confidential: for review only - bmj.com · 4 department of obstetrics and gynaecology, erasmus mc,...

Confidential: For Review O

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CIN3 and cancer risks among screen and triage negative

women in cervical cancer screening: fourteen years follow-up of a randomized high-risk HPV DNA screening trial

Journal: BMJ

Manuscript ID BMJ.2016.034286

Article Type: Research

BMJ Journal: BMJ

Date Submitted by the Author: 29-Jun-2016

Complete List of Authors: Dijkstra, Maaike; VU University Medical Center, Pathology; VU University Medical Center, Obstetrics & Gynaecology van Zummeren, Marjolein; VU University Medical Centre, Pathology Rozendaal, Lawrence; VU Medical Center, Pathology van Kemenade, Folkert; Erasmus MC, Pathology Helmerhorst, Theo; Erasmus MC, Obstetrics & Gynaecology Snijders, Peter; VU University Medical Centre, Pathology Meijer, Chris; VU University Medical Center, Pathology Berkhof, Johannes; VU University Medical Centre, Epidemiology and Biostatistics

Keywords: Human Papillomavirus DNA Tests, Triage, Cervical intraepithelial neoplasia, grade III, Uterine Cervical Neoplasms, Longterm effects, Mass Screening

https://mc.manuscriptcentral.com/bmj

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Cervical screening with an interval beyond five years requires different

rescreen times for HPV-negative and HPV-positive, triage negative

women: fourteen years follow-up of the POBASCAM trial

Maaike G. Dijkstra*, obstetrics and gynaecology resident1,2, Marjolein van Zummeren*, research

fellow1, Lawrence Rozendaal, pathologist

1, Folkert J. van Kemenade, pathologist

3, Theo J.M.

Helmerhorst, gynaecologist4, Peter J.F. Snijders, molecular biologist

1, Chris J.L.M. Meijer,

pathologist1, Johannes Berkhof, statistician

5

* Both authors contributed equally

1 Department of Pathology, VU University Medical Centre, P.O. Box 7057, 1007MB Amsterdam, the Netherlands

2 Department of Obstetrics and Gynaecology, VU University Medical Centre, P.O. Box 7057, 1007MB Amsterdam, the

Netherlands

3 Department of Pathology, Erasmus MC, P.O. Box 2040, 3000CA Rotterdam, the Netherlands

4 Department of Obstetrics and Gynaecology, Erasmus MC, P.O. Box 2040, 3000CA Rotterdam, The Netherlands

5 Department of Epidemiology and Biostatistics, VU University Medical Centre, P.O. Box 7057, 1007MB Amsterdam, the

Netherlands

Address for correspondence

Johannes Berkhof, PhD

Department of Epidemiology and Biostatistics, VU University Medical Centre

P.O. Box 7057, 1007 MB Amsterdam, the Netherlands

Tel: +31-20-444 4474, e-mail: [email protected]

Key words

Human Papillomavirus DNA Tests; Triage; Cervical intraepithelial neoplasia, grade III; Uterine Cervical

Neoplasms; Long-term effects; Mass Screening

Word count

Abstract: 307 words

Manuscript: 3,192 words

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Abstract

Objectives: Human papillomavirus (HPV)-based cervical screening programmes with a screening

interval beyond five years, as will be implemented in the Netherlands in 2017, must be supported by

estimates of long-term cancer and pre-cancer incidences (CIN3+). The aim of the present study is to

provide an early risk assessment of a screening interval extension beyond five years.

Design: Data from three consecutive five-yearly screening rounds of a Dutch population-based

randomized screening cohort.

Setting: Organised cervical screening in the Netherlands.

Participants: 43,339 women aged 29-61 years participating in the POBASCAM trial.

Interventions: Women were randomly assigned to HPV and cytology co-testing (intervention) or

cytology testing only (control) and managed accordingly.

Main outcome measures: Cumulative cancer and CIN3+ incidences were calculated by Kaplan-

Meier methods. Associations with age were expressed as incidence rate ratios. In HPV positive,

cytology negative women, reductions in CIN3+ incidence after negative repeat cytology and/or HPV

16/18 genotyping were estimated.

Results: The cumulative cancer and CIN3+ incidences among HPV negative women in the

intervention group, after three rounds of screening (0.09% and 0.56%), were similar to those among

women with negative cytology in the control group after two rounds (0.09% and 0.69%). CIN3+

incidence was 70% lower among HPV negative women aged ≥40 years compared to younger women,

but for end-point cancer, no significant association with age could be demonstrated. The CIN3+

incidence rate among HPV positive women with negative HPV16/18 genotyping and repeat cytology

was 10.4 times higher than among HPV negative women.

