STAT E O F T H E A RT R E V I E W

HPV testing as a screen for

cervical cancer
Annekathryn Goodman
Division of Gynecologic Oncology,
Massachusetts General Hospital, A B ST RAC T
Harvard Medical School, Boston, Human papillomavirus (HPV) has been identified as a necessary factor in the de-
MA 02114, USA
Correspondence to: A Goodman velopment of pre-invasive and invasive cancers of the lower genital tract, of which
agoodman@partners.org
Cite this as: BMJ 2015;350:h2372
cervical cancer is the most prevalent. A molecular understanding of malignant trans-
doi: 10.1136/bmj.h2372 formation and epidemiologic information has led to the development of many strate-
gies for detection and early intervention. Newer tests for oncogenic subtypes of HPV
have made it possible to predict the risk of future development of cervical cancer.
This review summarizes the current understanding of HPV related disease and ex-
amines the role of HPV testing as a screening tool for cervical cancer. It summarizes
the data from prospective and randomized controlled trials on HPV screening from
Europe and North America and includes smaller studies from low and middle income
countries where cervical cancer is the most common cancer in women.
Introduction Sources and selection criteria
Cervical cancer is a leading cause of death in women world- Medline, CINAHL, Embase, the Cochrane library, and
wide, with 530 000 new cases and 275 000 deaths world- PubMed were searched between 1 January 1990 and 30
wide each year.1 Cervical cancer is the third most common June 2014 with no language restrictions. Search terms
cancer worldwide; it is the sixth most common cancer in included “HPV”, “human papillomavirus”, “HPV test”,
women in developed countries and the second most com- “HPV screening”, “HPV vaccination”, “cervical neopla-
mon cancer in resource limited countries.1 Cervical can- sia”, “cervical carcinogenesis”, “cervical cancer screen-
cer is preventable because it has a long pre-invasive phase ing”, “cervical cancer prevention”, “cervical cytology”,
and is easily identified by clinical and histopathological “Papanicolaou smear”, and “Pap smear”. References
examination. The incidence of this disease is therefore identified from relevant articles were also searched. Arti-
directly related to a nation’s medical infrastructure and cles were selected if they contained level I or level II-1-3
the resources available for population-wide screening and evidence. Publications from low and middle income
the treatment of identified cancers. The goals of screening countries that reported case series were included.
programs for cervical cancer include the identification and
treatment of true precursors of cervical cancer. HPV subtypes
This review summarizes the current knowledge of HPV is an 8 kb, circular, non-enveloped, double stranded
human papillomavirus (HPV) related premalignant and DNA virus. The papillomavirus family is heterogeneous
malignant disease and the studies that have led to the rec- and highly species specific. More than 130 HPV geno-
ommendation of HPV testing as a primary screening test.2 types have been identified and can be subdivided into
mucosal and cutaneous. Of the mucosal subtypes, 40
Incidence and prevalence subtypes are associated with infections of the genital
In the United States the overall incidence of cervical cancer tract. HPV infections of the genital tract have been sub-
is 7.5 cases per 100 000 women. In countries with the high- classified into those associated with benign (low risk) and
est incidence, rates range from 37.8 per 100 000 in Fiji to malignant (high risk) genital tract disease. Low risk sub-
75.9 per 100 000 in Malawi.1 HPV infection is one of the most types include HPV-6, HPV-11, HPV-40, HPV-42, HPV-43,
common and contagious infections in the world. The lifetime HPV-44, HPV-53, HPV-54, HPV-61, HPV-72, and HPV-81.5
cumulative risk of HPV infection is greater than 80%.3 Most Almost all types of cervical cancer—squamous can-
genital HPV infections are transient, with a persistence rate cer, adenosquamous cancer, and adenocarcinoma—are
(presence of HPV for more than two years) of less than 10% now thought to be associated with HPV infections. When
for infections with a high risk subtype, which are associated information from 11 case-control studies in nine coun-
with pre-invasive lower genital tract disease and invasive tries was pooled, 15 high risk HPV types were identified
cancer.4 The proportion of HPV infections that are high risk in cervical cancers—HPV-16, HPV-18, HPV-31, HPV-33,
subtype versus low risk subtype varies by age and geogra- HPV-35, HPV-39, HPV-45, HPV-51, HPV-52, HPV-56,
phy; for example, adolescents may be at equivalent risk for HPV-58, HPV-59, HPV-68, HPV-73, HPV-82.6 HPV-16 and
low and high risk infections but high risk HPV infections HPV-18 are associated with 70% of all invasive cervical
constitute 50-80% of infections in women over age 30 years.3 cancers.7

For personal use only 1 of 14

 STAT E O F T H E A RT R E V I E W
Acquisition and natural course
HPV infection is sexually transmitted. The virus is spread
by skin to skin contact. Trauma may play a role in the dif-
ferential location of HPV related disease. Most infections
are transient and will clear within about eight months,
especially in women under 30 years. Viral load is usually
reduced to undetectable levels by two years.8
In a cohort of 1052 women aged 21-55 years who were
followed and tested for HPV at least three times over two
years, the rate of regression or persistence of HPV was
related to the concomitant cytologic finding.9 The rates of
persistence of HPV by cytology were 6.5%, 1.5%, 11.4%,
and 0.8%, respectively, for the following cytologic find-
ings: normal, low grade squamous intraepithelial lesion
(LSIL), high grade squamous intraepithelial lesion (HSIL),
and invasive squamous cell cancer. These persistence
rates reflect the fact that women with preinvasive and
invasive lesions were treated, whereas women with nor-
mal cytology were just monitored. Conversely spontane-
ous regression was 56.8%, 14.8%, and 0.2% for lesions
that were found to be normal, LSIL, and HSIL, respec-
tively. No invasive cancers spontaneously regressed. The
time of transformation to invasive cancer ranges from 12
months to 10 years.10
Persistent infection is defined as the presence of high
risk HPV for longer than two years. In a cohort of 354
women with high risk HPV infections, 9.3% with persis-
tent infections developed cervical intraepithelial neopla-
sia 3 (CIN 3; high grade squamous intraepithelial lesion,
severe dysplasia) over a median follow-up of 33 months.11
The prevalence of HPV in postmenopausal women
ranges from 14% to 38%. HPV infection is more likely
to be persistent in women over the age of 65 years, so a
positive HPV test is more likely to be clinically significant.
In a study of 260 menopausal women, 14% tested posi-
tive for HPV. Half of them had oncogenic subtypes and
most of these women had persistent infections.7 Because
persistent HPV infections are directly linked to cervical
cancer, the age specific incidence rates of cervical cancer
guide decisions about screening.
A study published in 2014 recalculated the incidence
of cervical cancer in older women after correcting for
hysterectomy rates in the United States.12 The age spe-
cific prevalence of hysterectomy increased with age, with
the highest rates being in women aged 75-84 years. The
uncorrected cervical cancer rates plateaued at ages 40-44
years, at 15.6 cervical cancer cases per 100 000 women.
However, after correcting for hysterectomies the incidence
of cervical cancer steadily increased until 65-69 years, at
which point it was 27.4 cases per 100 000 women. The
corrected incidence rates for older women aged 70-79
years, 80-84 years, and over 85 years are 23.2-24.2 per
100 000, 22.9 per 100 000, and 18.9 per 100 000, respec-
tively.
Role of HPV in malignant transformation
HPV infects the basal cells of the squamous epithe-
lium. The viral E6 and E7 gene products interact with
and inhibit host tumor suppressor gene products, p53
and retinoblastoma protein, respectively. These proteins
are important for cell cycle control and apoptosis, and
For personal use only
inactivation of these genes, which occurs with high risk
HPV infections, can induce malignant transformation.13
Although high risk HPV infection is a prerequisite for
cervical cancer, several other cofactors are needed for
malignant transformation to occur.
Persistence of high risk HPV infection at one and two
years after initial infection is highly predictive of a life-
time risk of pre-invasive and invasive cervical neoplasia.
