Youlin Qiao

Accelerating the elimination of global cervical cancer through intelligent training for colposcopy

Objective: Cervical cancer remains a global health challenge with substantial disparities between countries. High-quality colposcopy is essential for cervical cancer prevention, yet training opportunities remain inadequate worldwide. We developed the Intelligent Digital Education Tool for Colposcopy (iDECO) to address training gaps and evaluated the effect across diverse international settings. Methods: Six pre-post interventional training programmes were conducted in China, Mexico, and Mongolia from December 2024 to May 2025. A total of 369 trainees from 87 centers participated in a 3-week online training programme using iDECO, a bilingual web-based platform featuring authentic colposcopy cases, gamified learning pathways, and personalized analytics. The primary outcomes included colposcopy competence in general assessment, colposcopic findings, diagnostic accuracy, and management decisions. The secondary outcomes focused on participant feedback and satisfaction. Results: Of 369 participants who completed pretests, 333 (90.24%) completed post-training assessments. Significant improvements were observed across all competency domains. Diagnostic accuracy increased with an odds ratio (OR) of 1.72 (95% CI: 1.60–1.86) with the greatest gains in high-grade lesion identification [OR = 2.27 (95% CI: 1.94–2.64)]. Squamocolumnar junction visibility and transformation zone type assessments improved with ORs of 1.41 (95% CI: 1.31–1.51) and 1.87 (95% CI: 1.73–2.01), respectively. Biopsy decision-making accuracy also showed significant improvement [OR = 2.09 (95% CI: 1.91–2.29)]. International participants showed lower baseline performance but achieved the greatest improvements. Greater than 85% of participants rated the training highly satisfactory and 83.56% preferred intelligent training over traditional methods. Conclusions: iDECO-based training significantly improved colposcopy competence across diverse international settings with high user satisfaction. These findings support the potential for worldwide implementation of intelligent digital training tools to address colposcopy training gaps and contribute to the elimination of cervical cancer.

Evaluation of an intelligent digital platform for population management in cervical cancer screening

Objective: To describe temporal changes associated with deployment of an optical character recognition (OCR)-enabled One-Identity (One-ID) digital platform for rural cervical cancer screening, focusing on over-screening rates, CIN2+ detection, colposcopy follow-up, and CIN2+ management. Methods: A multi-county pre-post observational study was conducted in six rural counties in Shanxi, Yunnan, and Sichuan Provinces (2021–2024), encompassing 153,978 encounters. The digital platform integrates OCR identity capture, deterministic One-ID linkage, and real-time duplicate alerts. Over-screening proportions before and after digital deployment were compared, changes in CIN2+ detection rate were evaluated, and colposcopy follow-up and CIN2+ management were assessed. Differences were tested with χ2 or Fisher’s exact tests. Results: Among 153,978 encounters, the proportion of over-screening decreased from 12.64% in 2023 to 0.17% in 2024 with an absolute reduction of 12.17% (95% CI: 11.94–12.40; P < 0.001). The share of women receiving a first screening within the preceding 3 y increased from 78.3% to 88.2% (P < 0.001). Colposcopy completion improved from 64.1% to 84.9%. The CIN2+ detection rate rose from 0.35% (2021–2023 pooled) to 0.67% in 2024 (P < 0.001) and CIN2+ management completion increased from 56.0% to 76.2% (95% CI: 13.3–27.2; P < 0.001). These improvements were consistent across age groups, counties, and screening strategies. Conclusions: The OCR-enabled One-ID platform substantially reduced over-screening, increased CIN2+ detection rate, and strengthened case follow-up/management, particularly where baseline tracking was weak, supporting scalable digital reinforcement of rural screening programmes.

HPV vaccine awareness and uptake among women attending cervical screening in health-resource-limited areas of China: A multicenter cross-sectional study

Evidence shows HPV vaccination reduces infection, precancer and cervical cancer, yet coverage in health-resource-limited of China remains uncertain. We assessed awareness, uptake and correlates among women attending cervical screening, and examined associations with screening outcomes. We conducted a cross-sectional study in eight county sites in 2023-2024 among women aged 35-64 y. A standardized questionnaire captured sociodemographic factors, awareness and vaccination. Cervical samples were tested for hrHPV. Outcomes were awareness, vaccination, hrHPV, HPV16/18 and CIN2+. Associations were estimated using modified Poisson models with site fixed effects and HC3 robust errors. Adjusted prevalence ratios (aPRs) and covariate-standardized marginal estimates were reported. We included 93,027 unique participants. Awareness was 45.15% and vaccination 6.73%. hrHPV prevalence was 11.38% and CIN2+ detection was 0.70%. In 2024 versus 2023, awareness was lower (40.66% vs 51.34%) while vaccination was higher (7.61% vs 5.53%; aPR 1.25, 95% CI 1.18-1.32). Awareness and uptake declined with age; coverage was 23.23% at ages 35-39 and 0.29% at ages 60-64. Urban residence and higher education were associated with uptake (urban aPR 1.19, 95% CI 1.11-1.27; bachelor's or higher aPR 1.73, 95% CI 1.58-1.90). The age-by-year interaction was significant, with standardized gains concentrated at ages 35-49. Vaccination was associated with lower HPV16/18 infection (aPR 0.66, 95% CI 0.52-0.85) but not with overall hrHPV or CIN2+. HPV vaccine awareness and uptake were low among women aged 35-64 y in health-resource-limited areas, with strong age, educational and urban-rural gradients and marked site heterogeneity. Uptake increased in 2024, mainly at ages 35-49, and vaccination was associated with a lower prevalence of HPV16/18 infection.