Conclusions: The long-term cancer and CIN3+ incidences among HPV negative women are low and

supportive of an extension of the screening interval beyond five years. HPV positive, triage test

negative women have at least a tenfold higher CIN3+ risk than HPV negative women indicating that

HPV-based programmes with long intervals (>five years) are preferably implemented together with

risk-stratification.

Trial registration: POBASCAM trial; ISRCTN20781131

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What this paper adds” box

What is already known on this subject

� Randomised controlled trials have shown that primary HPV-based cervical screening leads to

earlier detection of CIN3 than cytology screening and provides a better protection against

cervical cancer.

� Evidence on the safety of screening intervals beyond five years is limited.

What this study adds

� The cumulative cancer and CIN3+ incidences among HPV negative women after three five-

yearly screening rounds are similar to those among cytology negative women after two

rounds.

� HPV-based programmes with long (≥five years) screening intervals are preferably

implemented together with risk stratification because HPV positive, triage negative women

have at least a tenfold higher CIN3+ risk than HPV negative women.

� Age-dependent screening intervals, as implemented in the Netherlands where the five years

interval is extended to ten years for HPV negative women of ≥40 years, are supported by

CIN3+ risk estimates but data on cancer risk are inconclusive.

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Introduction

Randomised controlled clinical trials have shown that primary high-risk human papillomavirus (HPV)

screening leads to earlier detection of cervical intraepithelial neoplasia (CIN) grade 3 or worse (CIN3+)

than cytology1–4

, and provides better protection against cervical cancer.5–10

HPV tests are more often

positive than cytology in the general screening population and triage testing of HPV positive women by

cytology and HPV16/18 genotyping has been recommended to prevent overdiagnosis.11–15

The screening programme may be further optimized by reducing the number of screening rounds. It

has been suggested to define separate intervals for HPV positive, triage test negative and HPV

negative women as they have substantially different CIN3+ risks.1,16–18

Stratification of screened

women on the basis of their HPV (DNA) test result will, however, add to the complexity of the

programme and should be supported by evidence from longitudinal studies.

Several countries have decided or recommended to implement HPV screening as a single primary

screening test (Australia, Italy, Netherlands, New Zealand, Sweden, UK) or in combination with

cytology (United States). In countries with two to three yearly screening, the interval will be extended

to five or seven years. In the Netherlands, the screening interval for HPV negative women aged ≥40

years will be extended from five to ten years. This extension is based on predictions from cost-

effectiveness models.19,20

However there is a remaining concern about an increase in the number of

interval cancers21

and hence, policy decisions should also be supported by estimates of long-term

cancer and pre-cancer incidences (CIN3+ risk) when available.

We assessed fourteen-year risks of histologically confirmed cancer and CIN3+, in women aged 29

years and older, who participated in a population-based randomised controlled trial (Population-Based

Screening study Amsterdam, POBASCAM).5 A follow-up of fourteen years comprises three screens,

i.e., at baseline, and after five and ten years. Women were randomly assigned to receive HPV and

cytology co-testing (intervention), or cytology testing only (control). Our aims were to compare cancer

and CIN3+ incidences, obtained when using HPV testing with those obtained when using cytology

testing, and to evaluate the safety of extending the screening interval beyond five years in HPV

negative women and in HPV positive, triage test negative women.

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Materials and methods

Study population

The design of the POBASCAM study has been published.1,5,15,22

In short, from January, 1999 to

September, 2002, women between 29-61 years of age were invited to participate in cervical screening

and randomised either to the intervention group (cytology and HPV testing) or the control group

(cytology with blinded HPV testing). In total 44,938 women were enrolled, 22,420 of whom were

randomised to the intervention group and 22,518 to the control group (see Figure 1A).

In the intervention group, HPV and cytology negative (double negative) women were referred to

routine five-yearly screening. Women with moderate dyskaryosis or worse cytology (comparable to

>ASC-US/LSIL) were directly referred for colposcopy. HPV positive women with negative cytology and

women with borderline or mild dyskaryosis cytology (comparable to ASC-US/LSIL) were advised to

repeat HPV and cytology testing at six and eighteen months. They were referred for colposcopy if they

were HPV positive or their cytology result was moderate dyskaryosis or worse.

In the control group, women with negative cytology were referred to routine screening and women with

moderate dyskaryosis or worse were immediately referred for colposcopy. Women with borderline or

mild dyskarysosis cytology were advised to repeat cytology at six and eighteen months and were

referred to colposcopy if their repeat cytology result was borderline dyskaryosis or worse.

