Jfac 142

Download as pdf or txt
Download as pdf or txt
You are on page 1of 25

SPECIAL REPORT

AACC Guidance Document on Cervical Cancer


Detection: Screening, Surveillance,
and Diagnosis
Yusheng Zhu ,a,b,* Sarah Feldman,c Shuk On Annie Leung,d Michael H. Creer,a
Joshua Warrick,a Nicole Williams,a and Stephen Mastoridese

Downloaded from https://academic.oup.com/jalm/article/8/2/382/7030135 by guest on 09 March 2023


Background: Persistent genital infection with high-risk human papilloma virus (hrHPV) causes the vast majority
of cases of cervical cancer. Early screening, ongoing surveillance, and accurate diagnosis are crucial for the
elimination of cervical cancer. New screening guidelines for testing in asymptomatic healthy populations and
management guidelines for managing abnormal results have been published by professional organizations.
Content: This guidance document addresses key questions related to cervical cancer screening and
management including currently available cervical cancer screening tests and the testing strategies for cervical
cancer screening. This guidance document introduces the most recently updated screening guidelines
regarding age to start screening, age to stop screening, and frequencies of routine screening as well as risk-
based management guidelines for screening and surveillance. This guidance document also summarizes the
methodologies for the diagnosis of cervical cancer. Additionally, we propose a report template for human
papilloma virus (HPV) and cervical cancer detection to facilitate interpretation of results and clinical decision-
making.
Summary: Currently available cervical cancer screening tests include hrHPV testing and cervical cytology
screening. The screening strategies can be primary HPV screening, co-testing with HPV testing and cervical
cytology, and cervical cytology alone. The new American Society for Colposcopy and Cervical Pathology
guidelines recommend variable frequencies of screening and surveillance based on risk. To implement these
guidelines, an ideal laboratory report should include the indication for the test (screening, surveillance, or
diagnostic workup of symptomatic patients); type of test (primary HPV screening, co-testing, or cytology alone);
clinical history of the patient; and prior as well as current testing results.

a
Department of Pathology and Laboratory Medicine, Pennsylvania State University College of Medicine, Hershey, PA, USA; bDepartment of
Pharmacology, Pennsylvania State University College of Medicine, Hershey, PA, USA; cDepartments of Obstetrics, Gynecology, and
Reproductive Biology, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA; dDepartment of Obstetrics and Gynecology,
McGill University Health Centre, McGill University, Montreal, QC, Canada; eDepartment of Pathology and Laboratory Medicine Service, James
A. Haley Veterans’ Hospital, Tampa, FL, USA.
*Address correspondence to this author at: Departments of Pathology and Laboratory Medicine, Pharmacology, Pennsylvania State University
College of Medicine, 500 University Dr., Mail Code H160, Hershey, PA, USA. E-mail yzhu@pennstatehealth.psu.edu.
This document was approved by the AACC Academy Content Development Committee in August 2022, the AACC Academy Council in September
2022, and the AACC Board of Directors in October 2022.
Received November 22, 2022; accepted December 08, 2022.
https://doi.org/10.1093/jalm/jfac142
© American Association for Clinical Chemistry 2023. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com

382 JALM | 382–406 | 08:02 | March 2023


AACC Guidance Document on Cervical Cancer Detection SPECIAL REPORT

IMPACT STATEMENT
Women with persistent high-risk human papilloma virus infection account for the vast majority of cases of
cervical cancer. This guidance document addresses key questions related to cervical cancer screening and
management and introduces the most recently updated screening guidelines, risk-based management for
screening and surveillance, as well as methodologies for the diagnosis of cervical cancer. Additionally, a labora­
tory report template is proposed for human papilloma virus and cervical cancer detection to facilitate inter­
pretation of results and clinical decision-making. This guidance document will help clinical laboratorians

Downloaded from https://academic.oup.com/jalm/article/8/2/382/7030135 by guest on 09 March 2023


and clinicians utilize the most recent guidelines for cervical cancer screening, surveillance, and diagnosis.

INTRODUCTION basaloid atypical characteristic of high grade


squamous intraepithelial lesions or the atypical
Cervical cancer is a group of invasive epithelial noninvasive glands of adenocarcinoma in situ
neoplasms of the cervix, all of which have meta­ (4). Over time, these cells acquire somatic driver
static potential. These comprise 70% squamous mutations and invade. The most common somat­
cell carcinoma and 25% adenocarcinoma, with ic mutations involve members of the PI3K/AKT
the remainder rare tumors, such as small cell car­ pathway, specifically activating mutations in
cinoma (1). The vast majority of cervical cancers PIK3CA and copy number losses or inactivating
are driven by infection with high-risk human papil­ mutations of PTEN, seen in both squamous cell
loma virus (hrHPV), most notably HPV types 16 and carcinoma and adenocarcinoma (5, 6). As the dis­
18, which are responsible for about 70% of cervical ease progresses, invasive cervical cancers are
cancers (1). Human papilloma virus (HPV) is a capable of local invasion as well as distant metas­
double-stranded DNA virus with over 200 known tasis and patient mortality.
genotypes. In addition to types 16 and 18, other Histopathologically, the precursor lesions of
clinically relevant high-risk types include 58, 33, squamous cell carcinoma of the cervix are termed
45, 31, 52, 35, 59, 39, 51, 56, 66, and 68 in order cervical intraepithelial neoplasia (CIN), which di­
of worldwide frequency from high to low. Several vides cervical cancer precursors into 3 groups:
biological steps must take place for infection with CIN 1, 2, and 3, corresponding to mild dysplasia,
hrHPV to progress to cervical cancer (2). The earli­ moderate dysplasia, and severe dysplasia/carcin­
est and most obvious is HPV acquisition, which is oma in situ, respectively. For exfoliative cytology
often spontaneously cleared (3). This can be specimens, cervical cancer precursors are classi­
seen histologically as the koilocytotic atypia char­ fied as low-grade squamous intraepithelial lesion
acteristic of low-grade squamous intraepithelial (LSIL) for lesions histopathologically classified as
lesions (4). If HPV infection persists, viral DNA koilocytotic atypia and CIN 1 and high-grade squa­
integrates into the host genome, inducing expres­ mous intraepithelial lesion (HSIL) for lesions called
sion of high levels of oncogenic viral proteins, such CIN 2 and CIN 3 in histopathology. For histopatho­
as E6- and E7-encoded oncoproteins, which facili­ logical reporting, it has been suggested using LSIL
tate degradation of the host tumor suppressor (CIN1) and HSIL (CIN 2 and CIN 3) (4) and both ter­
proteins p53 and RB1, respectively (3). These minology systems are currently in use. The 2019
are seen histologically in either the extensive American Society for Colposcopy and Cervical

March 2023 | 08:02 | 382–406 | JALM 383


SPECIAL REPORT

Pathology (ASCCP) guidelines recommend that the interpretation of risk to guide management is
histopathology report should include CIN 2 or CIN different.
3 qualifiers, that is, HSIL (CIN 2) and HSIL (CIN 3) (7). This guidance document introduces currently
Approaches for cervical cancer screening in­ available cervical cancer screening tests, testing
clude primary cervical hrHPV testing, co-testing strategies, and the most recently updated screen­
of hrHPV and cervical cytology, and cytology ing guidelines as well as risk-based management
screening alone. These approaches have variable guidelines. In addition, we propose a report tem­
sensitivity and specificity, which will be detailed in plate for HPV and cervical cancer detection to fa­
the later sections (8). cilitate interpretation of testing results and

Downloaded from https://academic.oup.com/jalm/article/8/2/382/7030135 by guest on 09 March 2023


In addition to screening, cervical cancer tests clinical decision-making.
are used in surveillance as well as diagnosis of cer­
vical cancer. It is important to distinguish between
screening, surveillance, and diagnostic testing. CERVICAL CANCER SCREENING TESTS
Screening refers to testing for disease among indi­
viduals who are asymptomatic and have not been Currently, cervical cancer screening tests include
tested previously or have normal prior results (i.e., HPV testing and cervical cytology in clinical settings.
low risk). Surveillance is the interval testing among Recently, it has been proposed that self-collected
individuals who had a prior abnormal result, with vaginal specimens are suitable for HPV testing, al­
or without treatment. Recent evidence indicates though the Food and Drug Administration (FDA)
that an individual’s risk of developing cervical pre­ has not yet approved any self-collection methods.
cancer or cancer can be estimated using current
screening test results and previous screening HPV Test
test and biopsy results, while considering personal HPV testing may be used alone for primary
factors such as age and immunosuppression (7). hrHPV screening or in conjunction with cervical cy­
These data form the basis of the 2019 ASCCP risk- tology as part of a co-testing strategy, which will be
based management consensus guidelines for ab­ discussed in detail in the “Screening Strategies” sec­
normal cervical cancer screening tests and cancer tion. There are currently 5 FDA-approved HPV mo­
precursors, which will be discussed in later sec­ lecular assays (10–14).
tions (7). When an individual’s history is unknown,
1. The HPV assays with the FDA approval for pri­
that individual’s risk falls somewhere in between
mary cervical cancer screening are:
screening and surveillance. It is important to
note that an unknown history is itself a risk factor (a) Cobas® HPV Assay (Roche Molecular
Systems, Inc, Roche Diagnostics)
for development of cervical precancer and cancer
(9). Finally, diagnosis refers to testing including col­ The FDA approved the assay in 2011 for reflex
poscopy and biopsy when an individual presents HPV testing and co-testing with cytology. In 2014,
with symptoms (e.g., bleeding, discharge, pain). In it was approved for primary cervical cancer screen­
addition to biopsy for histologic diagnosis, note ing but only on Hologic ThinPrep specimens (see
that cytology and/or HPV testing may also be the following “Cervical Cytology Test” section). The
used by clinician as part of a comprehensive work­ DNA real-time qPCR-based assay targets the L1
up to guide management. The distinction between gene of HPV. It covers 14 high-risk types (16, 18,
these three categories (screening, surveillance, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 66, and 68)
and diagnosis) is important because, although with genotyping of 16 and 18. The beta-globin
similar tests might be utilized, the subsequent gene serves as an internal control. The sensitivity

384 JALM | 382–406 | 08:02 | March 2023


AACC Guidance Document on Cervical Cancer Detection SPECIAL REPORT

for detecting CIN 2/3 ranges from 90.5% to 97% and mRNA transcription-mediated amplification assay
the specificity ranges from 13% to 67.6% (15–17). targets E6/E7 genes. It covers 14 high-risk types
(16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 66,
(b) The BD Onclarity™ HPV Assay (Becton,
and 68) with separate genotyping of 16, and 18/
Dickinson and Company)
45 by the Aptima 16,18/45 genotype assay. The
The FDA approved this assay in 2018 for reflex HPV HPV16 E6/7 transcript serves as an internal con­
testing and co-testing with cytology as well as primary trol. The sensitivity for detecting CIN2/3 ranges
cervical cancer screening but only on SurePath from 87.5% to 98% and the specificity ranges
Specimens (see the following “Cervical Cytology from 30% to 78% (10, 15, 17, 19, 24).

