clinical accuracy on FVU and vaginal self‐ versus cervical samples, although VenusHPV test required cut‐off optimization.

Clinical validation of the Roche cobas HPV test on the Roche cobas 5800 system for the purpose of cervical screening

ABSTRACT This study assessed the relative clinical sensitivity and specificity, as well as reproducibility, for high-risk HPV types of the Roche cobas HPV test when processed using the Roche cobas 5800 system. The results from this study demonstrate that the cobas HPV test using the cobas 5800 system fulfils the Meijer criteria for use in population-based cervical screening. This clinical validation study also examines the clinical sensitivity and specificity based on partial genotyping, with separate detection of HPV16 and HPV18, compared with the Roche cobas 4800 HPV test, a second-generation standard comparator assay. The cobas HPV test has a relative clinical sensitivity of 1.000, when compared with the cobas 4800 HPV test to detect histologically confirmed CIN2+ lesions in woman aged 30 years or older, with a relative clinical specificity of 0.995. The general intra- and inter-laboratory agreement for the cobas HPV test on the cobas 5800 system for finding a HPV positive result were 99.1% and 99.6%, respectively. IMPORTANCE This study demonstrates, for the first time, the clinical performance of the Roche cobas HPV test when processed using the new cobas 5800 system [cobas (5800)]. This study shows that the cobas (5800) demonstrates relative clinical sensitivity and specificity, when compared with a standard comparator HPV test, which meets the international HPV test validation requirements. Intra- and inter-laboratory reproducibility also fulfills these criteria. The current study demonstrates that the cobas (5800) can be used for primary HPV-based cervical screening on cervical specimens.

Criteria for second generation comparator tests in validation of novel HPV DNA tests for use in cervical cancer screening

Abstract While HC2 and GP5+/6+ PCR‐EIA were pivotal in test validation of new HPV assays, they represent the first generation of comparator tests based upon technologies that are not in widespread use anymore. In the current guideline, criteria for second‐generation comparator tests are presented that include more detailed resolution of HPV genotypes. Second‐generation comparator tests should preferentially target only the 12 genotypes classified as carcinogenic (IARC‐group I), and show consistent non‐inferior sensitivity for CIN2+ and CIN3+ and specificity for ≤CIN1 compared to one of the first‐generations comparators, in at least three validation studies using benchmarks of 0.95 for relative sensitivity and 0.98 for relative specificity. Validation should take into account used storage media and other sample handling procedures. Meta‐analyses were conducted to identify the assays that fulfill these stringent criteria. Four tests fulfilled the new criteria: (1) RealTime High‐Risk HPV Test (Abbott), (2) Cobas‐4800 HPV test (Roche Molecular System), (3) Onclarity HPV Assay (BD Diagnostics), and (4) Anyplex II HPV HR Detection (Seegene), each evaluated in three to six studies. Whereas the four assays target 14 carcinogenic genotypes, the first two identify separately HPV16 and 18, the third assay identifies five types separately and the fourth identifies all the types separately.

Evaluation of the Allplex HPV assay’s adherence to international guidelines for cervical cancer screening in clinician-collected samples

