All the guidelines recommend co testing as the modality of choice for cervical cancer screening. However, Cobas test was approved by FDA as primary screening modality in 2014.

1. HPV SCREENING & CO TESTING

2. Dr. Niranjan Chavan
MD, FCPS, DGO, DFP, MICOG, DICOG , FICOG
Professor and Unit Chief, L.T.M.M.C & L.T.M.G.H
Chairperson, FOGSI Oncology and TT Committee (2012-2014)
Treasurer, MOGS (2017- 2018)
Chair and Convener, FOGSI Cell- Violence against Doctors (2015-2016)
Chief Editor, AFG Times (2015-2017)
Editorial Board, European Journal of Gynecologic Oncology
Editor of FOGSI FOCUS, MOGS, AFG & IAGE Newsletters
Member, Managing Committee, IAGE (2013-2017)
Member , Oncology Committee, AOFOG (2013 -2015)
Recipient of 6 National & International Awards
Author of 15 Research Papers and 19 Scientific Chapters
Course Co-Ordinator, of 11 batches, of MUHS recognized Certificate Course of
Basic Infertility Management Including Endoscopy (BIMIE) at LTMGH

3. HPV PRIMARY TESTING
• HPV primary screening means that a cervical
screen sample is first tested for the presence of
an HPV infection.
• The cobas® HPV Test is the only FDA-approved
cervical cancer screening test that allows HPV
16 and 18 genotyping concurrently with high-
risk HPV testing.

4. COBAS HPV TEST
• It individually identifies
genotypes 16 and 18,
the two highest-risk
HPV genotypes while
simultaneously
detecting 12 other high
risk HPV genotypes.

5. COBAS HPV TEST
• The test utilizes amplification of target DNA by
the Polymerase Chain Reaction (PCR) and
nucleic acid hybridization for the detection of
14 high-risk (HR) HPV types in a single
analysis.
• It can run up to 282 tests in less than 12 hours.
• Approved on 24.04.2014

6. ATHENA TRIAL
• The ATHENA HPV trial was a large, prospective
clinical study evaluating the performance of the
cobas® HPV Test in three relevant populations:
1. Women with ASC-US cervical cytology
2. Women with normal cervical cytology
3. An overall screening population (25+ years)
• Over 47,000 women were enrolled.

8. HPV primary screening in women ≥25years is as effective as a hybrid
screening strategy that uses cytology if 25-29years and co testing if
≥30years.

9. FDA APPROVED HPV TESTS
Instrument
(Manufacturer)
Summary of the Test Test Principle Intended Use
Hybrid Capture 2 High
Risk HPV DNA test
(Digene)
Identifies genetic DNA
from HPV in cervical cells
Uses a DNA-Probe-Hybrid
immunoassay technique
Follow up test when a
PAP smear is mildly
abnormal
Cervista™ HPV HR and
Genfind™ DNA Extraction
(Hologic)
Identifies DNA from 14
high-risk genital HPV
types commonly
associated with cervical
cancer
Uses DNA-probe
technology
Determine a patient's risk
for developing cervical
cancer
Cervista™ HPV 16/18
(Hologic)
Identifies HPV types 16
and 18 in cervical
samples
DNA-probe technology Follow up test when a
PAP smear is mildly
abnormal

10. FDA APPROVED HPV TESTS
Instrument
(Manufacturer)
Summary of the Test Test Principle Intended Use
Cobas® HPV test (Roche
Molecular Systems)
Used on the cobas® 4800
system to identify DNA
from 14 high-risk genital
HPV types commonly
associated with cervical
cancers.
Uses fluorescent labelled
DNA probes
Primary HPV testing
PTIMA® HPV Assay (Gen-
Probe)
Used with the Tigris DTS
system to identify RNA
from 14 high-risk HPV
types. Detects messenger
RNA from two HPV viral
oncogenes, E6 and E7
Uses RNA capture and
amplification of HPV RNA
Used for women age 30
and over or any age with
borderline cytology
results to determine the
need for additional
follow up procedures

11. ISSUES WITH CYTOLOGY BASED SCREENING
• Highly subjective test: substantial inter-laboratory (as well as
intralaboratory) variability and limited reproducibility.
• Unable to identify those women who are at future risk of
developing cervical cancer precursors.
• Unclear how cytology will perform as HPV vaccination rates
increase.

