SOURIT CHAKROBORTY

Cervical Cancer and

HPV
• HPV is responsible for more than 99% of all cervical cancers.

• HPV is a common sexually transmitted DNA virus comprised of

more than 100 genotypes.

• HPV infections are very common and most women will clear
HPV infections within 6 to 12 months.

• The presence of HPV nucleic acid does not mean that cervical
dysplasia or cervical cancer is present.

• An effective approach for detection of cervical disease is to

target those oncogenic elements of HPV that foster persistent
viral infection and cellular transformation.
 HPV Genome

• The HPV viral genome is a double-stranded circular

DNA approximately 7900 base pairs in length.

• Fourteen HPV genotypes are considered pathogenic or

high-risk for cervical disease.

• Multiple studies have linked genotypes 16, 18, 31, 33,

35, 39, 45, 51, 52, 56, 58, 59, 66, and 68 to disease
progression.

• The E6 and E7 genes of high-risk HPV genotypes are

known oncogenes. Proteins expressed from E6/E7
mRNA alter cellular protein functions, leading to
disruption of cell-cycle check points and cell genome
instability.
Cervical cancer screening
Milestones & advancements

2011/2012
2006 Aptima® HPV Assay
ThinPrep® and Aptima®
Receives Glandular HPV 16 18/45
Indication Genotype Assay
1996 2003
ThinPrep® 2009
LBC Pap Test 1999 ThinPrep® Imaging Cervista® HPV HR &
1941 System
Conventional SurePath® LBC Cervista® HPV 16/18
Pap Test Genotyping Test
Pap Smear

1940 2011

1970s 1999
Research by hc2
2006 2009 2011
Harald zur Hausen Gardasil® cobas®
HPV Test Cervarix® HPV
HPV HPV
Vaccine
linking HPV to Vaccine Test
Cervical Cancer1

1. zur Hausen. Cancer Res. 1976;36:794.t

4
Cervical cancer screening evolution

THE CONVENTIONAL PAP SMEAR LIQUID-BASED CYTOLOGY

1
Limited
2
Improved
Sensitivity Sensitivity
Excellent Excellent
Specificity Specificity

HPV DNA TESTING HPV mRNA TESTING

3 4
Next
Excellent Generation
Sensitivity Excellent
Sensitivity
Limited
Specificity Increased
Specificity

5
Why HPV mRNA Testing?
DNA Expression of mRNA
Indicates Presence of HPV Indicates Presence and Activity of HPV

HPV Viral mRNA Expression by

Particles Active Virus

Viral DNA presence E6/E7 Oncoproteins

Genome Induce Carcinogenesis

• DNA tests detect only the presence of the viral DNA; the virus can be dead or dormant
• mRNA detects viral presence and activity.
• If the HPV virus is active the E6/E7 mRNA will be massively over-expressed and there will
be 1000‘s of copies of the mRNA, making it an excellent assay target. 6 Doorbar. Clinical Science 2006. 110(5):525-41
•https://www.youtube.com/watch?time_continue=19&v=40hYchtY_
cI&feature=emb_logo

7
mRNA and Cervical Disease
Aptima HPV Assay

• The Aptima HPV Assay is an in vitro nucleic acid

amplification test for the qualitative detection of E6/E7
viral mRNA from 14 high-risk types HPV in cervical
specimens.

• The high-risk HPV types detected by the assay include:

16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 66, and 68.

• The Aptima HPV Assay does not discriminate between

the 14 high-risk types.

• USFDA Approved

9
 Transcription Mediated
Amplification (TMA)
• The Aptima HPV Assay involves three main
steps:
• Target Capture
• Target Amplification by TMA
• Detection by HPA

• Single Tube Process

• Internal Control from start to finish monitors
the entire process
Cervical cancer
screening today
• “The optimal screening strategy should
identify those cervical cancer
precursors likely to progress to invasive
cancers (maximizing the benefits of
screening)…

• …and avoid the detection and

unnecessary treatment of transient HPV
infection and its associated benign
lesions that are not destined to become
cancerous (minimizing the potential
harms of screening)”
Cervical cancer
screening today
• “The optimal screening strategy should
High sensitivity
identify / Negative
those cervical cancerPredictive
Value (NPV)
precursors to detect
likely cancer
to progress to /invasive
cancer
cancers
risk(maximizing the benefits
and avoid false negativesof
screening)…

• …and avoid the detection and

unnecessary treatment of transient HPV
infection and its associated benign
lesions that are not destined to become
cancerous (minimizing the potential
harms of screening)”
 Aptima HPV
Same excellent clinical sensitivity as HPV DNA tests