HPV testing with 16/18 genotyping for risk stratification among women with normal cytology: a multicenter prospective cohort study from China

ABSTRACT To evaluate the clinical performance of Hybribio’s 14-type HPV real-time PCR with 16/18 genotyping (HBRT-H14) and its risk stratification utility among women with normal cytology (NILM). From 2017 to 2020, a multicenter cohort enrolled 8,401 women aged 30–64 years with NILM cytology. Baseline HPV testing used HBRT-H14. Women positive for HPV 16/18 were referred for colposcopy; follow-up was annual for 3 years or until the detection of cervical intraepithelial neoplasia grade 2 or worse (CIN2+). Analyses included 6,679 women who completed follow-up. Overall HPV positivity was 11.4%, including 2.3% HPV 16/18. Over 3 years, sensitivity and specificity of HPV positivity for CIN2+ were 92.3% (95% confidence interval [CI]: 84.2–96.4) and 89.6% (88.8–90.3). For HPV 16/18 positivity, sensitivity and specificity were 41.0% (30.8–52.1) and 98.2% (97.8–98.5). Three-year cumulative CIN2+ risk was 20.9% (15.2–28.1) for HPV 16/18-positive women, 6.6% (4.9–8.9) for other types, and 0.1% (0.04–0.2) for HPV-negative women. HBRT-H14 shows strong clinical performance for detecting CIN2+, and HPV 16/18 genotyping provides effective risk stratification among women with NILM cytology. Findings support integration of HBRT-H14 into HPV-based screening pathways with HPV 16/18 genotyping and cytology triage of other types. IMPORTANCE This multicenter prospective study evaluated the Hybribio 14 high-risk HPV real-time PCR assay (HBRT-H14) in 8,401 women with normal (NILM) cytology under guideline-based follow-up. The assay showed high clinical sensitivity and a very low risk among HPV-negative women, and HPV 16/18 genotyping provided clear risk stratification. These findings deliver large-scale, practice-oriented evidence supporting integration of HBRT-H14 into HPV-based screening pathways that use HPV 16/18 genotyping with cytology triage of other types.

Variations in the Natural History of High-Risk HPV Types Following HPV-16/18 Bivalent Vaccination in Females Aged 18-45 Years

Existing evidence regarding the impact of vaccination on the natural history of high-risk human papillomavirus (HPV) infections remains limited, understanding such effects is essential for optimizing cervical cancer screening in post-vaccination era. Using 10-year follow-up data from a phase 3 randomized trial of the Escherichia coli-produced HPV-16/18 bivalent vaccine (NCT01735006) and its extension study (NCT05045755, NCT04969445), we compared the spectra and natural history (persistence, clearance, and progression) of high-risk HPV infections between vaccinated and unvaccinated females aged 18-45 years. Data was analyzed using the Cox regression and the competing risk model. Our findings indicate that vaccination reduces the burden of HPV-16/18-associated lesions (HR = 0.12, p = 0.0041) primarily by preventing incident infections (HR = 0.45, p < 0.0001) and modifying the natural history of breakthrough infections (enhancing clearance: 98.5% vs. 93.8%, p < 0.0001; and attenuating progression: 1.5% vs. 6.2%, p = 0.0420). Conversely, the elevated burden of HPV-52-associated lesions (HR = 3.06, p = 0.0303) observed in the vaccine group stems mainly from altered natural history (reduced clearance: 90.3% vs. 97.9%, p = 0.0144; and increased progression: 9.7% vs. 2.1%, p = 0.0421), rather than an increase in incidence (HR = 1.09, p = 0.2669). In this work, the observed shifts in HPV infection profiles and natural history between vaccinated and unvaccinated populations suggest that cervical cancer screening recommendations may warrant adjustment for vaccinated individuals.

Age-specific clinical performance of HPV-based vs. cytology-based cervical cancer screening in China

Cervical cancer remains a significant health burden, and effective screening is essential, yet the age-specific performance of HPV primary screening is rarely studied. This multicenter study evaluates age-specific performance of primary human papillomavirus (HPV) testing as cross-sectional and longitudinal screening for cervical cancer among 28,501 Chinese women. At baseline, HPV screening with cytology triage demonstrates higher sensitivity (96.9% vs. 79.7%) but slightly lower specificity (88.8% vs. 92.7%) than cytology with HPV triage for cervical intraepithelial neoplasia grade 2 or worse (CIN2+). HPV sensitivities remain high across age groups (≤35: 100.0%; 36-45: 96.4%; >45: 96.8%), consistently exceeding the corresponding cytology sensitivities (66.7%, 75.7%, and 84.9%). Over a three-year follow-up, HPV screening maintains superior sensitivity (93.1% vs. 58.1%) and slightly lower specificity (89.6% vs. 92.4%) compared with cytology. Age-stratified analyses in the longitudinal setting reveal trends similar to those observed in the cross-sectional analyses. Women positive for HPV16/18 have a 43.0% three-year risk of CIN2+, compared with 0.2% for HPV-negative women. These findings support the durable protection of HPV-based screening and the feasibility of extending screening intervals.

