Development and clinical validation of a multi-type HPV E6/E7 oncoprotein test for cervical cancer screening and triage in low- and middle-income countries

 描述(申请人提供)：在大多数中低收入国家(LMIC)，宫颈癌仍然是癌症发病率和死亡率的主要原因。尽管基于细胞学的筛查计划在发达国家将宫颈癌死亡率降低了高达80%，但这些计划在发展中国家经常失败，主要是因为要求多次就诊以确定需要治疗的高危妇女。宫颈细胞学的低敏感性(约50%)导致通过终身筛查频繁重复检测；此外，阴道镜-活检的补充诊断要求妇女在短时间内多次就诊以接受适当的治疗。最近，检测致癌HPV的高灵敏度和可重复性的实验室技术已经开发出来，并被FDA批准作为宫颈癌的主要筛查方法。随机临床试验表明，HPV检测比细胞学更敏感(约90%对50%)，还表明HPV检测能在早期发现更多的疾病，并能更大程度地降低宫颈癌死亡率。这些技术正在改变墨西哥、阿根廷、哥伦比亚和萨尔瓦多等低收入和中等收入国家的筛查做法。尽管有其优势，但HPV检测的阳性预测价值很低；因此，它们需要额外的诊断程序(分诊)，以避免阴道镜诊所的负担过重或在没有进行确证诊断的情况下过度治疗(参见并治疗程序)。目前，对阳性妇女的分类是通过细胞学进行的，这再次由于敏感性低而产生了高召回率，在低资源环境下对筛查程序构成了挑战。目前，正在调查的分类测试中没有一项适合在LMIC中筛选计划，因为它的实施会导致高召回率或高后勤或基础设施要求。开发一种友好/手动格式的高精度测试，根据个人情况产生结果，将有助于在资源较少的情况下改善筛查计划的结果。我们将利用拉丁美洲国家(LAC)已有的宫颈癌研究网络的平台：(目标1)开发和改进基于E6/E7癌蛋白活性的HPV检测，以检测与宫颈癌相关的8种最常见的HPV类型；(目标2)通过在800个样本中挑战基于8-HPV型E6/E7的癌蛋白宫颈检测，评估其潜在的临床表现；(目标3)评估该测试在ESTAMPA研究的4,500名女性中检测HPV阳性女性(分流)癌症前驱症状的敏感性和特异性；(目标4)通过使用另外1,000名HPV阴性妇女的样本，评估该检测作为宫颈癌筛查的独立检测的潜力；(目标5)比较8-HPVE6/E7癌蛋白宫颈检测的结果(阳性/阴性)与妇女18个月后HPV持续存在和宫颈病变的发展；(目标6)通过在LAC的三个不同实验室处理4,500个样本，确定不同环境下检测结果的差异；(目标7)通过在五个不同的LAC中实时进行1,500个样本来确定扩大基于8-HPV E6/E7癌蛋白宫颈检测的宫颈癌筛查计划的操作要求；(目标8)描述包括HPV16和18癌蛋白的Origina OncoE6TM宫颈检测与新的基于8-HPV E6/E7癌蛋白宫颈检测之间的灵敏度和特异性的差异。

 DESCRIPTION (provided by applicant): Cervical cancer remains a leading cause of cancer incidence and mortality in most low and middle income countries (LMIC). Despite cytology based screening programs have reduce cervical cancer mortality up to 80% in developed nations, these programs have frequently failed success in developing countries mainly due to the requirement of multiple visits to identify women at risk who require treatment. The low sensitivity of cervical cytology (around 50%) induces the frequent repetition of the test through lifetime screening; in addition, the complementary diagnosis with colposcopy-biopsy requires women to attend multiple visits in the short time to undergo proper treatment. Recently, highly sensitive and reproducible laboratory techniques to detect carcinogenic HPV have been developed and approved by FDA as primary cervical cancer screening tests. Randomized clinical trials have demonstrated that HPV testing is more sensitive than cytology to detect cervical cancer precursors (around 90% vs 50%) and it has also been shown that HPV testing detects more disease at an earlier stage and induces a greater reduction in cervical cancer mortality. These technologies are changing screening practices in low and middle income countries such as Mexico, Argentina, Colombia, and El Salvador. Despite its advantages, HPV tests have a low positive predictive value; thus, they require additional diagnostic procedures (triage) to avoid overburden of colposcopy clinics or overtreatment if no confirmatory diagnosis is performed (see-and-treat programs). Currently, the triage for positive women is done with cytology, which again, due to the low sensitivity produces a high recall rate challenging screening programs in low resource settings. At the moment none of the triage tests under investigation is suitable for screening programs in LMIC due to the induction of high recall rates or high logistic or infrastructure requirements for its implementation. The development of a highly accurate test in a friendly/manual format producing results on individual basis will help improve outcomes of screening programs in low resource settings. We will use the platform of a cervical cancer research network already in place in Latin American countries (LAC) to: (Aim 1) developed and improved HPV test based on E6/E7 oncoprotein activity for the 8 most common HPV types associated with cervical cancer; (Aim 2) assess the potential clinical performance of the 8-HPV type E6/E7-based OncoProtein Cervical Test by challenging it against the whole spectrum of disease's histological diagnosis in 800 samples; (Aim 3) asses the sensitivity and specificity of the test for the detection of cancer precursors among HPV positive women (triage) in 4,500 women from the ESTAMPA study; (Aim 4) assess the potential of the test as standalone test for cervical cancer screening by using a sample of additional 1,000 HPV negative women; (Aim 5) to compare the results (positive/negative) of the 8-HPV type E6/E7-based OncoProtein Cervical Test with HPV persistence and development of cervical lesions after 18 months of women follow-up; (Aim 6) identify differences in the performance of test in different settings by processing 4,500 samples in three different labs in LAC; (Aim 7) identify operational requirements for scaling up cervical cancer screening programs based on the 8-HPV type E6/E7-based OncoProtein Cervical Test by performing 1,500 samples in real time in five different LAC; (Aim 8) describe differences in sensitivity and specificity between the origina OncoE6TM Cervical Test that included oncoproteins for HPV 16 and 18 and the new 8-HPV type E6/E7-based OncoProtein Cervical Test.