Clinical sensitivity for CIN3+

• Aptima HPV is as sensitive as HPV DNA tests in screening and referral populations

Referral Population Screening Population

100%

75%

50%

25%

0% Szarewski_ Dockter_x Reuschen Clad_x000 Ratnam_x CLEAR_x0 Ovestad_x Szarewski_ Eaton_x00 Cuschieri_ Cubie_x00 Binniker_x Castle_x0 Wu_x000d CLEAR_x0 Ratnam_x Mon- Cuzick_x0 Nieves_x0 Cook_x00
x000d_20 000d_200 bach d_2011 000d_201 00d_2011 000d_201 x000d_20 0d_2012 x000d_20 0d_2014 000d_201 00d_2015 _2010 00d_2011 000d_201 sonego_x 00d_2013 00d_2013 0d_2017
08 9 _x000d_2 1_x000d_( _x000d_(A 1 12 14 4 _x000d_( 1_x000d_( 000d_201
010 Referral) SC-US) NILM) Screening) 1

Aptima® HC2 cobas

Across referral or screening populations, Aptima HPV Assay has demonstrated the same excellent sensitivity as DNA based tests
Cervical cancer
screening today
• “The optimal screening strategy should
identify those cervical cancer
precursors likely to progress to invasive
cancers (maximizing the benefits of
screening)…

• …and avoid the detection and

unnecessary treatment of transient HPV
infection and its associated benign
lesions that are not destined to become
cancerous (minimizing the potential
harms of screening)”
Cervical cancer
screening today
• “The optimal screening strategy should
identify those cervical cancer
precursors likely to progress to invasive
cancers (maximizing the benefits of
screening)…

• …and avoid the detection and

unnecessary treatment of transient HPV
High specificity
infection / Positivebenign
and its associated Predictive
Value
lesions (PPV)
that to reduce
are not unnecessary
destined to become
overtreatment
cancerous (minimizing the potential
harms of screening)”
 Aptima HPV
Improved specificity compared to HPV DNA tests

Clinical specificity for <CIN2+

• Aptima HPV is more specific than HPV DNA tests in screening and referral
populations

Referral Population Screening Population

100%

75%

50%

25%

0% Szarewski Dockter Reuschen Clad Ratnam CLEAR Ovestad Szarewski Eaton Cuschieri Cubie Binniker Castle Wu CLEAR Ratnam Mon- Iftner Cuzick Nieves Cook Iftner
2008 2009 bach 2011 2011 2011 2011 2012 2012 2014 2014 2014 2015 2010 2011 2011 sonego 2012 2013 2013 2017 2017
2010 (Referral) (ASC-US) (NILM) (Screen- 2011
ing)

Aptima® HC2 cobas

Aptima HPV shows a higher specificity compared to DNA based HPV tests in referral and screening populations
16
Aptima HPV reduces false-positives
Minimizing false positives helps clinicians Fewer false-positives
target the right patients for colposcopy
1400%

• Aptima HPV assay showed 24% fewer false- 1200%

positive at baseline and 29% at 3 year follow up 1000%

test results compared to a DNA-based test in the 800%
CLEAR trial1,2
600%
• Other studies have shown 16%, 24% and up to
400%
40% reduction in false-positives3,4,5
200%

0%

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AS

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1. APTIMA HPV Assay [package insert, AW-11141-001 Rev 003

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(EN)], San Diego, CA; Hologic Inc., 2015. Table #22.

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2. Reid et al, Am J Clin Pathol 2015.

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ei
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3. Cook et al (FOCAL), poster presented at IPV 2017
4. Iftner et al., (GAST) J. Clin. Microbiol. 2015 Aptima HPV DNA based test
5. Monsonego et al. Intl J Cancer 2011, 129: 691-701

17
Aptima HPV reduces
false-positives
• Minimizing false positives helps clinicians
target the right patients for colposcopy
• Minimize challenging conversations
with patients
• Reduce the physical and emotional
burdens on patients
• Reduce unnecessary colposcopies by
up to 21%
• Minimize the potential harms of
screening
• Reduce health care costs

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What does that mean to women?