Downloaded from https://academic.oup.com/jalm/article/8/2/382/7030135 by guest on 09 March 2023


Test” section). The DNA PCR-based assay targets
E6/E7 genes. It covers 14 high-risk types including
16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 66, and Cervical Cytology Test
68 with genotyping of 16, 18, and 45. The beta-globin Cervical cytology screening, also known as the
gene serves as an internal control. The sensitivity for Pap smear test, involves the direct sampling of
detecting CIN2/3 ranges from 94% to 98% and the the transformation zone between the ectocervix
specificity ranges from 17% to 31% (17–19). and endocervix. The traditional Pap test involves
2. The HPV assays approved for reflex and co- collecting cells from the vagina or cervix, smearing
testing with cytology are: them onto a slide at the patient bedside, and
(a) Digene HC2 High-Risk HPV DNA Test (Qiagen) evaluating the slide in the laboratory under a
microscope. A significant advance in cervical can­
The FDA approved this assay in 2001 for reflex
cer screening is the introduction of liquid-based
HPV testing and co-testing with cytology. The DNA
cytology (LBC). Currently, LBC is utilized in over
signal amplification (non-PCR) assay utilizes a full
90% of Pap tests in the United States and has high­
genome probe. It covers 13 high-risk types (16, 18,
er sensitivity for high-grade lesions than conven­
31, 33, 35, 39, 45, 51, 52, 56, 58, 59, and 68). There
tional smears with a lower false negativity rate
is no built-in internal control. The sensitivity for de­
(25–28). LBC was first approved by the FDA in
tecting CIN 2/3 ranges from 80.8% to 98% and the
1996 with the ThinPrep® Pap test (Hologic Inc.).
specificity ranges from 21% to 70.6% (10, 16–20).
The FDA approved a second test in 1999, the BD
(b) Cervista HPV HR Assay (Hologic Inc.) SurePath™ Pap test (BD Diagnostic).
The FDA approved this assay in 2009 for reflex The ThinPrep® Pap test sample is collected by a
HPV testing and co-testing with cytology. The clinician with a plastic spatula and an endocervical
DNA signal amplification (non-PCR) assay targets brush or a Cervex-Brush Combi device (a broom-
L1, E6, and E7 genes. Cervista HPV HR assay covers like device with an integrated endocervical sam­
14 high-risk types (16, 18, 31, 33, 35, 39, 45, 51, 52, pler) and rinsed in a ThinPrep vial prefilled with a
56, 58, 59, 66, and 68). The Cervista HPV 16/18 as­ methanol-based fixative (PreservCyt). The vial is
say tests HPV 16 and 18 only. The HIST2H2BE gene sent to the laboratory for processing on the
serves as an internal control. The sensitivity for de­ ThinPrep Processor, an automated slide prepar­
tecting CIN2/3 ranges from 77% to 92.8% and the ation unit that uses a liquid-based vacuum filtra­
specificity ranges from 44.2% to 72.7% (21–23). tion method to disperse, filter, and transfer the
specimen onto a slide using air pressure for ad­
(c) Aptima HPV Assay (Hologic Inc.)
herence resulting in a uniform monolayer of cells.
The FDA approved the assay in 2011 for reflex The residual specimen is available for other diag­
HPV testing and co-testing with cytology. The nostic tests, for example, HPV testing (26, 27).

March 2023 | 08:02 | 382–406 | JALM 385


SPECIAL REPORT

The SurePath™ Pap test sample is collected by a


Table 1. The Bethesda system for reporting
clinician using a broom-like device with a detach­ cervical cytology diagnostic categories.
able head. The sample is placed in a collection
vial with an ethanol-based fixative (CytoRich) and Diagnostic category Comments
sent to the laboratory for processing. The cells Unsatisfactory Inadequate
are centrifuged, suspended within a sucrose dens­ cellularity,
ity gradient, and transferred to slide via gravity for Obscuring
inflammation or
adherence in a monolayer. The residual specimen blood
is available for other diagnostic tests, for example, Negative for intraepithelial Nonneoplastic

Downloaded from https://academic.oup.com/jalm/article/8/2/382/7030135 by guest on 09 March 2023


HPV testing (26, 27). lesion or malignancy (NILM) (tubal metaplasia,
Both ThinPrep and SurePath Pap tests are ap­ pregnancy
changes, atrophy),
proved for primary screening by automated ima­
Reactive changes,
gers. The ThinPrep Imaging System (TIS, Hologic
Organisms/viral
Corp.) is used with ThinPrep slides, and the cytopathic
FocalPoint GS Primary Screening System (Focal changes

Point GS, BD Diagnostics) can be used with ASC-US

SurePath and conventional Pap tests. The auto­ ASC-H

mated imagers have slightly increased sensitivity Squamous intraepithelial HPV cytopathic
lesion changes
over manual screening alone; however, there is a
-LSIL
slight decrease in specificity (29–32).
-HSIL
Evaluation of slides by automated screening or
Squamous cell carcinoma
manual screening by a cytotechnologist or cyto­
Glandular cells
pathologist is considered primary review. All ab­
-Atypical
normal cervical Pap smears must have a
• Endocervical cells, NOS
secondary review by a cytopathologist. The report­
• Endometrial cells, NOS
ing of results follows the Bethesda System for
• Glandular cells, NOS
Reporting Cervical Cytology (Table 1) (33). -Atypical
The spectrum of lesions in the cervix caused by • Endocervical cells, favor neoplastic
HPV ranges from premalignant dysplasia to inva­ • Glandular cells, favor neoplastic
sive carcinoma. Low-grade dysplasia or LSIL in cy­ -Adenocarcinoma in situ
tology may be indicative of HPV infection that can -Adenocarcinoma
be transient with regression within 2 years (34). Other malignancy Metastatic tumors,
Cytomorphologic changes of LSIL in Pap test are sarcoma,
neuroendocrine
similar to those identified as CIN 1 in cervical tissue
tumors, etc.
biopsies. Changes of LSIL can range from viral cy­
NOS, not otherwise specified.
topathic change (koilocytosis) to morphologic
changes of low-grade dysplasia. A Pap test with
atypical changes involving squamous cells that
fall short of criteria for LSIL can be reported as The cytomorphology of HSIL is similar to CIN 2 and
atypical squamous cells of undetermined signifi­ CIN 3 in tissue biopsy. Squamous cells with
cance (ASC-US). The ASC-US/LSIL ratio is a labora­ high-grade dysplasia are smaller than those with
tory quality indicator and can highlight ASC-US low-grade dysplasia. They have high nuclear to cyto­
overuse. plasmic ratio and marked nuclear membrane

386 JALM | 382–406 | 08:02 | March 2023


AACC Guidance Document on Cervical Cancer Detection SPECIAL REPORT

irregularity and can have nuclear hyperchromasia. has more prominent malignant cytomorphologic
Atypical changes that fall short of criteria for HSIL features and commonly associated degenerated
can be reported as atypical squamous cells—cannot blood and necrosis. Adenocarcinoma can be endo­
exclude high-grade squamous intraepithelial lesion cervical, endometrial, or rarely metastatic in con­
(ASC-H). firmatory tissue biopsy sections. Glandular and
Squamous cell carcinoma is the most common squamous abnormalities may be present in a single
malignancy of the cervix. Tissue architecture is Pap test and each interpretation should be reported.
not present in a cytology sample; however, other Publication of the 2019 ASCCP consensus
malignant features are present. Tumor cells can guidelines in April 2020 introduced a change

Downloaded from https://academic.oup.com/jalm/article/8/2/382/7030135 by guest on 09 March 2023


have similar cytomorphology as those seen in from test-result management to risk-based guide­
HSIL; however, these cells also may have increased lines. The new guidelines change one manage­
pleomorphism and dense eosinophilic cytoplasm ment strategy for all with similar diagnoses and
in keratinizing squamous cell carcinoma. varied risk levels to patient management based
Additionally, an associated tumor diathesis com­ on a combination of the patient’s level of risk, pre­
prised of necrotic debris and degenerated blood vious clinical history, and current screening test re­
clings to cells in liquid-based cytology. sults. Risk levels from tables of risk variables from
Cervical cytology is a screening test for squamous the 15-year Kaiser Permanente Northern
lesions; however, atypical glandular cells (AGC) and California cervical cancer screening study were uti­
changes suggestive of glandular malignancies can lized for comparison to identify a clinical action
also be identified. There is lower sensitivity for glan­ threshold for patient management decisions (9,
dular lesion detection by cytology due to several is­ 35). Generally, patients at higher risk will undergo
sues, including cellular degeneration, interpretation, more frequent cervical carcinoma screening, fol­
and sampling. AGC can be endocervical or endomet­ lowed by colposcopy and treatment as needed,
rial; however, it may not be possible to identify the ori­ while those at lower risk will have less frequent
gin based on cytology alone. AGC in Pap test samples surveillance (35). Therefore, patients with similar
may correlate to reactive inflammatory lesions, ex­ Pap test results may be managed differently based
tension of squamous dysplasia into endocervical on their risk for developing high-grade dysplasia.
glands, in situ, or invasive adenocarcinoma in tissue In summary, the Pap test is a screening test for
biopsy specimens. Cytomorphologic changes of aty­ precancerous changes of the cervix. Screening in­
pia include nuclear enlargement with overlapping, in­ tervals, management, and treatment are risk-
creased nuclear to cytoplasmic ratio, nucleoli, and based, taking into consideration the age of the
mild hyperchromasia. These changes are beyond patient, current cytology, pathology and HPV re­
those seen in reactive glandular epithelium; however, sults, previous test results, age, and immune status.
they fall short of the criteria for malignancy.
Changes suggestive of endocervical adenocarcin­ Self-Collected Vaginal Specimens for HPV
oma in situ include crowded hyperchromatic glandu­ Screening Test
lar cells in pseudostratified strips with occasional A potential new approach in cervical cancer
gland-like architecture or rosettes. Additionally, there screening is the use of self-collected vaginal
can be peripheral feathering and prominent nucleoli. specimens for genotyping of HPV; however, self-
These features may be subtle, and the interpretation sampling is not yet FDA-approved and is not cur­
of adenocarcinoma in situ can be difficult. rently the standard of care in the United States.
Challenging cases can be interpreted as atypical en­ Several studies have looked at the stability of these
docervical cells, favor neoplastic. Adenocarcinoma specimens, how these samples perform

March 2023 | 08:02 | 382–406 | JALM 387


SPECIAL REPORT

compared to clinician-collected samples, and ad­ correlation between self-collected vaginal speci­
vantages and potential concerns associated with mens and clinician-collected specimens for HPV
this type of specimen. screening were conducted in the Netherlands
(16 410 total randomized patients) and in Mexico
Stability of Self-Collected Vaginal Specimens (25 061 total randomized patients), respectively.
for HPV Genotyping In the Dutch study (40), 8212 participants were
Self-collected vaginal specimens for HPV randomly allocated to the self-sampling group and
genotyping are generally collected using a “dry” 8198 to the clinician-based sampling group. 569
or lavage-based HPV self-sampling approach, (7.4%) self-collected samples and 451 (7.2%)

Downloaded from https://academic.oup.com/jalm/article/8/2/382/7030135 by guest on 09 March 2023


most commonly using a brush/broom. A number clinician-collected samples tested positive for HPV
of studies have evaluated recovery and stability based on genotype analysis (relative risk 1.04 [95%
of HPV DNA from exfoliated cervical cells attached CI, 0.92–1.17]). After a median follow-up duration
to the hydrophobic material used for manufacture for HPV-positive women of 20 months, the sensitivity
of the collecting brush/broom (36–39). In one and specificity of HPV testing did not differ between
study (39), HPV DNA stability was evaluated with self-sampling and clinician-based sampling in terms
exfoliated cells remaining on the brush/broom in of the detection of CIN 2 + or CIN 3 + lesions in the
a “dry” state with specimens stored at tempera­ follow-up cytology testing. The authors concluded
tures ranging from 4 to 30 °C for up to 32 weeks. self-collected vaginal specimens for HPV genotyping
At various time points, HPV genotyping was per­ could be used as a primary screening method in rou­
formed along with an assessment of the degree tine cervical cancer screening.
of DNA fragmentation in the combined extracted In the study from Mexico (41), 12 330 women
HPV and human genomic material. DNA fragmen­ were randomly assigned to the self-collected vagi­
tation was modestly and progressively increased nal specimen arm and underwent HPV genotyping,
over time at all temperatures, however, HPV geno­ with follow-up colposcopy on patients testing posi­
typing utilizing PCR demonstrated minimal in­ tive. An additional 12 731 patients were randomly
creases in cycle threshold for oncogenic HPV assigned to undergo cervical cytology only. The
genotypes. goal was to determine whether self-collected vagi­
nal specimen could identify patients with CIN 2 or
Comparison of Results for Clinician-Collected worse as well as conventional cytology. HPV testing
Specimens and Self-Collected Vaginal identified 117.4 women with CIN 2 or worse per
Specimens 10 000 (95.2–139.5) compared with 34.4 women
The “gold standard” for evaluating the success of with CIN 2 or worse per 10 000 (23.4–45.3) identified
self-collected vaginal specimens for HPV screening by cytology. The relative sensitivity of self-collected
is based on the correlation of HPV genotyping re­ vaginal specimens to identify CIN 2 or worse cervical
sults obtained from self-collected specimens with cancer using HPV testing was 3.4 times greater
those obtained from specimens collected by a (2.4-4.9) than cervical cytology alone. On the other
trained clinician. hand, the positive predictive value of HPV testing
In the United States, utilization of self-collected for CIN 2 or worse was 12.2% (9.9-14.5) compared
vaginal specimens for HPV screening has thus far with 90.5% (61.7-100) for cytology alone. The
been relatively limited. Accordingly, the great ma­ authors concluded that despite the much lower
jority of published studies using self-collected vagi­ positive predictive value for HPV testing of
nal specimens have been conducted in foreign self-collected vaginal specimens compared with cy­
countries (40–45). Studies to examine the tology, such testing might be preferred for detecting