At the second screening round at five years, participants in both study groups were managed

according to their co-test result. At the third screening round at ten years, participants in both study

groups were managed according to their cytology result.

A conventional Pap smear was prepared on a glass slide after which the brush was placed in a vial

for GP5+/6+ PCR EIA HPV testing.22,23

Cytology and HPV testing were performed without knowledge

of the other test result. HPV positive samples were genotyped by a previously published reverse line

blot assay.24

The POBASCAM trial is approved by both the Medical Ethics Committee of the VU University Medical

Center (number 96/103A) and the Ministry of Public Health (VWS nr 328 650), and is registered as

ISRCTN20781131.

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Histology

Histological follow-up data were tracked through the nationwide network and registry of histo- and

cytopathology (PALGA).25

Histology was examined locally, and classified as no dysplasia, CIN grade

1,2,3, or invasive cancer according to international criteria.26

Adenocarcinoma in situ was included in

the CIN3 group. Treatment by loop electrosurgical excision procedure was recommended after CIN2

or CIN3, whereas cancer was treated depending on cancer stage and according to national

guidelines.

Statistical analysis

We included women from the intervention and control group with a negative HPV test or negative

cytology. Follow-up data were collected until October 2013 at which time all women had had the

opportunity of three rounds of five-yearly screening. Events occurring after fourteen years were

excluded because they are likely to be detected at the fourth screen after baseline. The censoring

date was decreased to the date at which an interrupting event, e.g. CIN2+ excision or uterus

extirpation, had occurred. When no screening test results had been reported at the third screen, the

censoring date was decreased to nine years after the study entry date. When no screening test results

had been reported at the second nor the third screen, the censoring date was decreased to four years.

Statistical analyses were carried out in SPSS Statistics for Windows, Version 20.0 (IBM Corp, Armonk,

NY) and Stata Statistical Software Release 11 (StataCorp, College Station, TX).

Cancer and CIN3+ cumulative incidences were estimated by Kaplan-Meier. Separate estimates were

reported for combined HPV and cytology strata from the intervention- and control group. Cytology was

labelled positive when the result was borderline dyskaryosis or worse (≥ASC-US/LSIL) and labelled

negative otherwise. Subgroup differences were evaluated by log-rank testing. Cancer and CIN3+

incidence rates were also reported and differences between subgroups were evaluated by Wald

testing.

To determine the level of reassurance from a negative test result, we compared the cumulative cancer

and CIN3+ incidences among HPV negative and double negative women from the intervention group

with those among cytology negative women from the control group. Furthermore, as the new Dutch

HPV-based screening programme involves an extension of the screening interval for women ≥40

years and older but not for younger women, we studied the effect of age (≥40 and <40 years) on

cancer and CIN3+ incidences among double negative and HPV negative women. Since age-specific

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CIN3+ and cancer incidences were similar in intervention and control group (log-rank p-values for end-

points cancer and CIN3+ >0.2), they were pooled over the two study groups.

Finally, in the intervention group, we compared the cancer and CIN3+ incidences among women with

a negative HPV test to those among women with a HPV positive, triage negative test. Four different

triage strategies were constructed by combining cytology at baseline, HPV16/18 genotyping at

baseline and repeat cytology testing at six months. These strategies were identified in previous post-

hoc analyses of triage algorithms and include the two times cytology triage strategy (baseline and

repeat cytology) that will be used in the new HPV-based screening programme in the Netherlands.13,15

Patient involvement

Study participants of the POBASCAM trial were enrolled from year 1999-2002 by their general

practitioner when attending the nationwide screening programme and provided written informed

consent. The general practitioners were invited to attend postgraduate medical education courses to

optimally inform the study participants. The participants were not individually involved in the

development of the research question or study design. The outcome measures were not directly

informed by patient priorities, experience and preferences, because POBASCAM is a screening trial

where outcomes are collected via PALGA. However study outcomes include screening related burden

measures such as test positivity, colposcopy referral rate and CIN detection rate.

As described in the study protocol, women in the intervention group were informed about their HPV

and cytology results. Women in the control group were only informed about their cytology results

(regular screening).22

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Results

In total, 43,339 women were included in this study (see Figure 1A). From the 21,623 women in the

intervention group, 20,490 had double negative test results, 764 had negative cytology with a positive

HPV result and 369 had positive cytology with a negative HPV result (see Figure 1B). In the control

group, 21,716 women were included. In this group, 20,533 women had double negative test results,

814 had negative cytology with a positive HPV result and 369 had positive cytology with a negative

HPV result. The mean age was 42.8 (range 29-61) in both study groups. Among women that were,

based on their age, eligible for at least two screening rounds, non-attendance in both the second and

third screen after enrolment was 9.3% (1,817/19,622) in the intervention group, and 9.7%

(1,916/19,772) in the control group. Among women that participated at the second screen and were

eligible for the third screen, non-attendance was 15.7% (2,450/15,572) in the intervention group, and

15.5% (2,416/15,579) in the control group.