ABSTRACT Clinically validated human papillomavirus (HPV) assays are crucial in cervical cancer screening. In this study, we evaluated the Allplex HPV HR Detection assay (Seegene, SouthKorea) for its clinical accuracy and reproducibility according to the international criteria, using the RealTime High Risk HPV m2000 assay (Abbott, USA) as standard comparator. The Allplex HPV HR assay exhibits significant non-inferior sensitivity to detect cervical intraepithelial neoplasia grade (CIN) 2 or worse (CIN2+) with a ratio of 1.00 (95% CI: 0.97–1.03, P = 0.006), insignificant non-inferior sensitivity to detect CIN3+ with a ratio of 1.00 (95% CI: 0.88–1.13, P = 0.098), and non-inferior specificity to exclude CIN2+ with a ratio of 0.99 (95% CI: 0.99–1.00, P < 0.001) compared to the standard comparator. In addition, the assay shows an excellent reproducibility within the same laboratory [96.5% (95% CI: 94.6–97.9) with a kappa value of 0.91 (95% CI: 0.87–0.95)] and between laboratories [96.7% (95% CI: 94.8–98.0) with a kappa value of 0.91 (95% CI: 0.87–0.95)] for overall high-risk HPV positivity as well as for each individual HPV type. Pooling our study data with those of another independent study supports the consistency of our findings. We conclude that both the clinical accuracy to detect cervical precancer and the reproducibility of Allplex HPV HR Detection assay fulfill the international validation criteria of use in cervical cancer screening. IMPORTANCE The clinical validation of human papillomavirus (HPV) assays in accordance with well-established international guidelines is crucial to ensure that only validated assays are used in the context of screening (Meijer et al., Int J Cancer, 2009). The guidelines, developed by an international consortium, require that a novel HPV assay has non-inferior accuracy against a standard comparator test for the detection of cervical intraepithelial neoplasia grade (CIN) 2 or worse (CIN2+). Additionally, a new HPV assay should meet specific criteria for both intra- and inter-laboratory reproducibility to ensure the assay consistently exhibits technical precision and robust performance. Pooling our study data with those of another independent study supports the consistency of our findings. In conclusion, both the clinical accuracy to detect cervical precancer and the reproducibility of Allplex HPV HR Detection assay fulfill the international validation criteria of use in cervical cancer screening.

Intra‐ and interlaboratory reproducibility evaluation toward international validation status of the AmpFire assay

Abstract To meet the screening goal of WHO's 90‐70‐90 strategy aimed at eliminating cervical cancer (CC) by 2030, clinical validation of human papillomavirus (HPV) assays is essential to provide accurate and valid results through fulfilling three criteria of the international validation guidelines (IVGs). Previously, the clinical accuracy of the AmpFire® HPV Screening 16/18/HR assay (AmpFire assay) was reported but reproducibility data are lacking. Here, we aim to evaluate the intra‐ and inter‐laboratory reproducibility of the AmpFire assay. The reproducibility of the isothermal AmpFire assay was assessed using 556 cervical cell samples collected from women attending CC screening and biobanked in a Belgian HPV national reference center. This assay detects HPV16, HPV18, and 12 other high‐risk HPV (hrHPV) types (31/33/35/39/45/51/52/56/58/59/66/68) in aggregate. Lower 95% confidence interval bound around the assay's reproducibility should exceed 87%, with κ  ≥ 0.50. Additionally, a literature review of the assay's clinical performance was performed. The AmpFire assay showed an excellent intralaboratory (96.4%, 95% CI:94.5–97.8%, κ  = 0.920) and interlaboratory (95.3%, 95% CI:93.2–96.9%, κ  = 0.897) reproducibility. One study demonstrated noninferior sensitivity of a prototype AmpFire assay targeting 15 hrHPV types (including HPV53) to detect CIN2+. However, clinical specificity became similar to the comparator after removing HPV53 from analyses. The low‐cost and easy‐to‐use AmpFire assay presents excellent reproducibility and—after removing HPV53 from the targeted types—fulfills also clinical accuracy requirements. Inclusion of HPV53, which is not recognized as carcinogenic, comprises clinical specificity of screening assays.