388 JALM | 382–406 | 08:02 | March 2023


AACC Guidance Document on Cervical Cancer Detection SPECIAL REPORT

CIN 2 or worse in low-resource settings where re­ due to inadequate sampling of the squamocol­
stricted infrastructure reduces the effectiveness of umnar junction.
cytology-based screening programs. (b) significant differences in screening perform­
Additional, smaller-scale studies have largely ance of different self-collected vaginal speci­
men collection methods
supported the conclusions from these 2 pivotal
(c) potential lack of appropriate follow-up
studies (42, 43), and a detailed meta-analysis of
(d) challenges with interpretation of results if not
self-collected vs clinician-collected samples was directly communicated to a professional care
published for studies performed prior to 2014 provider
(44). In addition, one study addressed self- vs

Downloaded from https://academic.oup.com/jalm/article/8/2/382/7030135 by guest on 09 March 2023


clinician-collected specimens for HPV screening
in post-menopausal women and demonstrated SCREENING STRATEGIES
that, even in this population, there was no signifi­
cant difference between the 2 sampling methods The availability of screening, along with vaccin­
for extended HPV genotyping (P = 0.827) (45). ation programs, has decreased the incidence and
mortality rates of cervical cancer (49–51).
Screening can detect precursors and early-stage
Advantages and Potential Concerns disease of squamous cell carcinoma and adenocar­
Associated with Self-Collected Vaginal
cinoma. Treatment of precursors and early-stage
Specimens
disease can prevent the development of invasive
The benefits and potential drawbacks of self- cervical cancer and reduce cervical cancer mortal­
collected vaginal specimens for HPV genotyping ity. The 3 available cervical screening strategies in
are summarized as follows: the United States are (a) primary HPV screening,
Advantages (46–48) (b) co-testing with HPV testing and cervical cytology,
(a) patient preference and (c) cervical cytology alone. Recommendations
(b) convenience, which helps reduce frequency of for screening aim to balance benefits of early detec­
missed appointments or failure to make tion of treatable lesions and reduction in incidence
appointments and mortality of cervical cancer with the potential
(c) increased availability to cervical cancer screen­ risk of false positives, unnecessary procedures,
ing in remote areas with limited access to and potential harms (e.g., patient discomfort,
healthcare providers
healthcare costs, and risks of treatment on future
(d) wider availability for underserved (uninsured)
pregnancies). The most recent screening recom­
populations with high HPV exposure risk
mendations from the 2018 US Preventive
(e) comparable performance compared to
clinician-collected specimens Services Task Force (USPSTF) (52) and the 2020
(f) reduced procedure costs and eliminated tra­ American Cancer Society (ACS) (53) are detailed
vel costs to a clinical site as the patient per­ next and summarized in Table 2. The main differ­
forms the procedure ences between the 2 guidelines relate to age to
initiate screening and the test used in individuals
Potential concerns (47)
ages 21 to 29 years old.
(a) increased frequency of specimen rejection (in­
adequate specimens) and decreased overall High-Risk HPV Testing Alone
screening performance compared to clinician-
collected specimens. With self-collected vagi­ The FDA approved the cobas® HPV test in
nal specimens, there is no direct visualization March 2014 and the BD Onclarity™ HPV Assay in
of the cervix so sampling errors may arise April 2018 for primary HPV testing for screening

March 2023 | 08:02 | 382–406 | JALM 389


SPECIAL REPORT

Table 2. Summary of screening recommendations.a

US Preventive Services Task Force, 2018 American Cancer Society, 2020

Age to start screening 21 25


Age to end screeninga 65 65
Screening test options and Ages 21–65: Cytology alone every 3 years HPV testing alone every 5 years
intervals or or
Ages 21–29: Cytology alone every 3 years Cytology plus HPV testing every 5
Ages 30–65: Cytology plus HPV testing every 5 years
years or

Downloaded from https://academic.oup.com/jalm/article/8/2/382/7030135 by guest on 09 March 2023


or Cytology alone every 3 years
Ages 21–29: Cytology alone every 3 years
Ages 30–65: HPV testing alone every 5 years
Preferred strategies Cytology alone every 3 years and HPV testing HPV testing alone every 5 years
alone
every 5 years (equally preferred) among women
ages 30–65 years.
a
Applies to women with all prior normal results and no symptoms. Patients with prior abnormal results will follow 2019 ASCCP management
guidelines.

in individuals 25 years or older (54). Both of these uncommon, and so, on balance, cytology
tests are approved for partial HPV genotyping. It screening is felt to be adequate for detection
has been demonstrated that primary HPV screen­ of serious disease, while avoiding the potential
ing is more effective than screening with cytology for overevaluation associated with the highly
alone and performs similarly to and with lower sensitive HPV test in patients younger than 30
costs than screening with co-testing (9, 55). The 2 years old. Based on this data, the USPSTF re­
FDA-approved tests for primary HPV screening commends that primary HPV screening only
are not available at all institutions. In many set­ be used for patients 30 years and older (52).
tings, co-testing will be ordered in lieu of primary An important difference in the ACS guideline is
testing until an FDA-approved primary test is the recommendation for the use of primary
available. HPV testing starting at 25 years old (53).
The USPSTF recommends that primary HPV Although based on the same data, the differ­
testing not be used to screen individuals 21 to ence in interpretation reflects the balance of in­
29 years old as a stand-alone test. This is due creased intervention (i.e., colposcopies) with
to the high prevalence of HPV in those under increased number of precancerous lesions
the age of 30 (56, 57), although this may change detected.
as an increasing number of people are vacci­ With regards to interval of screening, both orga­
nated. In one study, primary HPV screening start­ nizations recommend screening with primary HPV
ing at 25 years of age doubled the number of not occur at intervals shorter than 3 years and not
colposcopies but resulted in a 54% greater de­ beyond 5 years among patients with negative
tection of CIN 3 + when compared to the same screening results. An analysis by Ronco et al. con­
strategy starting at 30 years of age (58). cluded that a screening interval of at least 5 years
However, despite the increased detection of for HPV screening is safer than cytology every 3
CIN 3+, quick progression to cancer is years (59).

390 JALM | 382–406 | 08:02 | March 2023


AACC Guidance Document on Cervical Cancer Detection SPECIAL REPORT

High-Risk HPV and Cervical Cytology HPV testing to cytology also enhances the identi­
Co-Testing fication of women with adenocarcinoma of the
In co-testing, cytology and HPV testing are col­ cervix and its precursors (64, 65). Compared to
lected and reported together. In addition to the squamous cell cancers, cytology has been rela­
two FDA-approved tests for primary HPV screen­ tively ineffective in decreasing the incidence of in­
ing, the digene HC2 high-risk HPV DNA test, vasive adenocarcinoma of the cervix (66).
Cervista HPV HR assay, Cervista HPV 16/18 assay,
Cervical Cytology Alone
Aptima HPV assay, and Aptima HPV 1618/45 as­
say are all approved by the FDA as of March When cervical cytology alone is used, the cer­

Downloaded from https://academic.oup.com/jalm/article/8/2/382/7030135 by guest on 09 March 2023


vical sample is analyzed for cellular abnormalities.
2019 for co-testing and are available at most in­
After cytology is performed, there is an option to
stitutions (54). As not all institutions currently
perform reflex HPV testing when the cytology
have access to FDA-approved assays for primary
result returns positive for ASC-US. The USPSTF
HPV testing, providers may order co-testing when
recommends screening for cervical cancer every
HPV-based testing is recommended. Depending
3 years with cervical cytology alone in women
on the clinical scenario, patient population, and
ages 21 to 29 years (52). The ASCCP recommends
shared-decision making with the patient, co-
that, for patients ages < 25 years with ASC-US, re­
testing may be chosen by the provider if there flex HPV testing be performed (7). Given the high
is a concern for higher false-negative rates of cy­ prevalence of transient HPV infection among ado­
tology or HPV testing alone reported in the litera­ lescents and young adults, initial screening at age
ture. As laboratories increase in capacity and 21 years should be with cytology alone. If cytology
access to FDA-approved primary HPV screening alone is used, the ACS recommends that the
tests, either through new FDA-approvals or screening interval be every 3 years (53). Studies
through switching to approved platforms, adop­ of screening intervals in women with a history of
tion of primary HPV testing may increase in align­ negative cytology results report an increased risk
ment with the USPSTF and ACS preferred of cancer after 3 years even after controlling for
screening strategies. prior number of negative cytology tests (67).
The USPSTF recommends that co-testing be Conversely, the incidence of high-grade cytology
offered to patients 30 years and older with retest­ within 3 years of a normal cytology is low (10–66
ing in 5 years recommended after a negative per 10 000) (68) and modeling studies demon­
screen (52). Similar to primary HPV testing, the strating that detection was similar with annual or
ACS recommendation differs slightly in that co- triennial screening, but annual screening resulted
testing is also acceptable among those older in increased number of interventions (i.e., colpos­
than 25 years old (53). The addition of HPV testing copies) (69, 70).
to cytology increases the detection of prevalent
CIN 3 with a concomitant decrease in CIN 3 + or Comparison of Screening Strategies
cancer detected in subsequent rounds of screen­ There are no randomized trials comparing mor­
ing (60–62). The increase in diagnostic lead-time tality rates among the various screening strat­
with co-testing translates into lower risk following egies. One modeling study found that HPV-based
a negative screen, which allows for an interval of 5 screening strategies (i.e., primary HPV testing or
years between screens with incident cancer rates co-testing) were associated with fewer cervical
similar to or lower than screening with cytology cancer deaths (0.23–0.29 per 1000) compared
alone at 3-year intervals (63, 64). The addition of with screening strategies that included cervical

March 2023 | 08:02 | 382–406 | JALM 391


SPECIAL REPORT

cytology (i.e., cytology alone or reflex HPV testing, + was less than 1% in the next 5 to 10 years (63, 64,
0.30–0.76 per 1000) (69). 75–78). Meta-analysis indicated that, compared
With respect to detection, a systematic review with cytology-based testing, screening with HPV
found that primary HPV testing among individuals testing (mainly with co-testing) was associated
25 to 65 years compared with cytology alone was with a lower incident of cervical cancer at a median
associated with increased detection of CIN 3 + in follow up of 6.5 years (rate ratio 0.60, 95%CI, 0.40–
the initial round of screening (relative risk range, 0.89) (59). Consistent with the low risk associated
1.61 [95% CI, 1.09–2.37]) to 7.46 (95% CI, 1.02– with negative co-testing, modeling studies found
54.66) (8). Colposcopy rates were higher for primary that co-testing every 5 years was as effective as

Downloaded from https://academic.oup.com/jalm/article/8/2/382/7030135 by guest on 09 March 2023


HPV testing than for cytology alone in one of 3 trials screening with cytology alone every 3 years (79)
(NTCC Phase II) (62, 71) and similar in 2 trials and was associated with decreased colposcopies
[FINNISH (72) and HPV FOCAL (73)]. False-positive compared with co-testing every 3 years, with only
rates for CIN 2 + were higher for primary HPV testing a minimal change in lifetime cancer risk (0.39%
alone than for cytology alone in one trial (NTCC vs 0.61%) (80). Lastly, for centers with imaged
Phase II) and similar in another trial (FINNISH). LBC available, a recent study showed that more
In comparing detection of CIN 3 + using co- women subsequently diagnosed with cervical can­
testing vs cytology alone, randomized control cer within 1 year of co-testing were identified by
trials [NTCC Phase I (62, 71), SWEDESCREEN the LBC results than by the HPV results (85.1%,
(60), POBASCAM (61), ARTISTIC (74)] have found 1015/1193 vs 77.5%, 925/1193), confirming the
that including HPV testing leads to earlier detec­ value of LBC element in co-testing (81).
tion, but not reduced incidence, of high-grade
cervical dysplasia and cancer. In all 4 trials, HPV Beginning and Ending of Screening
testing in the first screening round detected Screening for cervical cancer in asymptomatic,
cases of CIN 3 + that were missed by cytology, immunocompetent patients, regardless of the
but there were fewer cases in the combined age of sexual debut, should not be performed in
HPV testing plus cytology group at round 2, and individuals younger than 21 years old (53).
over both screening rounds there were no signifi­ Cervical cancer rates have been reported to be
cant differences. In contrast, the HPV FOCAL 0.15% in females 15 to 19 years old and 1.4% in
study found a lower incidence of CIN 3 + asso­ women 20 to 24 years old (82). The prevalence
ciated with initial HPV testing (incidence ratio of CIN 3 in women under 21 is estimated at 0.2%
2.3 per 1000 [95% CI 1.5–3.5]) compared with ini­ while the false-positive cytology rate is reported
tial Pap testing (incidence ratio 5.5 per 1000 [95% at 3.1%, emphasizing the potential harm of early
CI 4.2–7.2]); relative risk 0.42 [95% CI, 0.25–0.69]) screening (83, 84). This is because exposure of cer­
(73). Colposcopy rates were higher for screening vical cells to HPV during vaginal intercourse may
with co-testing than for cytology alone in 2 trials lead to cervical precancers, but regression is com­
(ARTISTIC and NTCC Phase I) and not reported mon and is generally not a rapid process.
in the other 2 trials (SWEDESCREEN and Furthermore, screening initiation is not tied to sex­
POBASCAM). False-positive rates were higher ual debut because, although the incidence of HPV
for screening with co-testing in 3 of 4 trials infection is highest following the initiation of sexual
(SWEDESCREEN did not report the false-positive intercourse, the infection usually clears spontan­
rate for the intervention group). eously in 90% within 2 years (85). In counseling pa­
A benefit of co-testing is that, among individuals tients, it is important to emphasize the need for
with a negative co-test, the risk of developing CIN 3 screening even after vaccination. This is because