Over fourteen years of follow-up, in the intervention group, 149 CIN2, 152 CIN3, including five

adenocarcinomas in situ, eight squamous cell carcinomas and six adenocarcinomas were detected

(Figure 1B). In the control group, 126 CIN2, 169 CIN3, including five adenocarcinomas in situ,

seventeen squamous cell carcinomas and ten adenocarcinomas were detected. Table 1 shows

incidence rates for both study groups, separately for women with negative cytology and a positive HPV

test, positive cytology and a negative HPV test, and those with double negative test results. Among

women with negative cytology and a positive HPV test, the cancer incidence rate was significantly

lower in the intervention group than in the control group (rate ratio 0.29, 95%CI 0.10 – 0.87, p-value

0.020). For the other cytology and HPV test strata, the cancer incidences rate did not differ

significantly between intervention and control group. For none of the cytology and HPV test strata,

CIN3+ incidence rate showed a significant difference between the intervention and control group.

Cumulative cancer and CIN3+ incidences after two and three screens (corresponding with nine and

fourteen years after baseline, respectively) are displayed in Figure 2. Two-and three-round cancer

incidences were 0.03% (95%CI 0.003 – 0.05%) and 0.09% (95%CI 0.02 – 0.15%) among HPV

negative women from the intervention group, 0.01% (95%CI 0.00 – 0.03%) and 0.07% (95%CI 0.01 –

0.13%) among double negative women from the intervention group, and 0.09% (95%CI 0.04 – 0.13%)

and 0.19% (95%CI 0.11 – 0.26%) among cytology negative women from the control group. Two- and

three-round CIN3+ incidences were 0.31% (95%CI 0.23 – 0.40%) and 0.56% (95%CI 0.43 – 0.69%)

among HPV negative women from the intervention group, 0.27% (95%CI 0.19 – 0.35%) and 0.52%

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(95%CI 0.40 – 0.65%) among double negative women from the intervention group, and 0.69% (95%CI

0.56 – 0.81%) and 1.20% (95%CI 1.00 – 1.40%), among cytology negative women from the control

group. The three-round cancer incidences among HPV negative and double negative women were

similar to the respective two round incidences among cytology negative women, indicating that a

negative HPV test provides longer reassurance against cancer than negative cytology. The CIN3+

incidence among HPV negative and double negative women from the intervention group was slightly

lower after three rounds of screening than the two round CIN3+ incidence among cytology negative

women from the control group.

Among women with double negative test results pooled over the intervention and control group, the

cancer incidence rate was 64.2% (95%CI -37.6 – 332) higher in women ≥40 years than in younger

women. This increase was not statistically significant (p-value 0.32). CIN3+ incidences were 72.2%

(95%CI 60.5 – 80.4, p-value <.001) lower in women ≥40 years than in younger women. Among HPV

negative women, similar incidence rate changes were observed (62.0% for end-point cancer and

72.2% for CIN3+).

In women from the intervention group, the cervical cancer incidence among HPV positive women with

negative cytology triage was 11.9 (95%CI: 3.7 – 38.1; p-value <.001) times higher than among HPV

negative women. When HPV16/18 genotyping or repeat cytology was added as triage test, only one

cancer case was observed. Cumulative CIN3+ incidences are displayed in Figure 3. Cumulative CIN3+

incidences among HPV positive, triage test negative women were substantially higher than among

HPV negative women (p-values <.001). The fold increases in CIN3+ incidence rates, relative to the

CIN3+ incidence rate after a negative HPV test, were 29.1 (95%CI: 21.5 – 39.5) after positive HPV -

and negative cytology test, 18.5 (95%CI: 12.5 – 27.3) after positive HPV- and negative baseline and

repeat cytology tests, 15.5 (95%CI: 10.2 – 23.5) after positive HPV- and negative HPV16/18 test , and

10.4 (95%CI: 5.9 – 18.4;) after positive HPV-, negative HPV16/18 and negative baseline and repeat

cytology tests.

