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HPV Genotyping: A New Dimension in Cervical Cancer Screening Tests

Lee P. Shulman MD The Anna Ross Lapham Professor in Obstetrics and Gynecology and Chief,

Division of Clinical Genetics Feinberg School of Medicine of Northwestern University

The$natural$history$of$cervical$cancer$

Doorbar J. Clin Sci (London) 2006; 110:525–541. CIN, cervical intraepithelial neoplasia (terminology used to

describe histology of squamous cell lesions).

Basal layer

Surface

Months Years or decades Abnormal cell Normal cell

CIN2 CIN3 CIN1 carcinoma HPV infection

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•  Screening$to$prevent$cervical$cancer$

‒  Screening$with$cervical$cytology:&“A&triumph and a tragedy”*

* Koss L. The Papanicolaou test for cervical cancer detection. A triumph and a tragedy. JAMA. 1989;261(5):737-43.

http://seer.cancer.gov/statfacts/html/cervix.html: SEER 9 Incidence & U.S. Mortality 1975-2010, All Races, Females. Rates are Age-Adjusted. (accessed 12/29/13)

Year 1975 1980 1985 1989 1993 1997 2001 2005 5-Year Survival 68.1% 67.9% 66.4% 71.0% 70.9% 71.6% 70.4% 68.0%

New Cases, Deaths and 5-Year Relative Survival SEER 9 Incidence & U.S. Mortality 1975-2010

In recent years cervical cancer incidence has leveled off, as cytology is not reducing incidence further

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Screening$history$of$women$diagnosed$with$invasive$cervical$carcinoma$(ICC)$

1. Leyden WA, et al. J Natl Cancer Inst 2005; 97:675-683; 2. Andrae B, et al. J Natl Cancer Inst 2008; 100:622-629. ICC, invasive cervical carcinoma.

Cause, n (%) Kaiser study1

Swedish study2

No recent screen 464 (56%) 789 (64%)

Cytology detection failure 263 (32%) 300 (24%)

Failure of follow-up of abnormal cytology 106 (13%) 91 (7%)

Reasons$for$moving$from$cytology$to$HPV$co@tesAng:$

Cytology$is$subjecAve,$HPV$tesAng$is$objecAve$•  The&subjec4vity&of&cytology&decreases&&&&&&&&&&&&&&&&&&&&

clinical&confidence,&increasing&costs&•  Highly&variable&results&between&laboratories&

&&

Wright TC et al. Inter-laboratory Variation in the Performance of Liquid-based Cytology; Insights from the ATHENA trial. Stoler M.H, Schiffman M. JAMA 2001;285(11):1500–5.

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Conclusion:$The$accuracy$of$cytology$varies$significantly$even$across$good$labs,$whereas$HPV$tesAng$does$not$

Wright TC et al. Int J Cancer. 2013 Oct 7. doi: 10.1002/ijc.28514. [Epub ahead of print]

Sensitivity for CIN 2+(%)

Test LAB A (n=12,294)

LAB B (n=4,218)

LAB C (n=16,979)

LAB D (n=12,442)

Cytology 42.0 51.0 60.5 73.0

HPV testing 90.1 88.2 88.4 88.9

Cytology$is$SubjecAve:$$Inter@laboratory$variability$in$the$ATHENA$Trial$

SensiAvity$of$cytology$vs.$HPV$DNA$for$≥CIN2$

Whitlock EP, et al. Ann Intern Med. 2011; 155:687-697, W214-5.

Average increase 35.7%

Bigras (N=13,842)

Cardenas (N=1,850)

Coste (N=3,080)

Kulasingam (N=774)

Mayrand (N=9,977)

Petry (N=7,908)

0

20

40

60

80

100

Cytology HPV DNA Test

Studies performed in developed countries in women 30 years and older.

