Methods
In summary, from February 2013 to August 2014, almost 40 experts got together to update
the previously published recommendations[2 ] based on the best available evidence. Among these experts were prominent gynecologists
with known experience in the subject, as well as representatives of institutions involved
in cervical cancer screening and the follow-up of abnormal screening tests, who share
the authorship of this paper. The remaining participants of the revision and consensus
process are listed in the Acknowledgments. The review leaders were selected by a panel
of specialists leaded by the ABPTGIC. Each review leader invited other specialists
from other parts of the country, considering their work in the specific area of interest.
Each review group reviewed one main topic, searching for the best evidence in original
articles or secondary information sources, submitting their summary and updated recommendations
to the whole group. The result of the work of each group was discussed in videoconferences
and, at the end of this process, the final text was discussed in a special meeting
in Rio de Janeiro.
The following text presents, in each topic, evidence that supports the use of the
HPV-DNA tests in each individual scenario. The evidence from the literature was classified
as high, moderate or low, according to the risk of bias ([Table 1 ]).
Table 1
Level of certainty
Certainty Level[* ]
Description
High
The available evidence usually includes consistent results from well-designed and
well-conducted studies among the representative populations to which they apply. These
studies assess the effects of the preventive practice on health outcomes. This conclusion
is therefore unlikely to be strongly affected by the results of future studies.
Moderate
The available evidence is sufficient to establish the effects of the preventive practice
on health outcomes, but confidence is limited by factors such as:
• The number, size or quality of the individual studies
• Inconsistency in the findings across individual studies
• Limited generalizability of the findings to the routine practice
• Lack of consistency in the chain of evidence
As more information becomes available, the magnitude or direction of the observed
effect may change, and this change may be large enough to alter the conclusion.
Low
The available evidence is insufficient to assess effects on health outcomes. The evidence
is insufficient because of:
• The limited number or size of the studies
• Important flaws in the studies' designs or methods
• Inconsistency in the findings across individual studies
• Gaps in the chain of evidence
• Findings not generalizable to the routine practice
• Lack of information on important health outcomes
More information can allow estimates of the effects on health outcomes.
* The United States Preventive Services Task Force (USPSTF) attributes a level of certainty
based on the general nature of the evidence available to assess the net benefit of
a preventive practice.[3 ]
The summary of evidences is followed by specific recommendations that resulted in
the experts' consensus. Each recommendation is followed by a capital letter in parentheses,
meaning its strength, based on the degree of certainty from the best scientific evidence
and judgment of the participants ([Table 2 ]). In [Table 3 ] we list the most relevant recommendations.
Table 2
Strength of recommendation
Grade
Definition[* ]
Recommendations for practice
A
The practice is recommended. There is high certainty that the net benefit is substantial.
Offer or provide the practice.
B
The practice is recommended. There is high certainty that the net benefit is moderate
or there is moderate certainty that the net benefit is moderate to substantial.
Offer or provide the practice.
C
The practice is not routinely recommended. There may be considerations that support
the practice at an individual level. There is at least moderate certainty that the
net benefit is small.
Offer or provide this service for selected patients depending on individual circumstances.
D
The practice is not recommended. There is moderate or high certainty that the practice
has no net benefit, or that the damages outweigh the benefits.
Discourage the use of this practice.
I
The current evidence is insufficient to assess the balance between its benefits and
harms. The evidence is lacking, of poor quality, or conflicting, and the balance of
benefits and harms cannot be determined.
Read the introductory text containing evidence obtained in the literature review that
supports this recommendation. If the practice is offered, the patients should understand
that there is uncertainty in the balance between benefits and harms.
* The United States Preventive Services Task Force (USPSTF) defines certainty as the
“likelihood that the USPSTF's assessment of the net benefit of a preventive practice
is correct.” The net benefit is defined as the benefit minus the practice injury when
implemented in a general population.[2 ]
Table 3
Most relevant recommendations for the use of the HPV-DNA test in cervical cancer screening
and after an abnormal cytology
The HPV-DNA test can be the primary screening method as an alternative to cytology
in women aged 30 years or older. When negative, the test should be repeated every
5 years.
When the HPV-DNA test is positive for oncogenic HPV, triage with cytology is recommended.
If genotyping is available and if it is positive for HPV types 16 or 18, the woman
may be referred for colposcopy.
Women aged 30 years or older with ASC-US can perform the HPV-DNA test as an alternative
to a new cytology after 6 months.