Linkage of individual-patient data confirm protection of prophylactic human papillomavirus vaccination against invasive cervical cancer

Performance of BD Onclarity HPV assay on FLOQSwabs vaginal self-samples

ABSTRACT This study assessed the accuracy of high-risk human papillomavirus testing of BD Onclarity HPV (Onclarity) assay on vaginal self-collected FLOQSwab versus cervical samples to ensure similar accuracy to detect cervical intraepithelial neoplasia. Testing was performed on two automated platforms, BD Viper LT and BD COR, to evaluate the effect of machine and using two vaginal self-samples to analyze the influence of collection, transport, and freezing-unfreezing on the results. A cervical sample and two self-samples were collected from 300 women. The first collected vaginal and the cervical sample were tested on BD Viper LT, and the second swab was frozen and subsequently tested on both automated systems. Test results on vaginal and cervical specimens were considered the index and comparator, respectively; colposcopy and histology were reference standards. Relative sensitivity for ≥CIN2 on vaginal samples analyzed versus the cervical sample was 1.01 (0.97–1.06), 1.01 (0.97–1.06), and 1.00 (0.95–1.05), for the first, second self-collected sample tested on BD VIPER LT, and second self-collected sample tested on BD COR, respectively. Relative specificity was 0.83 (0.73–0.94), 0.76 (0.67–0.87), and 0.82 (0.73–0.92) using the three different workflows. Cut-off optimization for human papillomavirus (HPV) positivity defined at Ct ≤38.3 for HPV16, ≤ 34.2 for HPV18, and ≤31.5 for all other types showed an increased relative specificity with similar sensitivity. No significant difference was observed between self-samples tested with the two platforms and between first- and second-collected swabs. Onclarity assay on FLOQSwab using both platforms showed similar sensitivity but lower specificity to detect ≥CIN2 compared to cervical samples. By cut-off optimization, non-inferior specificity could be reached. IMPORTANCE Human papillomavirus (HPV) testing on self-collected vaginal samples has been shown to improve women’s participation to cervical cancer screening programs, particularly in regions with limited access to health care. Nevertheless, the introduction of self-sampling in cervical cancer screening programs requires prior clinical validation of the HPV assay in combination with a self-sample collection device, including also the laboratory workflow and automation required for high-throughput testing in screening. In this study, the performance of BD Onclarity HPV on FLOQSwab-collected vaginal self-samples has been compared to clinician-taken liquid-based cytology samples, to detect high-grade cervical intraepithelial neoplasia using two high-throughput platforms, BD Viper LT and BD COR. The study findings have shown a similar performance of BD Onclarity on testing self-collected samples, confirming the validation of the proposed pre-analytical and analytical protocols for their use in cervical cancer screening programs based on self-collected vaginal samples.

The impact of HPV vaccination beyond cancer prevention: effect on pregnancy outcomes

While the benefits of human papillomavirus (HPV) vaccination relating to cervical cancer prevention have been widely documented, recent published evidence is suggestive of an impact on adverse pregnancy outcomes (APOs) in vaccinated mothers and their infants, including a reduction in rates of preterm births and small for gestational age infants. In this review, we examine this evidence and the possible mechanisms by which HPV vaccination may prevent these APOs. Large-scale studies linking HPV vaccination status with birth registries are needed to confirm these results. Potential confounding factors to consider in future analyses include other risk factors for APOs, and historical changes in both the management of cervical precancerous lesions and prevention of APOs. If confirmed, these additional benefits of HPV vaccination in reducing APO rates will be of global significance, due to the substantial health, social and economic costs associated with APOs, strengthening the case for worldwide HPV immunization.

Geographic and temporal variations in the incidence of vulvar and vaginal cancers

