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Results From Women in a High-Risk Province of Costa Rica

Mark Schiffman, MD, MPH; Rolando Herrero, MD; Allan Hildesheim, PhD; Mark E. Sherman, MD; Maria Bratti, MD; Sholom Wacholder, PhD; Mario Alfaro, MD; Martha Hutchinson, MD; Jorge Morales, MD; Mitchell D. Greenberg, MD; Attila T. Lorincz, PhD

JAMA. 2000;283:87-93.

Context  Human papillomaviruses (HPVs) are known to cause most cervical cancer worldwide, but the utility of HPV DNA testing in cervical cancer prevention has not been determined.

Objective  To provide comprehensive data on the screening performance of HPV testing for the most common carcinogenic types, at different levels of analytic sensitivity.

Design  Laboratory analysis conducted during 1993-1995, using 3 cytologic techniques and cervicography, followed by colposcopic examination of women with any abnormal cervical finding, to detect all high-grade intraepithelial lesions and cancer (reference standard of clinically significant disease). The HPV testing was performed subsequently with masking regarding clinical findings.

Setting  Guanacaste Province, Costa Rica, a region with a high age-adjusted incidence of cervical cancer.

Participants  Of 11,742 randomly selected women, 8554 nonpregnant, sexually active women without hysterectomies underwent initial HPV DNA testing using the original Hybrid Capture Tube test; a stratified subsample of 1119 specimens was retested using the more analytically sensitive second generation assay, the Hybrid Capture II test.

Main Outcome Measures  Receiver operating characteristic analysis of detection of cervical high-grade intraepithelial lesions and cancer by HPV DNA testing based on different cut points of positivity.

Results  An analytic sensitivity of 1.0 pg/mL using the second generation assay would have permitted detection of 88.4% of 138 high-grade lesions and cancers (all 12 cancers were HPV-positive), with colposcopic referral of 12.3% of women. Papanicolaou testing using atypical squamous cells of undetermined significance as a cut point for referral resulted in 77.7% sensitivity and 94.2% specificity, with 6.9% referred. Specificity of the second generation assay for positivity for high-grade lesions and cancer was 89.0%, with 33.8% of remaining HPV DNA–positive subjects having low-grade or equivocal microscopically evident lesions. The higher detection threshold of 10 pg/mL used with the original assay had a sensitivity of 74.8% and a specificity of 93.4%. Lower levels of detection with the second generation assay (<1 pg/mL) proved clinically nonspecific without gains in diagnostic sensitivity.

Conclusions  In this study population, a cut point of 1.0 pg/mL using the second generation assay permitted sensitive detection of cervical high-grade lesions and cancer, yielding an apparently optimal trade-off between high sensitivity and reasonable specificity for this test. The test will perform best in settings in which sensitive detection of high-grade lesions and cancer is paramount. Because HPV prevalence varies by population, HPV testing positive predictive value for detection of high-grade lesions and cancer will vary accordingly, with implications for utility relative to other cervical cancer screening methods.

Author Affiliations: Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, Md (Drs Schiffman, Hildesheim, and Wacholder); International Agency for Research on Cancer, Lyon, France (Dr Herrero); Department of Pathology, Johns Hopkins Medical Institutions, Baltimore, Md (Dr Sherman); Costa Rican Social Security Administration, San Jose, Costa Rica (Drs Bratti, Alfaro, and Morales); Womens' and Infants' Hospital, Providence, RI (Dr Hutchinson); Omnia, Blue Bell, Pa (Dr Greenberg); and Digene Corp, Silver Spring, Md (Dr Lorincz).

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