Shift from Cotesting to HPV Primary Test: How much We are Prepared and What We Need to Do

Summary: Introduction: The greater understanding of persistent high-risk human papillomavirus (hrHPV) infection as a major cause of cervical cancer has led to new recommendations for screening strategies. Worldwide, there has been a gradual shift toward using hrHPV PCR as a primary screening tool. While HPV testing alone at longer intervals has shown great detection rates, we highlight the risk of missing high-grade dysplasia based on negative hrHPV test results. Materials and Methods: 24,412 PAP smears (ThinPrep) were collected at a county hospital during a 48-month period (2019-2023), and 38,157 smears at a private clinic during 28-month period (2020-2023). Patients with HSIL on PAP smear were investigated for corresponding hrHPV infection and surgical biopsies. Only patients with valid cotesting (hrHPV test and cytology) and biopsy-proven CIN 2 or worse lesions were included. In both populations, the Aptima HPV Assay, based on m-RNA detection, was used to evaluate for hrHPV. Results: At the county hospital, 155 patients had HSIL on cytology and 114 patients were included. 2 of 114 (1.8%) patients had persistent negative hrHPV tests. Two patients had one positive hrHPV among multiple tests within 3 years. At the private clinic, 87 patients had HSIL on cytology and 48 patients were included. 2 of 48 patients (4.1 %) had persistent negative hrHPV tests. The average age of the patients with negative hrHPV tests was 60 and 36 years, respectively. Conclusions: Our study demonstrated that a small percentage (1.8-4.1%) of patients with HSIL, detected by co-testing, was missed by hrHPV test alone. The detection rate of hrHPV as a screening test can vary based on the demographics of the population, collection method, low viral load, limited targeted viral probes, and DNA or m-RNA detection-based methodology. Guidelines for re-testing hrHPV, follow-up of cases with negative hrHPV in different risk groups, and cytology's future role are necessary to establish.