1. HPV Testing and Cervical Screening in the UK
Alex Sargent
HPA Manchester

2. Human Papillomaviruses
Mainly infect the anogenital tract ( approx 40 genotypes)
Quite often asymptomatic
LOW RISK (20 Types including types 6 and 11)
Anogenital warts
Very rarely found in cancers
HIGH RISK (approx 14 types)
Precursor lesions (CIN) cervical cancer
Most malignancies of the anogenital tract

3. 99.7% of cervical cancers are directly linked to previous infection with a High Risk HPV type
Walboomers et al 1999

4. High-risk HPV Prevalence (N=24,510)
Percentage of HR HPV
Age Group
Kitchener et al 2006

5. HR HPV Type by Cytology Grade
% of Type Specific HPV Prevalence
Cytology Grade

6. MRI Involvement in HPV
Malignant progression of laryngeal papilloma associated with human papilloma virus type 6 (HPV-6) DNA. A P Zarod, J D Rutherford, and G Corbitt. J Clin Pathol. 1988; 41: 280–283
Anal human papillomavirus and anal cancer. Tilston P. J Clin Pathol. 1997; 50:625-34
A study of anal intraepithelial neoplasia in HIV positive homosexual men. Lacey HB, Wilson GE, Tilston P, Wilkins EG, Bailey AS, Corbitt G, Green PM. Sex Transm Infect. 1999; 75:172-7
Natural history of cervical human papillomavirus infection in women during their first sexual relationship. Woodman CB, Collins S, Winter H, Bailey A, Ellis J, Prior P, Yates M, Rollason TP, Young LS. Lancet. 2001; 357:1831-6

7. More recent work has been our involvement in the ARTISTIC Trial
Designed to investigate the value of incorporating HPV testing in to the English cervical cancer screening programme
• Kitchener at al. Br J Cancer 2006; 95(1): 56-61
• Sargent et al. Br J Cancer 2008; 98(10):1704-9
• Kitchener et al Lancet Oncol. 2009;10(8):748.
• Kitchener at al Health Technol Assess. 2009; 13(51):1-150, iii-iv
• Sargent et al. J Clin Microbiol. 2010; 48(2), 554-8
• Kitchener at al Eur J Cancer. 2011; 47(6):864-71

8. ARTISTIC Trial
Main findings
• Primary cervical screening with combined LBC and HPV testing resulted in only a small reduction in the detection of high grade disease at the next screening round compared to LBC alone
• HPV testing, either for triage or as the initial screening test triaged by cytology, would be cost effective with no loss of sensitivity
• The screening interval could be increased from 3 to at least 6 years
• No significant adverse psychosocial effects were detected

9. NHS HPV Triage Pilot Studies
Studies showed
A reduction of inadequate smears (from 9% conventional cytology to 1-2% LBC)
• 46% (1680/3681) BNC & 83% (1507/1825) mild dyskaryosis were HPV positive
• The rate of repeat smears fell by 74% (70% for BNC & 87% for mild)
• Rate of referral to colposcopy more than doubled (increased from 15%-44% for BNC & 37% - 80% for mild)
• Direct referral of HPV positive women to colposcopy may lead to increased detection of CIN2+
Legood. BMJ 2006; 332:79-83
Moss. BMJ 2006; 332:83-85

10. Sentinel Sites project
Funded by the NHS Cervical Screening Programme
HPV Triage
March , 6 cytology centres (approx. 10% screening population in England) acted as sentinel sites for HPV triage
In the event of borderline or mild dyskaryosis cytology, residual material is tested for HR HPV using the Hybrid Capture 2 test (≥2RLU/Co)
HPV Positive women are referred to colposcopy
HPV Negative women are returned to routine recall (HPV testing has a high NPV)
Virology testing centralised in Manchester Virology lab and Bristol Cytology lab