Sens

itivi

ty* f

or ≥

CIN

2 (%

)

Cytology$has$low$sensiAvity$for$detecAng$CIN2$or$worse$

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HPV arm Cytology arm

When found CIN3 Cancer CIN3 Cancer

Round one 98 7 47 9

Round two 8 0 17 9

In total 106 7 64 18

Results$from$two$rounds$of$HPV$DNA$tesAng$versus$cytology$screening:$$$$$$$$$$$$$$$$$$$$$$$$$$94,000 women screened twice 3 years apart

Ronco G, et al. Lancet Oncol 2010; 11:249–257. Italian women aged 25-60 at recruitment.

HPV testing identified approximately double the number of ≥CIN3 cases compared to cytology at round one and ~40% more overall

Smith HO, et al. Gynecol Oncol 2000; 78:97–105;.

The$incidence$of$adenocarcinoma$conAnues$to$rise$despite$cytology$screening:&&SCC&and&adenocarcinoma&incidence&rates&

US data shown. SCC, squamous cell carcinoma;

ADC, adenocarcinoma.

SCC incidence is decreasing while ADC incidence is increasing

Age

-adj

uste

d ra

tes

per 1

00,0

00

wom

en in

the

US

0 1 2 3 4 5 6 7 8 9

10

1973–1977 1978–1982 1983–1987 1988–1992 1993–1996

Squamous cell carcinoma Adenocarcinoma

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DetecAon$of$CIN3,$AIS,$adenocarcinoma$and$SCC$in$the$ATHENA$Trial$

Castle PE et al. Lancet Oncol. 2011 Sep;12(9):880-90.

*a 25% difference

Sensitivity

Histology (number) Cytology HPV testing

CIN3 (254) 52% (132) 92% (254)

AIS (16) 63% (10) 88% (14)*

Adenocarcinoma and AdenoSq Ca (1) 100% (1)

100% (1)

Squamous cell carcinoma (3) 100% (3) 100% (3)

Evaluating screening with cytology vs. cytology plus HPV (co-testing) •  All women age 21-65 were screened with an HPV test with 16/18

genotyping (the Cobas 3 in 1 HPV test) and a Pap •  Any abnormal Pap (>ASC-US) or positive HPV test was referred to

colposcopy •  >1000 women with a negative Pap and negative HPV test were also

referred to colposcopy •  Everyone was biopsied: When no lesion was seen a random biopsy

was required

Trial$design:$The$cobas$HPV$test$was$evaluated$in$the$largest$US$screening$trial:$$ATHENA$

Enrolled >47,000 women

Follow-up Year 1

Follow-up Year 2

Follow-up Year 3

Follow-up phase (subset of ~8,000 women) Baseline phase

Wright TC Jr, et al. Am J Obstet Gynecol 2012; 206:46.e1–46.e11 ASC-US, atypical squamous cells of undetermined significance.

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Normal Pap

1.2

14 hrHPV–

0.8

14 hrHPV+

6.1

Absolute$risk$of$≥CIN2$straAfied$by$hrHPV$status$in$the$ATHENA$normal$Pap$populaAon$

Wright TC Jr, et al. Am J Clin Pathol 2011; 136:578–586.

Estim

ated

abs

olut

e ris

k (%

)

0

5

10

15

20

Normal Pap

1.2

14 hrHPV–

0.8

14 hrHPV+

6.1

12 hrHPV+

4.6

HPV18+

7.0

HPV16+

13.6

Absolute$risk$of$≥CIN2$straAfied$by$hrHPV$status$in$the$ATHENA$normal$Pap$populaAon$

Wright TC Jr, et al. Am J Clin Pathol 2011; 136:578–586.

