Cervical Cancer Screening in the 21st Century : Is it Time to Retire the PAP Smear ? Clinical Obstetrics and Gynecology Vol 50/ Number 2/ June 2007 Retire 물러가다.

Abstract Introduction Limitations of Cytology Performance of Cytology-based Prevention Programs Human Papilloma Virus DNA Testing Using HPV DNA Testing as an Adjunct to Cervical Cytology Alterative Strategies for Using HPV DNA Testing for Screening Summary

Abstract cytology-based cervical cancer prevention programs limited sensitivity expensive to maintain → programs based on testing for high-risk types of human papillomavirus (HPV) HPV testing more sensitive than cytology (either conventional or liquid-based) >30 years old : specificity ↓(slightly) Although have reduced the incidence of cervical cancer in many industrialized countries, the limited sensitivity of cervical cytology makes these programs difficult and Therefore, over the next several years it is likely that we will begin to (HPV testing slightly less specific when used in women 30 years of age and older)

Abstract Combination of cervical cytology and HPV testing to screen : cytology provides little benefit over using HPV testing alone to screen → HPV testing alone to screen → cervical cytology : a way to determine which HPV-positive women require additional follow-up or colposcopy Reserve : 보존하다. 남겨두다.

Introduction Cervical cytology the cornerstone of cervical cancer prevention programs highly effective in many countries considered by some cancer control experts to be the single most successful approach to the prevention of any cancer the limitations inherent in cytology-based screening →cytology-based screening programs have had even less of an impact The somewhat provocative title of this article underscores how newer molecular tests are changing our options for preventing cervical cancer. Cornerstone :초석 In the United States, widespread cytology-based screening was introduced in the 1960s and invasive cervical cancer incidence rates have been subsequently reduced by approximately 75%, with even greater reductions seen in populations of women that have full access to screening.

Limitations of Cytology Relatively poor sensitivity the sensitivity of a single Papanicolaou test : 50% for identifying women with CIN 2,3 or cervical cancer (CIN 2+) Meta-analyses that have reviewed the performance of cervical cytology sensitivity : 30% ~ 87% specificity : 86% ~ 100% meta-analysis conducted several years ago reviewed 94 screening studies overall sensitivity of cytology for CIN 2+ : 53% (95% CI 49%-57%) a review of recent European and North American cervical cancer screening studies by Cuzick et al 19% in a German study 77% in a recent large British study Although many of the studies that have been included in these meta-analyses are quite old and were conducted before the introduction of liquid-based cytology or the routine use of endocervical sampling with cytobrushes, more recent research studies continue to report that the sensitivity of a single cervical cytology test is relatively low found that the overall sensitivity of cytology continues to vary considerably

Limitations of Cytology liquid-based cytology conventional cytology for detecting CIN 2+ significantly more sensitive Systematic review - publications through 2003- no evidence that liquid-based cytology improves the sensitivity of cytology Positive predictive value (PPV) significantly reduced with a relative PPV of 0.61 (95% CI 0.38-0.97) compared with conventional cytology ASCUS cutoff, the sensitivity 71% (95% CI 58%-81%) 84% (71%-92%). ASCUS cutoff, PPV 9.4% (95% CI 7-12.3) 11.4% (95% CI 8.5-15.0).

Limitations of Cytology liquid-based cytology vs conventional cytology No significant differences of sensitivity or PPV for the identification of women with CIN 2+

Limitations of Cytology novel cervical cancer screening strategies alternative, non–cytology-based screening methods In this review, we discuss what these novel strategies are likely to be and how they will impact cervical cancer prevention programs.

Performance of cytology-based Prevention Programs The goal of a cervical cancer prevention programs to identify high-grade cervical cancer precursors (CIN 2,3) to allow the lesions to be treated to prevent the subsequent development of cervical cancer cov·er·age〔 〕 n. [U.C] 1 적용 범위 2【보험】 보상 (범위) 3【경제】 정화(正貨) 준비(금) 4 보도 (범위), 취재 (범위);(광고의) 도달 범위;(라디오·텔레비전의) 방송 (범위), 서비스[가청] 구역

Performance of cytology-based Prevention Programs The effectiveness of cervical cancer prevention programs : depends on several factors + the sensitivity of the screening test Other factors that are important include ; (1) whether or not there is heterogeneity among CIN 2,3 lesions (2) the time it takes for a CIN 2,3 to progress to an invasive cancer (ie, the transit time) (3) the frequency at which screening occurs (4) screening coverage (ie, proportion of the target population that is actually screened)