AbstractVulvar and vaginal cancers are relatively rare cancers, together responsible for less than 1% of the global cancer incidence among women in 2018. The majority of vaginal cancers and a lesser proportion of vulvar cancers are associated with HPV, with rising incidence rates of vulvar cancer observed in younger women, possibly due to an increased prevalence of high‐risk HPV types. This report assesses recent international variations in the incidence rates of vulvar and vaginal cancer derived from high‐quality data from population‐based cancer registries in 68 countries, and further assesses time trends for selected longer‐term series in eight countries (Australia, China, Colombia, India, Norway, Slovakia, the U.S., and the U.K.) over the period 1983 to 2012. We observed a 30‐fold variation in the recorded incidence rates of vulvar cancer in contrast with the threefold variation for vaginal cancer. We also observed a rising incidence of vulvar cancer in Australia, Norway and the U.K., and Slovakia, with a more rapid rise in the rates seen in women aged < 60 years at diagnosis. The annual percentage change over the most recent decade varied from 1.7% in Norway to 4.1% in Slovakia. The increases are largely confined to younger women and are likely linked to generational changes in sexual behaviour (earlier age at sexual debut and increasing transmission of HPV among cohorts born 1940 to 1950 and thereafter. Vaginal cancer incidence rates, in contrast, were lower and more stable, despite the higher HPV‐attributable fraction relative to vulvar cancer. Irrespective of the trends, an increasing number of women are predicted to be diagnosed worldwide with both cancer types in future decades as population ageing and growth continues. The promise of high‐coverage HPV vaccination will likely counter this rising burden, but the impact may take a number of decades.

The European response to the WHO call to eliminate cervical cancer as a public health problem

AbstractThe age‐standardised incidence of cervical cancer in Europe varies widely by country (between 3 and 25/100000 women‐years) in 2018. Human papillomavirus (HPV) vaccine coverage is low in countries with the highest incidence and screening performance is heterogeneous among European countries. A broad group of delegates of scientific professional societies and cancer organisations endorse the principles of the WHO call to eliminate cervical cancer as a public health problem, also in Europe. All European nations should, by 2030, reach at least 90% HPV vaccine coverage among girls by the age of 15 years and also boys, if cost‐effective; they should introduce organised population‐based HPV‐based screening and achieve 70% of screening coverage in the target age group, providing also HPV testing on self‐samples for nonscreened or underscreened women; and to manage 90% of screen‐positive women. To guide member states, a group of scientific professional societies and cancer organisations engage to assist in the rollout of a series of concerted evidence‐based actions. European health authorities are requested to mandate a group of experts to develop the third edition of European Guidelines for Quality Assurance of Cervical Cancer prevention based on integrated HPV vaccination and screening and to monitor the progress towards the elimination goal. The occurrence of the COVID‐19 pandemic, having interrupted prevention activities temporarily, should not deviate stakeholders from this ambition. In the immediate postepidemic phase, health professionals should focus on high‐risk women and adhere to cost‐effective policies including self‐sampling.

Self‐sampling as the principal modality for population based cervical screening: Five‐year follow‐up of the PaVDaG study

AbstractSelf‐sampling provides a powerful means to engage women in cervical screening. In the original Papillomavirus Dumfries and Galloway study (PaVDaG), we demonstrated cross‐sectional similarity of high‐risk human papillomavirus (Hr‐HPV) testing on self‐taken vaginal vs clinician‐taken samples for the detection of cervical intraepithelial neoplasia 2 or worse (CIN2+). Few data exist on the longitudinal performance of self‐sampling; we present longitudinal outcomes of PaVDaG. Routinely screened women provided a self‐taken and a clinician‐collected sample. Ninety‐one percent of 5136 women from the original cohort completed a further screening round. Sensitivity, specificity, positive predictive value and complement of the negative predictive value of the Hr‐HPV test on self‐samples for detection of CIN2+ and CIN3+ up‐to 5 years after testing were determined. Additionally, clinical accuracy of Hr‐HPV testing on vaginal and clinician‐collected samples was assessed. A total of 183 CIN2+ and 102 CIN3+ lesions were diagnosed during follow‐up. Risk of CIN2+ and CIN3+ following an Hr‐HPV negative self‐sample was 0.6% and 0.2%, respectively, for up to 5 years after testing. The relative sensitivity for CIN3+ and specificity for ≤CIN1 of Hr‐HPV testing on self‐taken specimens was slightly lower vs clinician‐collected samples: 0.95 (95% CI: 0.90‐0.99; PMcN = .0625) and 0.98 (95% CI: 0.95‐1.00; PMcN = <.0000), respectively. The low risk of CIN2+ in women with Hr‐HPV—self‐sample(s) suggests, that the 3 to 5‐year recall interval implemented in several cervical screening settings, based on clinician‐taken samples, may be safe for self‐samples. Future assessment will show if “universal” 5‐year screening is appropriate for programs based on self‐sampling.