392 JALM | 382–406 | 08:02 | March 2023


AACC Guidance Document on Cervical Cancer Detection SPECIAL REPORT

it is uncertain what level of vaccine uptake in the screening in the past 10 years with normal results
general population will achieve the level of indi­ and no history of CIN2 + within the past 25 years
vidual protection and herd immunity that would discontinue screening (53). Those with a history
warrant changes in screening protocols for all of precancer or cancer should continue to have
women or for those with documented vaccin­ testing for at least 25 years after diagnosis even
ation history (53). if the testing goes past age 65. The evidence for
As noted, the USPSTF recommends screening discontinuation of screening is based primarily
at 21 years and older with cytology every 3 years on a single modeling study with a model of contin­
(52) based on a meta-analysis of randomized ued screening up to age 90 (69). A prolonged

Downloaded from https://academic.oup.com/jalm/article/8/2/382/7030135 by guest on 09 March 2023


trials and observational studies that demon­ screening model only resulted in the reduction
strated higher false-positive rates with HPV test­ of 1.6 cancer cases and 0.5 cancer deaths per
ing because of the higher rates of transient 1000 women compared to an additional 127 col­
infection in this age group (8). Alternatively, the poscopies per 1000 women. However, it is im­
ACS recommends that screening begin at age portant to note that approximately 20% of
25 with primary HPV testing every 5 years (53). cervical cancers occur in patients older than 65
The higher age of screening initiation is based years, and evidence indicates that screening in
on the low incidence of cervical cancer (0.8%) those 65 years and older is associated with a low­
due to high rates of spontaneous regression of er risk of subsequent development of cervical
HPV infection (53, 86–88). The ACS favors primary cancer (90, 91). In patients with inadequate prior
HPV testing based on randomized controlled screening or unknown screening history, the high
trials showing higher sensitivity of HPV-based incidence of mortality from cervical cancer and
testing than cytology alone (59, 62), which is im­ modeling studies suggest that screening older pa­
portant in the context of increased vaccination tients who have never been screened with cytology
rates (89). This will become increasingly relevant could reduce mortality by 74% (92–94). Based on
as a greater number of women are vaccinated this data, the USPSTF suggests, in those with inad­
prior to exposure to HPV. equate or unknown prior screening, screening be
The timing to discontinue screening depends on continued until age 70 or 75 years old. Overall,
adequacy of screening, prior results, life expect­ data regarding the stopping age for screening are
ancy, and patient preferences. Adequate screen­ limited and should be based on an informed
ing is defined by (a) 2 consecutive negative HPV decision-making discussion with the patient.
tests within the past 10 years (with the most recent
within the previous 5 years), (b) 2 consecutive
negative co-tests within the past 10 years (with Criteria for Routine Screening
the most recent within the previous 5 years), or Despite the somewhat nuanced differences be­
(c) 3 consecutive negative Pap tests within the tween the ACS and USPSTF guidelines, there are 2
past 10 years (with the most recent test within key concepts to the implementation of screening:
the previous 3 years) (53). If results for the past (a) correctly identifying those who meet criteria for
10 years are unknown, screening would be consid­ routine screening and (b) ensuring that patients
ered inadequate. In addition to adequate screen­ who have abnormal Pap and/or HPV testing results
ing, the patient should not have had CIN 2 or are evaluated, usually by colposcopy with biopsy;
worse for the past 25 years. undergo treatment if appropriate; and finally adhere
The ACS and USPSTF both recommend that to follow-up. Figure 1 includes these concepts and is
those over age 65 who have had regular adapted from the 2019 ASCCP guideline to

March 2023 | 08:02 | 382–406 | JALM 393


SPECIAL REPORT

demonstrate how a patient’s risk is evaluated, irre­ long-term surveillance (i.e., annual cytology or
spective of which of the 3 screening strategies is every 3-year co-testing) (7).
used. • Clinical signs or symptoms of bleeding, dis­

To determine if an individual meets criteria for charge, and/or pain: It is important to note that
symptomatic patients of any age should undergo
routine screening, the following should be elicited
diagnostic evaluation regardless of prior or cur­
from clinical history: rent screening results. Signs and symptoms of
cervical disease could include abnormal dis­
• History of immunosuppression: Patients with HIV charge, abnormal bleeding, postcoital bleeding,
as well as solid organ transplant, allogeneic hem­ pelvic pain, change in bladder or bowel function,
atopoietic stem cell transplant, inflammatory bo­

Downloaded from https://academic.oup.com/jalm/article/8/2/382/7030135 by guest on 09 March 2023


and abnormality seen on visualization or palpa­
wel disease, lupus, and rheumatoid arthritis on tion of the cervix. Diagnostic evaluation here
immunosuppressants have a compromised im­ may include cytology; HPV testing; colposcopic
mune system. Guidelines on the screening and evaluation; diagnostic imaging; and cervical, en­
management in patients with immunosuppres­ docervical, or endometrial biopsy. The results of
sion account for the higher risk of cervical can­ the associated Pap test and HPV testing should
cer in this group (95). Screening should begin be interpreted in conjunction with colposcopic
within 1 year of first penetrative sexual activity evaluation and to complement biopsy results ra­
and continue throughout a patient’s lifetime: an­ ther than used in a screening or surveillance
nually for 3 years if all results are normal, then algorithm.
every 3 years (cytology only) until the age of 30
• Prior abnormal results and recent testing:
years, and then either continuing with cytology
Patients with any prior abnormal results, with or
alone or co-testing every 3 years after the age
without treatment, are at increased risk and
of 30 years (7, 100). All abnormal results need
should be managed based on the ASCCP guide­
to be evaluated.
lines (9). Furthermore, those without recent
• History of vulvar or vaginal dysplasia: Vulvar and
documented testing should also undergo testing
vaginal dysplasia share similar risk factors to cer­ as described in the next section.
vical dysplasia. It has been reported that the rate
of concurrent disease is approximately 3% and In summary, anyone with a history of immuno­
those who are immunosuppressed carries the suppression, vulvar or vaginal dysplasia, hysterec­
highest likelihood (odds ratio 20.1; 95% CI,
tomy with removal of cervix, clinical signs and
11.33–51.82) followed by those with HIV/AIDS
(odds ratio 17.4; 95%CI, 8.73–41.69) (101). symptoms, or prior abnormal results does not
There are no guidelines available to guide follow- meet criteria for routine screening per the ACS
up of patients with vulvar and vaginal dysplasia or USPSTF guidelines. For those with abnormal
(96–98). However, the increased risk of concur­ prior results without recent testing, patients
rent cervical disease raises the importance of should be triaged based on the ASCCP guidelines
modified surveillance in this group.
described next and illustrated in Fig. 1.
• History of hysterectomy with removal of cervix: If
a patient underwent hysterectomy with removal
of the cervix and either has no previous diagnosis
of CIN 2 + within the previous 25 years or has SURVEILLANCE USING RISK-BASED
completed 25 years of surveillance, continued GUIDELINES
testing is generally not recommended.
However, if testing is performed, abnormal vagi­ The 2019 ASCCP risk-based management
nal sample results should be managed according
guidelines incorporate HPV testing and cytology
to published guidelines (99). Alternatively, if hys­
terectomy was performed for treatment of any results with prior test results to estimate an indivi­
cervical abnormality, patients should have 3 con­ dual’s 5-year risk of CIN 3+ (9). The minimum
secutive annual HPV-based tests before entering amount of data required to generate a clinical

394 JALM | 382–406 | 08:02 | March 2023


AACC Guidance Document on Cervical Cancer Detection SPECIAL REPORT

Does the paent have one of the following? SCREENING


q History of immunosuppression (follow Ref A) NO Rou!ne Screening per ACS and USPSTF
q History of vulvar or vaginal dysplasia (follow Ref B)
(Refer to Table 1)
q Prior hysterectomy with removal of cervix (follow Ref C)
q Clinical signs or symptoms of bleeding, discharge, and/or pain (follow Ref D)

YES
Does the pa!ent have all normal PAP and nega!ve HPV within the past 25 years?
NO

Surveillance per ASCCP guidelines


Primary HPV testing, Co-testing (HPV and cytology), Cytology alone
Use of Risk-estimate calculator incorporating current and past results (Ref E)

Downloaded from https://academic.oup.com/jalm/article/8/2/382/7030135 by guest on 09 March 2023


Is immediate CIN3+ risk ≥4%

No Yes

5-year CIN3+ risk <0.15% Immediate CIN3+ risk 4-24%


Colposcopy adequate and low-grade
Return in 5 years Colposcopy recommended
abnormalities

5-year CIN3+ risk 0.15-0.54% Immediate CIN3+ risk 25-59%


Return in 3 years Expedited treatment or colposcopy acceptable High-grade abnormalities (HSIL,
ACIS, Cancer)
5-year CIN3+ risk ≥0.55% Immediate CIN3+ risk 60-100%
Return in 1 years Expedited treatment preferred
Treatment and Surveillance per
SURVEILLANCE DIAGNOSIS ASCCP Guidelines

Fig. 1. Triage algorithm for cervical cancer screening, surveillance, and diagnosis. This flow diagram in­
corporates the ACS and USPSTF recommendations for those who meet criteria for routine screening as
well as risk-based management guidelines from ASCCP. References for the following special popula­
tions and who do not qualify for routine screening are provided: (A), history of immunosuppression
(95); (B), history of vulvar or vaginal dysplasia (96–98); (C), history of hysterectomy with removal of cer­
vix (7, 99); (D), patients with any signs and/or symptoms should undergo further evaluation; (E), for
those with prior abnormal results and recent testing results is not available, surveillance based on risk-
based estimates provided by ASCCP is recommended (9).

action recommendation includes the patient’s age registrational trials (102, 103), the New Mexico
and current test results, recognizing that prior HPV Pap Registry (104, 105), and the Centers for
screening history might not be available. Disease Control and Prevention’s National Breast
However, ideally, prior cytology, HPV and path­ and Cervical Cancer Early Detection Program
ology data are entered into the risk calculator in (106). Patients with an immediate risk of CIN 3 +
order to create a personal risk score for the pa­ that is less than 4% undergo surveillance, and
tient, which determines management. Data tables based on their 5-year risk of CIN 3+, the interval
of risk estimates are to guide management clinical may be 1, 3, or 5 years. Those with an immediate
action thresholds under the principle of “equal CIN 3 + risk of greater than or equal to 4% are re­
management for equal risk” (9). The estimates ferred to diagnostic evaluation, which may include
are based on data from Kaiser Permanente colposcopic evaluation and/or excisional
Northern California (64), the BD Onclarity procedure.