Deep learning enabled liquid-based cytology model for cervical precancer and cancer detection

Deep learning (DL) enabled liquid-based cytology has potential for cervical cancer screening or triage. Here, we develop a DL model using whole cytology slides from 17,397 women and test it on 10,826 additional cases through a three-stage process. The DL model achieves robust performance across nine hospitals. In a multi-reader, multi-case study, it outperforms cytopathologists' sensitivity by 9%. Reading time significantly decreases with DL assistance (218s vs 30s; p  0.999), yet it has reduced specificity (0.831 vs 0.901; p < 0.0001). Notably, hospital-based opportunistic screening shows that junior cytopathologists with DL assistance significantly improve both their sensitivity and specificity (0.857 vs 0.657, 0.840 vs 0.737; both p < 0.0001). When triaging human papillomavirus-positive cases, DL assistance exhibits better performance than junior cytopathologists alone. These findings support using the DL model as an assistance tool in cervical screening and case triage.

AI-Based Identification Method for Cervical Transformation Zone Within Digital Colposcopy: Development and Multicenter Validation Study

Background In low- and middle-income countries, cervical cancer remains a leading cause of death and morbidity for women. Early detection and treatment of precancerous lesions are critical in cervical cancer prevention, and colposcopy is a primary diagnostic tool for identifying cervical lesions and guiding biopsies. The transformation zone (TZ) is where a stratified squamous epithelium develops from the metaplasia of simple columnar epithelium and is the most common site of precancerous lesions. However, inexperienced colposcopists may find it challenging to accurately identify the type and location of the TZ during a colposcopy examination. Objective This study aims to present an artificial intelligence (AI) method for identifying the TZ to enhance colposcopy examination and evaluate its potential clinical application. Methods The study retrospectively collected data from 3616 women who underwent colposcopy at 6 tertiary hospitals in China between 2019 and 2021. A dataset from 4 hospitals was collected for model conduction. An independent dataset was collected from the other 2 geographic hospitals to validate model performance. There is no overlap between the training and validation datasets. Anonymized digital records, including each colposcopy image, baseline clinical characteristics, colposcopic findings, and pathological outcomes, were collected. The classification model was proposed as a lightweight neural network with multiscale feature enhancement capabilities and designed to classify the 3 types of TZ. The pretrained FastSAM model was first implemented to identify the location of the new squamocolumnar junction for segmenting the TZ. Overall accuracy, average precision, and recall were evaluated for the classification and segmentation models. The classification performance on the external validation was assessed by sensitivity and specificity. Results The optimal TZ classification model performed with 83.97% classification accuracy on the test set, which achieved average precision of 91.84%, 89.06%, and 95.62% for types 1, 2, and 3, respectively. The recall and mean average precision of the TZ segmentation model were 0.78 and 0.75, respectively. The proposed model demonstrated outstanding performance in predicting 3 types of the TZ, achieving the sensitivity with 95% CIs for TZ1, TZ2, and TZ3 of 0.78 (0.74-0.81), 0.81 (0.78-0.82), and 0.8 (0.74-0.87), respectively, with specificity with 95% CIs of 0.94 (0.92-0.96), 0.83 (0.81-0.86), and 0.91 (0.89-0.92), based on a comprehensive external dataset of 1335 cases from 2 of the 6 hospitals. Conclusions Our proposed AI-based identification system classified the type of cervical TZs and delineated their location on multicenter, colposcopic, high-resolution images. The findings of this study have shown its potential to predict TZ types and specific regions accurately. It was developed as a valuable assistant to encourage precise colposcopic examination in clinical practice.

Artificial intelligence strengthenes cervical cancer screening – present and future

Cervical cancer is a severe threat to women’s health. The majority of cervical cancer cases occur in developing countries. The WHO has proposed screening 70% of women with high-performance tests between 35 and 45 years of age by 2030 to accelerate the elimination of cervical cancer. Due to an inadequate health infrastructure and organized screening strategy, most low- and middle-income countries are still far from achieving this goal. As part of the efforts to increase performance of cervical cancer screening, it is necessary to investigate the most accurate, efficient, and effective methods and strategies. Artificial intelligence (AI) is rapidly expanding its application in cancer screening and diagnosis and deep learning algorithms have offered human-like interpretation capabilities on various medical images. AI will soon have a more significant role in improving the implementation of cervical cancer screening, management, and follow-up. This review aims to report the state of AI with respect to cervical cancer screening. We discuss the primary AI applications and development of AI technology for image recognition applied to detection of abnormal cytology and cervical neoplastic diseases, as well as the challenges that we anticipate in the future.

The variations in the natural history of high‐risk human papillomavirus infections in Chinese healthy women aged 27–45 years compared with 18–26 years: A prospective cohort study