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Discussion

This study is the first to report on fourteen-year follow-up data of a large population-based screening

cohort i.e. the Dutch POBASCAM trial, with a five-year screening interval, in which participants were

managed on the basis of both cytology- and HPV test results. Our findings on the long-term protective

effect of a HPV negative test are consistent with previously reported data.4–6,8–10,16–18,27,28

Together,

these publications indicate that HPV-based screening provides significantly better protection against

CIN3 than cytology-based screening, and that compared to primary HPV testing the value of primary

HPV and cytology co-testing is limited. Our data also provide a long-term confirmation of the protective

effect against invasive cervical carcinomas, as previously described by Ronco et al.8

The major strengths of the current study are the large size, the long follow-up, and wide age range of

participants (29-61 years). Besides, the study is nested within a population-based screening

programme, indicating that results should be scalable to the country level. A limitation to our study is

that the presented cancer and CIN3+ incidence estimates were not adjusted for imperfections in

screen detection and diagnostic work-up. We think that this will not change the general picture, but it

may have a modest effect on the absolute incidence estimates. The following three points may

attribute to bias. Firstly, the third screen after study entry uses cytology only, and thus newly

developed CIN3 cases may have been missed. Secondly, we had no information on gynaecological

procedures, and therefore, were not able to assess how many cases were missed because women did

not comply with the colposcopy advice. Thirdly, the histological diagnoses themselves were performed

by local pathologists and may be subject to ascertainment bias. However, in earlier publications we

showed that inter-observer reliability of CIN3+ was very high (absolute agreement 0.97).5,22

The current cytological-based screening in the Netherlands has a five-year interval which provides a

cumulative five-year CIN3+ risk after a negative screen below one percent.29

A screening interval of

ten years for HPV negative women ≥40 years will be incorporated in the new primary HPV-based

screening programme that will start in 2017.21

Our data indicate that good safety at the level of both

cancer and CIN3+ risk is provided by extending the interval from five to ten years as the three-round

risks after a negative HPV test are similar to the respective two-round risks after negative cytology. In

the new HPV-based screening programme, the screening interval will only be extended among women

≥40 years. This age-specific recommendation is partially supported by our data as the CIN3+ risk in

women ≥40 years was estimated to be 70% lower than in younger women but cancer risks did not

decrease with age. Despite our analyses, the risk of an increase in interval cancers remains a point of

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concern. Controlling both cancer and CIN3+ risks is reassuring but an increase in the cancer risk

cannot be ruled out completely as long as the interval has not actually been extended. Therefore, it

remains important to closely monitor the number of interval cancers observed under the new HPV-

based screening programme.

Several other studies have also recommended extending the interval after a negative HPV test.

Recently, Elfström et al.18

reported on the potential for extending the screening interval with primary

HPV-based screening and recommended, based on CIN3+ risks, an extension from three to five years

for Sweden. A similar analysis was provided on the basis of six-years follow-up of the ARTISTIC

screening trial in the UK, which supported an extension of the interval from three to six years after a

negative HPV test.27

Ronco et al8 pooled data of four screening trials and recommended an extension

to five years after negative HPV testing when replacing a three-yearly cytological screening

programme. Katki et al.17

recommended an extension for the US from one year after negative cytology

to three years after a negative HPV test and up to five years after a negative co-test. Both studies

based their recommendations on estimated cancer risks. To summarize, recommendations are

consistent in the different studies. Extensions to ten years as in our analysis have not yet been studied

because other countries used one to three yearly cytological-based screening intervals as a

benchmark in their analyses.

Another conclusion that can be drawn from our data is that a long interval of ten years is supported

only for HPV negative women and not for HPV positive, triage negative women. The cancer and

CIN3+ risks among HPV positive, triage negative women, were at least ten times higher than those

among HPV negatives for all four triage strategies. Triaging distinguishes HPV positive women with

and without underlying CIN3+13,15

, but apparently does not offer additional reassurance against future

CIN3 or cervical cancer over a longer period of follow-up. Another Dutch screening study, in which

women were followed for five years, reached a similar conclusion.30

A US study evaluating the value of

three-yearly co-testing to identify women at high risk of CIN3+, also concluded that HPV positive

women with negative cytology accrued substantial risk of CIN3+ over five years, and thus require

follow-up.17

The use of the HPV test result and age to define the year of next screen is a first step towards risk-

based screening. Tailoring screening to individual risks may lead to a more efficient screening

programme and eventually provide optimal prevention for all women. However, risk stratification also

adds to the complexity of the programme and it may become challenging to maintain a high quality

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screening programme. An important prerequisite for a risk-based programme is the availability of a

linked digitalized screening registry and invitation system. Such a system is not yet in place in every

country with an organized programme. Linking of screening and invitation systems is however

recommendable, since the benefits of risk-based screening are expected to become even larger in the

future. Then, individual cancer risks can be based on information from multiple HPV screening rounds

and vaccination status yielding individual risk assessments that will strongly deviate from average

risks. This will offer substantial room for further optimization of resource allocation in the health care

system.