Women 30 years of age or older with LSIL can perform the HPV-DNA test to select those
who should be referred for colposcopy.
In women with ASC-H or HSIL and normal colposcopy, a negative HPV-DNA test will virtually
rule out precursor lesions or invasive disease.
In women with AGC or AIS and normal colposcopy, a negative HPV-DNA test means a low
probability of cervical disease, demanding investigation of the endometrium and other
pelvic organs.
The HPV-DNA test may be used at follow-up after the treatment of CIN II/III and AIS
to exclude residual or recurrent lesions, and it is recommended between 6 and 12 months
after the treatment.
Abbreviations: ASC-H, atypical squamous cells, cannot exclude high-grade squamous
intraepithelial lesion; ASC-US, atypical squamous cells of undetermined significance;
AGC, atypical glandular cells; AIS, adenocarcinoma in situ; CIN, cervical intraepithelial
neoplasia; HPV, human papillomavirus; HPV-DNA, human papillomavirus deoxyribonucleic
acid; HSIL, high-grade squamous intraepithelial lesion; LSIL, low-grade squamous intraepithelial
lesion.
HPV-DNA Test Use in Cervical Cancer Screening
The occurrence of false-negative and unsatisfactory cytology tests prompted the development
of new technologies that improve screening quality.[4 ] In addition, the evidence of a causal relationship between oncogenic HPV infection
and cervical cancer and its precursor lesions led to the development of HPV-DNA detection
techniques to prevent and identify these lesions.[5 ]
There is currently scientific evidence supporting HPV-DNA tests as the primary screening
method for women aged 30 years or older. Screening for HPV-DNA has a high sensitivity,
and anticipates the diagnosis of cervical intraepithelial neoplasia (CIN) II and III
even when the screening is performed in a 5-year interval. This technique is better
than regular cervical cytology in the diagnosis of glandular lesions (adenocarcinoma)
(evidence level: high).[6 ] Staff training is fast, laboratory results are reproducible, and it qualifies for
self-sample HPV-DNA-based screening (evidence level: high).[7 ]
The main limitation of HPV-DNA-based tests is their low specificity (positive results
when there is no lesion – a common finding in women under 30 years of age) (evidence
level: high).[8 ] To avoid an excessive number of women unnecessarily referred to colposcopy because
they were screened with a positive HPV result, triage methods are necessary. One option
is the cytology triage of HPV-DNA-positive cases, referring only women who tested
positive for HPV-DNA and whose cytology test was abnormal (evidence level: high).[9 ] This strategy has proven to be more sensitive and to have the same specificity as
cytology alone in a Swedish randomized clinical trial, which was part of the national
population-based screening program (evidence level: high).[10 ]
Screening for HPV-DNA has a greater operational advantage if performed using a sample
that would also allow a cytology triage, and this is the case of the liquid medium.
Therefore, if the HPV-DNA test is positive, the cytology test can be performed in
the same sample, and a new sample collection is not necessary, thus saving time and
resources.
Human papillomavirus types 16 and 18 (genotyping) in women with a positive HPV-DNA
test and a negative cytology have shown favorable results for the selection of women
with a higher probability of having CIN II or higher type (CIN II +). Prospective
studies with a large number of women support the immediate referral of patients with
positive HPV-DNA types 16 and 18 to colposcopy, regardless of the use of cytology
as triage (evidence level: high).[11 ]
[12 ]
[13 ]
In summary, screening with HPV-DNA-based tests may be advantageous in women aged 30
years or older, followed by a triage with cytology, provided that only those with
cytological atypia are referred for colposcopy. This is true for an organized screening
scenario, that is, one in which there is a control of who should be screened at the
recommended time intervals. There are only a few municipalities with organized cervical
cancer screening programs in Brazil. There is no suitable control of the women who
carry out their screening or how often they do it. Thus, there are no tools to ensure
that the interval between screening tests will be effectively widened with the adoption
of an HPV-DNA test, nor that women missed by this screening program will be identified.
Furthermore, in most Brazilian municipalities, the cost-effectiveness improvement
of HPV-DNA testing is not warranted. Given this background, the use of this technology
in each and every municipality of Brazil can only be recommended once their screening
program is organized and operational.