AbstractData investigating the natural history of high‐risk human papillomavirus (HR‐HPV) infection in mid‐adult women compared with young adult women from regions exhibiting a bimodal distribution pattern are scarce. From November 2012 to September 2019, 3681 healthy women aged 18–45 years from the control group of a bivalent HPV vaccine Phase 3 trial in China were followed over 5.5 years. At scheduled visits (Day 0, months 7, 12, 18, 24, 30, 42, 54, and 66), cervical samples were collected for ThinPrep Pap tests and HPV DNA testing, women with abnormal cytology were referred for colposcopy. Data was analyzed using Cox regression model and a competing risk model. Sensitivity analyses were performed among participants attending all scheduled visits. The incidences of HR‐HPV persistent infections (over 6 months [6mPIs]) were 35.5 and 29.0 per 1000 person‐years (PYs) (hazard ratio [HR] = 1.21, 95% confidence interval [CI]: 1.00, 1.46), and HR‐HPV associated CIN grade 2 or greater (CIN2+) were 4.3 and 1.9 per 1000 PYs (HR = 2.31, 95% CI: 1.25, 4.26) in women aged 18–26 and 27–45 years. Competing risk models showed that the cumulative incidence of HR‐HPV infections that progressed to CIN2+ was significantly higher in women aged 18–26 than in women aged 27–45 (5.3% vs. 2.9%, Gray's test p = .0291). The cumulative clearance rates of HR‐HPV infections in women aged 18–26 and 27–45 were similar (94.7% vs. 95.8%, Gray's test p = .3309) during the study period. In conclusion, although mid‐adult women exhibit lower incidences of HR‐HPV infection and associated cervical lesions compared to young women, this population continues to face a substantial risk of acquiring causal HPV infections, which may progress to cervical lesion.

Development and validation of an artificial intelligence system for grading colposcopic impressions and guiding biopsies

AbstractBackgroundColposcopy diagnosis and directed biopsy are the key components in cervical cancer screening programs. However, their performance is limited by the requirement for experienced colposcopists. This study aimed to develop and validate a Colposcopic Artificial Intelligence Auxiliary Diagnostic System (CAIADS) for grading colposcopic impressions and guiding biopsies.MethodsAnonymized digital records of 19,435 patients were obtained from six hospitals across China. These records included colposcopic images, clinical information, and pathological results (gold standard). The data were randomly assigned (7:1:2) to a training and a tuning set for developing CAIADS and to a validation set for evaluating performance.ResultsThe agreement between CAIADS-graded colposcopic impressions and pathology findings was higher than that of colposcopies interpreted by colposcopists (82.2% versus 65.9%, kappa 0.750 versus 0.516,p &lt; 0.001). For detecting pathological high-grade squamous intraepithelial lesion or worse (HSIL+), CAIADS showed higher sensitivity than the use of colposcopies interpreted by colposcopists at either biopsy threshold (low-grade or worse 90.5%, 95% CI 88.9–91.4% versus 83.5%, 81.5–85.3%; high-grade or worse 71.9%, 69.5–74.2% versus 60.4%, 57.9–62.9%; allp &lt; 0.001), whereas the specificities were similar (low-grade or worse 51.8%, 49.8–53.8% versus 52.0%, 50.0–54.1%; high-grade or worse 93.9%, 92.9–94.9% versus 94.9%, 93.9–95.7%; allp &gt; 0.05). The CAIADS also demonstrated a superior ability in predicting biopsy sites, with a median mean-intersection-over-union (mIoU) of 0.758.ConclusionsThe CAIADS has potential in assisting beginners and for improving the diagnostic quality of colposcopy and biopsy in the detection of cervical precancer/cancer.

Effect of Sequential Rounds of Cervical Cancer Screening on Management of HPV-positive Women: A 15-year Population-based Cohort Study from China

Abstract Women are anticipated to go through more than two rounds of cervical screening in their lifetime. Human papillomavirus (HPV) testing is increasingly used as the primary cervical cancer screening test. However, triage strategies for HPV-positive women were usually evaluated at baseline screening. We assessed the effect of sequential rounds of cervical screening on several algorithms for HPV triage. A total of 1,997 women ages 35–45 years were enrolled in 1999 in Shanxi, P.R. China and followed up three times at approximately 5-year intervals. Cervical intraepithelial neoplasia (CIN) grade 2 or worse (CIN2+) prevalence by prior HPV results and performance of 12 triage algorithms with cytology, genotyping, and prior HPV were examined among 229 HPV-positive women at the fourth round. CIN2+ prevalence varied from 56.5% (95% confidence interval, 36.8%–74.4%) following 15 years HPV persistence to 3.5% (1.2%–9.9%) with an incident HPV within 15 years. Triage with cytology (with threshold of atypical squamous cells of undetermined significance) yielded positive predictive value (PPV) of 21.4% (13.8%–29.0%), entailing immediate colposcopic referral, and negative predictive value (NPV) of 97.4% (94.6%–100%), permitting retesting at short intervals. Triage with genotyping (16/18/31/33/45/52/58) or prior HPV results showed comparable performance with cytology. Among 11 triage algorithms with similar NPV to cytology, triage with prior HPV results and reflex genotyping (16/18) achieved highest PPV of 28.9% (18.8%–39.1%) and lowest colposcopy referral of 33.2% (27.4%–39.5%). HPV persistence across rounds is an effective risk stratifier in HPV-positive women. Mainstream cytology and genotyping, with or without consideration of prior HPV results, remain effective for HPV triage at fourth round. Prevention Relevance: The study highlights the sustained effectiveness of mainstream HPV triage methods, such as cytology and genotyping, after sequential rounds of cervical screening. It also suggests that use of HPV persistence across rounds can improve management of HPV-positive women in cervical cancer screening.