The HPV genotype seems to be the most important factor
in persistence, with HPV-16 and HPV-18 being the most
likely to persist.14
Immunosuppression promotes persistent HPV infec-
tion. HIV coinfection may also promote HPV related
malignant transformation at a molecular level. Women
with HIV have a twofold to fivefold increased risk of HPV
infection compared with HIV uninfected women, and
they have a threefold to fivefold increased likelihood of
developing CIN, recurrent lesions, and cervical cancer.15
Genetic predisposition may play a role in the develop-
ment of persistent HPV infection. The role of the HLA
genes in protecting against or increasing the risk of per-
sistence has been studied intensively.16  17 The results
have been variable and differentially associated with eth-
nic group. In the analysis of the entire HLA region, DQ/DR
genes were found to be associated with the development
of cervical cancer, whereas the HLA-DRB1*13 group was
linked to protection against cervical cancer.
Oral contraceptives and hormone replacement therapy
may upregulate HPV viral expression.7 Active smoking
and passive smoking are significant risk factors, with an
odds ratio of 3.7 and 2.1 respectively, for the develop-
ment of squamous cell cancer of the cervix.18
Other cofactors that may play a role in persistent infec-
tion include host factors, such as age and genetics, and
external cofactors, such as nutrition and environment.
Screening tests for cervical cancer
Screening tests have traditionally identified an existing
pre-invasive or invasive lesion.
The simplest and cheapest method—visual inspection
with acetic acid (VIA)—is used in many mass screening
programs in low income countries. When a 3-5% solu-
tion of acetic acid is applied to the cervix, nuclear dense
lesions can be seen as acetowhite. The test has a specific-
ity of 82% (range 64-98%) and sensitivity of 84% (66-
96%) owing to a high false positive rate.19
The Papanicolaou (Pap) smear or cervical cytology has
been the mainstay of cervical cancer screening for 60
years. The advantages of cytology are its simplicity and
low cost. An abnormal cytologic report requires biopsy
and confirmation by histology. Cytologic and histologic
diagnoses agree in about 50% of cases. The sensitivity of
cytology has been reported as 78% (range 30-87%), with a
specificity of 62% (61-94%).20 However, these results were
published more than two decades ago so they should be
interpreted with caution. No recent studies have assessed
the accuracy of cytologic testing and directly compared its
sensitivity and specificity with current tests.
A case-control study comprising 1062 women who
died from cervical cancer and 10 494 women without
cervical cancer evaluated the risk of death based on
2 of 14
 STAT E O F T H E A RT R E V I E W
Test indicators
Analysis of the accuracy of testing uses the following
indicators: sensitivity, specificity, positive predictive value,
negative predictive value, false positive rates, and false
negative rates.
Sensitivity is the actual number of truly abnormal results
(or a positive test result) over the total number with the
condition being tested. Therefore, sensitivity equals the true
positive results divided by the sum of the true positive and
false negative results.
Specificity defines the true negative rate of a test or the
true negative results divided by the sum of the true negative
test results plus the false positive test results.
Positive and negative predictive values represent the
ability to predict the accuracy or inaccuracy of a test. This
prediction is influenced by the prevalence of the condition.
A positive predictive value is the number of true positives
divided by the sum of true positives and the false positives.
A negative predictive value is defined as the number of true
negatives divided by the sum of true negatives and false
negatives.
In summary:
• Sensitivity: true positives/disease positives
• Specificity: true negatives/disease negatives
• Positive predictive value: true positive/test positive
• Negative predictive value: true negative/test negative.
The false positive rate is the number of positive test results
in the absence of disease. Statistically this is called a type
I error. The false negative rate is the number of negative
test results when the disease condition is truly present.
Statistically this is called a type II error.
the women’s history of cervical cytology over a 20 year
period.21 Screening performed within three to 36 months
of the time of data collection was associated with a signifi-
cantly reduced risk of death from cervical cancer, with an
odds ratio of 0.28 to 0.60.
HPV testing was originally used as reflex testing (after
the cytologic diagnosis of atypical squamous cells) to
help triage atypical Pap smears to colposcopy or to close
follow-up. This recommendation came out of the 2003
ASCUS-LSIL Triage Study (ALTS) Group report.22 This
was the beginning of the use of HPV to help resolve some
uncertain cytologic diagnoses.23 HPV testing was not rec-
ommended by the American Congress of Obstetricians and
Gynecologists (ACOG) when a gross cervical lesion was
present or when a cytologic report was severely abnor-
mal.24 HPV testing followed cytology as the next gen-
eration of testing in asymptomatic women with visually
normal cervices to predict future risk of cervical cancer.
Rationale for HPV testing in cervical cancer screening
Cytologic or Pap smear screening is associated with
several potential sources of error. The lesion may not be
sampled, the abnormal cells may not transfer from the
smear applicator to the slide or vial, preservation of the
cells may be inadequate, or a reading error may occur.
The interpretation of cytologic slides is subject to inter-
observer variability. Cervical cytology is less sensitive at
detecting pre-invasive and invasive glandular lesions
than it is at detecting squamous cell lesions.
The sensitivity of cytology varies between countries
and cytology laboratories and depends on the medical
infrastructure of a particular region (box).
For personal use only
The false negative rate of Pap smears is hard to ade-
quately measure but has been cited as 50%.20 Few large
studies have been performed because most women who are
screened do not undergo confirmatory colposcopy after a
normal Pap smear. The sensitivity of cytology to detect high
grade lesions ranges from 55% to 94%, depending on the
laboratory, the experience of the cytologist, the adequacy
of the sample, and the fixation technique.20
One meta-analysis of 94 studies of conventional Pap
smears and three studies of liquid based cytology gives a
range of sensitivities from 30% to 87%.25
A population based study found that 30-60% of women
who presented with an invasive cervical cancer had nor-
mal Pap smears three to five years before diagnosis. This
suggests that the negative predictive value of cytology is
of short duration and that the test should be repeated at
least every three years.26
By contrast, the negative predictive value of HPV test-
ing is high but it lacks specificity. The false negative rate
for HPV polymerase chain reaction (PCR) analysis for
detection of the presence of a cervical HPV related lesion
is low at 0% (95% confidence interval 0% to 0.047%),
and the specificity is 60.7%. The sensitivity of HPV testing
is about 90%.27 Polymerase chain reaction (PCR) testing
for HPV DNA had a very low false negative rate for pre-
dicting HPV related lesions of the cervix in a community
based population.27 One study showed that women who
tested negative for high risk HPV subtypes remained at
low risk for the development of pre-invasive cervical
lesions over a study period of five to 18 years.28
There are three main strategies for HPV testing. These
strategies have been examined in North America and
Europe. The first—primary cytology with HPV triage—is
the current approach for women under 30 years. This
strategy is good in a population with a high prevalence of
HPV. Current recommendations are to use the HPV test as
reflex testing for atypical squamous cells of undetermined
significance (ASCUS).22
The second is primary HPV testing with cytology or col-
poscopy triage. This approach has low specificity unless
used in a population with a low prevalence of HPV. The
third strategy, which is currently used for women over 30
years, is to test with cytology also to test for HPV.29
Despite the differences in sensitivity and specificity
between screening tests, most cervical cancers occur
because screening was not performed, rather than a fail-
ure of screening to detect the cancer. Sixty per cent of
women with cervical cancer in the US have never had a
Pap smear or have not had one in more than five years.30
In low resource environments almost all women with
cervical cancer have never been screened. Cytologic
screening is significantly more effective at preventing
cervical cancers and increasing survival rates than no
screening at all—where intervention occurs only when a
woman has abnormal symptoms.19 Several cohort stud-
ies have shown that the incidence of cervical cancer falls
after the institution of screening. For instance, Japan
instituted cytologic screening for women over 30 years
in 1982. Since then mortality from cervical cancer has
fallen by 50%—the incidence rate of invasive cervical
cancer decreased from 13.4 to 7.2 per 100 000 women
3 of 14
 STAT E O F T H E A RT R E V I E W
from 1975 to 1998. The Japan Collaborative Cohort Study
analyzed 63 541 women, aged 30-79 years, who were free
from any cancer history at enrolment. An age adjusted Cox
model indicated significantly lower cervical cancer mor-
tality rates in women who had Pap smear screening com-
pared with those who did not (hazard ratio 0.30, 0.12 to
0.74).31 For women who were screened versus those who
received treatment for cervical cancer only when they had
symptoms, the proportion of women with screen detected
invasive cancer who were cured was 92% (75% to 98%)
versus 66% (62% to 70%) for unscreened women, a sig-
nificant difference in cure rate of 26% (16% to 36%).32
In summary, cytologic screening (Pap smear) was the
first cervical cancer screening test to reduce the incidence
and mortality of cervical cancer. Recent prospective stud-
ies from Japan and Sweden have confirmed that its use
significantly reduces the incidence of cervical cancer.32  33
However, the sensitivity of this test to detect high grade
lesions ranges from 55% to 94%, depending of the labo-
ratory and the expertise of the technologists. HPV testing
was first used as a triage test of mildly abnormal cytologic
findings and is now used concurrently with Pap smear
testing or as a primary screening test. HPV testing has
increased the sensitivity of detecting abnormal lesions
but has a lower overall specificity.