12. ACCURACY OF SCREENING TESTS
Test Sensitivity (%) Specificity (%)
Cytology 31-78% 91-99%
VIA 50-96% 44-97%
VILI 44-93% 75-85%
HPV testing 61-90% 62-94%
Sankaranarayan R et al. Overview of Cervical Cancer in the Developing World Int J Gynaecol Obstet 2006; 95 (1): S205-
S210

13. Screening test Strengths Limitations
HPV DNA  Automated &standardized
 Objective result
 High sensitivity, good
specificity
 More effective in
postmenopausal women
 Potential for self sampling
 Requires lab support
 Cost
 Lag can contribute to
loss to F/U and delay.
OVERVIEW OF PRIMARY SCREENING TOOLS FOR CERVICAL CANCER

15. CLINICAL UTILITY OF HPV TESTING
• Preferred method as co-testing (age>30 years) or as
primary screening (age >25 years)
Huh W K etal. Use of Primary High-Risk Human Papillomavirus Testing for Cervical Cancer
Screening:
Interim Clinical Guidance J Low Genit Tract Dis 2015. 19(2); 91-96
• In the management of women with ASCUS cytology
– triage
ASCCP Guidelines , J Low Genit Tract Dis,2013; ACOG,2016

16. CLINICAL UTILITY OF HPV TESTING
• Following treatment for CIN- HPV testing is more sensitive but less
specific than cytology in post treatment follow-up and it may result in
earlier diagnosis of persistent or recurrent disease
KockenM et al. Hr HPV testing versus cytology in predicting post-treatment disease in women treated for high- grade
cervical disease: a systematic review and meta-analysis. Gynecol Oncol 2012 ;125(2):500-7

17. AGE TO
START
SCREENING
Primary HPV
screening should not
be initiated prior to
age 25.

18. OPTIMAL INTERVAL FOR PRIMARY HPV
SCREENING
• Rescreening after a negative screen should occur no
sooner than every 3 years.
• In the ATHENA trial, the incidence of CIN 3 over 3
years was less than 1%.
• European trials have used 3 year screening
intervals. Until further US data is available,
screening no sooner than 3 years is recommended.

19. INTERIM CLINICAL GUIDELINES: ASCCP GUIDELINE

20. POTENTIAL BENEFITS OF ADOPTING HPV PRIMARY
SCREENING
• Decrease in cervical cancer incidence and
mortality
• Better detection of risk of precancerous cervical
cell changes
• Providing a more effective test for women who
have had the HPV vaccine as well as those who
have not
• Safe but less frequent screening (every five years
rather than every three).

21. RCTS OF HPV TESTING IN SCREENING
• BC RCT (HPV FOCAL): Canada (Ogilvie et al, BJC 2012)
• ATHENA Trial: United States
• Indian Trial (Osmanabad) (Sankaranarayanan et al. NEJM 2009)
• ARTISTIC trial: UK (Kitchener et al. Lancet Oncol 2009)
• NTCC Italian Study (Ronco et al., Lancet Oncol, 2006; JNCI 2006)
• SWEDESCREEN: Swedish trial (Elfgren et al. AJOG 2005; Naucleret al., NEJM
2007; JNCI 2009)
• Finnish RCT (Kotaniemi et al., BJC 2005; Eur J Cancer 2008; IJC2008;
Leinonen et al., JNCI 2009)

22. COMPARISON TO CO TESTING
CIN 3 CANCER
CYTOLOGY 8.7% 12.2%
HPV 6% 18.6%
CO TESTING 1.2% 5.5%
*Blatt AJ, Kennedy R, Luff RD, Austin RM, Rabin DS. Comparison of cervical cancer screening results among
256,648 women in multiple clinical practices. Cancer Cytopathol. 2015 May;123(5):282-8. doi:
10.1002/cncy.21544. Epub 2015 Apr 10. Erratum in: Cancer Cytopathol. 2016 May;124(5):362-3.
Retrospective study*
reported in 2015 looked
at missed cases of CIN 3
or cancer

23. HPV COTESTING
• Co-testing using the combination of Pap cytology plus
HPV DNA testing.
• Any low-risk woman between 30-65 years old who
receives negative test results on both Pap cytology
screening and HPV DNA testing should be rescreened
in 5 years.
• Women who test positive for HPV 16 or HPV 16/18
should be referred directly for colposcopy.
• Women with negative results for HPV 16 or HPV 16/18
should be co-tested in 12 months
The American College of Obstetricians and Gynecologists. ACOG Practice Bulletin. Clinical Management Guidelines for
Obstetrician-Gynecologists: Screening for Cervical Cancer. November, 2012.