11. Sentinel Sites project
Test of cure
In the event of an abnormal cytology report post-treatment, women are referred for colposcopy (standard practice)
In the event of a normal cytology report, residual material is tested for high risk HPV by HC2 (≥2 RLU/Co)
HPV negative women are referred for 3-year recall ( rather than annual recall for 10 years) and HPV positive women referred for colposcopy
HPV-directed referral strategy is of considerable benefit to women in terms of reducing anxiety, uncertainty and the need for repeat smears, as well as reducing work load in cytology
Kitchener et al. BJOG 2008; 115:

12. HR HPV Positivity Rate by Referral Site

13. Improvements to the NHS CSP
Increased identification of high grade CIN and increased specificity in women undergoing HPV triage
HPV triage offers immediate referral to colposcopy for those who may have significant disease & rapid return to routine recall for women unlikely to have significant disease due to high NPV of HPV testing
HPV ToC offers rapid return to routine recall for treated women (approx. 80%)
Reduced repeat testing will give rise to savings in primary care and laboratories

14. HPV TESTING NEW TECHNOLOGIES STUDY.

15. Qiagen HC2 assay Clinically regarded as the “Gold Standard”
Approved cervical specimens include Cytyc ThinPrep PreservCyt® solution & SurePath preservative fluid
Signal amplification DNA screening assay
Targets 13 HR types
Semi-automated system available
No internal control for sample integrity
Known issues regarding cross-reactivity

16. Qiagen Hybrid Capture 2 (HC2) Test

17. The Rapid Capture™ System
Courtesy of Digene

18. ALTERNATIVE HPV TESTS

19. Basic Methodologies
HPV Detection performed by molecular assays - Signal Amplification (HC2 ; Cervista) - Nucleic Acid Amplification (PCR ; TMA ; NASBA)

20. Screening assays Genotyping assays
Designed to detect the group of High Risk HPV Genotypes
Some assays also have limited genotyping capacity for types 16 and 18
Genotyping assays
Designed to Genotype the majority of the HPV types infecting the Genital Tract-particularly the High Risk Genotypes
Usually based on either a line blot assay format or micro-array system
As yet of questionable value in the cervical screening programme

21. Some Commercial Screening Assays
Qiagen HC2 GenProbe APTIMA Roche AMPLICOR Roche Real Time Abbott Real Time Hologic Cervista Norchip Bio-Tools Gen ID Genomica

22. Clinical Validation
• In the case of HPV infections there is a big difference between analytical sensitivity and clinical sensitivity /specificity • Meijer CJ et al have recently developed guidelines for high-risk HPV test requirements for primary cervical screening and validation guidelines for candidate HPV assays Int J Cancer 2009 Feb (3)

23. Guidelines for HPV Testing
The sensitivity of the candidate test for CIN2+ should be at least 90%** of the sensitivity of the HC2 assay to Detect Clinical Disease
The specificity of the candidate test for CIN2+ should be at least 98% of the specificity of the HC2 assay
**For our study the minimum sensitivity has been raised to 95%

24. New Technologies Study
Aim
• To demonstrate non-inferiority of any new test relative to Qiagen Hybrid Capture 2, in terms of both sensitivity and specificity for detection of high grade disease (≥CIN2)
• To assess the clinical utility of the test for triage of low grade cytology
• New tests were assessed at Bristol HPA and Manchester HPA SurePath LBC and 2500 ThinPrep LBC

25. Commercial Assays Under Evaluation
New Test
Surepath
Thinprep
Roche Cobas 4800 
Abbott rt HPV
Gen-probe HPV APTIMA ++
Hologic Cervista HPV
++ non-CE marked

26. Conclusions
All assays so far have proved non-inferior to the HC2 assay
Genprobe (SurePath) and Hologic are still under evaluation
New tests are highly automated
All assays have internal controls
Abbott and Roche tests can simultaneously detect and identify types 16 and 18

27. Possible Future
Setting up of sentinel sites to pilot primary HPV testing in cervical screening
Use of self sampling to improve coverage of the cervical screening programme

28. Acknowledgements Prof Henry Kitchener and the ARTISTIC Team
Prof Julietta Patnick and members of the NHSCSP
Members of the Primary Screening Group
Andrew Bailey and Staff in Virology, Manchester Royal Infirmary