Performance of cytology-based Prevention Programs Long transit time the time for a CIN 2,3 → an invasive cancer ☞ average 10 years the introduction of cervical cytology →reductions in cervical cancer incidence : highly variable between countries ( reduction range 20% ~ 90%) - Epidemiologic studies from Canada, Scandinavia, and the United Kingdom This relatively long transit time for high-grade precursors to progress to an invasive cancer allows us to at least partially overcome the low sensitivity of cervical cytology by screening women at relatively short intervals. in·fre·quent〔 〕 a. 드문, 좀처럼 없는;보통이 아닌, 진기한

The audits included the clinicians obtaining the cytology specimens 1970s ~ 1980s : minimal impact on cervical cancer incidence FIGURE 1. Impact of the introduction of organized screening on the incidence of cervical cancer in the United Kingdom. Modified from BMJ. 1999;318:904–908. Audit : 심사, 결산 Comprehensive : 포괄적인 Incorporated : 합동한, As part of the audit, performance indicators were introduced for all laboratories evaluating cervical cytology specimens and for all colposcopy clinics in the National Health Service to assure performance to a high standard. In 1988, the National Health Service introduced a comprehensive cytology-based screening program that incorporated a comprehensive system of audits. The audits included the clinicians obtaining the cytology specimens laboratories evaluating the specimens specialists treating women with precursor lesions

Performance of cytology-based Prevention Programs “call-recall” system every woman in England of the targeted ages receives a regular invitation to be screened screening coverage (1988 ~1995) : 40% → 85% (↑) → incidence of invasive cervical cancer : dropped by 40% death rate from cervical cancer : reduced by almost 50%. (by 2004) family practices : 가족의료

Performance of cytology-based Prevention Programs Compensating for the poor sensitivity of cytology → frequent screening In U.S. most women are overscreened some women do not undergo regular screening 10,000 women who develop cervical cancer each year in the U. S. - recent screening (X) : half of them - recent screening (O) : half of them more sensitive test

Human Papilloma Virus DNA Testing

Human Papilloma Virus DNA Testing invasive cervical cancer : 15 “high-risk” or “oncogenic” types of human papilloma virus (HPV) molecular test for detecting the DNA of high-risk types of HPV in clinical specimens is a solution hybridization test called Hybrid Capture 2 (hc2) (Digene Diagnostics, Gaithersburg, MD) overcome the limitations of cervical cytology for screening lower cost 13 high-risk types of HPV : 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, and 68 Over the last decade, astonishing progress has been made in our understanding of the pathogenesis of cervical cancer. The availability of these sensitive molecular testing techniques provides us an opportunity to overcome the limitations of cervical cytology for screening and to provide women with greater protection against cervical cancer at a lower cost.

Human Papilloma Virus DNA Testing TABLE 1. Performance of Hybrid Capture 2 and Cervical Cytology for Screening in Women 30 Years of Age and Older in Cross-sectional Studies*The target age for the study was 30 years and older for women and 97% of the women enrolled were in the target age.Modified from references J Natl Cancer Inst. 2006;98:765–774; Lancet. 2003;362:1871–1876; Br J Cancer. 2003;88:1570–1577; and Br J Cancer. 2005;93:575–581. presents the results from recent large European trials.

Human Papilloma Virus DNA Testing Sensitivity HPV DNA testing > cervical cytology for identifying women with CIN 2,3 or cancer (CIN 2+) negative predictive value : cytology(-) & high-risk HPV DNA (-) →extremely high (> 99.9% in most of the studies) → risk of having an undetected CIN 2+ lesion in women who are screened with both tests : very low (approximately 1 in 1000) Undetected : 발견되지 않는

Human Papilloma Virus DNA Testing late adolescent females and young women : multiple partners within several years of initiating sexual activity → prevalence of high-risk HPV DNA positivity ↑↑ → multiple sequential infections with different types of HPV Ω most of these infections : transient women 30 years and older older they tend, fewer new sexual exposures resulting in fewer new HPV infections HPV prevalence ↓ Several years ago, when we first considered using HPV DNA testing for screening there was considerable concern that the prevalence of high-risk HPV DNA positivity among women in the general population would be too high to allow HPV DNA testing to be useful