24. PROPOSED DEFINITION OF SETTING ACCORDING TO AVAILABILITY OF RESOURCES
Setting Screening Options Management
Options
Type of Health care
Facility – example
Type of Service
Provider
Maximal
(No resource
constraints)
HPV DNA test
Cytology
(+ HPV Genotyping &
newer modalities for
triaging*)
Colposcopy
LEEP
Conization
Cryotherapy
+Thermocoagulation
Tertiary care centres
Multispecialty hospitals
Private clinics with access to
hospital
Trained Gynaecologist
Enhanced** Cytology, VIA
Colposcopy
LEEP
Conization
Cryotherapy
+Thermocoagulation
Tertiary care centres
Hospitals
Nursing homes
Trained Gynaecologist
Limited** VIA
Colposcopy
Cryotherapy
LEEP
+ Conization
+ Thermocoagulation
CHCs
District hospitals
Nursing homes
Trained
Gynaecologist/
Doctors
Basic** VIA Cryotherapy
+Thermocoagulation
Public health service
(PHC, subcentre, small clinics)
Trained
Gynaecologist/
Doctors/ Nurses/
Health workers

25. PROPOSED RESOURCE STRATIFIED PROTOCOL FOR CERVICAL CANCER
SCREENING
Resource setting Maximal Enhanced Limited Basic
Target Age Group
(years)
25-65 25-65 30-65 30-65
(In postmenopausal
women, screening with
VIA may not be as
effective)
Age to start (years) Cytology -25
HPV Testing - 30
25 30 30
Modality HPV DNA testing
• Primary HPV testing
• Co-testing (HPV &
Cytology)
Cytology
Colposcopy and biopsy
Cytology
Colposcopy and biopsy
VIA
Colposcopy ± Biopsy
VIA
Frequency Primary HPV Testing or
Co-testing -every 5
year
Cytology – every 3
years
Every 3 years Every 5 years Every 5 years
(at least 1-3 times in life
time )

26. Facility based Maximal Enhanced Limited Basic
Triage HPV genotyping/
Cytology
Colposcopy/ VIA Colposcopy/
Treatment
Treatment
Age to stop
(years)
- 65 with consistent negative results in last 15 years
-women with no prior screening should undergo tests once at 65
years and if negative they should exit screening.
Follow up
method after
treatment and
interval
HPV DNA
testing,
12 months
Cytology,
12 months
VIA,
12 months
VIA,
12 months
PROPOSED RESOURCE STRATIFIED PROTOCOL FOR CERVICAL CANCER
SCREENING

27. CONCLUSION
• All the guidelines recommend co testing as the modality of choice
for cervical cancer screening.
• However, Cobas test was approved by FDA as primary screening
modality in 2014.
• ATHENA Trial proved the efficacy and sensitivity of Cobas test.
• Currently, ASCCP provided an interim guideline for HPV Primary
test.

28. CONCLUSION
• Govt of Australia and New Zealand has even implemented HPV
primary screening since 1 Dec 2017
• Even the pilot run in England seems promising.
• To conclude, HPV primary screening is effective, sensitive and easy
screening tool for cervical cancer and advent of this new
technology warrants a change in the screening guidelines.

30. REFERENCES
• Public Health England; NHS Cancer Screening Programmes, 2015. HPV Primary Screening Protocol
Algorithm.www.gov.uk/government/uploads/system/uploads/attachment_data/file/437976/hpvps-
flowchart-jan15.pdf.
• Blatt AJ, Kennedy R, Luff RD, Austin RM, Rabin DS. Comparison of cervical cancer screening results
among 256,648 women in multiple clinical practices. Cancer Cytopathol. 2015 May;123(5):282-8. doi:
10.1002/cncy.21544. Epub 2015 Apr 10. Erratum in: Cancer Cytopathol. 2016 May;124(5):362-3.
• The American College of Obstetricians and Gynecologists. ACOG Practice Bulletin. Clinical Management
Guidelines for Obstetrician-Gynecologists: Screening for Cervical Cancer. November, 2012.
• Stoler MH, Wright TC, Sharma A, et al. High-risk human papillomavirus testing in women with ASC-US
cytology: results from the ATHENA HPV study. Am J Clin Pathol. 2011;135(3):468-475.
• KockenM et al. Hr HPV testing versus cytology in predicting post-treatment disease in women treated
for high- grade cervical disease: a systematic review and meta-analysis. Gynecol Oncol 2012 ;125(2):500-
7