In summary, our results indicate that primary HPV screening provides superior long-term protection

against cervical cancer compared to cytology testing. HPV negative women have a very low long-term

CIN3+ risk, indicating extension of the screening interval to ten years seems justifiable. For HPV

positive, triage negative women the long-term CIN3+ risk was too high to support an extension of the

screening interval beyond five years for any of the used triage strategies.

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Acknowledgments

We gratefully acknowledge all women and general practitioners participating in the POBASCAM trial.

We also thank the research staff and technicians of the unit of Molecular Pathology of the Department

of Pathology at the VU University Medical Center Amsterdam for HPV testing and genotyping, the

cytotechnologists of the Spaarne Gasthuis (Hoofddorp / Haarlem), LCPL-Pathan cytology and

pathology laboratory (Rijswijk), and VU University medical Centre (Amsterdam) for cytological testing

and logistics, and the administrative workers and the information technology team of the Department

of Pathology, VU University Medical Center, Amsterdam for their supportive work.

Details of contributors

CJLMM is principal investigator of the POBASCAM study and CJLMM and JB led this follow-up study.

MGD, LR, FJVK, TJMH, PJFS and CJLMM were involved in data collection. MVZ and LR collected the

clinical follow up data. JB and MVZ analysed the data. LR managed the database. MGD, MVZ,

CJLMM and JB drafted the manuscript. All authors critically reviewed the manuscript and approved the

final version. All authors had full access to all of the data in the study and can take responsibility for

the integrity of the data and the accuracy of the data analysis. JB affirms that the manuscript is an

honest, accurate, and transparent account of the study being reported; that no important aspects of

the study have been omitted; and that any discrepancies from the study as planned have been

explained.

Conflicts of interests

All authors have completed the ICMJE uniform disclosure at www.icmje.org/coi_disclosure.pdf and

declare that: (1) PJFS has been on the speakers bureau of Roche, Gen-Probe, Abbott, Qiagen and

Seegene and has been a consultant for Crucell B.V; (2) CJLMM has been on the speakers bureau of

GlaxoSmithKline, Qiagen, Merck/SPMSD, Roche, Menarini and Seegene, and has served

occasionally on the scientific advisory board of GlaxoSmithKline, Qiagen, Merck/SPMSD, Roche and

Genticel, and has occasionally been consultant for Qiagen; (3) JB has received speakers’ fees from

Qiagen and consultancy fees from Roche, DDL Diagnostic Laboratory, GlaxoSmithKline and

Merck/SPMSD; all JB’s fees were collected by his employer; (4) formerly, CJLMM was a minority

shareholder of Delphi Biosciences, which bankrupted in 2014; (5) CJLMM has been a minority

shareholder of Diassay B.V.; (6) CJLMM and PJFS are minority shareholders of Self-Screen B.V., a

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spin-off company of VU University Medical Center; (7) Self-Screen B.V. holds a patent on the HPV risk

test; (8) MGD, MVZ, LR, FJVK and TJMH do not have any conflicts of interest to disclose.

Funding statement

This work was supported by the Netherlands Organisation for Health research and Development (Zorg

Onderzoek Nederland), grant number 30-05220 for the POBASCAM study, and by EC FP7 Health

2013 Innovation 1 CoheaHr, grant number 603019. The funders had no role in the study design, data

collection, data analysis, data interpretation, or writing of the report.

Data sharing statement

Data sharing: no additional data available.

Exclusive licence

The Corresponding Author has the right to grant on behalf of all authors and does grant on behalf of

all authors, a worldwide licence

(http://www.bmj.com/sites/default/files/BMJ%20Author%20Licence%20March%202013.doc) to the

Publishers and its licensees in perpetuity, in all forms, formats and media (whether known now or

created in the future), to i) publish, reproduce, distribute, display and store the Contribution, ii)

translate the Contribution into other languages, create adaptations, reprints, include within collections

and create summaries, extracts and/or, abstracts of the Contribution and convert or allow conversion

into any format including without limitation audio, iii) create any other derivative work(s) based in whole

or part on the on the Contribution, iv) to exploit all subsidiary rights to exploit all subsidiary rights that

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the Contribution to third party material where-ever it may be located; and, vi) licence any third party to

do any or all of the above.

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3. Naucler P, Ryd W, Törnberg S, Strand A, Wadell G, Elfgren K, et al. Human papillomavirus and Papanicolaou tests to screen for cervical cancer. N Engl J Med 2007;357(16):1589–97.