Recommendations
Testing based on HPV-DNA as an alternative to cytology in cervical cancer screening
should be performed every 5 years in women aged 30 years or older, and may be extended
up to when the patients are 64 years of age (B). Testing for HPV-DNA is unacceptable
before the age of 30 (D). When an HPV-DNA test is positive for oncogenic types, a
cytology exam should be performed, preferably using the same sample, since no further
sampling would be necessary. Therefore, the recommended medium for HPV-DNA test collection
is the same as for liquid-based cytology (B).
If an HPV-DNA test is positive for oncogenic types and the cytology shows any atypia
(ASC-US or worse), the woman should be referred for colposcopy (A). Instead, if the
cytology is negative, the woman should repeat the HPV-DNA test after 12 months (A).
If the HPV-DNA result remains positive for oncogenic types, the woman should be referred
for colposcopy (A). If the sample is negative for oncogenic HPV on the first or second
sampling opportunity after a negative cytology, a new cytology exam must be performed
after three years (A). If HPV-DNA genotyping is available and is positive for HPV
types 16 or 18, the woman should be directly referred for colposcopy, bypassing the
cytology test (A). If an HPV-DNA test (with or without genotyping) is negative, it
should be repeated in 5 years (A). Any therapeutic procedure performed because of
a positive HPV-DNA test is unacceptable (D). Women between the ages of 25 and 29 should
keep performing cytology tests (A). Women aged 65 years or older who tested negative
for HPV-DNA may discontinue screening (B). [Fig. 1 ] summarizes the recommendations for the use of HPV-DNA tests in cervical cancer screening.
Fig. 1 Recommendations for HPV-DNA testing in cervical cancer screening in women aged 30
to 64 years.*
Use of HPV-DNA Tests in the Follow-up of Women with Abnormal Cytology Results
Atypical Squamous Cells
Atypical Squamous Cells of Undetermined Significance (ASC-US), Possibly Non-neoplastic
The cytology diagnosis of atypical squamous cells of undetermined significance (ASC-US)
does not mean, in most cases, the presence of a precursor lesion or cancer. However,
identifying which women with this diagnosis are more likely to have one of these lesions
has led to several screening recommendations for colposcopy referral.
As mentioned in the Brazilian Guidelines for Cervical Cancer Screening,[1 ] there is a similarity among management recommendations for woman with ASC-US in
France,[14 ] the United Kingdom,[15 ] and Australia and New Zealand.[16 ] In these countries, a repeat cytology test is recommended after 6 to 12 months.
The American Society for Colposcopy and Cervical Pathology (ASCCP) states that using
the oncogenic HPV-DNA test for women aged over 25 with ASC-US cytology is preferable
to cytology. This same guideline states that this test is acceptable in 21- to 24-year-old
women with ASC-US, but repeat cytology is preferable in this age range.[17 ] The guidelines published in Korea[18 ] and Argentina[19 ] follow ASCCP recommendations and endorse the use of oncogenic HPV-DNA testing in
women with ASC-US cytology.
Recommendations
Women with ASC-US cytology can perform the HPV-DNA test alternatively to a new cytology
test within 6 months. If the test is positive for oncogenic types, the woman should
be referred for colposcopy (A).
The HPV-DNA test can also be used to outline the follow-up of women with ASC-US cytology
aged 30 years or older after a negative colposcopy. If the test is positive, the woman
should be followed in the primary care unit in the same way as the others. She should
undergo a new cytology test every 6 months (for women aged 30 years or more) or annually
(for younger women) (I) until 2 consecutive negative test results are achieved, then
she should return to triennial cytological screening, unless a different cytology
result occurs (A). If the HPV-DNA test is negative for oncogenic types, this woman
may return to triennial screening (A).
Atypical Squamous Cells, Cannot Exclude High Squamous Grade Intraepithelial Lesion
(ASC-H)
Differently from the diagnosis of ASC-US, in the presence of atypical squamous cells,
cannot exclude high squamous grade intraepithelial lesion (ASC-H), the probability
of a precursor lesion or cancer is significantly higher. Of all current recommendations,
the most favored is referral to colposcopy.
However, in many cases, colposcopy cannot ensure there is no lesion, and a negative
oncogenic HPV-DNA test virtually ensures its absence (evidence level: moderate).[20 ]
Recommendations
When available, the HPV-DNA test may also be used in women with an ASC-H cytology
who have a type-III transformation zone (TZ) and no abnormal colposcopy findings (B).