Offering HPV self-sampling kits: an updated meta-analysis of the effectiveness of strategies to increase participation in cervical cancer screening

Human papillomavirus (HPV) testing on self-samples represents a great opportunity to increase cervical cancer screening uptake among under-screened women. A systematic review and meta-analysis on randomised controlled trials (RCTs) were performed to update the evidence on the efficacy of strategies for offering self-sampling kits for HPV testing compared to conventional invitations and to compare different self-sampling invitation scenarios. Four experimental invitational scenarios were considered. Women in the control group were invited for screening according to existing practice: collection of a cervical specimen by a healthcare professional. Random-effects models were used to pool proportions, relative participation rates and absolute participation differences. Thirty-three trials were included. In the intention-to-treat analysis, all self-sampling invitation scenarios were more effective in reaching under-screened women compared to controls. Pooled participation difference (PD) and 95% confidence interval (CI) for experimental vs. control was 13.2% (95% CI = 11.0-15.3%) for mail-to-all, 4.4% (95% CI = 1.2-7.6%) for opt-in, 39.1% (95% CI = 8.4-69.9%) for community mobilisation & outreach and 28.1% (23.5-32.7%) for offer at healthcare service. PD for the comparison opt-in vs. mail-to-all, assessed in nine trials, was -8.2% (95% CI = -10.8 to -5.7%). Overall, screening participation was higher among women invited for self-sampling compared to control, regardless of the invitation strategy used. Opt-in strategies were less effective than send-to-all strategies.

Can HPV Selfy be considered as a clinically validated HPV test for use in cervical cancer screening?

Validation of BD Onclarity HPV Assay on Vaginal Self-Samples versus Cervical Samples Using the VALHUDES Protocol

Abstract Background: In this study, we evaluated accuracy of HPV testing on self-samples versus clinician-taken samples through the VALHUDES protocol. VALHUDES was designed as a diagnostic test accuracy study, where women referred to colposcopy collected self-samples followed by clinician-taken cervical samples. Methods: Four hundred eighty-five women recruited in five colposcopy clinics (median age = 40 years; IQR, 31–49) with valid results for all specimens were included in the main analysis: 230 vaginal self-samples were collected with Evalyn Brush and 255 with Qvintip. Cervical samples were taken by the gynecologist with the Cervex-Brush. HPV testing was performed with BD Onclarity HPV assay (Onclarity). Colposcopy and histology were used as the reference standard for accuracy estimation. Results: The sensitivity for CIN2+ on vaginal self-samples overall was not different from cervical samples (ratio = 0.96; 95% CI, 0.90–1.03), whereas specificity was significantly higher (ratio = 1.09; 95% CI, 1.02–1.16). However, the relative accuracy (self- vs. clinician sampling) differed by vaginal collection device: relative sensitivity and specificity ratios of 1.00 (95% CI, 0.94–1.06) and 1.15 (95% CI, 1.05–1.25), respectively for Evalyn-Brush; 0.91 (95% CI, 0.79–1.04) and 1.03 (95% CI, 0.95–1.13), respectively for Qvintip. Conclusions: Clinical accuracy of BD Onclarity HPV assay on vaginal self-samples was not different from cervical samples. Impact: VALHUDES study showed that HPV testing with Onclarity HPV on vaginal self-samples is similarly sensitive compared with cervical specimens. However, differences in accuracy by self-sampling devices, although not significant, were noted. Onclarity HPV testing on vaginal self-samples following validated collection and handling procedures may be used in primary cervical cancer screening.