4. Kitchener HC, Almonte M, Thomson C, Wheeler P, Sargent A, Stoykova B, et al. HPV testing in combination with liquid-based cytology in primary cervical screening (ARTISTIC): a randomised controlled trial. Lancet Oncol. 2009;10(7):672–82.

5. Rijkaart DC, Berkhof J, Rozendaal L, van Kemenade FJ, Bulkmans NWJ, Heideman DAM, 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(1):78–88.

6. Ronco G, Giorgi-Rossi P, Carozzi F, Confortini M, Palma PD, Del Mistro A, 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(3):249–57.

7. Anttila A, Kotaniemi-Talonen L, Leinonen M, Hakama M, Laurila P, Tarkkanen J, et al. Rate of cervical cancer, severe intraepithelial neoplasia, and adenocarcinoma in situ in primary HPV DNA screening with cytology triage: randomised study within organised screening programme. BMJ. 2010;340:c1804.

8. Ronco G, Dillner J, Elfström KM, Tunesi S, Snijders PJF, Arbyn M, et al. Efficacy of HPV-based screening for prevention of invasive cervical cancer: Follow-up of four European randomised controlled trials. Lancet. 2014;383(9916):524–32.

9. Arbyn M, Ronco G, Anttila A, Meijer CJLM, Poljak M, Ogilvie G, et al. Evidence regarding human papillomavirus testing in secondary prevention of cervical cancer. Vaccine 2012;30 Suppl 5:F88–99.

10. Gage JC, Schiffman M, Katki HA, Castle PE, Fetterman B, Wentzensen N, et al. Reassurance against future risk of precancer and cancer conferred by a negative human papillomavirus test. J Natl Cancer Inst. United States; 2014 Aug;106(8).

11. Castle PE, Stoler MH, Wright TC, Sharma A, Wright TL, Behrens CM. 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(9):880–90.

12. Wright TC, Stoler MH, Sharma A, Zhang G, Behrens C, Wright TL, 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(4):578–86.

13. Rijkaart DC, Berkhof J, Van Kemenade FJ, Coupe VMH, Hesselink AT, Rozendaal L, et al. Evaluation of 14 triage strategies for HPV DNA-positive women in population-based cervical screening. Int J Cancer. 2012;130(3):602–10.

14. Naucler P, Ryd W, Tornberg S, Strand A, Wadell G, Elfgren K, 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(2):88–99.

15. Dijkstra MG, Van Niekerk D, Rijkaart DC, Van Kemenade FJ, Heideman DAM, Snijders PJF, et al. Primary hrHPV DNA testing in cervical cancer screening: How to manage screen-positive women? a POBASCAM trial substudy. Cancer Epidemiol Biomarkers Prev. 2014;23(1):55–63.

16. Castle PE, Glass AG, Rush BB, Scott DR, Wentzensen N, Gage JC, et al. Clinical human papillomavirus detection forecasts cervical cancer risk in women over 18 years of follow-up. J Clin Oncol. 2012;30(25):3044–50.

17. Katki HA, Kinney WK, Fetterman B, Lorey T, Poitras NE, Cheung L, 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(7):663–72.

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18. Elfström KM, Smelov V, Johansson AL V, Eklund C, Nauclér P, Arnheim-Dahlström L, et al. Long term duration of protective effect for HPV negative women: follow-up of primary HPV screening randomised controlled trial. BMJ 2014;348(January):g130.

19. Berkhof J, Coupé VM, Bogaards JA, Van Kemenade FJ, Helmerhorst TJ, Snijders PJ, et al. The health and economic effects of HPV DNA screening in the Netherlands. Int J Cancer. 2010;127(9):2147–58.

20. Van Rosmalen J, De Kok IMCM, Van Ballegooijen M. Cost-effectiveness of cervical cancer screening: Cytology versus human papillomavirus DNA testing. BJOG An Int J Obstet Gynaecol. 2012;119(6):699–709.

21. Noordaa J van der, Ansink AC, Ballegooijen M van, Beaufort ID de, Bindels PJE, Dissel JT van, et al. Report Dutch Health Counsil: Screening for cervical cancer. 2011

22. Bulkmans NWJ, Rozendaal L, Snijders PJF, Voorhorst FJ, Boeke AJP, Zandwijken GRJ, et al. POBASCAM, a population-based randomized controlled trial for implementation of high-risk HPV testing in cervical screening: Design, methods and baseline data of 44,102 women. Int J Cancer. 2004;110(1):94–101.

23. Jacobs M V., Snijders PJF, Van den Brule AJC, Helmerhorst TJM, Meijer CJLM, Walboomers JMM. A general primer GP5+/GP6+-mediated PCR-enzyme immunoassay method for rapid detection of 14 high-risk and 6 low-risk human papillomavirus genotypes in cervical scrapings. J Clin Microbiol. 1997;35(3):791–5.