If there is no oncogenic HPV, this woman may return to triennial cytology screening
(I). If there are abnormal findings, this woman should continue to undergo the investigation
of the endocervical canal as recommended by the Brazilian Guidelines for Cervical
Cancer Screening (I). If the presence of a precursor or invasive lesion is not proven,
the HPV-DNA test may also be used at the follow-up. In this case, it should be performed
within 6 months of the initial cytology test (A). If there is no oncogenic HPV, this
woman can go back to triennial screening (A). If oncogenic HPV is present, this woman
should be referred for colposcopy to ensure there are no precursor lesions (I).
In postmenopausal women with an ASC-H cytology test, the HPV-DNA test may also be
used, avoiding topical estrogens before a new colposcopy, as indicated in the Brazilian
Guidelines (I). If there is no oncogenic HPV, this woman may return to triennial cytological
screening (I). If positive for oncogenic HPV, she should be followed as recommended
in the Brazilian Guidelines for Cervical Cancer Screening: continuation of the investigation,
preferably with estrogen preparation (I).
Atypical Glandular Cells (AGC)
Atypical Glandular Cells of Undetermined Significance, Possibly Non-neoplastic or
Atypical Glandular Cells in Which High-grade Intraepithelial Lesions Cannot Be Ruled
Out
Atypical glandular cells are another challenge. The prevalence of precursor lesions
and invasive disease in women with this cytological diagnosis is higher than in women
with ASC-US. In addition, most glandular lesions are in the endocervical canal, which
is often a colposcopic challenge, with less specific colposcopic findings than those
of squamous lesions.
Considering the limitations of cytology and colposcopy in such situations, the HPV-DNA
test may provide additional information to the investigation. The presence of oncogenic
HPV-DNA also showed association with invasive or precursor glandular disease (evidence
level: high).[21 ] The probability that an intraepithelial lesion may reach 40% when oncogenic HPV
types are present, compared with 4% when absent, points to a possible use of this
test in the investigation of these women (evidence level: high).[22 ]
Recommendations
In women with an AGC cytology, and in situations in which the colposcopy cannot ensure
the absence of glandular disease, a negative oncogenic HPV-DNA test will virtually
rule out precursor or malignant disease of the cervix (A).
Low-grade Squamous Intraepithelial Lesion (LSIL)
This cytology result implies a low probability of cancer or a precursor lesion. In
order to identify women at a greater risk of developing these diseases and to define
the need to refer them for colposcopy, the use of HPV-DNA tests was proposed. In this
situation, HPV-DNA tests have a significantly higher sensitivity, but significantly
lower specificity, when compared with repeat cytology (evidence level: high).[23 ] The low specificity of HPV-DNA tests is due to the high HPV prevalence in women
with LSIL (76.9%) (evidence level: high),[24 ] which would imply the referral of most women for colposcopy, compromising the cost-effectiveness
strategy. However, a positive HPV-DNA test is determined by the prevalence of HPV
infection, which in turn is age-dependent. More recent studies have shown that several
HPV-DNA tests have increased specificity with increasing age, in addition to high
sensitivity, for the detection of CIN II + in women with LSIL (evidence level: high).[25 ]
[26 ] Scientific evidence suggests that HPV-DNA tests may be useful for the triage of
older women with LSIL. However, because of the lack of stratified data, we don't have
enough evidence to recommend the best moment to use it in this situation (evidence
level: high).[27 ]
A meta-analysis of studies on the performance of HPV-DNA test as a triage for the
colposcopy of women with LSIL cytology published in 2013 concluded that these tests
may have a greater ability to detect cases of NIC II +. However, their use should
be weighed against the costs of the testing and the colposcopy, in addition to the
adherence to follow-up. Furthermore, they point out that DNA-HPV tests are certainly
useless in young women with LSIL, that more studies are needed to define their usefulness
in the triage of older women (in the US it is recommended for postmenopausal women),
and that higher cut-off points might be used to consider the test positive (evidence
level: high).[22 ]
In the follow-up after colposcopy, if there are no abnormal findings, or when the
result is compatible with CIN I or a less severe type, the sensitivity of the biannual
cytology control and the 12-month HPV-DNA test for CIN II+ detection was similar (89%
and 92% respectively). However, the referral rates for new colposcopy were different
(64% for cytology and 55% for HPV-DNA), pointing to a higher cost-effectiveness of
the HPV-DNA test (evidence level: high).[26 ]
Recommendations
Where HPV-DNA testing is available, it may be used in women with LSIL cytology who
are aged 30 years or older for referral for colposcopy. If the HPV-DNA test is negative
for oncogenic types, the woman should return to triennial cytology screening (I).