Types of HPV tests
Two general types of HPV tests are available: those that
report the detection of high risk subtypes, without speci-
fying which ones, and those that report the presence of
HPV-16 and HPV-18. HPV can be detected through HPV
DNA testing, RNA testing, and the detection of cellular
markers of HPV associated malignant transformation.
A control for specimen adequacy is necessary for a
negative HPV test to be meaningful. β globin is commonly
measured by gel electrophoresis, enzyme linked immuno-
sorbent assay (ELISA), or PCR to check for adequate epi-
thelial cellularity. Specimens for HPV tests are obtained
using a swab, cervical brush, or tampon, which is then
placed in HPV transport test medium. Before HPV testing,
the material from the swab has to be reconstituted in a
liquid medium.
In the US, no Food and Drug Administration approved
tests are available for head and neck, anal, or penile
specimens, and there are no FDA approved tests that use
serum or blood.
One hundred and forty eight different HPV tests are
commercially available worldwide, and another 44 tests
are variants of these.33 Most assays target the L1 or the
E6/E7 region of the HPV genome.34 It cannot be assumed
that all HPV screening tests are comparable. Some HPV
tests that are currently available do not have a control for
epithelial cellularity, and a test can be falsely negative
if the sample has sparse or insufficient squamous cells.
In 2005, the World Health Organization established
a worldwide network to standardize the quality of HPV
laboratory testing, and it periodically reports on the pro-
ficiency of various HPV tests.34
It is important to measure viral load so that the
clinical significance of a positive HPV DNA test can be
determined. A viral load of less than 10 HPV genomic
For personal use only
equivalents is not clinically significant and probably
reflects a transient infection. A viral load of greater than
10 genomic equivalents reflects the existence of dysplas-
tic changes or a high risk of developing dysplasia.34
There are two main methods of testing for HPV DNA,
and all commercial DNA HPV tests use one of these two
techniques. Signal amplification uses hybridization in the
liquid phase. The second technique, target amplification,
uses gene amplification with PCR. Detection of particular
genotypes requires amplification followed by hybridiza-
tion with specific probe types. In addition, quantitative
detection of viral HPV DNA can be used to assess viral
load. A third approach is the detection of mRNA encoding
proteins E6 and E7 of high risk HPV subtypes.
Specific HPV tests
In the US and Europe four types of HPV tests are approved
for primary screening: the hybrid capture 2 (HC2), Cer-
vista HPV HR, Cobas 4800 System, and Aptima mRNA.
These tests are approved for primary screening (as a co-
test with a Pap smear) in women over 30 years and for
reflex testing after a positive ASC-US result in women 21
years or more.
DNA tests
The HC2 assay (Qiagen, Gaithersberg, MD, USA; previ-
ously Digene Corp), which was approved by the FDA in
2003, is a nucleic acid hybridization assay that quanti-
tatively detects HPV subtypes. It identifies the presence
of 13 high risk HPV types.
The Cervista HPV HR test (Hologic), which was
approved in 2009, detects HPV-66 in addition to the 13
subtypes detected by HC2. Another Cervista test (Cerv-
ista 16/18) that detects the HPV-16 and HPV-18 high risk
subtypes is also available. It is approved for use only in
women 30 years or more as a follow-up test after a posi-
tive HPV screen for the 14 high risk HPV types. The HPV
16/18 test is intended to be used adjunctively with cytol-
ogy as follow-up to a less specific HPV test.
The Cobas 4800 System (Roche Molecular Systems,
Alameda, CA USA) detects HPV-16 and HPV-18 and
also provides a pooled result for another 12 high risk
subtypes. The test simultaneously detects HPV-16 and
HPV-18, along with HPV-31, HPV-33, HPV-35, HPV-39,
HPV-45, HPV-51, HPV-52, HPV-56, HPV-58, HPV-59,
HPV-66, and HPV-68. It is based on PCR, which is a sen-
sitive technique, and can detect fewer than 10 copies
of HPV DNA in a background of 1000 human cell DNA
equivalents.
RNA tests
The Aptima mRNA test (Gen-Probe, San Diego, CA, USA)
identifies E6 and E7 RNA, and it detects 14 high risk sub-
types of HPV. This test has recently received FDA approval
for cervical HPV testing. It has a similar sensitivity to HC2
of 100% but is more specific 84%.35
Accuracy of HPV tests
Several trials have sequentially evaluated different HPV
tests. Five HPV tests (HC2, RealTime HR-HPV, Aptima,
Cervista HPV HR, and Cervista 16/18) were evaluated
4 of 14
 STAT E O F T H E A RT R E V I E W
in post-treatment follow-up in the Scottish Test of Cure
Study (STOCS-H).35 Sensitivity was 100%, with all assays
able to detect CIN 2 at six months after treatment. Speci-
ficity ranged from 75% to 84%. Another comparison
study evaluated seven tests in 1099 women with abnor-
mal smears: HC2, Cobas, RealTime, BD HPV test, PreTect
Hpv-Proofer assay (NorChip), Aptima, and p16 cytology.
Sensitivities of HC2, Cobas, BD HPV test, Aptima, and
RealTime ranged from 93.5% to 96.3% compared with
88.9% for cytology.36
While these studies found similar performance among
the five tests, in the US, the 2014 FDA advisory panel rec-
ommended the Cobas 4800 System as the only HPV test
for primary screening.2 This was based on the results of
the ATHENA (Addressing THE Need for Advanced HPV
diagnostics) trial, which showed that the Cobas 4800
System was more accurate than HC2.37 For CIN 3 the sen-
sitivity and specificity of the Cobas 4800 System were
93.5% and 69.3%, respectively, compared with 91.3%
and 70% for HC2.2
Overall, HPV screening tests that detect L1 DNA have
a high negative predictive value but less than a 50%
positive predictive value for the determination of CIN 2
and greater. The addition of tests for E6 and E7 mRNA
improves the positive predictive value to 78%.38
In the setting of an HPV prevalence of 20.6%, PCR for
HPV DNA had a false negative rate of zero and a 61.8%
specificity for identifying HPV related lesions. That is
61.8% of women whose biopsies were negative were HPV
DNA negative.2
HPV as a primary screening test
Although the prevention of cervical cancer should be
used to evaluate the efficacy of a screening test, most
studies use CIN 2 and CIN 3 to assess either equivalency
of HPV with cytology or the predictive value of HPV test-
ing. The important question is for how long does a nega-
tive HPV test predict the absence of cervical cancer? Three
main types of study have been used to evaluate HPV test-
ing: randomized studies, population based cohort stud-
ies, and cross sectional studies. It is difficult to summarize
these studies because of the different study designs, time
frames over which the populations were evaluated, and
comparison groups.
Study types
Population based cohort studies and prospective rand-
omized testing with long term follow-up give predictive
information about future risk of cervical cancer and pro-
vide the highest level of evidence for the value of HPV
testing compared with cytology.
Observational studies either directly compare HPV test-
ing with cytology at one point in time to provide informa-
tion on sensitivity and specificity of testing, or they follow
a cohort over time.