Clinical Performance of the RealTi m e High Risk HPV Assay on Self-Collected Vaginal Samples within the VALHUDES Framework

Self-samples are becoming a crucial part of HPV-based cervical cancer screening programs to reach nonattendee women and increase screening coverage. Therefore, the VALHUDES framework was established to validate and evaluate HPV tests and devices on self-samples.

Accuracy of HPV E6/E7 oncoprotein tests to detect high-grade cervical lesions: a systematic literature review and meta-analysis

Abstract Background Cervical carcinogenesis is mediated by the HPV-E6 and E7 oncoproteins, considered as biomarkers usable in managing screen-positive women. Methods We conducted a systematic review and meta-analysis assessing the accuracy of HPV-E6/E7-oncoprotein tests to detect underlying cervical-precancer and cancer. We included studies reporting data on oncoprotein test accuracy detecting cervical intraepithelial neoplasia grade 3 or worse. Random effects logistic regression models were applied for pooling absolute and relative accuracy. Results Twenty-two studies were included. Sensitivity and specificity estimates ranged from 54.2% (95%CI: 45.2–63.0) to 69.5% (95%CI:60.8–76.9) and from 82.8% (95%CI: 50.4–95.8) to 99.1 (95%CI: 98.8–99.3), respectively in the population irrespective of HPV status. Higher sensitivity estimates ranging from 60.8% (95%CI: 49.6–70.9) to 75.5% (95%CI: 71.7–78.9) but lower specificity estimates ranging from 83.7% (95%CI: 76.1–89.3) to 92.1% (95%CI: 88.5–94.6) were observed in studies enrolling high-risk-HPV-positive women. Studies recruiting only HIV-positive women showed a pooled sensitivity of 46.9% (95%CI: 30.6–63.9) with a specificity of 98.0% (95%CI: 96.8–98.7). Conclusions The high specificity of oncoprotein tests supports its use for triaging HPV-positive women. However, oncoprotein-negative women would not be recommended to undertake routine screening, requiring further follow-up. Large-scale and longitudinal studies are needed to further investigate the role of E6/E7-oncoprotein detection in predicting the risk of developing cervical pre-cancer and cancer.

Clinical Accuracy of Alinity m HR HPV Assay on Self- versus Clinician-Taken Samples Using the VALHUDES Protocol

The VALHUDES protocol was established to evaluate clinical accuracy of human papillomavirus (HPV) assays to detect cervical precancer on first-void urine (FVU) and vaginal self-samples versus matched clinician-collected cervical samples (CCSs). Here we evaluated clinical performance of Alinity m HR HPV assay in a colposcopy referral population. Home-collected FVU (Colli-Pee FV 5020) 1 day before colposcopy (n = 492), at-clinic collected dry vaginal self-samples [multi-Collect Swab (mC; n = 493), followed by Evalyn Brush (EB; n = 233) or Qvintip (QT; n = 260)] and matched CCSs, were available for the study. Sensitivity to detect cervical intraepithelial neoplasia grade 2 or higher (CIN2

Clinical performance of the novel full‐genotyping OncoPredict HPV Quantitative Typing assay using the VALGENT framework

AbstractClinical validation of human papillomavirus (HPV) assays according to international criteria is prerequisite for their implementation in cervical cancer screening. OncoPredict HPV Quantitative Typing (QT) assay (Hiantis Srl, Milan, Italy) is a novel full‐genotyping multiplex real‐time PCR quantitative assay targeting E6/E7 genes, allowing individual viral load determination of 12 high‐risk (HR) HPV types. Quality controls for sample adequacy, efficiency of nucleic acid extraction and PCR inhibition are included in the assay. Clinical performance of OncoPredict HPV QT test was assessed as part of the “Validation of HPV Genotyping Tests” (VALGENT‐2) framework, consisting of 1300 cervical liquid‐based cytology (LBC) samples of women aged between 20 and 60 years who had originally attended for routine cervical screening in Scotland. The clinical accuracy of the OncoPredict HPV QT (index test) for the detection of CIN2+ was assessed relative to the GP5+/6+ Enzyme ImmunoAssay (GP5+/6+ EIA) (comparator test), using noninferiority criteria. Intra‐ and interlaboratory reproducibility of the assay was assessed on a subpopulation, comprising 526 samples. The relative sensitivity and specificity for OncoPredict HPV QT vs GP5+/6+‐PCR‐EIA were 1.01 (95% CI: 0.99‐1.03) and 1.03 (95% CI: 1.0‐1.06) respectively. The P‐values for noninferiority were ≤0.001. The intra‐ and inter‐laboratory reproducibility demonstrated a high concordance (>98.7%) with kappas for individual types ranging from 0.66 to 1.00. OncoPredict HPV QT fulfills the international validation criteria for the use of HPV tests in cervical cancer screening.