The challenges of colposcopy for cervical cancer screening in LMICs and solutions by artificial intelligence

AbstractBackgroundThe World Health Organization (WHO) called for global action towards the elimination of cervical cancer. One of the main strategies is to screen 70% of women at the age between 35 and 45 years and 90% of women managed appropriately by 2030. So far, approximately 85% of cervical cancers occur in low- and middle-income countries (LMICs). The colposcopy-guided biopsy is crucial for detecting cervical intraepithelial neoplasia (CIN) and becomes the main bottleneck limiting screening performance. Unprecedented advances in artificial intelligence (AI) enable the synergy of deep learning and digital colposcopy, which offers opportunities for automatic image-based diagnosis. To this end, we discuss the main challenges of traditional colposcopy and the solutions applying AI-guided digital colposcopy as an auxiliary diagnostic tool in low- and middle- income countries (LMICs).Main bodyExisting challenges for the application of colposcopy in LMICs include strong dependence on the subjective experience of operators, substantial inter- and intra-operator variabilities, shortage of experienced colposcopists, consummate colposcopy training courses, and uniform diagnostic standard and strict quality control that are hard to be followed by colposcopists with limited diagnostic ability, resulting in discrepant reporting and documentation of colposcopy impressions. Organized colposcopy training courses should be viewed as an effective way to enhance the diagnostic ability of colposcopists, but implementing these courses in practice may not always be feasible to improve the overall diagnostic performance in a short period of time. Fortunately, AI has the potential to address colposcopic bottleneck, which could assist colposcopists in colposcopy imaging judgment, detection of underlying CINs, and guidance of biopsy sites. The automated workflow of colposcopy examination could create a novel cervical cancer screening model, reduce potentially false negatives and false positives, and improve the accuracy of colposcopy diagnosis and cervical biopsy.ConclusionWe believe that a practical and accurate AI-guided digital colposcopy has the potential to strengthen the diagnostic ability in guiding cervical biopsy, thereby improves cervical cancer screening performance in LMICs and accelerates the process of global cervical cancer elimination eventually.

Outcomes in women with biopsy-confirmed cervical intraepithelial neoplasia grade 1 or normal cervix and related cofactors: A 15-year population-based cohort study from China

To estimate long-term outcomes of biopsy-confirmed cervical intraepithelial neoplasia grade 1 (CIN1) or normal cervix and identify the cofactors during disease progression. In 1999, a cervical cancer screening cohort in Shanxi, China, enrolled 1997 women aged 35-45. They were followed up at year 6, 11, and 15 after enrollment with high-risk human papillomavirus (hrHPV) DNA testing, liquid-based cytology, and visual inspection with acetic acid. Progression, persistence, and regression rates were calculated, stratified by baseline hrHPV and cytological status. Risk factors associated with hrHPV acquisition, persistence, and progression were examined. The cumulative rates of progression to CIN2+ among CIN1 over 6, 11, and 15 years were 7.5%, 21.4%, and 24.0%, respectively; the regression rates to normal cervix were 85.0%, 76.7%, and 72.9%, respectively. Over 6, 11, and 15 years, 0.7%, 2.9%, and 5.2% of normal cervix developed CIN2+, respectively, but over 90% remained normal after 15 years. CIN1 or normal cervix positive for hrHPV had significantly higher progression rates to CIN2+ than those without hrHPV. Similarly, the severity of cytological status was found to be associated with an increased risk of developing CIN2+. Women who had an earlier sexual debut were at a higher risk of acquiring new HPV infection and repeated HPV infections. Clinical follow-up strategies for women with CIN1 or normal cervix could be adjusted accordingly based on hrHPV/cytology status.

Performance of HPV Genotyping Combined with p16/Ki-67 in Detection of Cervical Precancer and Cancer Among HPV-Positive Chinese Women

Abstract Women with positive high-risk human papillomavirus (hrHPV) need efficient triage testing to determine colposcopy referrals. Triage strategies of combining p16/Ki-67 with extended HPV genotyping were evaluated in this study. In total, 899 women attending cervical cancer screening program and 858 women referred to colposcopy from five hospitals were recruited. All the participants were tested by HPV assays and p16/Ki-67 dual staining. Colposcopy and biopsy were performed on women with any abnormal results. HPV genotypes were divided into four strata (HPV16/18, HPV31/33/58/52, HPV45/59/56/66, and HPV51/39/68/35) according to their risks for cervical intraepithelial neoplasia grade 3 or worse (CIN3+). The positive rates of four genotype strata among CIN3+ women were 3.47% (HPV51/39/68/35), 7.73% (HPV45/59/56/66), 14.7% (HPV31/33/58/52), and 78.1% (HPV16/18), respectively (Ptrend &amp;lt; 0.001). The positive rates of p16/Ki-67 increased with the elevation of HPV risk hierarchical from 65.0% in HPV51/39/68/35-positive women to 88.0% in HPV16/18-positive women (Ptrend &amp;lt; 0.001). p16/Ki-67 was an effective method for risk stratification of CIN2+ among HPV31/33/58/52- and HPV45/59/56/66-positive women [HPV31/33/58/52: OR for dual stain+ (ORDS+) of 26.7 (16.8–42.4) and OR for dual stain− (ORDS−) of 3.87(1.89–7.91); HPV45/59/56/66: ORDS+ of 10.3(5.05–21.0) and ORDS− of 1.27(0.38–4.26)]. The combination of HPV16/18 genotyping and p16/Ki-67 triage of HPV31/33/58/52/45/59/56/66-positive women resulted in a lower referral rate (40.1% vs. 41.3%; P &amp;lt; 0.001) as compared with triage of 12 other HPV-positive women with p16/Ki-67, although sensitivity and specificity levels for these two strategies were identical. Combining HPV extended genotyping and p16/Ki-67 can be considered as a promising strategy for cervical cancer screening and triage.