Many studies have shown that HPV testing, alone or
combined with cervical cytology, is more sensitive than cer-
vical cytology alone at detecting high or low grade cervical
histopathology. Table 1 summarizes the studies that have
shown that HPV testing has a higher sensitivity than cytol-
ogy for the detection of high grade pre-invasive disease.26-50
For personal use only
Randomized studies
Many studies have shown that HPV testing, alone or com-
bined with cervical cytology, is more sensitive than cervi-
cal cytology alone at detecting high or low grade cervical
histopathology. A randomized trial of HPV testing as the
initial screen and cytology as triage versus cytology alone
enrolled more than 100 000 women.47 Detection of CIN 2
was significantly higher for HPV DNA screening with cytol-
ogy triage compared with conventional screening (relative
rate 1.39, 1.03 to 1.88). Relative rates of detection of CIN 1
and CIN 3+ were not significantly different. The specificity
of HPV testing with cytology triage was similar to conven-
tional screening in all age groups, although in women aged
35 years or more specificity was higher for HPV testing with
cytology triage than for conventional screening. The posi-
tive predictive values for HPV DNA screening with cytology
triage were consistently higher than those for conventional
screening. Interestingly, the detection of invasive cancer
was the same in both arms. A trial of 40 901 women with
both liquid based cytology and Cobas HPV testing showed
that the Cobas HPV test was more sensitive than cytology for
the detection of CIN 3 and cancer.51 In another randomized
study of more than 18 000 women, HPV testing increased
the detection of CIN 2+ compared with cytology alone.48
A summary of four European randomized trials (Swede-
screen, POBASCAM, ARTISTIC, NTCC) of HPV testing
versus cytology examined the overall outcomes.50 HPV
testing provided 60-70% greater protection against inva-
sive cervical cancer over 6.5 years of follow-up. Each
study compared cytology plus HPV testing with cytology
alone.45  46  49  52
In all studies, women with HPV positive, cytology nega-
tive results underwent repeat HPV and cytology six to 18
months later before referral to colposcopy. There was an
increased cumulative detection of CIN 2 and CIN 3 com-
pared with cytology alone. In this population, however,
the incidence of invasive cervical cancer was low—only
107 cervical cancers were identified in 176 464 women
screened and followed over 6.5 years.
By contrast, the ARTISTIC study, which compared
cytology with or without HPV testing, found similar over-
all rates of CIN 3 or invasive cancer in both groups over
two rounds of screening.37 Cytology picked up equivalent
rates of high grade lesions to HC2 testing in screened pop-
ulations. This suggests that in well screened low preva-
lence populations, HPV and cytology are equally effective
screening tools but in unscreened populations, HPV test-
ing gives a higher yield for abnormal cervical findings.
Unlike the ARTISTIC study, a randomized trial of HPV
versus cytology as a primary screening tool found that ini-
tial screening for HPV with and without cytology reduced
the occurrence of invasive cervical cancer at the second
round of screening.46
The ATHENA study examined the predictive value of
Cobas to identify the risks of the development of CIN 2
and CIN 3.37 Absolute risks of CIN 2 by Cobas were 14%
for all high risk HPV subtypes, 24% for HPV-16, and 4.3%
for HPV-18 versus 0.75% for HPV negativity. The relative
risk for CIN 2 and CIN 3 in women who were positive for
high risk HPV was 18.6 and 29.7, respectively. A follow-
up report of the ATHENA study evaluated 10 screening
5 of 14
 STAT E O F T H E A RT R E V I E W

Table 1 | Summary of trials evaluating cytology versus HPV testing for cervical cancer screening*
No of Age
Study Country women (years) HPV test Strategy Follow-up Outcome
Observational studies
Pan 201439 China 25 404 15-59 HC2 Cytology, cytology+HPV triage None beyond Cytology+HPV co-testing had highest
co-testing, HPV alone; pooled analysis colposcopy and biopsy sensitivity and NPV does not allow
of 13 cross sectional population based assessment of lead time detection of CIN by
studies cytology v HPV
Elfstrom 201444 Sweden 12 527 23-60 GP 5+/6+ PCR HPV† Cytology v cytology/HPV every 3 years 13 years Cumulative incidence of CIN 2/3 same for
ages 23-50; every 5 years ages 51-60 HPV+cytology and cytology; HPV testing
allows earlier detection
Mayrand 200740 Canada 10 154 30-69 HC2 Cytology v HPV test 3 years HPV more sensitive and less specific than
cytology for CIN 2/3
Cox 201341 USA 47 000 >21 Cobas 10 screening strategies 1 year HPV alone with colposcopy for HR-HPV most
sensitive with highest false positive rate
42
Louvanto 2014 Canada 23 739 30-65 HC2 HPV screen; if positive then Pap smear; 3 years Detection of HSIL increased 3-fold. Time to
if abnormal then colposcopy colposcopy with HR-HPV decreased from 11
months to 3 months; follow-up poor; only
46% of HR-HPV women had cytology; only
24% of HR-HPV women had colposcopy
Castle 201228 UK 19 512 16-94 HC2 and prototype Cervical lavage tested retrospectively 18 years HPV testing predicted who developed CIN 3
Cervista 16/18 for HR-HPV women followed 10-18 years later
prospectively with routine cytologic
screening
Katki 201126 USA 315 061 >30 HC2 Co-testing and assessment of risk of 6 years Prevalent CIN3 similar for HPV and cytology;
CIN 3 HPV predicts future risk
Zorzi 201343 Italy 11 895 25-64 HC2 HPV screen; if positive then pap smear; 2 years 7% HR-HPV; compliance 78.6%; referral to
if abnormal then colposcopy colposcopy 4.6%; CIN 2 detection 4.5%
Randomized studies
Stoler 201137 USA 47 208 >21 Cobas v HC2 ASCUS Pap smears, colposcopies, None Cobas test comparable to HC-2
biopsies, HPV test
Kitchener 200945 UK 24 510 20-64 HC2 Cytology v cytology/HPV 2 years Co-testing did not detect higher rate of
CIN 2/3
Rijkaart 201246 Netherlands 44 938 29-56 GP 5+/6+ PCR HPV† Cytology v cytology/HPV 5 years Earlier detection with HPV but no difference
in incidence of CIN 3
Leinonen 200947 Finland 108 425 25-65 GP 5+/6+ PCR HPV† Cytology v cytology/HPV Cytology/HPV detected more CIN 2; no
difference in cervical cancer rate
Ogilvie 201248 Canada 18 648 25-65 HC2 Cytology v different referrals to HPV arm had increased CIN 2 detection v
colposcopy cytology alone
Ronco 201049 Italy 94 370 25-69 HC2 Round 1: cytology v cytology/HPV test; 3 years Detection ratio of CIN 2 in women aged
round 2: HPV test alone 25-34 4.09 in round 1 and 0.64 in round 2
Ronco 201450 Sweden, 176 464 20-64 HC2 and GP 5+/6+ HPV v cytology; pooled analysis of 4 6.5 years HPV screening gives 60-70% increased
Netherlands, PCR HPV† randomized trials protection
UK, Italy
*ASCUS= atypical squamous cells of undetermined significance; CIN=cervical intraepithelial neoplasia; HC2=hybrid capture 2; NPV=negative predictive value; Pap=Papanicolaou; HPV=human papillomavirus;
HR=high risk; PCR=polymerase chain reaction.
†PCR based assay that uses the general primer mediated 5+/6+ (GP5+/GP6+) systems to amplify sequences from the L1 region of the HPV genome.

strategies and determined that HPV testing with imme-
diate referral to colposcopy gave the highest sensitivity
of 89% but also the highest false positive rate of 38%.41
Cohort studies
The Canadian Cervical Cancer Screening Trial (CCCaST)
followed 10 154 women aged 30-69 years with both HPV
testing and conventional cytology.40 Sensitivity for CIN 2
and higher was 94.6% for HPV testing versus 55.4% for
cytology. Specificity was 94.1% for HPV testing versus
96.8% for cytology.
The feasibility and efficacy of HPV testing as a pri-
mary screen in women aged 30-65 years over a three
year time interval was evaluated.42 Women who tested
positive (1646/23 739 women; 6.9%) were referred for
a Pap smear. Women with Pap smears showing ASCUS
or worse were referred to colposcopy. Women who tested
HPV negative were rescreened every three years. The
colposcopy rate per 1000 women with an HPV positive
test was 19.36 compared with 14.54 for older Pap smear
data. The detection rate of high grade cervical cancer was
6.58 compared with 2.37 for these historic controls (rate
ratio 2.78). The investigators identified a serious prob-
lem with follow-up, however. Only 46% of HPV positive
women received a Pap smear and only 24% underwent
colposcopy. In a community setting, there is a risk of loss
to follow-up with HPV testing.
A 13 year follow-up of a nested case-control study in
Sweden (12 527 women) compared HPV testing with
cytology every three years. It found a similar detection
rate for new CIN 2 (3.2%) and CIN 3 (1.9%) in both
groups,44 although HPV testing allowed earlier detec-
tion. Thus, the sensitivity of HPV based screening after
five years was the same as for cytology based screening
after three years. Women with a negative HPV test had a
low risk of developing CIN, and the authors concluded
that with HPV testing screening could be reduced from
every three years to every five years.