Human Papilloma Virus DNA Testing Specificity : cervical cytology > HPV DNA testing > 2 tests in combination women ≥ 30 years old, who are screened using both cytology and high-risk HPV DNA testing → an abnormality on one or the other test → require either workup or additional follow-up --------------------------------------------------------10% In general, the specificity of HPV DNA testing is somewhat lower than that of cervical cytology and as expected, the specificity of using the 2 tests in combination is lower than that of either test. The specificity of HPV DNA testing, cervical cytology, and a combination of both tests when used in women 30 years of age and older in 4 European screening trials is shown in

as an Adjunct to Cervical Cytology Using HPV DNA Testing as an Adjunct to Cervical Cytology

Using HPV DNA Testing as an Adjunct to Cervical Cytology FIGURE 2. Management of women using a combination of cervical cytology and HPV DNA testing for primary screening in women 30 years and older. Modified from Obstet Gynecol. 2004;103:304–309.

Using HPV DNA Testing as an Adjunct to Cervical Cytology both high-risk HPV DNA and cytology negative → recommended that not require rescreening for 3 years supported by the results of 2 studies Study NCI study followed women enrolled from Kaiser Permanente Portland, OR study from France F/U up to 10 years for 36 months result high-risk HPV DNA (-) → the risk of developing biopsy-confirmed CIN 3 : low cervical cytology high-risk HPV DNA →biopsy-confirmed CIN 2+ : 0.08% Adjunct : 부가적 (-)

Using HPV DNA Testing as an Adjunct to Cervical Cytology How to manage HPV DNA (+), cytology (-) → reflect these women's risk for having, or developing, CIN2+ HPV DNA (+), cytology (-) Lower risk for having CIN 2+ than are women with ASC-US ( 5~17%) HPV DNA (+) & Cytology (-) In the French study study from England CIN 2+ risk 4.2% 2.8%

Using HPV DNA Testing as an Adjunct to Cervical Cytology HPV DNA(+), cytology(-) → colposcopy not be performed the 2004 Interim Guidance recommends → retested in 6 to 12 months using both cervical cytology and HPV DNA testing (Fig. 2) persistent HPV infections or cytology ≥ low-grade squamous intraepithelial lesions → colposcopy In the French & English studies in the Kaiser Permanente Northern California HPV DNA(+) half of women were persistently at 6 months only 35% were persistent at 12 months spared :할애하다. 내 주다. the majority of HPV DNA (+), cytology (-) : spared the costs and inconvenience associated with colposcopy if the clinician simply waits and retests them in 12 months.

Using HPV DNA Testing as an Adjunct to Cervical Cytology transiently shed HPV DNA → very low risk for having CIN 2+ both repeat tests : cytology(-), HPV DNA (-) → 3 yearly screening shed<피·눈물 등을> 흘리다;<물·액체 등을> (샘솟듯) 솟구치게 하다, 내뿜게 하다 2 <잎 등을> 저절로 떨어지게 하다, <가죽·껍질·뿔 등을> 벗다, 갈다, 탈락시키다;<옷을> 벗어버리다;<무용지물·나쁜 버릇을> 버리다;해고하다;이혼하다

Alterative Strategies for Using HPV DNA Testing for Screening HPV testing as an adjunct to cytology : long-standing problems large numbers of cytotechnicians the variability in abnormal rate between laboratories relatively slow turnaround times To maximize the benefits of incorporating HPV testing into screening → identify as many women with CIN 2+ as possible at the initial visit, while limiting the number referred to colposcopy Drawback : 결점, 약점 triage : 선별, 선택 Marginalizes : 사회의 주류에서 몰아내다. 무시하다.

Alterative Strategies for Using HPV DNA Testing for Screening Goal of cervical cancer screening the risk of cervical cancer the level of risk reduction the costs potential inconvenience or harm to those being screened to reduce not eliminate Inconvenience : 불편, 귀찮은 거

Alterative Strategies for Using HPV DNA Testing for Screening common misperception : receive regular screening → completely protected against cervical cancer → develop cancer → their clinician or the cytology laboratory, has failed them → frequent litigation for a failure to diagnose cervical cancer compensatory overscreening by clinicians to try and assure that none of their patients develop cervical cancer → increases the costs of screening → unnecessary interventions such as colposcopy Litigation : 소송, 기소