24. Van Den Brule AJC, Pol R, Schouls LM, Meijer CJLM, Snijders PJF, Fransen-daalmeijer N. GP5+/6+ PCR followed by Reverse Line Blot Analysis Enables Rapid and High-Throughput Identification of Human Papillomavirus Genotypes. J Clin Microbiol. 2002;40(3):779–87.

25. Casparie M, Tiebosch T, Burger G, Blauwgeers H, van de Pol A, van Krieken JHJM, et al. Pathology databanking and biobanking in The Netherlands, a central role for PALGA, the nationwide histopathology and cytopathology data network and archive. Cell Oncol. 2007;29(1):19–24.

26. M.C. Anderson. Premalignant and malignant squamous lesions of the cervix. Obstetrical and gynaecologcial pathology. 1995. p. 292–7.

27. Kitchener HC, Gilham C, Sargent A, Bailey A, Albrow R, Roberts C, et al. A comparison of HPV DNA testing and liquid based cytology over three rounds of primary cervical screening: Extended follow up in the ARTISTIC trial. Eur J Cancer. 2011;47(6):864–71.

28. Smelov V, Elfstrom KM, Johansson ALV, Eklund C, Naucler P, Arnheim-Dahlstrom L, 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. 2015;136:1171–80.

29. van der Veen N, Carpay M, van Delden J, Brouwer E, Grievink L, Hoebee B, et al. Rijkstinstituut voor Volksgezondheid en Milieu. Uitvoeringstoets wijziging bevolkingsonderzoek baarmoederhalskanker. RIVM rapport 225121002/2013. 2013

30. Uijterwaal MH, Polman NJ, Van Kemenade FJ, Van Den Haselkamp S, Witte BI, Rijkaart D, et al. Five-year cervical (pre)cancer risk of women screened by HPV and cytology testing. Cancer Prev Res. 2015;8(6):502–8.

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Figure 1: POBASCAM consort flow diagram with A) an overview POBASCAM study and selection and B) 14 years follow-up analysis

A

B ≥BMD = Borderline or Mild Dyskaryosis or worse; HPV = Human PapillomaVirus; NTD = Not To Determine; CIN0/1 = no dysplasia or Cervical Intraepithelial Neoplasia grade 1; CIN2/3 = Cervical Intraepithelial Neoplasia grade 2 or 3; ACIS = AdenoCarcinoma In Situ; SCC = Squamous Cell Carcinoma; AdCa = AdenoCarcinoma

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Figure 2: Cumulative incidence of A) cervical cancer and B) CIN3+ per trial group and baseline screening result A B

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Figure 3: Cumulative CIN3+ incidence following different triage strategies in the intervention group

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Table 1: Incidence rates per study group, shown for women with cytology negative or a HPV negative test result See attachment

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Confidential: For Review Only

Table 1. Incidence rates per study group, shown for women with cytology negative and/or a HPV negative test result$

Woman years Cancer CIN3+ Cervical cancer CIN3+

Intervention group

Cyt - / HPV - 211,544 7 74 3.3 (1.6 - 6.9) 35.0 (27.9 - 43.9)

Cyt - / HPV + 7,224 4 82 55.4 (20.8 - 147.5) 1,135.1 (914.2 - 1,409.4)

Cyt + / HPV - 3,764 3 10 79.7 (25.7 - 247.1) 265.7 (143.0 - 493.8)

Control group

Cyt - / HPV - 211,590 12 86 5.7 (3.2 - 10.0) 40.7 (32.9 - 50.2)

Cyt - / HPV + 7,859 15 94 190.9 (115.1 - 316.6) 1,196.1 (977.2 - 1,464.1)

Cyt + / HPV - 3,746 0 16 13.4* (0.8 - 213.4) 427.1 (261.7 - 697.2)

Cervical cancer CIN3+

Intervention group

versus control group

Cyt - / HPV - 0.58 (0.23 - 1.48) 0.86 (0.63 - 1.17)

Cyt - / HPV + 0.29 (0.10 - 0.87) 0.95 (0.71 - 1.28)

Cyt + / HPV - 5.97* (0.30 - 119.22) 0.62 (0.28 - 1.37)

$ Including only women with valid test results for both cytology and HPV testing

* Cancer count 0 replaced by 0.5

(95% confidence interval)

Incidence rate per 100,000 woman years

Count (95% confidence interval)

Incidence rate ratio

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confidential: for review only - bmj.com · 4 department of obstetrics and gynaecology, erasmus mc,...

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