In a population based screening study, 40 000 women
aged 30-59 years were randomized to cytology alone or

For personal use only 6 of 14

 STAT E O F T H E A RT R E V I E W
cytology plus HPV testing using PCR.46 At five years, all
women had a repeat Pap smear and HPV test. HPV test-
ing led to earlier detection but not a reduced incidence of
high grade cervical lesions.
A population study based in clinical practice of women
over age 30 years used HPV and cytology in various com-
binations. It found a five year incidence of cervical cancer
of 3.2 per 100 000 women in those who were both HPV
and cytology negative, 3.8 per 100 000 in women who
were HPV negative, and 7.5 per 100 000 in women who
were negative for cytology.26 Of note, 17 of the 27 women
with adenocarcinoma were positive on HPV testing but
negative on cytology, which confirms the difficulty in
detecting adenocarcinoma with cytology.
The most compelling predictive data on HPV testing
come from a study that looked at 19 512 women who were
followed with Pap smear for up to 18 years. All women
had undergone cervical lavage, which was retrospec-
tively tested for high risk HPV. HPV testing for HPV-16
and HPV-18 predicted who would develop CIN 3 10-18
years later.28
Cross sectional studies
A meta-analysis of 25 studies, 24 of which were cross sec-
tional, showed a sensitivity of HC2 HPV testing of 90% for
detecting CIN 2 compared with cytology, but specificity
was lower than for cytology (86.5% v 91.9%).53
A pooled analysis of 13 cross sectional studies from
China directly compared four screening strategies: cytol-
ogy alone, cytology with HPV triage for ASCUS results,
HPV testing with cytology triage for positive HPV results,
and cytology with HPV co-testing.39 Cytology with HPV
co-testing had the highest sensitivity (99.3% for CIN 3)
and negative predictive value but the lowest specificity
(76%) and positive predictive value (7.1%). Referral to
colposcopy ranged from 9.6% for HPV testing alone with
cytology triage to 25% for co-testing. The standard proto-
col of cytology alone with HPV triage for ASCUS led to a
sensitivity of 95%, specificity of 91.1%, positive predic-
tive value of 16.2, negative predictive value of 99.9, and
a 10.5% referral rate to colposcopy.
Other strategies for HPV screening
Another triage strategy to reduce colposcopy referrals is
the genotyping of high risk HPV to identify HPV-16 or
HPV-18 when high risk HPV testing is positive but cytol-
ogy results are negative. Women with HPV-16 and nor-
mal cytology have a 10% risk of developing CIN 3.54 One
caveat is that 30% of cervical cancers are associated with
HPV subtypes other than HPV-16 and HPV-18.55 There-
fore, clinical judgment (cytology, clinical symptoms, and
examination) should be used when deciding which HPV-
16, HPV-18 negative women to refer to colposcopy. Con-
versely for women with ASCUS cytology who are positive
for any HPV subtype, the five year cumulative risk of CIN
3 and cancer is 6.8%. This group should be referred for
colposcopy without the need for genotyping.55
Summary of HPV testing strategies
Testing for high risk HPV is more sensitive than cytol-
ogy at identifying pre-invasive but not invasive cervical
For personal use only
cancer in cross sectional studies. High risk HPV testing
gives superior predictive information about future risk
of cancer.
However, two cohort studies identified concerns that
21-64% of women who were positive for high risk HPV
subtypes were lost to follow-up.42  43
Use of HPV testing for follow-up after treatment for
cervical disease
Disease recurs in 5-20% of women treated for high grade
cervical dysplasia.56 Observational studies show that
HPV testing is as specific after the treatment of CIN as
it is when used as a triage tool, identifying residual and
recurrent pre-invasive disease more efficiently than cytol-
ogy.57 On the basis of case series, the ideal time to repeat
HPV testing after a cone biopsy is 18-24 months.58
HPV testing can be used as a test of cure because it has
a sensitivity of 85-97%.35 Knowledge about the subtype
of high risk HPV helps predict the subsequent risk of CIN
3. In a 14 year follow-up of a 12 527 women in a Swedish
cohort, women who were positive for HPV-16, HPV-18,
HPV-31, or HPV-33 had a 14 year cumulative incidence
for developing CIN 3 of greater than 28%. This figure was
14-18% for women who were positive for HPV-35, HPV-
45, HPV-52, or HPV-58, and less than 10% for those who
were positive for HPV-39, HPV-51, HPV-56, HPV-59, HPV-
66, or HPV-68.59
HPV testing after treatment for high grade cervical
lesions is predictive of risk of recurrence, persistent infec-
tions, and time to next recurrence. In a study of 58 paired
cervical cone biopsies, 95.9% of women had persistent
high risk HPV infection. Of these, 74.5% were HPV-16
and HPV-18 positive. The time between the first and sec-
ond cone biopsy was shorter for women over 40 years
(median time 2.6 years) than for those under 40 years (6
years) and for women with HPV-16 and HPV-18 infections
(1.8 years) than for those with other high risk subtypes
(3.8-8.2 years).60 These data reinforce the importance of
age and HPV subtype in persistent HPV infections.
Accuracy of HPV testing
Poor specificity and correspondingly poor positive predic-
tive value limits the use of HPV testing alone as a primary
screening test, particularly in younger women. HPV test-
ing has better specificity in women over 30 years than
in younger women. In addition, HPV infection in older
women is more likely to be persistent and is therefore
more likely to be clinically significant.61
False negative HPV testing has been evaluated in retro-
spective studies.56  62  63 Women with HPV negative ASC-H
(atypical squamous cells rule out high grade dysplasia)
have a 2% risk of developing invasive cancer in the next
five years. Women who have HSIL on cytology but a nega-
tive HPV test still have a 29% risk of developing CIN 3 and
a 7% risk of developing invasive cancer in the next five
years.56 Women who have HSIL on cytology who also have
a falsely negative HPV test or whose cancer is not related
to HPV will be missed by an HPV only screening protocol.
The HC2 test has a false negative rate of 1-5% in CIN
2/3. False negative rates are higher for small lesions
and in women over 40 years. The observation that HPV
7 of 14
 STAT E O F T H E A RT R E V I E W
prevalence has two peaks—women under 30 years and
those in their mid-50s—has led to the concept of HPV
latency with later reactivation of infection. According
to this hypothesis, HPV infections can be dormant in
patients with normal immunity but be reactivated at a
later age. Women with latent infections will have a nega-
tive HPV test.62
The detection of high risk HPV can vary with the
menstrual cycle,63 so there is a risk of missing an HPV
infection when using a single DNA test. In one study, 33
women aged 22-53 years took vaginal swabs twice weekly
for 16 weeks. A significant short term variation in positiv-
ity was noted, with an estimated risk of missing 24% of
HPV positive smears.64 Neither vaginal sex nor condom
use during follow-up was associated with recurrent viral
detection or loss of detection.
HPV testing in resource poor environments
Cervical cancer is the second most common cancer in
women in developing countries and in low and middle
income countries, where 85% of deaths from cervical
cancer occur.1
The prevalence and distribution of HPV subtypes varies
geographically and ethnically.65 The International Agency
for Research on Cancer (IARC) HPV prevalence survey,
which tested women from 26 regions for HPV subtype
infections, reported a high prevalence of HPV in sub-
Saharan Africa, Latin America, and India. These regions
have the highest rates of cervical cancer worldwide.66
In a retrospective evaluation of 8977 paraffin speci-
mens of invasive cervical cancer from six continents, high
risk HPV subtypes were identified using PCR analysis.67
The prevalence of HPV-16 associated cancer was 66-72%
in Europe and North America, 59% in South America and
Oceania, 60% in Asia, and 48% in Africa. The greatest
proportion of HPV-18 associated cervical cancers (23%)
occurred in Africa. Ten per cent of cervical cancers in
Africa and 4-7% of cancers on other continents were
associated with high risk HPV-45.
An international cost effectiveness analysis evaluated
several strategies for cervical cancer screening in Thai-
land, India, Peru, Kenya, and South Africa.68 It found
that the lifetime risk of cervical cancer was reduced by
25-35% in women who are screened once in their life-
time, at around age 35 years, with VIA or HPV testing.
The risk is reduced by 40% if women are screened twice.