Intra‐ and interlaboratory reproducibility of the RIATOL qPCR HPV genotyping assay

AbstractThe implementation of cervical screening based on human papillomavirus (HPV) continues to progress rapidly across countries. Evidence has shown that assays detecting high‐risk human papillomavirus (hrHPV) deoxyribonucleic acid (DNA) are more effective than cytology‐based screening. Validation of new hrHPV DNA assays requires both noninferior clinical accuracy compared to a standard comparator for cervical precancer and good reproducibility. This study builds upon previous diagnostic accuracy assessments of the RIATOL HPV genotyping qPCR assay and aims to evaluate the international validation criteria for reproducibility. The intra‐ and interreproducibility of the RIATOL‐qPCR assay were assessed using 550 remnant cervical cell material from the cytology archive of the National Reference Center for HPV in Belgium. Specimens were collected in the context of cervical cancer screening and tested in two different laboratories. The international reproducibility criteria include the lower bound of 95% confidence interval of the intra‐ and interlaboratory agreement regarding the detection of hrHPV DNA exceeding 87% with kappa ≥0.50. The RIATOL‐qPCR assay demonstrated excellent intralaboratory reproducibility, achieving an overall agreement of 98.2 (95% CI 96.6–99.1%) and a kappa of 0.96. Interlaboratory testing showed an overall agreement of 98.5 (95% CI 97.1–99.4%) with a kappa of 0.97. The RIATOL‐qPCR assay fulfills the third criterion for HPV test reproducibility requirement for use in cervical cancer screening.

Comparison of the Clinical Accuracy of Xpert HPV Assay on Vaginal Self-Samples and Cervical Clinician-Taken Samples within the VALHUDES Framework

The accuracy of high-risk human papillomavirus testing with the Xpert HPV assay on vaginal self-samples was compared with clinician-taken samples within the VALidation of HUman papillomavirus assays and collection DEvices for Self-samples and urine samples (VALHUDES) framework. Five-hundred and twenty-three women were recruited in five Belgian colposcopy clinics, of whom 483 (median age, 40 years; interquartile range, 31 to 49 years) were included in the main analysis (226 collected with Evalyn Brush and 257 collected with Qvintip). Cervical samples were collected with Cervex-Brush. Colposcopy and histology outcomes were considered as the reference standard. The Xpert HPV assay had similar accuracy for cervical intraepithelial neoplasia ≥2 on self-collected versus clinician-collected samples [relative sensitivity, 0.96 (95% CI, 0.91-1.02); and relative specificity, 0.96 (95% CI, 0.89-1.04)]. The relative accuracy slightly differed by vaginal collection device [sensitivity ratios of 0.98 (95% CI, 0.90-1.06) and 0.94 (95% CI, 0.87-1.02) for Evalyn and Qvintip, respectively; specificity ratios of 1.06 (95% CI, 0.95-1.19) and 0.88 (95% CI, 0.80-0.98) for Evalyn and Qvintip, respectively]. No difference in cycle threshold values was observed between vaginal and cervical samples. In conclusion, the sensitivity of Xpert HPV assay for cervical intraepithelial neoplasia ≥2 on vaginal self-samples was similar to that of cervical specimens. The clinical specificity was lower than on clinician-collected samples when self-samples were taken with Qvintip.