Alterative Strategies for Using HPV DNA Testing for Screening sensitivity of HPV DNA testing : high HPV DNA testing with cytology Cytology with adjunctive HPV testing Cytology-based screening → HPV-based strategy CIN 2+ dectection cytology : no cases of CIN 2+ that were missed by HPV testing 1 ~ 3 cases /10,000 compared with using HPV testing alone 12 ~ 30 additional cases / 10,000 In 2 South African screening studies In other European screening studies utilizing HPV DNA testing alone as the primary screening test

Alterative Strategies for Using HPV DNA Testing for Screening several potential approaches that can be used for managing HPV DNA positive women : Novel HPV-based screening strategies incorporating either “reflex” cytology HPV genotyping, or a combination of both → a specimen would be obtained from all women using a liquid collection media suitable for both HPV DNA testing and cytology → initially be tested for high-risk types of HPV → HPV DNA (+) processed for cytology perform HPV genotyping or

FIGURE 4. Novel HPV-based screening strategies incorporating either “reflex” cytology HPV genotyping, or a combination of both.

Alterative Strategies for Using HPV DNA Testing for Screening most of the high-risk HPV DNA positive → developed biopsy-confirmed CIN 3 : HPV 16 or HPV18 In the Kaiser Portland, OR, follow-up study other high-risk types of HPV : slightly increased risk high-risk types of HPV such as HPV 16, 18, 33, 45, or 31 (the 5 most common HPV types found in cervical cancers) → to be referred to colposcopy → followed-up in 12 months with a repeat HPV DNA test

FIGURE 3. Impact of HPV status on the development of CIN 3 in women 30 years and older enrolled from Kaiser, Portland, OR. Solid circles represent women who were HPV 16 positive entry, open circles are those who were HPV 18 positive, solid triangles are women with other high-risk types of HPV, and open triangles are women who were high-risk HPV DNA negative. Modified from J Natl Cancer Inst. 2005;97:1072–1079. HPV16(+) HPV18(+) Other high risk types of HPV High-risk DNA (-)

Alterative Strategies for Using HPV DNA Testing for Screening Alternative strategy : screen using HPV DNA testing alone → then use a combination of both reflex cytology and HPV genotyping to identify which HPV DNA positive women need colposcopy - even more promising Promising : 장래성이 있는 , we identify significantly more women with CIN 2+ at the time of initial screening using this approach than we do using the currently accepted strategy of cervical cytology and HPV DNA testing for all women. Alternative strategy : 대안

Summary novel HPV-based screening → overcome many of the limitations of cervical cytology → will maximize the number of women with CIN 2+ identified at the screening visit → make loss to follow-up less of a concern HPV-based screening strategies : sensitivity↑ → safely extend screening intervals from 3 to 5 years → less expensive to the health care system → more convenient for patients health care system :의료보험 체제

Thank you for your attention !

Summary

Alterative Strategies for Using HPV DNA Testing for Screening Several studies have now clearly demonstrated that women infected with certain high-risk types of HPV are at much greater risk for developing CIN 2+ than are women infected with other high-risk types of HPV. This approach would be almost as sensitive as using HPV DNA testing as an adjunct to cytology but would eliminate the need for cytology in 90% to 95% of women

Alterative Strategies for Using HPV DNA Testing for Screening The problem with eliminating cytology is that when both cytology and HPV DNA testing are utilized, the cytology result allows HPV DNA positive women to be triaged into 2 groups, those requiring colposcopy and those who can simply be followed-up. This triage function is needed since 5% to 8% of women 30 years and older will be found to be high-risk HPV DNA positive (Table 1) “reflex :반사적인1 반전시키다, 되접다, 휘게 하다 2 반사 작용을 일으키게 하다, 반사시키다 3【통신】 …에 리플렉스 증폭 장치를 하다

Over the next decade, the extraordinary advances that have been made in our understanding of the pathogenesis of cervical cancer are going to allow us to develop novel HPV-based screening strategies that will be able to overcome many of the limitations of cervical cytology. These strategies will maximize the number of women with CIN 2+ identified at the screening visit and make loss to follow-up less of a concern. Because of the increased sensitivity of these HPV-based screening strategies, we will be able to safely extend screening intervals from 3 to 5 years. This will be less expensive to the health care system and more convenient for patients. Already large randomized screening trials are underway in Europe to evaluate whether we can replace cervical cytology with HPV DNA testing. Hopefully such trials will begin in the United States in the near future.