More than 90% of women in low and middle income
countries have never had a Pap smear because of a lack
of infrastructure and the need for skilled cytotechnolo-
gists. Programs have been developed where slides can be
processed and screened on site during a clinic session.69
In a meta-analysis of 11 African and Indian cohort and
cluster randomized trials of VIA followed by colposcopy
and biopsy, VIA had a sensitivity of 79% and a speci-
ficity of 85% for the detection of CIN 2 or greater.70 In a
seven year follow-up in which more than 80 000 women
were randomized to VIA versus health education, the
incidence of cervical cancer decreased significantly by
25% in the VIA group compared with education alone
(incidence hazard ratio 0.75, 0.55 to 0.95) and mortality
hazard ratio 0.65 (0.47 to 0.89).71 Women in rural India
For personal use only
were randomized to HPV testing with HC2 or no screen-
ing, cytological analysis, or VIA. In eight years of follow-
up, there were 34 deaths from cervical cancer in the HPV
screened group versus 54 deaths in the cytology group,
56 deaths in the VIA group, and 64 in the no screen group
(hazard ratio 0.52, 0.33 to 0.83).19
In general, HPV tests are too expensive for low resource
settings. However, the careHPV (Qiagen, Gaithersberg,
MD, USA) kit costs just $5.00 (£3.3; €4.4). In a rand-
omized study of 2388 women aged 30-54 years, VIA,
cytology, HPV testing with HC2 and careHPV was per-
formed. Colposcopy with biopsy was done as needed.
The sensitivities and specificities, respectively, of detect-
ing CIN 2/3 were 41.4% and 94.5% for VIA, 85.3% and
87.5% for cytology, 97.1% and 85.6% for HC2, and
84.3% and 87.7% for careHPV (areas under the curve
significantly different, P=0.0001 and P=0.0031, for cervi-
cal and vaginal specimen comparisons for the careHPV
test, respectively).
The IARC is creating an electronic directory of global
screening programs through its screening group (http://
screening.iarc.fr/cervicalindex.php ). As more com-
plete data on HPV prevalence by region and screening
programs emerge, it will be possible to design low cost
screening and vaccination programs that are tailored to
different regions and ethnic groups.
HPV vaccination and the future of HPV testing
The current duration of protection is 8.4 years for the
bivalent vaccine (HPV-16 and HPV-18) and five years
for the quadrivalent vaccine (HPV-6, HPV-11, HPV-16,
and HPV-18).72  73 HPV-16 and HPV-18 vaccination has
reduced CIN 3 by 17-33%, and colposcopy and treatment
by 10% and 25%, respectively.72 A nine valent prophylac-
tic vaccine (HPV-6, HPV-11, HPV-16, HPV-18, HPV-31,
HPV-33, HPV-45, HPV-52, and HPV-58) is currently being
developed and tested. This new vaccine will extend pro-
tection against oncogenic HPV subtypes.
Guidelines
Table 2 summarizes guidelines and current data on rates
of cervical cancer by age group.
WHO has published guidelines for cervical cancer
screening and a guide to care.75 These guidelines are
mindful of resource poor regions and are pragmatically
focused on women aged 30-50 years. WHO recommends
primary screening with HPV testing, if possible, over VIA
or cytology. Several algorithms are given for the manage-
ment of positive high risk HPV results but immediate
treatment with cryotherapy of loop electrosurgical exci-
sion is encouraged.
The 2012 guidelines from the American Cancer Society,
US Preventive Services Task Force, and the American Col-
lege of Obstetricians and Gynecologists and the European
guidelines from the IARC continue to be the standard and
accepted guidelines for cervical cancer screening in North
America and Europe, respectively.2  74 Screening should
start at age 21 years. Cytologic screening alone should
be performed every three years. For women aged 30-65
years, either cytologic screening every three years or
cytology and HPV co-testing every five years if the results
8 of 14
 STAT E O F T H E A RT R E V I E W

Table 2 | Primary screening guidelines

Cervical cancer/ Guidelines
Age range 100 000
(years) US women IARC74 ASCCP 201229 WHO75 FDA advisory panel 20142
0-20 0.1 No screening No screening No screening No screening
21-25 4.5 No screening Cytology every 3 years No screening Follow ASCCP guidelines
25-30 4.5 Cytology every 5 years, Cytology every 3 years No screening Primary HPV test (Cobas) or
HPV preferred as co-test with cytology
31-39 13.9 Cytology every 5 years, Cytology every 3 years cytology or Cytology, HR-HPV, or VIA (primary Follow ASCCP guidelines
HPV preferred cytology with HR-HPV every 5 years HPV best) every 3-5 years
40-49 16.5 Cytology every 5 years, Cytology every 3 years cytology or Cytology, HR-HPV, or VIA (primary Follow ASCCP guidelines
HPV preferred cytology with HR-HPV every 5 years HPV best) every 3-5 years
50-64 15.4 Cytology every 5 years, Cytology every 3 years cytology or Cytology, HR-HPV, or VIA (primary Follow ASCCP guidelines
HPV preferred cytology with HR-HPV every 5 years HPV best) every 3-5 years
>65 14.6 Stop screening at Stop screening Not covered Follow ASCCP guidelines
60-64 years
65-69 27.4
70-79 23.7
80-84 22.9
>85 18.9
ASCCP= American Society for Colposcopy and Cervical Pathology; FDA=Food and Drug Administration; HR-HPV=high risk human papillomavirus; IARC=International
Agency for Research on Cancer; WHO=World Health Organization.

are negative is recommended.29 Women should discon-
tinue screening at age 65 years if they have had three
negative Pap smears or two negative Pap and HPV tests
in the preceding 10 years. Women who have been treated
for pre-invasive disease should continue to be screened
annually for at least 20 years after treatment. These
screening guidelines do not apply to high risk women
with a history of lower genital tract neoplasia or other
risk factors for malignant transformation, such as immu-
nosuppression (for example, women with HIV infection)
or a history of diethylstilbestrol exposure.
Given that the new data on the prevalence of cervical
cancer (adjusted for women who have had a hysterec-
tomy) show increased rates of cervical cancer in women
over 65 years, the age to stop cervical cancer screening
must be reconsidered.12 Careful prospective documenta-
tion of the incidence of cervical cancer after age 65 years
will guide future recommendations.
Concern has been raised that reducing the frequency
of co-testing with a Pap smear and HPV testing will
increase the incidence of cervical cancer. A modeling
study showed that the recent US Preventive Task Force
guideline revision (co-testing every five years instead
of every three years) would lead to an extra one in 369
women who follow screening guidelines developing cer-
vical cancer.76
The newest FDA advisory approves the use of the
Cobas 4800 System for primary HPV screening after age
25 years.2 The FDA panel suggests that women who test
positive for HPV-16 or HPV-18 should have an immediate
colposcopy. It recommends cytology triage first for the
RESEARCH QUESTIONS
What is the incidence of cervical cancer in women over 65
years who have not undergone hysterectomy?
What factors lead to persistent high risk human
papillomavirus (HPV) infections and how can this be
measured?
What is the ideal follow-up for a high risk HPV positive test?
How should guidelines change for women who have
received HPV vaccination?
other 12 high risk HPV types. The panel stresses that its
recommendation does not change current medical prac-
tice guidelines for cervical cancer screening.
Conclusions
In 2014 an FDA advisory panel recommended the use of
HPV testing alone. This recommendation was based on
data showing the long term predictive value of a positive
high risk HPV test result.
In an ideal world, in which women have regular follow-
up, primary HPV screening is as effective as primary cytol-
ogy screening. The duration of the protective effect of a
negative HPV negative test is twice as long as for a nega-
tive cytology test because cytologic changes are down-
stream of HPV acquisition. Clear algorithms for reflex
cytology and for appropriate colposcopy referrals can
balance the loss of specificity with HPV testing.
The challenge with a new screening paradigm of pri-
mary HPV testing, which reduces the frequency of surveil-
lance, will be to assure robust tracking and follow-up of
women at risk for cervical cancer.
Competing interests: I have read and understood BMJ policy on
declaration of interests and declare the following interests: none.
Provenance and peer review: Commissioned; externally peer reviewed.
1 Globocan. Cervical cancer estimated incidence, mortality, and prevalence
worldwide in 2012. http://globocan.iarc.fr/old/FactSheets/cancers/
cervix-new.asp.
2 Food and Drug Administration. FDA news release. FDA approve first
human papillomavirus test for primary cervical cancer screening.