An Internet-Based Education Program for Human Papillomavirus Vaccination Among Female College Students in Mainland China: Application of the Information-Motivation-Behavioral Skills Model in a Cluster Randomized Trial

Background Patients diagnosed with cervical cancer in the last 2 decades were mainly young females. Human papillomavirus (HPV) vaccination is the most radical way to prevent HPV infection and cervical cancer. However, most female college students in mainland China have not yet been vaccinated, and their relevant knowledge is limited. Theory-based education delivered via the internet is a potentially accessible and useful way to promote HPV vaccination among this population. Objective This 3-month follow-up study intended to identify the feasibility and efficacy of an information-motivation-behavioral skills (IMB) model–based online intervention for promoting awareness and willingness regarding HPV vaccination among female college students. Methods A 7-day online HPV education program for female college students in mainland China was developed using a cluster randomized trial design. Recruitment and questionnaire surveys were performed online without face-to-face contact. SPSS 23.0 was used for statistical analysis. The chi-square test and t test were used to compare differences in qualitative and continuous variables between intervention and control groups. The generalized estimating equation was used to test the effectiveness of the intervention with a consideration of the time factor. Results Among 3867 participants, 102 had been vaccinated against HPV before the study (vaccination rate of 2.6%). A total of 3484 participants were followed up after the baseline survey, with no statistical difference in the loss rate between the intervention and control groups during the intervention and follow-up periods. At different follow-up time points, HPV-related knowledge, and the motivation, behavioral skills, and willingness regarding HPV vaccination were higher in the intervention group than in the control group. HPV-related knowledge was statistically different between the 2 groups, while the motivation, behavioral skills, and willingness regarding HPV vaccination only showed statistical differences right after the intervention, reaching a peak right after the intervention and then gradually reducing over time. Furthermore, there was no statistical difference in the HPV vaccination rate between the 2 groups. Conclusions IMB model–based online education could be a promising way to increase the HPV vaccination rate and reduce the burden of HPV infection and cervical cancer among high-risk female college students in China. Trial Registration Chinese Clinical Trial Registry ChiCTR1900025476; http://www.chictr.org.cn/showprojen.aspx? proj=42672 International Registered Report Identifier (IRRID) RR2-DOI:10.1186/s12889-019-7903-x

Implementation of visual inspection with acetic acid and Lugol's iodine for cervical cancer screening in rural China

AbstractObjectiveTo address the value of visual inspection where HPV‐based screening is not yet available, we evaluated the real‐world effectiveness of visual inspection with acetic acid (VIA) and with Lugol's iodine (VILI) as a primary screening method for cervical cancer in rural China.MethodsA total of 206 133 women aged 30–59 years received two rounds of VIA/VILI screening for cervical cancer in 2006–2010. Women with positive screening results underwent colposcopy and direct biopsy, and were treated if cervical intraepithelial neoplasia grade 2 or worse (CIN2+) was diagnosed. Clinical effectiveness of VIA/VILI was evaluated by process and outcome measures.ResultsThe VIA/VILI positivity rate, biopsy rate and detection rate of CIN2+ in the second round were significantly lower than in the first round. The 2‐year cumulative detection rate of CIN2+ varied from 0.53% to 0.90% among the four cohorts initiated in 2006, 2007, 2008, and 2009. The first round of screening detected 60%–83% of CIN2, 70%–86% of CIN3, and 88%–100% of cervical cancer. Over 92% of CIN2+ were found at the early stage.ConclusionMultiple rounds of visual inspection with continuous training and quality assurance could act as a temporary substitutional screening method for cervical cancer in resource‐restricted settings.

Improving colposcopic accuracy for cervical precancer detection: a retrospective multicenter study in China

Abstract Background Colposcopy alone can result in misidentification of high-grade squamous intraepithelial or worse lesions (HSIL +), especially for women with Type 3 transformation zone (TZ) lesions, where colposcopic assessment is particularly imprecise. This study aimed to improve HSIL + case identification by supplementing referral screening results to colposcopic findings. Methods This is an observational multicenter study of 2,417 women, referred to colposcopy after receiving cervical cancer screening results. Logistic regression analysis was conducted under uni- and multivariate models to identify factors which could be used to improve HSIL + case identification. Histological diagnosis was established as the gold standard and is used to assess accuracy, sensitivity, and specificity, as well as to incrementally improve colposcopy. Results Multivariate analysis highlighted age, TZ types, referral screening, and colposcopists’ skills as independent factors. Across this sample population, diagnostic accuracies for detecting HSIL + increased from 72.9% (95%CI 71.1–74.7%) for colposcopy alone to 82.1% (95%CI 80.6–83.6%) after supplementing colposcopy with screening results. A significant increase in colposcopic accuracy was observed across all subgroups. Although, the highest increase was observed in women with a TZ3 lesion, and for those diagnosed by junior colposcopists. Conclusion It appears possible to supplement colposcopic examinations with screening results to improve HSIL + detection, especially for women with TZ3 lesions. It may also be possible to improve junior colposcopists’ diagnoses although, further psychological research is necessary. We need to understand how levels of uncertainty influence diagnostic decisions and what the concept of “experience” actually is and what it means for colposcopic practice.