Maximizing the benefits

• Detect every woman at true risk early to save her
health and life
• Especially important in primary HPV programs
with their longer intervals

Minimizing potential harms

• Protect women from unnecessary anxiety and
stress caused by a false-positive HPV test result
• Avoid mortality, fear and cost related to
unnecessary follow-up interventions

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 For women with
Aptima HPV positive results
Aptima HPV 16,
18/45 Genotype
2
0
Assay
Aptima HPV 16 18/45 Genotype Assay
• Aptima HPV GT Assay is an In vitro
nucleic acid amplification test for
women with Aptima HPV positive
results.
• Aptima HPV 16 18/45 genotype assay
can differentiate HPV 16 from HPV 18
and/or HPV 45
• It does not differentiate between HPV
18 and HPV 45.
• It is estimated that almost 75% of
cervical cancers are due to genotypes
16, 18 and 45
23
 Hologic provides complete solution for
cervical health screening

• HOLOGIC offers scalable

instrumentation solutions ready for any
algorithm:
• -the best LBC test and automation
• -the best HPV test and automation
• -the only LBC sample medium approved
for all FDA approved HPV tests

• From sample collection to primary testing and triage:

– Cutting edge technology for your service quality and efficiency
 Commercial HPV Tests
• DNA-based detection and genotyping assays:
• Hybrid Capture 2 (Qiagen) detecting 13 HR-HPV genotypes collectively.
• Cobas 4800 HPV test (Roche) detection of 14 HR HPV types. The test separately identifies HPV 16 and HPV 18, while
concurrently detecting the 12 remaining the high-risk types as a group (31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 66 and 68).
• Abbott RealTime High Risk HPV assay (Abbott) qualitative multiplex real-time test also separately identifies HPV 16 and
HPV 18 while concurrently detecting the 12 remaining high-risk types as a group (31, 33, 35, 39, 45, 51, 52, 56, 58, 59,
66 and 68).
• BD HPV test (BD Diagnostics). Real-time, which detects 14 HR HPV types. Type-specific detection is achieved using
sequence-specific (non-consensus) E6/E7 DNA amplification. Typing is provided for types 16, 18, 31, 45, 51, 52 and 59.
The remaining HPV types are grouped into two pools: (33, 56, 58, 66) and (35, 39, 68).
• RNA-based detection assays
• PreTect HPV-Proofer (NorChip Norway) real-time multiplex NASBA assay for isothermal amplification of E6/E7 mRNA
expressed by five high-risk HPV types (16, 18, 31, 33 and 45)
• APTIMA HPV Assay (Hologic). transcription-mediated amplification for the detection of E6/E7 mRNA expression of 14
HR HPV types. APTIMA HPV 16 18/45 genotype (AHPV-GT) assay specificially detects HPV 16, 18 and 45.
Relative sensitivity, specificity and PPV of different tests for the
detection of high-grade disease
Test Sensitivity (95% CI) Specificity (95% CI) PPV (%,all) (95% CI) PPV (%,only for those referred for colposcopy) (95% CI)
BD HPV
CIN3+ 100.0 (82.4–100.0) 2.0 (1.2–3.0) 16.5 (10.3–24.6)
CIN2+ 97.5 (86.8–99.9) 84.3 (83.3–85.2) 4.0 (2.9–5.5) 33.9 (25.3–43.3)
Roche Cobas
CIN3+ 100.0 (82.4–100.0) 2.0 (1.2–3.1) 16.7 (10.3–24.8)
CIN2+ 97.5 (86.8–99.9) 84.5 (83.6–85.4) 4.1 (2.9–5.5) 34.2 (25.6–43.7)
Qiagen Hybrid Capture 2
CIN3+ 100.0 (82.4–100.0) 2.1 (1.3–3.3) 16.0 (9.9–23.8)
CIN2+ 97.5 (86.8–99.9) 85.4 (84.5–86.3) 4.3 (3.1–5.8) 32.8 (24.4–42.0)
Abbott RealTime High Risk HPV
CIN3+ 94.7 (74.0–99.9) 2.2 (1.3–3.5) 16.1 (9.8–24.2)
CIN2+ 95.0 (83.1–99.4) 87.2 (86.3–88.0) 4.7 (3.4–6.5) 33.9 (25.3–43.5)
Hologic APTIMA
CIN3+ 100.0 (82.4–100.0) 3.1 (1.9–4.7) 17.4 (10.8–25.9)
CIN2+ 97.5 (86.8–99.9) 90.2 (89.5–91.0) 6.3 (4.5–8.5) 35.8 (26.8–45.5)
NorChip PreTect HPV-Proofera
CIN3+ 68.8 (41.3–89.0) 3.7 (1.9–6.5) 20.0 (10.4–33.0)
CIN2+ 71.4 (53.7–85.4) 95.2 (94.7–95.8) 8.4 (5.5–12.2) 45.5 (32.0–59.4)
British Journal of Cancer (2013) 108, 908–913 | doi: 10.1038/bjc.2013.22
  Excellent sensitivity & NPV

 8 year longitudinal evidence

 Significantly improved
specificity compared to DNA
assays

 Genotype 45 for increasing

adenocarcinoma trend

 Easiest, most cost efficient,

Aptima HPV Assay fully automated system

Key Messages
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Thank you