Cervical screening with primary HPV
– from research to clinical effectivenessav
Lovisa Bergengren
Akademisk avhandling
Avhandling för medicine doktorsexamen i medicinsk vetenskap med inriktning kirurgi,
som kommer att försvaras offentligt fredagen den 15 maj 2020 kl. 09.00, Hörsal C1 , X-huset Universitetssjukhuset Örebro
Opponent: Professor Matts Olovsson Institutionen för kvinnors och barns hälsa
Uppsala universitet
Örebro universitet
Institutionen för medicinska vetenskaper 701 82 ÖREBRO
Abstract
Lovisa Bergengren (2020): Cervical screening with primary HPV – from research to clinical effectiveness. Örebro Studies in Medicine 209. Organized cervical screening has greatly reduced the incidence of cervical can-cer where implemented. Human papilloma virus (HPV) is the cause of can- cer-vical cancer, and in later years, convincing evidence has led to cercer-vical screening with HPV as the primary method being implemented around the world. The overall aim of this thesis is to improve cervical screening, with focus on HPV screening.
Papers I–III were performed with focus on postmenopausal women. Women aged, 55–59 years, excluded from the screening with a normal cy-tology cervical sample were found to have a high-risk HPV (hrHPV) prev-alence of 5.5% in paper II. In a follow-up sample, 56% (71/126) had a persistent infection with the same genotype. Nineteen per cent of the women had dysplasia, where the majority of the high-grade squamous intraepithe-lial lesions (HSILs) were associated with HPV types other than HPV 16/18.
Women 55-59 has a lower attendance rate in the study region, and since self-sample has been proven to increase attendance, paper I was performed to compare self-sample and professionally collected samples in these post-menopausal women. The concordance between the sampling methods was 83%, and both tests detected all histological HSILs. When including a study with older women (aged 70 years) in paper III, 23% of histological HSILs were found in hrHPV-positive women.
Paper IV is a scientific evaluation of an implemented HPV-based screen-ing programme, comparscreen-ing clinical effectiveness and cost with cytology screening. More HSIL+ were detected in the new programme but at a higher cost than the old cytology-based programme. The screening visits for sam-pling accounted for two thirds of the costs.
Altogether, the results indicate the importance of having a negative HPV test before exiting screening. Data also present the necessity to find bi-omarkers that are more specific than cytology and HPV 16/18 for triaging women with hrHPV to further follow-up, both among postmenopausal women and other age groups when screening with HPV, since many women without HSIL are coming for clinical follow-up and treatment. Extending the screening interval between hrHPV-negative tests as well as implementing self-sampling to a greater extent can be important changes, since two thirds of the costs in the programme come from screening visits for sampling.
Keywords: cervical cancer, screening, human papillomavirus (HPV), HPV
prevalence, HPV genotypes, precancerous lesion, HSIL, self-sampling, postmenopausal women, health economy
Lovisa Bergengren, School of Health and Medical Sciences.