Temporal Trends and Projection of Cancer Attributable to Human Papillomavirus Infection in China, 2007–2030

Abstract Background: Information on temporal trends of cancer attributable to human papillomavirus (HPV) in China is limited. Methods: Cancer incidence and mortality during 2007 to 2015 were extracted from the Chinese Cancer Registry Annual Report and the national population from the National Bureau of Statistics. HPV-attributable cancer burden and the average annual percentage change during 2007 to 2015 were estimated and cancer burden during 2016 to 2030 was projected. Results: HPV-attributable cancer cases have increased by 3.8% [95% confidence interval (CI), 2.9%–4.8%] annually from 85,125 to 113,558 and age-standardized incidence rate (ASIR) rose by 3.0% (95% CI, 2.5%–3.5%) from 4.67 to 5.83 per 100,000 persons during 2007 to 2015. Cervical, female anal, and vulva cancer cases have increased by 3.8% (95% CI, 2.8%–4.7%), 6.5% (95% CI, 1.2%–12.2%), and 3.7% (95% CI, 1.6%–5.8%) per year. Male anal and oropharyngeal cancer cases have elevated by 7.5% (95% CI, 2.8%–12.5%) and 4.4% (95% CI, 2.4%–6.3%) annually. The increases of cervical and anal cancer were most rapid among those aged 50 and older. HPV-attributable cancer deaths and mortality rate have risen by 4.7% (95% CI, 2.9%–6.7%) and 3.3% (95% CI, 0.9%–5.8%) respectively. HPV-attributable cancer cases and ASIR are projected to reach 214,077 and 9.35 of 100,000 persons by 2030 respectively, with 87.7% being cervical cancer, and anal cancer cases are expected to triple. Conclusions: HPV-attributable cancer burden has largely increased in the past and will keep rising for the next decade. Cervical cancer control should be the priority and anal cancer prevention should be addressed. Impact: This study supplies fundamental evidence for policy-making on HPV-attributable cancer control.

Knowledge, willingness, uptake and barriers of cervical cancer screening services among Chinese adult females: a national cross-sectional survey based on a large e-commerce platform

Abstract Background Improving the coverage rate of cervical cancer screening is a challenge mission for cervical cancer elimination. This study attempted to assess the knowledge, willingness, and uptake of cervical cancer screening services among Chinese females and determined associated factors. Methods This is a cross-sectional online survey conducted in China from March to April 2022. Information on demographic characteristics, knowledge, willingness, and uptake of cervical cancer screening was collected through a large e-commerce platform. Women aged 18–65 were included in the analysis. Logistic regression analysis was employed to detect the possible factors associated with knowledge, willingness, and screening participation. Results A total of 4518 women (37.83 ± 9.14 years) were included in the final analysis, of whom 87.16% (n = 3938) lived in urban areas. About 93.40% (n = 4220) of the respondents reported hearing of cervical cancer screening. The median score of knowledge about cervical cancer was 16 out of 26. Over 84% (n = 3799) of the respondents were willing to receive regular cervical cancer screening. Nearly 40% (n = 1785) had never received cervical cancer screening. Among the screened women, 21.26% (n = 581), 35.24% (n = 1151), and 42.37% (n = 1158) were screened through a national cervical cancer screening program, employee physical examination, and self-paid physical examination, respectively. Knowledge was positively associated with willingness and screening participation. Age, marital status, occupation, monthly household income, and HPV vaccination history could influence screening participation (all p &lt; 0.05). Conclusions Though women had high-level awareness and strong participation willingness in cervical cancer screening, the overall screening coverage among Chinese women was still low. Besides, the knowledge about cervical cancer was still limited. Comprehensive health education should be enhanced by utilizing social media platforms and medical workers. It is also important to promote national free cervical cancer screening with high-performance screening methods.

Diagnostic value of high‐risk HPV other than type 16/18 in high‐grade cervical neoplasia among cytology‐negative women: A multicenter retrospective study

AbstractBackgroundHuman papillomavirus (HPV) is a necessary cause of cervical cancer, and a tool more sensitive than cytology for the early screening of cervical precancers. The two most carcinogenic genotypes HPV 16/18 have been reported in the majority of studies. High‐risk HPVs other than HPV 16/18 (non‐16/18‐hrHPVs) cause approximately a quarter of cervical cancers, and we aimed to analyze the genotype‐specific prevalence, risk and diagnostic efficiency of non‐16/18‐hrHPVs in cervical carcinogenesis among Chinese cytology‐negative women.MethodsA total of 7043 females who had abnormal cervical testing results from January 2018 to October 2021 were enrolled, among them 3091 were cytology‐negative. Descriptive statistics was used to estimate the HPV genotype‐specific prevalence, and multivariable logistic regression was used to estimate the genotype‐specific non‐16/18 hrHPVs risk of cervical carcinogenesis. The evaluation of diagnostic value among HPV genotypes included the possibility of predicting cervical intraepithelial neoplasia grade 2/3 or worse (CIN2+/CIN3+) and the diagnostic efficiency measured by increased referral rate and referral numbers of colposcopies per additional CIN2+/CIN3+ detected.ResultsAmong HPV‐positive cytology‐negative women, the five dominant genotypes for CIN2+/CIN3+ were HPV 31/33/35/52/58. HPV 52/58/33 had comparatively high sensitivity and specificity in predicting CIN2+/CIN3+, while the referral strategy of multiple HPV58 required 26 colposcopies to detect 1 CIN3+, compared with 14, 12, and 8 required by multiple HPV52, 31, and 33, respectively.ConclusionsHPV31/33/35/52/58 infections are significant risk factors for cervical lesions, and multiple HPV 31/33/52 infections should be included in the previously recommended HPV16/18 genotyping triage for colposcopy in China, as the benefits of disease prevention may outweigh the disadvantages of increasing requirements for colposcopy services.