2014. www.fda.gov/newsevents/newsroom/pressannouncements/
ucm394773.htm.
3 Dunne EF, Unger ER, Sternberg M, et al. Prevalence of HPV infection
among females in the United States. JAMA 2007;297:813-9.
4 De Sanjosé S, Diaz M, Castellsagué X, et al. Worldwide prevalence and
genotype distribution of cervical human papillomavirus DNA in women
with normal cytology: a meta-analysis. Lancet Infect Dis 2007;7:453-9.
5 Kawana K, Adachi K, Kojima S, et al. Therapeutic human papillomavirus
vaccines: a novel approach. Open Virol J 2012;6:264-9.
6 Muñoz N, Bosch FX, de Sanjosé S, et al. Epidemiologic classification of
human papillomavirus types associated with cervical cancer. N Engl J Med
2003;348:518-27.
7 Smith EM, Ritchie JM, Levy BT, et al. Prevalence and persistence of human
papillomavirus in postmenopausal age women. Cancer Detect Prev
2003;27:472-80.
8 Rodriguez AC, Schiffman M, Herrero R, et al. Rapid clearance of human
papillomavirus and implications for clinical focus on persistent
infections. Proyecto Epidemiologico Guanacaste Group. J Natl Cancer Inst
2008;100:513-17.

For personal use only 9 of 14

 STAT E O F T H E A RT R E V I E W
9 An HJ, Sung JM, Park AR, et al. Prospective evaluation of longitudinal
changes in human papillomavirus genotype and phylogenetic
clade associated with cervical disease progression. Gynecol Oncol
2011;120:284-90.
10 Ostor AG. Natural history of cervical intraepithelial neoplasia: a critical
review. Int J Gynecol Pathol 1993;12:186-92.
11 Nobbenhuis MA, Walboomer JM, Helmerhorst TJ, et al. Relation of
human papillomavirus status to cervical lesions and consequences for
cervical-cancer screening: a prospective study. Lancet 1999;354:20-5.
12 Rositch AF, Nowak RG, Gravitt PE. Increased age and race-specific
incidence of cervical cancer after correction for hysterectomy prevalence
in the United States from 2000-2009. Cancer 2014;120:2032-8.
13 Zur Hausen H. Papillomaviruses causing cancer: evasion from
host-cell control in early events in carcinogenesis. J Natl Cancer Inst
2000;92:690-8.
14 Thomsen LT, Frederiksen K, Munk C, et al. High-risk and low-risk human
papillomavirus and the absolute risk of cervical intraepithelial neoplasia
or cancer. Obstet Gynecol 2014;123:57-64.
15 Ahdieh L, Klein RS, Burk R, et al. Prevalence, incidence, and type-specific
persistence of human papillomavirus in human immunodeficiency virus
(HIV)-positive and HIV-negative women. J Infect Dis 2001;184:682-90.
16 Zoodsma M, Nolte IM, Schipper M, et al. Analysis of the entire HLA
region in susceptibility for cervical cancer: a comprehensive study. J Med
Gen 2005;42:e49.
17 Bernal-Silva S, Granados J, Gorodezky C, et al. HLA-DRB1 Class II antigen
level alleles are associated with persistent HPV infection in Mexican
women; a pilot study. Infect Agents Cancer 2013;8:31.
18 Natphopsuk S, Settheetham-Ishida W, Sinawat S, et al. Risk factors for
cervical cancer in northeastern Thailand: detailed analyses of sexual
and smoking behavior. Asian Pacific J Cancer Prevent 2012;13:5489-
95.
19 Sankaranarayanan R, Nene BM, Shastri SS, et al. HPV screening for
cervical cancer in rural India. N Engl J Med 2009;360:1385-94.
20 Soost HJ, Lang HJ, Lehmacher W, et al. The validation of cervical cytology.
Sensitivity, specificity, and predictive values. Acta Cytol 1991;35:8-14.
21 Vicus D, Sutradhar R, Lu Y, et al; Ontario Cancer Screening Research
Network. The association between cervical cancer screening and
mortality from cervical cancer: a population based case-control study.
Gynecol Oncol 2014;133:167-71.
22 ASCUS-LSIL Triage Study (ALTS) Group. Results of a randomized trial on
the management of cytology interpretations of atypical squamous cells
of undetermined significance. Am J Obstet Gynecol 2003;188:1383-92.
23 Kinney WK, Manos MM, Hurley LB, et al. Where’s the high-grade cervical
neoplasia? The importance of minimally abnormal Papanicolaou
diagnoses. Obstet Gynecol 1998;91:973-6.
24 American Congress of Obstetricians and Gynecologists (ACOG).
Management of abnormal cervical cancer test results and cervical
cancer precursors Practice Bulletin number 99, 2008.
25 Nanda K, McCrory DC, Myers ER, et al. Accuracy of the Papanicolaou
test in screening for and follow-up of cervical cytologic abnormalities: a
systematic review. Ann Inten Med 2000;132:810-9.
26 Katki HA, Kinney WK, Fetterman B, et al. Cervical cancer risk for women
undergoing concurrent testing for human papillomavirus and cervical
cytology: a population-based study in routine clinical practice. Lancet
Oncol 2011;12:663-72.
27 Zazove P, Reed BD, Gregoire L, et al. Low false-negative rate of PCR
analysis for detecting human papillomavirus related cervical lesions. J
Clin Microbiol 1998;36:2708-13.
28 Castle PE, Glass AG, Rush BB, et al. Clinical human papillomavirus
detection forecasts cervical cancer risk in women over 18 years of
follow-up. J Clin Oncol 2012;30:3044-50.
29 Saslow D, Solomon D, Lawson HW, et al. American Cancer Society,
American Society for Colposcopy and Cervical Pathology, and American
Society for Clinical Pathology screening guidelines for the prevention
and early detection of cervical cancer. Am J Clin Pathol 2012;137:516-
42.
30 Coleman DV, Poznansky JJ. Review of cervical smears from 76 women
with invasive cervical cancer: cytological findings and medicolegal
implications. Cytopathology 2006;17:127-36.
31 Aklimunnessa K, Mori M, Khan MM, et al. Effectiveness of cervical cancer
screening over cervical cancer mortality among Japanese women. Jpn J
Clin Oncol 2006;36:511-8.
32 Andrae B, Andersson TM, Lambert PC, et al. Screening and cervical
cancer cure: population-based cohort study. BMJ 2012;344:e900.
33 Dillner J. Primary human papillomavirus testing in organized cervical
screening. Curr Opin Obstet Gynecol 2013;25:11-6.
34 Eklund C, Forslund O, Wallin KL, et al. Global improvement in genotying
of human papillomavirus DNA: the 2011 HPV LabNet International
Proficiency Study. J Clin Microbiol 2014;52:449-59.
35 Cubie HA, Canham M, Moore C, et al. Evaluation of commercial HPV
assays in the context of post-treatment follow-up: Scottish Test of Cure
Study (STOCS-H). J Clin Pathol 2014;67:458-63.
36 Szarewkis A, Mesher D, Cadman L, et al. Comparison of seven tests for
high-grade cervical intraepithelial neoplasia in women with abnormal
smears: the Predictors 2 study. J Clin Microbiol 2012;50:1867-73.
37 Stoler MH, Wright TC Jr, Sharma A, et al. High-risk human papillomavirus
testing in women with ASC-US cytology. Results from ATHENA HPV study.
Am J Clin Pathol 2011;135:468-75.
For personal use only
38 Coquillard G, Palao B, Patterson BK. Quantification of intracellular HPV
E6/E7 mRNA expression increases the specificity and positive predictive
value of cervical cancer screening compared to HPV DNA. Gynecol Oncol
2011;120:89-93.
39 Pan Q-J, Hu S-Y, Guo H-Q, et al. Liquid-based cytology and human
papillomavirus testing: a pooled analysis using data from 13 population-
based cervical cancer screening studies from China. Gynecol Oncol
2014;133:172-9.
40 Mayrand MH, Duarte-Franco E, Rodrigues I, et al. Human papillomavirus
DNA versus Papanicolaou screening tests for cervical cancer. N Engl J Med
2007;357:1579-88.
41 Cox JT, Castle PE, Behrens CM, et al. Comparison of cervical cancer
screening strategies incorporating different combinations of cytology,
HPV testing, and genotyping for HPV 16/18: results from the ATHENA HPV
study. Am J Obstet Gynecol 2013;208:184e1-11.