March 2023 | 08:02 | 382–406 | JALM 395


SPECIAL REPORT

Surveillance is defined as follow-up testing at a of cervical precancer warranting close follow-up


shorter interval than that currently recommended (9, 107). HPV testing and co-testing are more sen­
for routine screening with either HPV primary test­ sitive than cytology alone in detecting CIN 2 + in
ing or co-testing (i.e., sooner than 5 years). both the post-colposcopy and post-treatment
Surveillance is recommended for patients whose settings (108, 109).
risk of CIN 3 + based on current test results and The ASCCP guideline also addresses the issue of
screening history is higher than the risk for the long-term follow-up surveillance after treatment
general screening population but lower than the for both high-grade and low-grade abnormalities
risk at which colposcopy is recommended (7). (7). For those with a history of treated high-grade

Downloaded from https://academic.oup.com/jalm/article/8/2/382/7030135 by guest on 09 March 2023


For patients with an estimated 5-year CIN 3 + risk histology or cytology, after initial intensive surveil­
of less than 0.15%, return to routine screening at lance period, the ASCCP recommends surveillance
5-year intervals using HPV-based testing is recom­ at 3-year intervals for at least 25 years, which may
mended. This is based on the estimated 5-year continue as long as the patient is in reasonably
CIN 3 + risks after a negative HPV test (0.14%; good health. This is based on data from long-term
95% CI, 0.13%–0.15%) and co-test (0.12%; 95%CI, population studies that demonstrate a persistent
0.12%–0.13%). Cytology alone is never recom­ 2-fold increase in cervical cancer risk after treat­
mended at 5-year intervals. For patients who ment of high-grade lesions (107). For those with
have an estimated 5-year CIN 3 + risk of 0.15% or history of low-grade cytology (HPV-positive nega­
greater but less than 0.55%, repeat testing in 3 tive for intraepithelial lesion or malignancy;
years with HPV-based testing is recommended. ASC-US, or LSIL) or histologic LSIL abnormalities
Finally, for those with an estimated risk of greater without evidence of histologic or cytologic high-
than 0.55% but less than 4% (threshold for imme­ grade, co-test in 1 year is advised, and, if results
diate colposcopy), repeat testing in 1 year with are all normal, they should be followed by contin­
HPV-based testing is recommended. For example, ued surveillance at 3-year intervals.
follow-up at 1 year is recommended after a
screening test showing minimal abnormalities:
HPV-positive/negative for intraepithelial lesion or DIAGNOSTIC TESTING/EVALUATION
malignancy or HPV-negative/LSIL with unknown
previous screening history (immediate risks 2.1% Colposcopy
and 1.1%, respectively) (9). Colposcopy standards have been outlined by the
Surveillance also applies to patients who are ASCCP (110, 111). It is recommended that practi­
referred for colposcopic evaluation and/or treat­ tioners follow the standardized terminology, which
ment and are found to have CIN 1 or normal re­ captures 6 major areas: (a) general assessment, (b)
sults. The 5-year CIN 3 + risks for various clinical evaluation for presence of any acetowhite lesions,
scenarios are available based on publicly avail­ (c) description of normal colposcopic findings, (d)
able risk tables (https://CervixCa.nlm.nih.gov/ description of abnormal colposcopic findings, (e)
RiskTables). For individuals diagnosed with high- description of other/miscellaneous findings, and
grade abnormalities and who are treated, more (f ) reporting of the colposcopic impression, defined
frequent surveillance with HPV-based testing at as the highest grade impression of any visible lesion
6 months is preferred and, if positive, colposcopy on the cervix. A comprehensive colposcopic exam­
with biopsies should be performed. Individuals ination should include description of the cervix visi­
treated for histologic HSIL with a subsequent ab­ bility, squamocolumnar junction visibility, presence
normal screening test result have an elevated risk of acetowhitening, presence and visualization of a

396 JALM | 382–406 | 08:02 | March 2023


AACC Guidance Document on Cervical Cancer Detection SPECIAL REPORT

lesion, color/contours/borders/vascular changes of patients meeting the high-risk criteria, which


lesions, the location and size(s) of lesion(s), other found that 89% of all women with HSIL had
features, and the colposcopic impression. A dia­ CIN 2+, whereas other studies have shown some­
gram or marked image annotating the findings what lower risk from 73% to 86% (111, 114, 115).
should also be included. Minimum criteria for re­ Endocervical curettage is preferred for non­
porting findings at colposcopic examination should pregnant patients when colposcopy is inadequate
include the following: squamocolumnar junction and in those not at lowest risk and no lesion is
visibility (fully/not fully), acetowhitening (yes/no), le­ identified. It can also be considered when a lesion
sion(s) present (acetowhite or other) (yes/no), and is seen (116).

Downloaded from https://academic.oup.com/jalm/article/8/2/382/7030135 by guest on 09 March 2023


colposcopic impression (normal/benign, low grade,
high grade, cancer). Colposcopy training is currently Biopsy
not regulated in United States, and there is no cer­ HPV induces histologic changes in the squa­
tification (112). Standards in many other countries mous epithelium of the uterine cervix, particularly
do include training and generally stipulate that all at the transformation zone. These changes com­
clinicians who perform colposcopic examinations prise a diverse spectrum of alterations (Fig. 2).
should have completed a formal colposcopic train­ On one end of the spectrum are mild koilocytic
ing program conducted by expert trained person­ changes, which have a degree of overlap with re­
nel whose clinical competence and teaching active atypia. On the other end of the spectrum
abilities are well documented (113). are atypical basaloid epithelial cells involving the
For those at lowest risk (i.e., less than HSIL cy­ full thickness of a markedly thickened squamous
tology, no evidence of HPV 16/18 infection) with epithelium. Lesions along this spectrum must be
a completely normal colposcopic impression, ran­ classified into discrete categories to guide clinical
dom biopsies are not recommended. This is based management. Two schemata are current recog­
on Kaiser Permanente Northern California data nized to do this: the 3-tier CIN system and the
that demonstrated that the risk of occult CIN 2 + 2-tier SIL (1). The CIN system classifies lesions as
was 1% to 7% and CIN 3 + was less than 1% in CIN 1, 2, or 3, ranging lowest to highest grade.
the afore-described low-risk group, which under­ CIN 1 includes lesions with koilocytic changes
went 4-quadrant biopsies and endocervical curet­ and basal atypia confined to the lower one-third
tage in that cohort. If these criteria are not met, of the epithelial thickness. CIN 2 includes
multiple targeted biopsies (at least 2 and up to 4) lesions with basal atypia involving the lower and
are recommended, targeting all acetowhite areas middle thirds of the epithelial thickness. CIN 3 in­
to improve detection of precancers. Moreover, bi­ cludes those with full-thickness basal atypia.
opsies are needed for any degree of acetowhiten­ The SIL system classifies lesions as either high
ing, metaplasia, or abnormalities (111). grade (HSIL) or low grade (LSIL). LSIL includes
In nonpregnant women 25 years and older with CIN 1. HSIL includes CIN 2 and CIN 3. While the lat­
a very high risk of precancer, either immediate ex­ ter category has the benefit of simplicity, it loses
cisional treatment without biopsy confirmation or the informative distinction between CIN 2 and
colposcopy with multiple targeted biopsies is ac­ CIN 3.
ceptable (111). High risk in this context is defined There is only moderate reproducibility among
as at least 2 of the following: HSIL cytology, pathologist in classifying HPV-induced squamous
HPV16 and/or HPV 18 positive, high-grade colpos­ lesions, using both the CIN and SIL systems. This
copy impression. This is based on systematic re­ is largely a consequence of the great diversity in
view of see-and-treat management strategies for the histomorphology of these lesions and the

March 2023 | 08:02 | 382–406 | JALM 397


SPECIAL REPORT

Downloaded from https://academic.oup.com/jalm/article/8/2/382/7030135 by guest on 09 March 2023


Fig. 2. Histology of SIL/CIN (all H&E stained sections except [C], all 200X magnification). Sections of various
CIN lesions demonstrate the diversity in histology seen within categories. A classic CIN 1 with koilocytic
change and virtually no basaloid atypia (A) contrasts with a CIN 1 lesion with basaloid atypia involving
the lower one-third of epithelial thickness (B). As an example, the latter was positive for p16 immunohis­
tochemistry, with nuclear and cytoplasmic expression continuously involving the lower one-third of the
epithelium. At least 30% of adjudicated CIN 1 cases are p16-positive (C). CIN 2 is similarly diverse. Some
cases demonstrate considerable koiloctyic change and abundant cytoplasm (D). Others demonstrate
less of this feature (E). Some lesions fall on the border between CIN 2 and CIN 3, lacking full thickness basal
atypia but having a degree of surface maturation (F). There is also variability in CIN 3. Some cases demon­
strate marked nuclear atypia and modest cytoplasm (G). Others demonstrate comparatively modest nu­
clear atypia, scant cytoplasm, and relatively thin epithelial thickness (H). Still others have modest nuclear
atypia, scant cytoplasm, and dramatically thickened epithelial thickness (I).

substantial fraction of cases with features that are for the diagnosis of CIN 2 (117, 119), which is often
not clearly high or low grade. For example, while difficult to distinguish from CIN 1 and CIN
reproducibility is good for the distinction between 3. Consistency in diagnosis has been aided by
CIN 1 and CIN 3 (117, 118), reproducibility is poor the addition of immunohistochemistry for p16, a

398 JALM | 382–406 | 08:02 | March 2023


AACC Guidance Document on Cervical Cancer Detection SPECIAL REPORT

protein product of the cell cycle gene CDKN2A. This THE IDEAL LABORATORY REPORT
marker is sensitive for high-grade lesions but is
also expressed in a substantial subset of low- Based on the previous discussion of the import­
grade lesions. Expression of p16 is particularly ance of specifying the indication for testing (i.e.,
high in low-grade lesions driven by high-risk HPV screening, surveillance, or diagnosis) and the test
types, with diffuse expression of p16 seen in near­ used, we propose the following report template
ly 90% of hrHPV-positive LSIL in one study (120). (Table 3) to facilitate results interpretation and
CIN 1 lesions that are p16-positive progress to clinical decision-making. While this template can
CIN 2 or higher in 10% to 35% of cases, while those be modified for local needs, we believe it incorpo­

Downloaded from https://academic.oup.com/jalm/article/8/2/382/7030135 by guest on 09 March 2023


that are p16-negative progress in <5% of cases rates the most important components. It is im­
(118). The negative predictive value of p16 is portant to allow for all available (or most recent)
thus high for predicting progression to a high- prior results to be summarized in the current re­
grade squamous lesion. port to facilitate risk-based decision-making.
The Lower Anogenital Squamous Terminology Furthermore, the specific HPV test used by the la­
guidelines by the College of American Pathologists boratory should be specified. Note the p16/Ki67
and the ASCCP recommend using p16 immunohis­ dual-stain may be performed in cases where cy­
tochemistry when the differential is between pre­ tology results are abnormal (LSIL or ASCUS) and/
cancer (CIN2/3) and a mimic of precancer (121). In or hrHPV-positive, but it has not been included in
addition, if the pathologist is entertaining an H&E the current guidelines and is optional (122).
morphologic interpretation of CIN 2, p16 immuno­
histochemistry is recommended to help clarify
the situation. Strong and diffuse block-positive SUMMARY OF RECOMMENDATIONS AND
p16 results support a categorization of precan­ FUTURE DIRECTIONS
cer. Negative or non-block-positive staining
strongly favors an interpretation of low-grade The goal of a screening protocol is to optimize
disease or a non–HPV-associated pathology the detection of precancerous lesions at a time
(121). The Lower Anogenital Squamous when they are treatable while limiting the harm of
Terminology guidelines recommend against the overtreating benign disease. This begins with cor­
use of p16 as a routine adjunct to histologic as­ rectly identifying those patients suitable for routine
sessment of biopsy specimens with morphologic screening vs those who require surveillance and/or
interpretations of negative, CIN 1, and CIN diagnosis. The introduction of risk-based manage­
3. However, in special circumstances, p16 may ment considers factors that influence clinical ac­
be used as an adjunct to morphologic assess­ tion thresholds allowing for greater tailoring of
ment for biopsy specimens interpreted as CIN 1 screening strategy for patients. The most recent
that are at high risk for missed high-grade dis­ ASCCP guideline highlights that prior history pro­
ease, which is defined as a prior cytologic inter­ foundly influences risk estimates, specifically cur­
pretation of HSIL, ASC-H, ASC-US/HPV-16þ, or rent HPV and cytology test results, previous HPV
AGC (not otherwise specified) (121). Positivity for test results, and history of histologic HSIL (9). The
p16 is defined specifically as continuous strong estimated risk guides decisions regarding surveil­
nuclear or nuclear plus cytoplasmic staining of lance interval, colposcopic referral, and treatment.
the basal cell layer with extension upward involv­ In all 3 recommendations, the concepts of
ing at least one-third of the epithelial thickness screening, surveillance, and diagnosis are import­
(Fig. 2C). ant in framing the clinical situation at hand and

March 2023 | 08:02 | 382–406 | JALM 399


SPECIAL REPORT

Table 3. HPV and cervical cancer testing report template.

