Human Papillomavirus Oncogenic mRNA Testing for Cervical Cancer Screening

Jennifer L. Reid, PhD; Thomas C. Wright Jr, MD; Mark H. Stoler, MD; Jack Cuzick, PhD; Philip E. Castle, PhD; Janel Dockter; Damon Getman, PhD; Cristina Giachetti, PhD


Am J Clin Pathol. 2015;144(3):473-483. 

In This Article


Participant Disposition and Demographic Information

A total of 13,495 women were included in this clinical study (Figure 1). Of the 12,869 women 30 years or older, 227 had an unsatisfactory or missing cytology result and 1,001 had an abnormal Pap result: ASC-US (5.7%), low-grade squamous intraepithelial lesion (1.5%), high-grade squamous intraepithelial lesion (0.2%), ASC-H (0.1%), atypical granular cells, atypical granular cells favor neoplastic, or "other" (0.2% combined prevalence). The remaining 11,641 women 30 years or older with a NILM cytology at baseline were enrolled in the Adjunct Study and tested with the AHPV and HC2 tests. In total, 10,860 women were available for the baseline analysis, including 864 women (525 HPV+ and 339 HPV–) with a baseline colposcopy (781 women withdrew; see Figure 1 for reasons). Approximately 50% of the women referred to colposcopy had an ECC biopsy only, and approximately 50% had ECC plus one or more directed biopsies, resulting in the identification of 20 cases of CIN2+.

After the baseline evaluation, 10,509 women were eligible for follow-up (331 women withdrew for various reasons; see Figure 1). During follow-up, 7,247 women returned for an annual cytology visit during year 1, 6,517 returned during year 2, and 6,339 returned during year 3, with 6,201 women completing the study. Of the women who completed the study, 4,452 returned during all 3 years; the remaining returned only once during the first 2 years and in year 3 or had CIN2+ and exited the study prior to year 3. In each follow-up year, 4% to 6% of the women had ASC-US or greater cytology.

Demographics are presented in Table 1. The median age was 43 years, with 61.4% age 40 years or older; 44.0% were non-Hispanic white, 16.7% were Hispanic white, 12.5% were black, 5.7% were Asian, and 21.1% were categorized as "other" race or unknown.

HPV and Disease Prevalence

Cervical disease and HPV status are shown in Table 2 for the baseline evaluation and cumulatively after 3 years of follow-up. Of the 10,860 evaluable participants with NILM cytology at baseline, 512 were positive for AHPV, yielding a prevalence of 4.7% for HR-HPV E6/E7 oncogenic mRNA, whereas prevalence of HR-HPV DNA was 6.5% among 10,229 women with HC2 results. A total of 845 HPV RNA-positive or DNA-positive women and 556 randomly selected HPV-negative women were referred to colposcopy at baseline (Figure 1).

At baseline, the percentage of colposcopy attendance was similar between HPV-positive (62%, n = 526) and randomly selected HPV-negative (61%, n = 339) women with 29 cases of CIN1, nine cases of CIN2, eight cases of CIN3, and three cases of adenocarcinoma in situ (AIS) identified (Table 2). Four of the CIN2 cases and two of the AIS cases were identified based on an ECC biopsy specimen only.

In total, 6,271 women completed the 3-year follow-up with a known disease status (Table 2). Of these, 6,098 (97.2%) women had normal (negative) disease status, and 56 (0.9%) had low-grade lesions (CIN1). In addition to the 20 women with CIN2+ identified at baseline, 15 (0.2%) women had CIN2 and 12 (0.2%) women had CIN3 identified during follow-up, with two cases identified from an ECC biopsy specimen only.

Of the 27 women with CIN2+ identified during follow-up, two had CIN1 at baseline, with CIN3 identified during year 1. Ten women had no disease found at baseline, with five cases of CIN2+ identified during year 1, one case of CIN2+ identified during year 2, and four cases of CIN2+ identified during year 3. The remaining 15 women with CIN2+ identified during follow-up did not have a baseline colposcopy; among them, two cases of CIN2+ were identified during year 1, six cases of CIN2+ during year 2, and seven cases of CIN2+ during year 3.

AHPV Assay Performance

Baseline risk and prevalence estimates adjusted for verification bias are provided in Table 3. The prevalence of CIN2+ was 0.9% in the overall population. CIN2+ occurred in 4.5% (95% CI, 2.7%-7.4%) of women with positive AHPV results and in 0.6% (95% CI, 0.2%–1.9%) of women with negative AHPV results, yielding a relative risk of 7.5 (95% CI, 2.1–26.3). This indicates that women with a positive AHPV result are at significantly greater risk of CIN2+ than women with a negative AHPV result. The CIN2+ relative risk obtained for the HC2 test at baseline was similar (7.3; 95% CI, 1.6–33.5). For CIN3+ diagnosis, the overall prevalence was 0.4%. The AHPV relative risk was 24.9 (95% CI, 2.0–307.0), again with a similar relative risk for HC2 (21.0; 95% CI, 1.0–423.8).

Cumulative absolute and relative risks for AHPV and HC2 over the 3-year follow-up period for HPV-positive and HPV-negative women are shown in Table 4. Women with an HPV-negative result with either test had very low cervical disease risk after 3 years of follow-up (<0.3%). Comparatively, 5% to 6% of women with an HPV-positive result had CIN2+ and 3% to 4% had CIN3+, with overall cumulative absolute and relative risks slightly higher for the AHPV assay than for HC2. Younger women aged 30 to 39 years who were HPV positive had twice the prevalence of disease but a similar increase in relative risk of cervical disease compared with HPV-positive women 40 years and older (Table 4). Risk of cervical disease in HPV-negative women did not vary by age group.

Figure 2 and Figure 3 show the cumulative absolute risk of CIN2+ and CIN3+, respectively, by year according to AHPV or HC2 positivity status at baseline. Both assays show a similar trend, with consistent slightly higher risk for the AHPV assay each year.

Figure 2.

Cumulative absolute risk of cervical intraepithelial neoplasia grade 2 or higher (CIN2+) by year. AHPV, Aptima HPV (Hologic, San Diego, CA); HC2, Hybrid Capture 2 (Qiagen, Gaithersburg, MD).

Figure 3.

Cumulative absolute risk of cervical intraepithelial neoplasia grade 3 or higher (CIN3+) by year. AHPV, Aptima HPV (Hologic, San Diego, CA); HC2, Hybrid Capture 2 (Qiagen, Gaithersburg, MD).

After 3 years of follow-up, the specificity of AHPV for CIN2 or lower was 96.3% (95% CI, 95.8%-96.7%), significantly greater (P < .001) compared with HC2 specificity of 94.8% (95% CI, 94.3%-95.4%) Table 5. AHPV specificity for CIN3 or lower (96.2%; 95% CI, 95.5%–96.5%) was also significantly greater (P < .001) than HC2 specificity (94.7%; 95% CI, 94.1%-95.2%). Estimated sensitivities for detection of CIN2+ and CIN3+ were similar between the two assays (P = .219 and P = 1.0, respectively). For detection of CIN2+, AHPV sensitivity was 55.3% (95% CI, 41.2%-68.6%), and HC2 sensitivity was 63.6% (95% CI, 48.9%-76.2%). For CIN3+ detection, AHPV sensitivity was 78.3% (95% CI, 58.1%-90.3%), and HC2 sensitivity was 81.8% (95% CI, 61.5%-92.7%) (Table 5).