If the HPV-DNA test is positive for oncogenic types, the woman should be referred
for colposcopy (I). In addition, after the first colposcopy, in the follow-up of the
women with no abnormal findings or after the histology diagnosis of CIN I, a 12-month
HPV-DNA test may be used (A) as an option. When oncogenic types are present, the follow-up
should be continued as aforementioned (A). Negative cases should go back to the triennial
cytology screening routine (A).
High-grade Squamous Intraepithelial Lesion (HSIL)
The use of HPV-DNA tests is of no value for the colposcopy referral of women after
this cytology result. However, in view of the high prevalence of oncogenic HPV types
in precursor lesions (evidence level: high),[20 ] it can be useful in situations in which the colposcopy cannot rule out disease.
Recommendations
In cases of high-grade squamous intraepithelial lesion (HSIL) cytology, the HPV-DNA
test, when available, may be used only if there are normal or low-grade colposcopy
findings. If no oncogenic types are present, precursor or invasive disease is virtually
excluded, and the woman can return to triennial cytology screening (A).
Adenocarcinoma in situ (AIS) and Invasive Adenocarcinoma
These cytology results are a challenge for colposcopy. These lesions are usually located
inside the endocervical canal and are not easily recognized, even by experts. Occasionally,
the disease may come from the endometrium or other pelvic organs.
As a result, there usually are no abnormal findings at the colposcopy, and that requires
an excisional diagnostic procedure, as well as investigation of the endometrium and
other pelvic organs in women aged 35 years or older, or below that age if there is
any abnormal bleeding.[1 ]
A negative oncogenic HPV-DNA test may be useful in identifying women at a higher risk
of having endometrial disease, especially those over 50 years of age (evidence level:
moderate).[28 ]
Recommendations
Where available, HPV testing may be used in the initial investigation of women with
a cytology result of adenocarcinoma in situ (AIS) or invasive adenocarcinoma. If negative,
this will mean a lower probability of having cervical disease, and that will endorse
the evaluation of the endometrium as well as of other pelvic organs in women aged
35 years or older and in those with abnormal bleeding under 35 years of age (I).
Use of the HPV-DNA Test in the Follow-up of Women Treated for Cervical Cancer Precursor
Lesions
After Treatment of CIN II/III
Long-term follow-up studies indicate that women treated for CIN II/III are at a higher
risk of developing cervical cancer for at least 10 years, and perhaps up to 20 years
after treatment, when compared with the general population (evidence level: high).[29 ]
The ideal follow-up for the detection of residual or recurrent disease appears to
be cytology associated with colposcopy, but current data suggests that the HPV-DNA
test identifies disease earlier, with greater sensitivity and specificity, than the
cytology follow-up (evidence level: moderate).[30 ]
Several studies have reported the elimination or persistence of HPV infections after
the treatment of high-grade squamous intraepithelial cervical lesions. These reports
vary, and they sometimes show conflicting results. One study reported that out of
49 women treated with large loop excision of the transformation zone (LLETZ), only
6 (12.2%) persisted with viral infection 3 months after the treatment (evidence level:
moderate).[28 ] Another study identified that at 31 months of follow-up after a high-grade lesion
treatment, the HPV-DNA test was still positive in 19.6% of the patients, and no longer
detectable in 80.4% of the women (evidence level: moderate).[31 ] Another study showed that 94% of women with a positive HPV-DNA test before treatment
had cleared the infection in 12 months (evidence level: moderate).[32 ]
Brazilian studies showed that most patients undergoing excisional treatment for high-grade
lesions were negative for HPV-DNA six months after the procedure (evidence level:
moderate).[33 ]
Recommendations
The HPV-DNA test may be used for follow-up after NIC II/III treatment to exclude residual
or recurrent lesions. In this case, it should be performed between 6 and 12 months
after the treatment (A). If cleared from oncogenic types, the woman may return to
triennial cytological screening (A).
After Treatment of Adenocarcinoma in situ
The HPV-DNA test can also be useful after a conservative treatment for AIS (when the
uterus is maintained) because, if negative, it indicates that the patients have a
lower risk of persistence and relapse (evidence level: moderate).[34 ]
Recommendations
The HPV-DNA test may be used at follow-up after a conservative AIS treatment (when
the uterus is maintained) to exclude residual or recurrent lesion. In this case, it
should be performed 6 to 12 months after the treatment (A). If the oncogenic HPV-DNA
test is negative, the woman may return to triennial cytological screening (A).