Patient identification Name


Date of birth
Medical record number
Date of collection
Accession number
Name of submitting physician and/or clinic
Indication □ Screening

Downloaded from https://academic.oup.com/jalm/article/8/2/382/7030135 by guest on 09 March 2023


□ Surveillance
□ Diagnostic workup of symptomatic patients
Clinical history Provider description
Pregnant? □ Yes □ No
Immunosuppressed? □ Yes □ No
Prior results Date Result
Cytology
HPV
Histopathology
Current testing □ Cytology alone
□ Primary HPV (with reflex testing)
□ Co-testing
Current results HPV □ Positive
□ Negative
HPV test used
HPV genotype (if positive) □ 16
□ 18
□ Other high-risk subtypes
□ Unknown
Cytology Per Bethesda terminology
p16/Ki67 dual-stain □ Positive
□ Negative
□ Not performed
Other adjunctive tests (please specify)
Name of reviewing pathologist
Date of report
Name and address of the laboratory

the appropriate use and interpretation of tests. For screening intervals. Furthermore, the ACS and
example, the intervals of 1-, 3-, and 5-year dis­ USPSTF guidelines were developed prior to the
cussed within the ASCCP guidelines are surveillance ASCCP guidelines, and nuanced differences may
intervals whereas the 3- and 5- year intervals dis­ be noted, specifically with updates to the use of pri­
cussed in the ACS and USPSTF guidelines refer to mary HPV testing. For example, the ASCCP

400 JALM | 382–406 | 08:02 | March 2023


AACC Guidance Document on Cervical Cancer Detection SPECIAL REPORT

guidelines recommend that when primary HPV calculation. Ideally, standardized reports would in­
screening is used as the initial test alone, additional clude HPV test used, genotype information, cy­
reflex triage test (e.g., reflex cytology) for all positive tology, and histology using common terminology
HPV tests be performed regardless of genotype (7); (e.g., Lower Anogenital Squamous Terminology) in­
this is a change from the 2015 interim guidelines tegrated with other clinical information from a pa­
(58). However, if primary HPV screening test geno­ tient’s electronic health record. This would not only
typing results are HPV 16- or HPV 18-positive and allow for accurate risk estimates but also establish a
reflex triage testing from the same laboratory spe­ reliable tracking and reminder system to facilitate
cimen is not feasible, patients should proceed dir­ communication, improve patient safety and quality

Downloaded from https://academic.oup.com/jalm/article/8/2/382/7030135 by guest on 09 March 2023


ectly to colposcopy (58). The perspective of the of care, and minimize missed or delayed diagnoses.
ASCCP guidelines is to use surveillance to address Second, as additional HPV tests and data from
potential clinical situations involving abnormal re­ studies become available, the FDA assessment of
sults (e.g., HPV-positive) whereas the ACS and HPV assays may potentially increase the number
USPSTF guidelines target routine screening in low- of tests approved for primary HPV testing.
risk patients. Lastly, once an individual has an ab­ Primary HPV testing is attractive as it has been de­
normal test result, depending on subsequent find­ monstrated to be more effective than screening
ings and estimated risk, the majority will remain in with cytology alone and performs similarly to and
surveillance with a small subset who would qualify with lower costs than screening with co-testing. In
to return to routine screening. addition, HPV testing is also more amenable to self-
Moving forward, several future directions in re­ collection, which opens new opportunities to
search and implementation have the potential to screen difficult to reach and underscreened popu­
improve access and implementation of these lations at high risk of cervical cancer (123–125).
guidelines. Given that the risk estimates are based Ultimately, the key message to patients, and provi­
on both current and prior testing results, auto­ ders alike, is stated by the ACS: “The most important
mated extraction from medical records and la­ thing to remember is to get screened regularly, no
boratory reports would simplify risk-estimate matter which test you get.”

Nonstandard Abbreviations: ACS, American Cancer Society; ASCCP, American Society for Colposcopy and Cervical Pathology;
AGC, atypical glandular cells; ASC-H, atypical squamous cells—cannot exclude high-grade squamous intraepithelial lesion;
ASC-US, atypical squamous cells of undetermined significance; CIN, cervical intraepithelial neoplasia; FDA, Food and Drug
Administration; HSIL, high-grade squamous intraepithelial lesion; hrHPV, high risk human papilloma virus; HPV, human papil­
loma virus; LBC, liquid-based cytology; LSIL, low-grade squamous intraepithelial lesion; USPSTF, US Preventative Services
Task Force.
Author Contributions: The corresponding author takes full responsibility that all authors on this publication have met the following
required criteria of eligibility for authorship: (a) significant contributions to the conception and design, acquisition of data, or analysis
and interpretation of data; (b) drafting or revising the article for intellectual content; (c) final approval of the published article; and (d)
agreement to be accountable for all aspects of the article thus ensuring that questions related to the accuracy or integrity of any part
of the article are appropriately investigated and resolved. Nobody who qualifies for authorship has been omitted from the list.

Authors’ Disclosures or Potential Conflicts of Interest: Upon manuscript submission, all authors completed the author disclosure
form. Disclosures and/or potential conflicts of interest: Employment or Leadership: S.O.A. Leung, American College of Obstetricians
and Gynecologists, District I Quebec Section Fellow Vice Chair, International Papillomavirus Policy Committee Member, American
Cancer Society Cervical Cancer Screening Initiative, Provider Needs Workgroup Member; S. Feldman, Board of IPVS. Consultant
or Advisory Role: None declared. Stock Ownership: None declared. Honoraria: S. Feldman, Indian Health Service, post-graduate
courses at Harvard Medical School. Research Funding: Y. Zhu, funding from Abbott Laboratories to institution; M.H. Creer, Abbott
Clinical Diagnostics, Siemens Clinical Diagnostics, Fujirebio; S. Feldman, funding from National Cancer Institute/National Institutes of
Health and Society to Improve Diagnosis in Medicine to institution, gift to institution from Glyciome. Expert Testimony: None

March 2023 | 08:02 | 382–406 | JALM 401


SPECIAL REPORT

declared. Patents: None declared. Other Remuneration: S. Feldman, royalties from Uptodate, payment for travel from American
Cancer Society and ASCCP.
Role of Sponsor: The funding organizations played no role in the design of study, choice of enrolled patients, review and inter­
pretation of data, preparation of manuscript, or final approval of manuscript.

REFERENCES
1. Kurman RJ. International agency for research on cancer, assays in primary cervical cancer screening:
world health organization. WHO classification of systematic review. Clin Microbiol Infect 2018;24:
tumours of female reproductive organs. 4th Ed. Lyon 29–36.

Downloaded from https://academic.oup.com/jalm/article/8/2/382/7030135 by guest on 09 March 2023


(France): International Agency for Research on Cancer; 13. Cuzick J, Cadman L, Mesher D, Austin J, Ashdown-Barr L,
2014. Ho L, et al. Comparing the performance of six human
2. Bosch FX, Lorincz A, Munoz N, Meijer CJ, Shah KV. papillomavirus tests in a screening population. Br J
The causal relation between human Cancer 2013;108:908–13.
papillomavirus and cervical cancer. J Clin Pathol 2002;55: 14. Salazar KL, Duhon DJ, Olsen R, Thrall M. A review of the
244–65. FDA-approved molecular testing platforms for human
3. Schiffman M, Wentzensen N, Wacholder S, Kinney W, papillomavirus. J Am Soc Cytopathol 2019;8:284–92.
Gage JC, Castle PE. Human papillomavirus testing in the 15. Ge Y, Christensen P, Luna E, Armylagos D, Schwartz MR,
prevention of cervical cancer. J Natl Cancer Inst 2011; Mody DR. Performance of Aptima and Cobas HPV testing
103:368–83. platforms in detecting high-grade cervical dysplasia and
4. Kurman RJ. Blaustein’s pathology of the female genital cancer. Cancer Cytopathol 2017;125:652–7.
tract. 6th Ed. Berlin (Germany): Springer Science & 16. Phillips S, Garland SM, Tan JH, Quinn MA, Tabrizi SN.
Business Media; 2013. Comparison of the Roche Cobas® 4800 HPV assay to
5. Verlaat W, Snijders PJ, van Moorsel MI, Bleeker M, Digene Hybrid Capture 2, Roche Linear Array and Roche
Rozendaal L, Sie D, et al. Somatic mutation in PIK3CA is a Amplicor for detection of high-risk human papillomavirus
late event in cervical carcinogenesis. J Pathol Clin Res genotypes in women undergoing treatment for cervical
2015;1:207–11. dysplasia. J Clin Virol 2015;62:63–5.
6. Cancer Genome Atlas Research Network. Integrated 17. Mesher D, Szarewski A, Cadman L, Austin J,
genomic and molecular characterization of cervical Ashdown-Barr L, Ho L, et al. Comparison of human
cancer. Nature 2017;543:378–84. papillomavirus testing strategies for triage of women
7. Perkins RB, Guido RS, Castle PE, Chelmow D, Einstein referred with low-grade cytological abnormalities. Eur J
MH, Garcia F, et al. 2019 ASCCP risk-based management Cancer 2013;49:2179–86.
consensus guidelines for abnormal cervical cancer 18. Ejegod DM, Junge J, Franzmann M, Kirschner B, Bottari F,
screening tests and cancer precursors. J Low Genit Tract Sideri M, et al. Clinical and analytical performance of
Dis 2020;24:102–31. the BD Onclarity HPV assay for detection of CIN2 +
8. Melnikow J, Henderson JT, Burda BU, Senger CA, Durbin lesions on SurePath samples. Papillomavirus Res 2016;
S, Weyrich MS. Screening for cervical cancer with 2:31–7.
high-risk human papillomavirus testing: updated 19. Cuzick J, Ahmad AS, Austin J, Cadman L, Ho L, Terry G,
evidence report and systematic review for the US et al. A comparison of different human papillomavirus
Preventive Services Task Force. JAMA 2018;320: tests in PreservCyt versus SurePath in a referral
687–705. population—PREDICTORS 4. J Clin Virol 2016;82:145–51.
9. Egemen D, Cheung LC, Chen X, Demarco M, Perkins RB, 20. Ko V, Tambouret RH, Kuebler DL, Black-Schaffer WS,
Kinney W, et al. Risk estimates supporting the 2019 Wilbur DC. Human papillomavirus testing using Hybrid
ASCCP risk-based management consensus guidelines. J Capture II with SurePath collection: initial evaluation and
Low Genit Tract Dis 2020;24:132–43. longitudinal data provide clinical validation for this
10. Cuschieri K, Cubie H, Graham C, Rowan J, Hardie A, method. Cancer 2006;108:468–74.
Horne A, et al. Clinical performance of RNA and DNA 21. Einstein MH, Martens MG, Garcia FA, Ferris DG,
based HPV testing in a colposcopy setting: influence Mitchell AL, Day SP, Olson MC. Clinical validation of the
of assay target, cut off and age. J Clin Virol 2014;59: Cervista HPV HR and 16/18 genotyping tests for use in
104–8. women with ASC-US cytology. Gynecol Oncol 2010;
11. Zhou H, Mody RR, Luna E, Armylagos D, Xu J, Schwartz 118:116–22.
MR, et al. Clinical performance of the Food and Drug 22. Guo M, Khanna A, Feng J, Patel S, Zhang W, Gong Y, et al.
Administration-approved high-risk HPV test for the Analytical performance of Cervista HPV 16/18 in
detection of high-grade cervicovaginal lesions. Cancer SurePath Pap specimens. Diagn Cytopathol 2015;43:
Cytopathol 2016;124:317–23. 301–6.
12. de Thurah L, Bonde J, Lam JUH, Rebolj M. Concordant 23. Min KJ, So KA, Lee J, Hong HR, Hong JH, Lee JK, Kim AR.
testing results between various human papillomavirus Comparison of the Seeplex HPV4A ACE and the Cervista

402 JALM | 382–406 | 08:02 | March 2023


AACC Guidance Document on Cervical Cancer Detection SPECIAL REPORT

HPV assays for the detection of HPV in Hybrid Capture 2 38. van Baars R, Bosgraaf RP, ter Harmsel BW, Melchers WJ,
positive media. J Gynecol Oncol 2012;23:5–10. Quint WG, Bekkers RL. Dry storage and transport of a
24. Waldstrom M, Ornskov D. Comparison of the clinical cervicovaginal self-sample by use of the Evalyn brush,
performance of an HPV mRNA test and an HPV DNA test providing reliable human papillomavirus detection
in triage of atypical squamous cells of undetermined combined with comfort for women. J Clin Microbiol
significance (ASC-US). Cytopathology 2012;23:389–95. 2012;50:3937–43.
25. Díaz-Rosario LA, Kabawat SE. Performance of a 39. Ejegod DM, Pedersen H, Alzua GP, Pedersen C, Bonde J.
fluid-based, thin-layer papanicolaou smear method in Time and temperature dependent analytical stability of
the clinical setting of an independent laboratory and an dry-collected Evalyn HPV self-sampling brush for cervical
outpatient screening population in New England. Arch cancer screening. Papillomavirus Res 2018;5:192–200.
Pathol Lab Med 1999;123:817–21. 40. Polman NJ, Ebisch RMF, Heideman DAM, Melchers WJG,
26. Limaye A, Connor AJ, Huang X, Luff R. Comparative Bekkers RLM, Molijn AC, et al. Performance of human