Estim

ated

abs

olut

e ris

k (%

)

0

5

10

15

20

cobas® HPV16 genotyping results identify a sub-population of women with negative cytology who are at the highest risk of ≥CIN2

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Abs

olut

e ris

k of

≥C

IN2*

(%)

0

5

10

15

ComparaAve$absolute$risk$in$the$ASC@US$populaAon$pooled$hrHPV+$and$normal$Pap$populaAon$HPV16+$

1. Stoler MH, et al. Am J Clin Pathol 2011; 135:468–475; 2. Wright TC Jr, et al. Am J Clin Pathol 2011; 136:578–586.

Women with ASC-US who test pooled hrHPV positive have a risk for ≥CIN2 equivalent to that of HPV16 and/or HPV18 positive women with negative cytology

HPV16+

13.6

≥30 years

14.0

14 hrHPV+

≥21 years

ASC-US Pap1 NILM (normal Pap)2

ASC-US, atypical squamous cells of undetermined significance; NILM, negative for intraepithelial lesion or malignancies; * Estimated absolute risk shown for NILM;. Note absolute risk measurements are estimates based on raw study data.

Management(of(co,tes.ng(results:((women&30)65&years&

Pap & HPV

Normal Pap & HPV+

Immediate HPV 16/18 genotyping

Colposcopy Repeat cotest 12 mo Cotest 3 years

HPV 16/18 neg HPV 16/18 +

Both neg Either positive

Option 2

ASCCP$and$ACOG$2012$Management$Guidelines$

Massad LS, et al. Am J Obstet Gynecol. 2013

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US Guidance on Primary HPV Screening ASCCP & SGO (2015)

•  Primary HPV testing can be considered as an alternative to current US cytology-based cervical cancer screening methods for women starting at age 25.

•  Women with a negative primary HPV test result should not be retested again for at least three years.

•  An HPV test positive for HPV 16 or 18 should be followed with colposcopy.

•  A test that is positive for the 12 other high risk types should be followed with cytology testing.

•  Clinicians should not use an FDA-approved test without a specific primary hrHPV screening indication.

Huh, W. et al. Gynecol Oncol. 2015; 136: 178-182 Huh, W. et al. Obstet Gynecol 2015; 125: 330-337

Primary Screening Algorithm

hrHPV

45

31 33

39

35

51

52 56 58

59 66 68

16 18

Routine screening

HPV−

COLPOSCOPY

HPV16/18+

Follow-up in 12 months

≥ASC-US COLPOSCOPY

Cytology 12 other hrHPV+

NILM

hrHPV=high risk HPV

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Comparison to ASC-US Triage

Data from Medical Devices Advisory Committee Microbiology Panel Meeting: Sponsor Executive Summary Adjusted results 1Relative to Cytology with Reflex HPV Strategy *Statistically significant differences compared to Cytology with Reflex HPV Strategy †Co-testing: Cytology with ASC-US triage in women 25-29, Co-testing with cytology and HPV in women 30+

Strategy

≥CIN3

Relative Sensitivity1

%

Relative Specificity1

%

ASC-US Triage 1.00 1.00

Co-testing† with 16/18 Genotyping 1.28* 0.99*

HPV with Genotyping and Reflex Cytology 1.40* 0.99*

HPV16 and HPV18 genotyping identifies a subset of hrHPV-positive women with NILM cytology who would benefit from colposcopy1* •  >1 in 10 women who tested positive for HPV16 had ≥CIN3 at baseline

despite having negative cytology •  HPV16-positive women are at high and immediate risk of cervical

precancer •  HPV18-positive women appear to have lower baseline risk of

having high-grade disease, but are at risk of developing precancer in the future2

•  A negative HPV is far better predictor of reduced progression to advanced cervical dysplasia and malignancy than cytology

NILM, negative for intraepithelial lesion or malignancies. by current ASCCP guidelines.

Summary

1. Wright TC Jr, et al. Am J Obstet Gynecol 2011; 136:578–586; 2. Khan MJ, et al. J Natl Cancer Inst 2005; 97:1072–1079; 3. ASCCP, HPV Genotyping Clinical Update 2009, (accessed December 2011), available

from from http://www.asccp.org/consensus.shtml

HPV DNA testing with integrated HPV16 and HPV18 genotyping adds medical value to adjunct screening programmes1-3

* Supported