Reflections Regarding Validation of New HPV Tests With Reduced HPV Genotypes: Report From an IARC Expert Consultation

ABSTRACT Of the 12 HPV genotypes classified as carcinogenic to humans (Group 1), over 95% of HPV‐positive cervical cancers are linked to eight genotypes (HPV16/18/31/33/35/45/52/58). Screening programmes may consider HPV tests incorporating only these genotypes to improve screening efficiency and reduce programmatic costs. Validation of such tests requires fine‐tuning of existing criteria. An expert group convened by the International Agency for Research on Cancer discussed how existing criteria by Meijer et al. for HPV screening clinical validation should be adapted to evaluate new reduced‐valency HPV tests. Experts identified four key criteria: (1) Clinical performance criteria should meet WHO HPV test Target Product Profiles (TPP) minimal standards with high relative sensitivity ( ≥ 0.90 for CIN2+ and ≥ 0.95 for CIN3+) and relative specificity ( ≥ 0.98 for ≤ CIN1) to detect CIN2/3+ lesions associated with types targeted by the test, as established by a comparator test providing information on the presence of the targeted genotypes; (2) Comparator tests should be clinically validated according to Meijer criteria principles for comparator tests, and should offer HPV genotyping to detect at least the types included in the reduced‐valency test; (3) Cervical samples should be representative of a population‐based screening programme; (4) Intra‐ and inter‐laboratory reproducibility should adhere to Meijer criteria and, preferentially also the more stringent TPP. As the global HPV type distribution in cervical cancer is well known, a future evaluation strategy may consider including both virological and simplified clinical standards. The consultation highlights essential criteria building on existing clinical accuracy standards, enriched with analytical standards. These criteria will be instrumental in ensuring both accuracy and reliability of new reduced‐valency HPV tests for cervical cancer screening highly needed to assure 70% coverage aim of cervical cancer elimination.

Mailing Vaginal or Urine Self-Sampling Kits versus Conventional Invitation Letters: A Randomized Trial to Assess the Effect on Cervical Cancer Screening Attendance

Abstract Background: Human papillomavirus testing on vaginal self-samples (VSS) has recently been offered in France as an option for women aged 30 to 65 years who are not regularly screened for cervical cancer. Human papillomavirus testing can also be performed on first-void urine. Methods: The CapU4 study is a three-arm randomized controlled trial enrolling 14,997 women aged 30 to 65 years who had no screening test recorded for more than 4 years and who did not respond to an invitation letter 12 months prior. Women were allocated to two experimental arms [mailing of a VSS or a urine self-sampling (USS) kit] or to a control arm (invitation to visit a physician to collect a cervical specimen). Results: A total of 13,061 women were included. The intention-to-treat analysis demonstrated that the participation rate increased in the self-sampling arms (USS: 23.6%; VSS: 23.5%) compared with the control arm (12.9%). The per-protocol analysis did not show a favorable effect (USS: 11.1%; VSS: 12.6%), particularly for USS. Conclusions: Invitations including VSS or USS kits increased participation in cervical cancer screening by approximately 11%. Half of the responding women in the self-sampling arms visited a physician to take a cervical specimen. Impact: There is evidence that sending VSS kits can increase attendance at cervical cancer screening. However, no data exist suggesting that sending urine collection kits may also be effective in triggering participation compared with conventional invitation letters. The results of the CapU4 trial may generate innovative tools that could help optimize attendance at cervical cancer screening.

Validation of Human Papillomavirus Assays and Collection Devices for Self-samples and Urine Samples

The VALHUDES study is a Diagnostic Test Accuracy study that aims to document the clinical accuracy of hrHPV testing on urine samples, collected under standardised and optimised conditions, and on two types of vaginal self-samples and compare results with those from matching samples taken by a clinician.