Overview of Human Papillomavirus-Based and Other Novel Options for Cervical Cancer Screening in Developed and Developing Countries
Overview of Human Papillomavirus-Based and Other Novel Options for Cervical Cancer Screening in Developed and Developing Countries
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DOI：
10.1016/j.vaccine.2008.06.019
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发表时间：
2008-08-19
期刊：
影响因子：
5.5
通讯作者：
Meijer, Chris J. L. M.
中科院分区：
文献类型：
--
作者：
Cuzick, Jack;Arbyn, Marc;Meijer, Chris J. L. M.
在有足够资源确保高质量和高覆盖率的高危人口的国家，通过细胞学检查宫颈癌前兆非常成功。在许多发达国家，死亡率降低了50%以上;然而，在世界上许多地方，该程序通常效率低下且不可行，因为适当的基础设施不完善。本文提供了最近发表的关于人乳头瘤病毒（HPV）DNA检测四种可能临床应用的荟萃分析和系统评价的总结和更新：（1）对有可疑或低度细胞学异常的妇女进行分诊;（2）对阴道镜检查/活组织检查阴性的筛查结果异常的妇女进行随访;（3）预测宫颈上皮内瘤变（CIN）治疗后的治疗结果，最重要的是（4）初步筛查HPV DNA检测，单独或结合巴氏涂片检查，以检测宫颈癌的前兆。HPV DNA检测在老年妇女可疑涂片、低级别涂片的分诊和CIN治疗后妇女的治疗后监测中有明显的益处。然而，关于如何最好地在初级筛查中使用HPV DNA检测仍然存在问题。使用Hybrid Capture（R）2（HC 2）进行的初步筛查通常可检测到超过90%的所有CIN 2、CIN 3或癌症病例，并且为25%（95%CI）：15-36%），在未确定意义的异常鳞状细胞（ASCUS）临界值时，比细胞学检查相对更敏感（或低度鳞状上皮内病变（LSIL），如果ASC-US不可用），但6%（95%CI：4-7%）相对较低的特异性。目前正在评估几种方法来处理与短暂感染相关的HPV DNA检测的低特异性。这些包括HPV-16和-18/45的HPV分型，增殖性病变的标志物，如p16和编码病毒E6和/或E7蛋白的mRNA，具有潜在的临床用途，建议对阳性者进行更积极的管理。初筛最有吸引力的选择是使用HPV DNA检测作为唯一的筛查方式，细胞学检查保留用于HPV阳性女性的分诊。已建立的基于细胞学的计划也应该逐步转向更多地使用HPV DNA检测，以提高其有效性并安全地延长筛查间隔。与细胞学相比，HPV DNA检测的灵敏度更高，这有力地证明了在新实施的方案中使用HPV DNA检测作为主要筛查检测，除非资源极其有限，并且只有基于目视检查的方案才能负担得起。在这些国家，需要对HPV阳性患者进行简单的HPV DNA检测，然后根据目视检查立即进行“筛查并治疗”算法，以最大限度地减少就诊次数并充分利用有限的资源。HPV是一种性传播感染，这一事实可能会导致焦虑和对性关系的关注。本文还讨论了这些心理社会方面以及需要更多关于HPV的信息和教育计划。(C)2008爱思唯尔有限公司保留所有权利。
Screening for cervical cancer precursors by cytology has been very successful in countries where adequate resources exist to ensure high quality and good coverage of the population at risk. Mortality reductions in excess of 50% have been achieved in many developed countries; however the procedure is generally inefficient and unworkable in many parts of the world where the appropriate infrastructure is not achievable.A summary and update of recently published meta-analyses and systematic reviews on four possible clinical applications of human papillomavirus (HPV) DNA testing is provided in this article: (1) triage of women with equivocal or low-grade cytological abnormalities; (2) follow-up of women with abnormal screening results who are negative at colposcopy/biopsy; (3) prediction of the therapeutic outcome after treatment of cervical intraepithelial neoplasia (CIN), and most importantly (4) primary screening HPV DNA test, solely or in combination with Pap smear to detect cervical cancer precursors. There are clear benefits for the use of HPV DNA testing in the triage of equivocal smears, low-grade smears in older women and in the post-treatment surveillance of women after treatment for CIN. However, there are still issues regarding how best to use HPV DNA testing in primary screening. Primary screening with Hybrid Capture (R) 2 (HC2) generally detects more than 90% of all CIN2, CIN3 or cancer cases, and is 25% (95% CI): 15-36%) relatively more sensitive than cytology at a cut-off of abnormal squamous cells of undetermined significance (ASCUS) (or low-grade squamous intraepithelial lesions (LSIL) if ASC-US unavailable), but is 6% (95% CI: 4-7%) relatively less specific. Several approaches are currently under evaluation to deal with the lower specificity of HPV DNA testing as associated with transient infection. These include HPV typing for HPV-16 and -18/45, markers of proliferative lesions such as p16 and mRNA coding for the viral E6 and/or E7 proteins, with a potential clinical use recommending more aggressive management in those who are positive.In countries where cytology is of good quality, the most attractive option for primary screening is to use HPV DNA testing as the sole screening modality with cytology reserved for triage of HPV-positive women. Established cytology-based programmes should also be gradually moving towards a greater use of HPV DNA testing to improve their efficacy and safely lengthen the screening interval. The greater sensitivity of HPV DNA testing compared to cytology argues strongly for using HPV DNA testing as the primary screening test in newly implemented programmes, except where resources are extremely limited and only programmes based on visual inspection are affordable. In such countries, use of a simple HPV DNA test followed by immediate 'screen and treat' algorithms based on visual inspection in those who are HPV-positive are needed to minimise the number of visits and make best use of limited resources. A review of studies for visual inspection methods is presented.The fact that HPV is a sexually transmitted infection may lead to anxiety and concerns about sexual relationships. These psychosocial aspects and the need for more information and educational programmes about HPV are also discussed in this article. (C) 2008 Elsevier Ltd. All rights reserved.