Downloaded from https://academic.oup.com/jalm/article/8/2/382/7030135 by guest on 09 March 2023


analysis of conventional papanicolaou tests and a papillomavirus testing on self-collected versus
fluid-based thin-layer method. Arch Pathol Lab Med clinician-collected samples for the detection of cervical
2003;127:200–4. intraepithelial neoplasia of grade 2 or worse: a
27. Hoda RS, Loukeris K, Abdul-Karim FW. Gynecologic randomised, paired screen-positive, non-inferiority trial.
cytology on conventional and liquid-based preparations: Lancet Oncol 2019;20:229–38.
a comprehensive review of similarities and differences. 41. Lazcano-Ponce E, Lorincz AT, Cruz-Valdez A, Salmeron J,
Diagn Cytopathol 2013;41:257–78. Uribe P, Velasco-Mondragon E, et al. Self-collection of
28. Hatch KD, Sheets E, Kennedy A, Ferris DG, Darragh T, vaginal specimens for human papillomavirus testing in
Twiggs L. Multicenter direct to vial evaluation of a cervical cancer prevention (MARCH): a
liquid-based Pap test. J Low Genit Tract Dis 2004;8: community-based randomised controlled trial. Lancet
308–12. 2011;378:1868–73.
29. Friedlander MA, Rudomina D, Lin O. Effectiveness of the 42. Ketelaars PJW, Bosgraaf RP, Siebers AG, Massuger L, van
Thin Prep imaging system in the detection of der Linden JC, Wauters CAP, et al. High-risk human
adenocarcinoma of the gynecologic system. Cancer papillomavirus detection in self-sampling compared to
2008;114:7–12. physician-taken smear in a responder population of the
30. Jayamohan Y, Karabakhtsian RG, Banks HW, Davey DD. Dutch cervical screening: results of the VERA study. Prev
Accuracy of ThinPrep imaging system in detecting Med 2017;101:96–101.
atypical glandular cells. Diagn Cytopathol 2009;37: 43. Tranberg M, Jensen JS, Bech BH, Blaakær J, Svanholm H,
479–82. Andersen B. Good concordance of HPV detection
31. Parker EM, Foti JA, Wilbur DC. Focalpoint slide between cervico-vaginal self-samples and general
classification algorithms show robust performance in practitioner-collected samples using the cobas 4800
classification of high-grade lesions on SurePath HPV DNA test. BMC Infect Dis 2018;18:1–7.
liquid-based cervical cytology slides. Diagn Cytopathol 44. Arbyn M, Verdoodt F, Snijders PJ, Verhoef VM, Suonio E,
2004;30:107–10. Dillner L, et al. Accuracy of human papillomavirus testing
32. Thrall MJ. Automated screening of papanicolaou tests: a on self-collected versus clinician-collected samples: a
review of the literature. Diagn Cytopathol 2019;47:20–7. meta-analysis. Lancet Oncol 2014;15:172–83.
33. Nayar R, Wilbur DC. The Pap test and Bethesda 2014. 45. Bergengren L, Kaliff M, Larsson GL, Karlsson MG,
Acta Cytol 2015;59:121–32. Helenius G. Comparison between professional sampling
34. Ho GY, Bierman R, Beardsley L, Chang CJ, Burk RD. and self-sampling for HPV-based cervical cancer
Natural history of cervicovaginal papillomavirus screening among postmenopausal women. Int J
infection in young women. N Engl J Med 1998;338: Gynaecol Obstet 2018;142:359–64.
423–8. 46. Hawkes D, Keung MHT, Huang Y, McDermott TL,
35. Cheung LC, Egemen D, Chen X, Katki HA, Demarco M, Romano J, Saville M, et al. Self-collection for cervical
Wiser AL, et al. 2019 ASCCP risk-based management screening programs: from research to reality. Cancers
consensus guidelines: methods for risk estimation, (Basel) 2020;12:1053.
recommended management, and validation. J Low Genit 47. Camara H, Zhang Y, Lafferty L, Vallely AJ, Guy R,
Tract Dis 2020;24:90–101. Kelly-Hanku A. Self-collection for HPV-based cervical
36. Bosgraaf RP, Verhoef VM, Massuger LF, Siebers AG, screening: a qualitative evidence meta-synthesis. BMC
Bulten J, de Kuyper-de Ridder GM, et al. Comparative Public Health 2021;21:1503.
performance of novel self-sampling methods in 48. Malone C, Barnabas RV, Buist DSM, Tiro JA, Winer RL.
detecting high-risk human papillomavirus in 30 130 Cost-effectiveness studies of HPV self-sampling: a
women not attending cervical screening. Int J Cancer systematic review. Prev Med 2020;132:105953.
2015;136:646–55. 49. Peirson L, Fitzpatrick-Lewis D, Ciliska D, Warren R.
37. Jentschke M, Chen K, Arbyn M, Hertel B, Noskowicz M, Screening for cervical cancer: a systematic review and
Soergel P, Hillemanns P. Direct comparison of two meta-analysis. Syst Rev 2013;2:35.
vaginal self-sampling devices for the detection of human 50. Whitlock EP, Vesco KK, Eder M, Lin JS, Senger CA, Burda
papillomavirus infections. J Clin Virol 2016;82:46–50. BU. Liquid-based cytology and human papillomavirus

March 2023 | 08:02 | 382–406 | JALM 403


SPECIAL REPORT

testing to screen for cervical cancer: a systematic review 63. Dillner J, Rebolj M, Birembaut P, Petry K-U, Szarewski A,
for the U.S. Preventive Services Task Force. Ann Intern Munk C, et al. Long term predictive values of cytology
Med 2011;155:687–97. and human papillomavirus testing in cervical cancer
51. Sankaranarayanan R, Nene BM, Shastri SS, Jayant K, screening: joint European cohort study. BMJ (Clinical
Muwonge R, Budukh AM, et al. HPV screening for cervical research ed) 2008;337:a1754.
cancer in rural India. N Engl J Med 2009;360:1385–94. 64. Katki HA, Kinney WK, Fetterman B, Lorey T, Poitras NE,
52. Curry SJ, Krist AH, Owens DK, Barry MJ, Caughey AB, Cheung L, et al. Cervical cancer risk for women
Davidson KW, et al. Screening for cervical cancer: US undergoing concurrent testing for human
Preventive Services Task Force recommendation papillomavirus and cervical cytology: a
statement. JAMA 2018;320:674–86. population-based study in routine clinical practice.
53. Fontham ETH, Wolf AMD, Church TR, Etzioni R, Flowers Lancet Oncol 2011;12:663–72.
CR, Herzig A, et al. Cervical cancer screening for 65. Anttila A, Kotaniemi-Talonen L, Leinonen M, Hakama M,

Downloaded from https://academic.oup.com/jalm/article/8/2/382/7030135 by guest on 09 March 2023


individuals at average risk: 2020 guideline update from Laurila P, Tarkkanen J, et al. Rate of cervical cancer,
the American Cancer Society. CA Cancer J Clin 2020;70: severe intraepithelial neoplasia, and adenocarcinoma in
321–46. situ in primary HPV DNA screening with cytology triage:
54. US Food and Drug Administration. FDA executive randomised study within organised screening
summary: new approaches in the evaluation for high- programme. BMJ (Clinical research ed) 2010;340:c1804.
risk human papillomavirus nucleic acid detection 66. Bray F, Carstensen B, Moller H, Zappa M, Zakelj MP,
devices. Prepared for the March 8, 2019, meeting of the Lawrence G, et al. Incidence trends of adenocarcinoma
Microbiology Devices Panel of the Medical Devices of the cervix in 13 European countries. Cancer Epidemiol
Advisory Committee. https://www.fda.gov/media/ Biomarkers Prev 2005;14:2191–9.
122799/download (Accessed November 13, 2022). 67. Miller MG, Sung H-Y, Sawaya GF, Kearney KA, Kinney W,
55. Wright TC, Stoler MH, Behrens CM, Sharma A, Zhang G, Hiatt RA. Screening interval and risk of invasive
Wright TL. Primary cervical cancer screening with human squamous cell cervical cancer. Obstet Gynecol 2003;
papillomavirus: end of study results from the ATHENA 101:29–37.
study using HPV as the first-line screening test. Gynecol 68. Sawaya GF, Kerlikowske K, Lee NC, Gildengorin G,
Oncol 2015;136:189–97. Washington AE. Frequency of cervical smear
56. Dunne EF, Unger ER, Sternberg M, McQuillan G, Swan abnormalities within 3 years of normal cytology. Obstet
DC, Patel SS. Prevalence of HPV infection among females Gynecol 2000;96:219–23.
in the United States. JAMA 2007;297:813–9. 69. Kim JJ, Burger EA, Regan C, Sy S. Screening for cervical
57. Peyton CL, Gravitt PE, Hunt WC, Hundley RS, Zhao M, cancer in primary care: a decision analysis for the US
Apple RJ. Determinants of genital human papillomavirus Preventive Services Task Force. JAMA 2018;320:
detection in a US population. J Infect Dis 2001;183: 706–14.
1554–64. 70. Sawaya GF, McConnell KJ, Kulasingam SL, Lawson HW,
58. Huh WK, Ault KA, Chelmow D, Davey DD, Goulart RA, Kerlikowske K, Melnikow J, et al. Risk of cervical cancer
Garcia FAR, et al. Use of primary high-risk human associated with extending the interval between
papillomavirus testing for cervical cancer screening: cervical-cancer screenings. N Engl J Med 2003;349:1501–9.
interim clinical guidance. Gynecol Oncol 2015;136: 71. Ronco G, Giorgi-Rossi P, Carozzi F, Dalla Palma P, Del
178–82. Mistro A, De Marco L, et al. Human papillomavirus
59. Ronco G, Dillner J, Elfström KM, Tunesi S, Snijders PJF, Arbyn testing and liquid-based cytology in primary screening of
M, et al. Efficacy of HPV-based screening for prevention of women younger than 35 years: results at recruitment for
invasive cervical cancer: follow-up of four European a randomised controlled trial. Lancet Oncol 2006;7:
randomised controlled trials. Lancet 2014;383:524–32. 547–55.
60. Naucler P, Ryd W, Törnberg S, Strand A, Wadell G, Elfgren 72. Leinonen MK, Nieminen P, Lönnberg S, Malila N,
K, et al. Human papillomavirus and papanicolaou tests Hakama M, Pokhrel A, et al. Detection rates of
to screen for cervical cancer. New Engl J Med 2007;357: precancerous and cancerous cervical lesions within
1589–97. one screening round of primary human papillomavirus
61. Bulkmans NW, Berkhof J, Rozendaal L, van Kemenade FJ, DNA testing: prospective randomised trial in Finland.
Boeke AJ, Bulk S, et al. Human papillomavirus DNA BMJ 2012;345:e7789.
testing for the detection of cervical intraepithelial 73. Ogilvie GS, van Niekerk D, Krajden M, Smith LW, Cook D,
neoplasia grade 3 and cancer: 5-year follow-up of a Gondara L, et al. Effect of screening with primary cervical
randomised controlled implementation trial. Lancet HPV testing vs cytology testing on high-grade cervical
2007;370:1764–72. intraepithelial neoplasia at 48 months: the HPV FOCAL
62. Ronco G, Giorgi-Rossi P, Carozzi F, Confortini M, Dalla randomized clinical trial. JAMA 2018;320:43–52.
Palma P, Del Mistro A, et al. Efficacy of human 74. Kitchener HC, Almonte M, Thomson C, Wheeler P,
papillomavirus testing for the detection of invasive Sargent A, Stoykova B, et al. HPV testing in combination
cervical cancers and cervical intraepithelial neoplasia: a with liquid-based cytology in primary cervical screening
randomised controlled trial. Lancet Oncol 2010;11: (ARTISTIC): a randomised controlled trial. Lancet Oncol
249–57. 2009;10:672–82.