42 Louvanto K, Chevarie-Davis M, Ramanakumar AV, et al. HPV testing with
cytology triage for cervical cancer screening in routine practice. Am J
Obstet Gynecol 2014;210:474.e1-7.
43 Zorzi M, del Mistro A, Farruggio A, et al. Use of a high-risk human
papillomavirus DNA test as the primary test in a cervical cancer screening
programme: a population-based cohort study. Br J Obstet Gynaecol
2013;120:1260-8.
44 Elfstrom KM, Smelov V, Johansson AL, et al. Long term duration of
protective effect for HPV negative women: follow-up of primary HPV
screening randomized controlled trial. BMJ 2014;348:g130.
45 Kitchener HC, Almonte M, Thomson C, et al. HPV testing in combination
with liquid-based cytology in primary cervical screening (ARTISTIC): a
randomised controlled trial. Lancet Oncol 2009;10:672-82.
46 Rijkaart DC, Berkhof J, Rozendaal L, et al. Human papillomavirus testing
for the detection of high-grade cervical intraepithelial neoplasia and
cancer: final results of the POBASCAM randomised controlled trial. Lancet
Oncol 2012;13:78-88.
47 Leinonen M, Nieminen P, Kotaniemi-Talonen L, et al. Age-specific
evaluation of primary human papillomavirus screening vs conventional
cytology in a randomized setting. J Natl Cancer Inst 2009;101:1612-23.
48 Ogilvie GS, Krajden M, van Niekerk DJ, et al. Primary cervical cancer
screening with HPV testing compared with liquid-based cytology: results
of round 1 of a randomised controlled trial—the HPV FOCAL Study. Br J
Cancer 2012;107:1917-24.
49 Ronco G, Giorgi-Rossi P, Carozzi F, et al. Efficacy of human papillomavirus
testing for the detection of invasive cervical cancers and cervical
intraepithelial neoplasia: a randomised controlled trial. Lancet Oncol
2010;11:249-57.
50 Ronco G, Dillner J, Elfström KM, et al, and the International HPV screening
working group. Efficacy of HPV-based screening for prevention of invasive
cervical cancer: follow-up of four European randomised controlled trials.
Lancet 2014;383:524-32.
51 Castle PE, Stoler MH, Wright TC, et al. Performance of carcinogenic human
papillomavirus (HPV) testing and HPV16 or HPV18 genotyping for cervical
cancer screening of women aged 25 years and older: a subanalysis of the
ATHENA study. Lancet Oncol 2011;12:880-90.
52 Naucler P, Ryd W, Tornberg S, et al. Efficacy of HPV DNA testing with
cytology triage and/or repeat HPV DNA testing in primary cervical cancer
screening. J Natl Cancer Inst 2009;101:88-99.
53 Koliopoulos G, Arbyn M, Martin-Hirsch P, et al. Diagnostic accuracy of
human papillomavirus testing in primary cervical screening: a systematic
review and meta-analysis of non-randomized studies. Gynecol Oncol
2007;104:232-46.
54 Wright TC Jr, Stoler MH, Sharma A, et al. Evaluation of HPV-16 and HPV-18
genotyping for the triage of women with high risk HPV + cytology negative
results. Am J Clin Pathol 2011;136:578-86.
55 Massad LS, Einstein MH, Huh WK, et al. 2012 updated consensus
guidelines for the management of abnormal cervical cancer screening
tests and cancer precursors. 2012 ASCCP Consensus Guidelines
Conference. J Low Genit Tract Dis 2013;17(5 suppl 1):S1-27.
56 Katki HA, Schiffman M, Castle PE, et al. Five-year risk of recurrence after
treatment of CIN 2, CIN3, or AIS: performance of HPV and pap cotesting in
posttreatment management. J Lower Gen Tract Dis 2013;17:S78-84.
57 Arbyn M, Ronco G, Anttila A, et al. Evidence regarding human papillomavirus
testing in secondary prevention of cervical cancer. Vaccine 2012;30S:F88-99.
58 Coupé VM, Berkhof J, Verheijen RH, et al. Cost effectiveness of human
papillomavirus testing after treatment for cervical intraepithelial
neoplasia. Br J Obstet Gynaecol 2007;114:416-24.
59 Smelov V, Elfström KM, Johansson AL, et al. Long-term HPV type-specific
risks of high-grade cervical intraepithelial lesions: A 14-year follow-up of a
randomized primary HPV screening trial. Int J Cancer 2014;136:1171-80.
60 Vintermyr OK, Iversen O, Thoresen S, et al. Recurrent high-grade cervical
lesion after primary conization is associated with persistent human
papillomavirus infection. Gynecol Oncol 2014;133:159-66.
61 Datta SD, Koutsky LA, Ratelle S, et al. Human papillomavirus infection
and cervical cytology in women screened for cervical cancer in the United
States 2003-2005. Ann Intern Med 2008;148:493-500.
62 Del Pino M, Rodriguez-Carunchio L, Alonso I, et al. Clinical, colposcopic
and pathological characteristics of cervical and vaginal high-grade lesions
negative for HPV by hybrid-capture 2. Gynecol Oncol 2011;122:515-20.
63 Schmeink CE, Massuger LF, Lenselink CH, et al. Effect of the menstrual
cycle and hormonal contraceptives on human papillomavirus detection
in young, unscreened women. Obstet Gynecol 2010;116:67-75.
10 of 14
 STAT E O F T H E A RT R E V I E W
64 Liu SH, Cummings DA, Zenilman JM, et al. Characterizing the temporal
dynamics of human papillomavirus DNA detectability using short-
interval sampling. Cancer Epid Biomark Prev 2014;23:200-8.
65 Natphopsuk S, Settheetham-Ishida W, Pientong C, et al. Human
papillomavirus genotypes and cervical cancer in northeast Thailand.
Asian Pacific J Cancer Prev 2013;14:6961-4.
66 Franceschi S, Herrero R, Clifford GM, et al. Variations in the age-specific
curves of human papillomavirus prevalence in women worldwide. Int J
Cancer 2006;119:2677-84.
67 De Sanjosé S, Quint WGV, Alemany L, et al. Human papillomavirus
genotype attribution in invasive cervical cancer: a retrospective cross-
sectional worldwide study. Lancet Oncol 2010;11:1048-56.
68 Goldie SJ, Gaffikin L, Goldhaber JD, et al. Cost-effectiveness of
cervical-cancer screening in five developing countries. N Engl J Med
2005;353:2158-68.
69 Suba EJ, Nguyen CH, Nguyen BD, et al. De novo establishment and cost-
effectiveness of Papanicolau cytology screening services in the socialist
republic of Vietnam. Cancer 2001;91:928-39.
70 Arbyn M, Sankaranarayanan R, Muwonge R, et al. Pooled analysis of
the accuracy of five cervical cancer screening tests assessed in eleven
studies in Africa and India. Int J Cancer 2008;123:153-60.
For personal use only
71 Sankaranarayanan R, Esmy PO, Rajkumar R, et al. Effect of visual
screening on cervical cancer incidence and mortality in Tamil Nadu,
India: a cluster-randomised trial. Lancet 2007;370:398-406
72 Paavonen J, Naud P, Salmerón J, et al. Efficacy of human papillomavirus
(HPV)-16/18 AS04-adjuvanted vaccine against cervical infection
and precancer caused by oncogenic HPV types (PATRICIA): final
analysis of a double-blind, randomized study in young women. Lancet
2009;374:301-14.
73 Dochez C, Bogers JJ, Verhelst R, et al. HPV vaccines to prevent cervical
cancer and genital warts: an update. Vaccine 2014;32:1595-601.
74 Arbyn M, Anttila A, Jordan J, et al, eds. European guidelines for
quality assurance in cervical cancer screening. 2nd ed. International
Agency for Research on Cancer, 2008. http://screening.iarc.fr/doc/
ND7007117ENC_002.pdf
75 WHO. Guidelines for screening and treatment of precancerous lesion for
cervical cancer prevention. 2013. www.who.int/reproductivehealth/
publications/cancers/screening_and_treatment_of_precancerous_
lesions/en/.
76 Kulasingam SL, Havrilesky LJ, Ghebre R, et al. Screening for cervical
cancer: a modeling study for the US preventive services task force. J Low
Genit Tract Dis 2013;17:193-202.
11 of 14