Limitations of Cytology When liquid-based cytology was first introduced, a number of studies found that liquid-based cytology was significantly more sensitive than conventional cervical cytology for detecting CIN 2+. These studies had 1 of 2 designs. With 1 design, clinicians collect both a conventional cytology and a liquid-based cytology from the same patient at the same time. This allows a direct comparison of the performance of the 2 types of cytology. The other study design compares the results obtained using liquid-based cytology with results obtained by the same laboratory using conventional cytology before the introduction of liquid-based cytology (ie, historical controls). Unfortunately, in the majority of the studies the end point was a cytologic one (ie, detection of low-grade squamous intraepithelial lesions or high-grade squamous intraepithelial lesions) rather than a histologic one (ie, detection of biopsy-confirmed CIN 2,3). Moreover, both types of studies can be easily biased. Because of these limitations, many in the screening community have remained skeptical that liquid-based cytology is truly more sensitive than conventional cytology. skep·ti·cal│scep-〔 〕 ;a. 1 의심 많은, 회의적인, 회의를 나타내는, 회의론자 같은;신용하지 않는     be skeptical about[of] …을 의심하다 2 무신론적인 3 [Skeptical] 【철학】 회의(학)파의, 회의론(자)의 skeptical·ly ad. skeptical·ness n.

Limitations of Cytology A recent systematic review of publications through 2003 that compared the performance of liquid-based cytology with that of conventional cytology concluded that only 4 of 56 published studies provided sufficient verified data to allow any estimates of sensitivity and specificity and comparisons of test performance to be made. The systematic review concluded that there is no evidence in high-quality studies that liquid-based cytology improves the sensitivity of cytology. The review also concluded that randomized clinical trials were needed. Since the systematic review was completed, several randomized trials have been published comparing the performance of the 2 cytology methods. One large randomized study of Italian women 25 to 34 years of age reported that the sensitivity of liquid-based cytology was not significantly higher than that of conventional cytology. The relative sensitivity of liquid-based cytology for CIN 2+ using an atypical squamous cells of undetermined significance cutoff was 1.24 (95% CI 0.75-2.03) compared with that of conventional cytology.

Limitations of Cytology However, the positive predictive value (PPV) of liquid-based cytology was significantly reduced with a relative PPV of 0.61 (95% CI 0.38-0.97) compared with conventional cytology. Another publication from the same group focused on women 35 years of age and older and found similar results. The relative sensitivity of liquid-based cytology in the older population was 1.06 (95% CI 0.72-1.55) compared with conventional cytology. In this study, the PPV of liquid-based cytology was also significantly reduced (relative PPV=0.58, 95% CI 0.33-0.98) compared with conventional cytology. In a recent randomized study from South Africa in which all women underwent colposcopy at the time of screening, we found no significant differences in either the sensitivity or PPV of liquid-based cytology compared with conventional cytology for the identification of women with CIN 2+. At an atypical squamous cells of undetermined significance cutoff, the sensitivity of liquid-based cytology was 71% (95% CI 58%-81%), whereas that of conventional cytology was 84% (71%-92%). The PPV of liquid-based cytology was 9.4% (95% CI 7-12.3) whereas that for conventional cytology was 11.4% (95% CI 8.5-15.0).

Performance of cytology-based Prevention Programs In Norway after the introduction of opportunistic (ie, nonorganized) screening, the incidence of cervical cancer actually increased through the mid-1970s and only subsequently began a somewhat slow decline. In large part, the minimal impact was attributable to the fact that relatively few women were being screened (ie, there was low coverage) and the screening frequency was too infrequent. However, in 1995 Norway introduced an organized cytology-based cervical cancer screening program and since its introduction the rates of invasive cervical cancer have dropped considerably. au·dit〔 〕〔L 「들음, 듣기」의 뜻에서〕 n. 1 회계 감사, (회사 등의) 감사(監査);결산     an internal audit (회사 자체가 하는) 내부 감사     an independent audit (외부 기관이 하는) 독립 감사 2 (문제의) 심사

Human Papilloma Virus DNA Testing Recently, Kaiser Permanente of Northern California began offering HPV DNA testing to all women 30 years of age and older. On the basis of the data from over 200,000 women, the overall prevalence of high-risk HPV DNA positivity was just 6.4%. For comparison, 7.8% of the women had some degree of cytological abnormality. 14 In Kaiser, a total of 11.6% of the women had either a cytologic abnormality or were high-risk HPV DNA positive.