Cervical cancer prevention in China: where are we now, and what’s next?

Temporal trends in cervical cancer incidence and mortality in economically emerging countries, 1992–2021: an age-period-cohort analysis

Introduction The economically emerging countries contributed to over half of the global cervical cancer (CC) burden and are good examples showing how rapid economic growth and health policy change affect the trends of CC burden. This study aimed to analyse the time trends of CC burden across Brazil, Russia, India, China and South Africa (BRICS) and associations with age, period and birth cohort from 1992 to 2021. Methods Data on CC incident cases, deaths, age-standardised incidence rates (ASIRs) and age-standardised mortality rates (ASMRs) were sourced from the Global Burden of Disease Study 2021 to demonstrate the temporal trends of CC burden for BRICS countries from 1992 to 2021. An age-period-cohort model was used to determine the net drift, local drift, longitudinal age curves, as well as period and cohort relative risks regarding CC incidence and mortality. Results Between 1992 and 2021, the ASIR of CC decreased from 16.5 to 15.6 per 100 000 women (−5.5%) and the ASMR declined from 10.1 to 6.7 per 100 000 women (−33.7%) in BRICS. Brazil reported continuous decreases in both CC incidence (net drift: −1.1%, 95% CI −1.1% to −1.0%) and mortality (net drift: −1.7%, 95% CI −1.80% to −1.6%). India also had reduced CC incidence and mortality but experienced worsening period effects from 2012 onwards. Russia and China experienced decreasing trends in mortality yet increasing trends in incidence, and there were apparent unfavourable trends among young and middle-aged women in Russia. South Africa maintained the highest CC incidence (40.0 per 100 000 women, 95% CI 35.0 to 45.6) and mortality (21.3 per 100 000 women, 95% CI 18.8 to 24.1) across the BRICS and had the steepest growth of CC incidence and mortality rates with increasing age. Conclusion Despite an overall decreasing trend of CC burden in BRICS, substantial heterogeneity exists across nations. Identifying country-specific priority groups and tailoring interventions is essential, and the patterns observed have implications for public health strategies applicable not just to BRICS nations but also to many other emerging economies facing substantial CC burden.

Reproductive factors and risk of epithelial ovarian cancer: results from the Asia Cohort Consortium

Abstract Background There are scarce data on risk factors for epithelial ovarian cancer (EOC) in Asian populations. Our goal was to advance knowledge on reproductive -related risk factors for EOC in a large population of Asian women. Methods This study used pooled individual data from baseline questionnaires in 11 prospective cohorts (baseline years, 1958–2015) in the Asia Cohort Consortium. A Cox proportional hazards regression model was used to estimate hazard ratios (HRs) and 95% confidence intervals (CIs) adjusting for age, parity and cohort. Results After a mean = 17.0 years (SD = 6.3) of follow-up, 674 incident invasive EOC cases were identified among 325,626 women. In multivariable adjusted models we observed an inverse association with parity (5+ children vs. 0, HR = 0.44, 95% CI = 0.28–0.68, Ptrend &lt; 0.001), and a positive association with increasing menopausal age (55+ years vs. &lt;45, HR = 1.77, 95% CI = 1.05–3.01, Ptrend = 0.02) for risk of all EOC. Conclusions In this large study of Asian women we identified an inverse association with parity and a positive association with higher menopausal age in relation to EOC risk. Further work is needed to understand EOC risk factors for rare histologic subtypes that occur more frequently in Asian populations.

Real-World Performance of HPV DNA–Based Screening in Health Resource–Limited Areas of China: A Multicenter Implementation Study

Abstract Background: Cervical cancer remains a significant health burden in China. National policies now allow human papillomavirus (HPV) DNA as a primary screening test, but many health resource–limited counties have not adopted it because programs cannot fund reagents or laboratory platforms. We conducted a multicenter study in 10 pilot counties where HPV DNA screening was introduced with project-supported reagents, platforms, and training. Methods: We analyzed data from 10 pilot counties designated by the National Cervical Cancer Prevention Program. A total of 63,223 women aged 35 to 64 years were screened with three strategies: (i) cytology alone, (ii) HPV DNA testing with cytology triage, and (iii) HPV DNA testing with visual inspection with acetic acid/Lugol iodine (VIA/VILI) triage. Key indicators included screen positivity rate, colposcopy rate, cervical intraepithelial neoplasia (CIN) 2+ detection, positive predictive value (PPV), and number needed to refer (NNR). Inverse probability weighting was used to adjust for loss to follow-up. Results: HPV-based strategies were superior to cytology across all indicators. CIN2+ detection was two to three times higher, with the highest PPV in the HPV + cytology group (21.9%) and the lowest NNR (5.73), indicating higher referral efficiency. Loss to follow-up rate was also significantly reduced under the HPV + VIA/VILI strategy. These advantages were most prominent among women aged ≥45 years. Conclusions: Within the first year of implementation, HPV DNA–based screening is feasible and more effective in health resource–limited areas of China and flexible triage models can be adapted. Impact: The findings support the integration of HPV DNA testing into national cervical cancer screening programs and highlight needs for robust follow-up systems in underserved populations.