404 JALM | 382–406 | 08:02 | March 2023


AACC Guidance Document on Cervical Cancer Detection SPECIAL REPORT

75. Sherman ME, Lorincz AT, Scott DR, Wacholder S, Castle selected local area vaccination coverage among
PE, Glass AG, et al. Baseline cytology, human adolescents aged 13–17 years—United States, 2018.
papillomavirus testing, and risk for cervical neoplasia: a MMWR Morb Mortal Wkly Rep 2019;68:718–23.
10-year cohort analysis. J Natl Cancer Inst 2003;95:46–52. 90. Gravitt PE, Landy R, Schiffman M. How confident can we
76. Kjaer SK, Frederiksen K, Munk C, Iftner T. Long-term be in the current guidelines for exiting cervical
absolute risk of cervical intraepithelial neoplasia grade screening? Prev Med 2018;114:188–92.
3 or worse following human papillomavirus infection: 91. Feldman S, Cook E, Davis M, Gershman ST, Hanchate A,
role of persistence. J Natl Cancer Inst 2010;102: Haas JS. Cervical cancer incidence among elderly women
1478–88. in Massachusetts compared with younger women. J Low
77. Wright TC J, Schiffman M, Solomon D, Cox JT, Garcia F, Genit Tract Dis 2018;22:314–7.
Goldie S, et al. Interim guidance for the use of human 92. Fletcher A. Screening for cancer of the cervix in elderly
papillomavirus DNA testing as an adjunct to cervical women. Lancet 1990;335:97–9.

Downloaded from https://academic.oup.com/jalm/article/8/2/382/7030135 by guest on 09 March 2023


cytology for screening. Obstet Gynecol 2004;103:304–9. 93. Fahs MC, Mandelblatt J, Schechter C, Muller C. Cost
78. Khan MJ, Castle PE, Lorincz AT, Wacholder S, Sherman M, effectiveness of cervical cancer screening for the elderly.
Scott DR, et al. The elevated 10-year risk of cervical Ann Intern Med 1992;117:520–7.
precancer and cancer in women with human 94. Power EJ. Pap smears, elderly women, and Medicare.
papillomavirus (HPV) type 16 or 18 and the possible Cancer Invest 1993;11:164–8.
utility of type-specific HPV testing in clinical practice. J 95. Moscicki AB, Flowers L, Huchko MJ, Long ME, MacLaughlin
Natl Cancer Inst 2005;97:1072–9. KL, Murphy J, et al. Guidelines for cervical cancer screening
79. Moyer VA. Screening for cervical cancer: U.S. Preventive in immunosuppressed women without HIV infection. J Low
Services Task Force recommendation statement. Ann Genit Tract Dis 2019;23:87–101.
Intern Med 2012;156:880–91. 96. American College of Obstetrics and Gynecology. Committee
80. Stout NK, Goldhaber-Fiebert JD, Ortendahl JD, Opinion No.675: management of vulvar intraepithelial
Goldie SJ. Trade-offs in cervical cancer prevention: neoplasia. Obstet Gynecol 2016; 128:e178–82.
balancing benefits and risks. Arch Intern Med 2008; 97. Satmary W, Holschneider CH, Brunette LL, Natarajan S.
168:1881–9. Vulvar intraepithelial neoplasia: risk factors for
81. Kaufman HW, Alagia DP, Chen Z, Onisko A, Austin RM. recurrence. Gynecol Oncol 2018;148:126–31.
Contributions of liquid-based (papanicolaou) 98. Preti M, Scurry J, Marchitelli CE, Micheletti L. Vulvar
cytology and human papillomavirus testing in intraepithelial neoplasia. Best Pract Res Clin Obstet
cotesting for detection of cervical cancer and Gynaecol 2014;28:1051–62.
precancer in the United States. Am J Clin Pathol 2020; 99. Khan MJ, Massad LS, Kinney W, Gold MA, Mayeaux EJ Jr,
154:510–6. Darragh TM, et al. A common clinical dilemma: management
82. Benard VB, Watson M, Castle PE, Saraiya M. Cervical of abnormal vaginal cytology and human papillomavirus test
carcinoma rates among young females in the United results. Gynecol Oncol 2016;141:364–70.
States. Obstet Gynecol 2012;120:1117–23. 100. National Institutes of Health. Guidelines for the prevention
83. Insinga RP, Glass AG, Rush BB. Diagnoses and outcomes and treatment of opportunistic infections in adults and
in cervical cancer screening: a population-based study. adolescents with HIV. 2021. Human papillomavirus
Am J Obstet Gynecol 2004;191:105–13. disease. (https://clinicalinfo.hiv.gov/en/guidelines/hiv-
84. Peto J, Gilham C, Deacon J, Taylor C, Evans C, Binns W, clinical-guidelines-adult-and-adolescent-opportunistic-
et al. Cervical HPV infection and neoplasia in a large infections/human-0?view=full) (Accessed November 13,
population-based prospective study: the Manchester 2022).
cohort. Br J Cancer 2004;91:942–53. 101. Meinhardt SS, Grubman J, Nambiar A, Lea J. Concurrent
85. Gravitt PE. The known unknowns of HPV natural history. J cervical and vulvar dysplasia and/or cancer—high
Clin Invest 2011;121:4593–9. likelihood in the immunocompromised [38E]. Obstet
86. Maura G, Chaignot C, Weill A, Alla F, Heard I. Cervical Gynecol 2019;133:61S.
cancer screening and subsequent procedures in 102. Wright TC Jr, Stoler MH, Behrens CM, Apple R, Derion T,
women under the age of 25 years between 2007 and Wright TL. The ATHENA human papillomavirus study:
2013 in France: a nationwide French healthcare design, methods, and baseline results. Am J Obstet
database study. Eur J Cancer Prev 2018;27:479–85. Gynecol 2012;206:46.e1–46.e11.
87. Landy R, Birke H, Castanon A, Sasieni P. Benefits and 103. Stoler MH, Wright TC Jr, Parvu V, Vaughan L, Yanson K,
harms of cervical screening from age 20 years compared Eckert K, et al. The Onclarity human papillomavirus trial:
with screening from age 25 years. Br J Cancer 2014;110: design, methods, and baseline results. Gynecol Oncol
1841–6. 2018;149:498–505.
88. Castanon A, Leung VM, Landy R, Lim AW, Sasieni P. 104. Gage JC, Schiffman M, Hunt WC, Joste N, Ghosh A,
Characteristics and screening history of women Wentzensen N, et al. Cervical histopathology variability
diagnosed with cervical cancer aged 20–29 years. Br J among laboratories: a population-based statewide
Cancer 2013;109:35–41. investigation. Am J Clin Pathol 2013;139:330–5.
89. Walker TY, Elam-Evans LD, Yankey D, Markowitz LE, 105. Wheeler CM, Hunt WC, Cuzick J, Langsfeld E, Pearse A,
Williams CL, Fredua B, et al. National, regional, state, and Montoya GD, et al. A population-based study of human

March 2023 | 08:02 | 382–406 | JALM 405


SPECIAL REPORT

papillomavirus genotype prevalence in the United 117. Carreon JD, Sherman ME, Guillen D, Solomon D, Herrero
States: baseline measures prior to mass human R, Jeronimo J, et al. CIN2 is a much less reproducible and
papillomavirus vaccination. Int J Cancer 2013;132: less valid diagnosis than CIN3: results from a histological
198–207. review of population-based cervical samples. Int J
106. Ekwueme DU, Uzunangelov VJ, Hoerger TJ, Miller JW, Gynecol Pathol 2007;26:441–6.
Saraiya M, Benard VB, et al. Impact of the national 118. Huang EC, Tomic MM, Hanamornroongruang S, Meserve
breast and cervical cancer early detection program on EE, Herfs M, Crum CP. P16ink4 and cytokeratin 7
cervical cancer mortality among uninsured low-income immunostaining in predicting HSIL outcome for
women in the U.S., 1991–2007. Am J Prev Med 2014;47: low-grade squamous intraepithelial lesions: a case
300–8. series, literature review and commentary. Mod Pathol
107. Strander B, Andersson-Ellstrom A, Milsom I, Sparen P. 2016;29:1501–10.
Long term risk of invasive cancer after treatment for 119. Stoler MH, Schiffman M. Atypical squamous cells of

Downloaded from https://academic.oup.com/jalm/article/8/2/382/7030135 by guest on 09 March 2023


cervical intraepithelial neoplasia grade 3: population undetermined significance-low-grade squamous
based cohort study. BMJ 2007;335:1077. intraepithelial lesion triage study G. Interobserver
108. Arbyn M, Ronco G, Anttila A, Meijer CJ, Poljak M, Ogilvie G, reproducibility of cervical cytologic and histologic
et al. Evidence regarding human papillomavirus testing interpretations: realistic estimates from the
in secondary prevention of cervical cancer. Vaccine ASCUS-LSIL Triage study. JAMA 2001;285:1500–5.
2012;30(Suppl 5):F88–99. 120. Klaes R, Benner A, Friedrich T, Ridder R, Herrington S,
109. Clarke MA, Unger ER, Zuna R, Nelson E, Darragh TM, Jenkins D, et al. p16INK4a immunohistochemistry
Cremer M, et al. A systematic review of tests for improves interobserver agreement in the diagnosis of
postcolposcopy and posttreatment surveillance. J Low cervical intraepithelial neoplasia. Am J Surg Pathol 2002;
Genit Tract Dis 2020;24:148–56. 26:1389–99.
110. Wentzensen N, Massad LS, Mayeaux EJ Jr, Khan MJ, 121. Darragh TM, Colgan TJ, Cox JT, Heller DS, Henry MR,
Waxman AG, Einstein MH, et al. Evidence-based Luff RD, et al. The Lower Anogenital Squamous
consensus recommendations for colposcopy practice Terminology Standardization Project for
for cervical cancer prevention in the United States. J Low HPV-Associated Lesions: background and consensus
Genit Tract Dis 2017;21:216–22. recommendations from the College of American
111. Wentzensen N, Schiffman M, Silver MI, Khan MJ, Perkins Pathologists and the American Society for Colposcopy
RB, Smith KM, et al. ASCCP colposcopy standards: and Cervical Pathology. Arch Pathol Lab Med 2012;
risk-based colposcopy practice. J Low Genit Tract Dis 136:1266–97.
2017;21:230–4. 122. Clarke MA, Cheung LC, Castle PE, Schiffman M,
112. Mayeaux EJ J, Novetsky AP, Chelmow D, Garcia F, Choma K, Tokugawa D, Poitras N, et al. Five-year risk of
Liu AH, et al. ASCCP colposcopy standards: colposcopy cervical precancer following p16/Ki-67 dual-stain
quality improvement recommendations for the United triage of HPV-positive women. JAMA Oncol 2019;5:
States. J Low Genit Tract Dis 2017;21:242–8. 181–6.
113. Mayeaux EJ, Novetsky AP, Chelmow D, Choma K, Garcia 123. Obiri-Yeboah D, Adu-Sarkodie Y, Djigma F,
F, Liu AH, et al. Systematic review of international Hayfron-Benjamin A, Abdul L, Simpore J, Mayaud P.
colposcopy quality improvement guidelines. J Low Genit Self-collected vaginal sampling for the detection of
Tract Dis 2017;21:249–57. genital human papillomavirus (HPV) using CareHPV
114. Wentzensen N, Walker JL, Gold MA, Smith KM, Zuna RE, among Ghanaian women. BMC Womens Health 2017;
Mathews C, et al. Multiple biopsies and detection of 17:86.
cervical cancer precursors at colposcopy. J Clin Oncol 124. Haile EL, Cindy S, Ina B, Belay G, Jean-Pierre VG,
2015;33:83–9. Sharon R, et al. HPV testing on vaginal/cervical
115. Ebisch RM, Rovers MM, Bosgraaf RP, van der nurse-assisted self-samples versus
Pluijm-Schouten HW, Melchers WJ, van den Akker PA, clinician-taken specimens and the HPV prevalence,
et al. Evidence supporting see-and-treat management of in Adama Town, Ethiopia. Medicine (Baltimore) 2019;
cervical intraepithelial neoplasia: a systematic review 98:e16970.
and meta-analysis. BJOG 2016;123:59–66. 125. Dutton T, Marjoram J, Burgess S, Montgomery L, Vail A,
116. Massad LS, Einstein MH, Huh WK, Katki HA, Kinney WK, Callan N, et al. Uptake and acceptability of human
Schiffman M, et al. 2012 Updated consensus guidelines papillomavirus self-sampling in rural and remote
for the management of abnormal cervical cancer aboriginal communities: evaluation of a nurse-led
screening tests and cancer precursors. J Low Genit Tract community engagement model. BMC Health Serv Res
Dis 2013;17(Suppl 1):S1–S27. 2020;20:398.

406 JALM | 382–406 | 08:02 | March 2023

You might also like