HPV Testing

Uses and Abuses

Barbara S. Apgar, MD, MS
Professor of Family Medicine
University of Michigan Medical Center
Ann Arbor, Michigan

Objectives
Understand the current uses of HPV testing.
Discuss when HPV testing is or is not indicated.
Compare the sensitivity of HPV testing and cervical

cytology for cervical cancer screening.

Progression to Invasion
Cervical cancer

Apgar, Brotzman, Spitzer

Persistent positivity with oncogenic HPV types is uncommon but
required for progression

HPV Types in CIN 2, CIN 3 and Cervical Cancer,

Iceland, 1990-1994 and 1999-2003
#
1

#2

Sigurdsson K et al. Int J Cancer 2007;2682-2687.

Hybrid Capture 2: FDA approved

Low risk HPV types
6, 11, 42, 43, 44
Triage, management and co-testing should be
by HR HPV types only

High risk HPV types

16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 68

Methods to detect HPV DNA

Pooled mixture of probes for high-risk HPV types:

16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 68 + 66.
Does not distinguish individual types.

Polymerase chain reaction.

Molecular amplification method identifying a small amount

of a target DNA.
Identification of specific type of HPV.

FDA-approved HPV DNA tests

Hybrid Capture 2 HPV DNA Assay (13 pooled)-Quigen
HPV types: 16, 18, 31, 33, 35, 39, 45, 51, 52,

56, 58, 59, 68.

HPV detected by chemiluminescence
Cervista HPV HR (14 pooled).
Same HPV types as HC 2 + HPV type 66.
Cervista HPV 16/18.
HPV type-specific test (genotyping).

FDA-approved HPV tests

cobas 4800 HPV test. (approved 2011)-Roche
PCR-based.
14 HR HPV types.
Genotyping for HPV 16 and 18 integrated into the assay.
Concurrently detects remaining 12 types as a group.

Aptima HPV test (GenProbe)-FDA 2013

Detects E6/E7 mRNA expression of 14 HR HPV types
Approved for testing on Hologic system.
HPV E6/E7 overexpression: necessary condition for the start

and progression of cervical neoplasia.

E6 and E7 inactivates p53 and pRb suppressor proteins.
Is correlation between HPV mRNA and CIN 3 a true

biomarker of risk?
94% and 100% of women with CIN 3 and cancer were + for
E6/E7 mRNa activity. (Castle et al. Clin CA 2007;13)

HPV mRNA detection

HPV mRNA detection may improve specificity.
It is unknown which lesions will regress or progress.
Increased monitoring needed.
Detection of mRNA transcripts may allow clinicians to

know whether or not HPV is actively replicating E6

and E7 oncogenes.
Bottom line: May be able to stratify risk of progression

to CIN 3 in women with abnormal cytology.

Brown AJ et al. Best Prac Res Clin OG 2012;26:233

HPV tests for detection of CIN 2 and 3

Cuzick J et al. Br J Cancer 2013;108(4):908-913

 HPV tests should be FDA approved or supported by

peer-reviewed published data on sensitivity and

specificity.
Performance should be similar to assays used in
clinical trials.
Tests should have documented clinical performance
characteristics (92% +/- 3% sensitivity for CIN 3+)
> 85% specificity in screening setting.
Saslow D et al. ACA Cancer J Clin. 2012;62(3):147-72.
Stoler MH et al. Am J Clin Pathol. 2007;127(3):335-7.

Home brewed HPV assays

Some molecular labs have developed their own HPV

assays.
Usually PCR-based.
Problem: cut-offs are not clinically validated.
Not FDA-approved.
What does a positive or negative result actually mean?

Exercise caution!

HPV DNA Testing

Areas of clinical utility
Co-testing with cervical cytology in women > 30.
Assess the risk of recurrence/persistence after

treatment of CIN 2,3 (cotesting).

Preferred option for ASC-US triage because of cost
and predictive value.
Acceptable option for LSIL triage in
postmenopausal women.

HPV testing not recommended

Routine screening in women < age 30 (except

ASCUS triage).
Women > 24 years with ASC-H, LSIL, HSIL, AGC
(except postmenopausal LSIL reflex HPV
testing).
Women considering HPV vaccination.
Routine STI screening.
As part of sexual assault workup.

HPV Genotyping
Both DNA and mRNA tests available

Prognostic information seems similar.

5 year risk of CIN2+ if HPV 16 = ~10%
Risk of CIN2+ is lower if HPV 18 , but there is

association for adenocarcinoma.

Bottom line: ASCCP guidelines show genotyping

acceptable without recommending for or against use
Allows for clinician discretion and patient choice

2013 ASCCP management guidelines

Wright TC, et al. J Lower Genital Tract Disease, 2007; 11: 201-222 and 223-239

Comments on HPV genotyping

Not recommended yet: Women with ASC-US.
Cotesting.
Genotyping triages cytology negative, HPV 16/18+ to

colposcopy.
Colposcopy is indicated for all women with HPV+
ASCUS regardless of genotyping result.
Threshold for colposcopy exceeded by both
groups.

Are guidelines being followed?

Estimated that > 50% of the 75 million US Pap tests

performed in 2010 in the US were:

Outside guideline compliance.
Therefore, unnecessary.
More anxiety in woman with negative Pap and HPV +
results than in woman with normal Pap and unknown
HPV status.
Solomon D et al. CA Cancer J Clin 2007;105.
Kitchener HC et al. Int J Gynecol Ca 2008;18
Berkowitz Z et al. Obstet Gynecol 2010;116.

2010 CDC survey of IM, FP, ObGyn

950 Pap test providers
Primary outcomes were responses to clinical case

vignette of a 35 year old woman who had cervical

cancer screening.
Negative Pap and + HPV test (co-testing).

Questions: when to do the next Pap and HPV test?

Adherent with guidelines or not?

Berkowitz Z et al. Obstet Gynecol 2010;116.

Results of 2010 CDC survey

> 80% of all physicians reported that HPV DNA

testing with Pap has higher sensitivity than Pap

alone.
35 year old: negative Pap and + HPV test.

54% recommended HPV test at the same time

as the Pap (adherent with guidelines).

Conclusions of 2010 CDC Survey

About 50% of women > 30 years did not receive

recommended management of Pap negative,

HPV+ cotesting.

Knowledge of HPV tests - CDC

12% of clinicians did not know there was a high

risk and low risk HPV test.
56% of clinics use high risk tests only.
25% use both high and low risk HPV tests.

Bottom line: low risk HPV testing adds cost without

additional value to health care.

High and low-risk HPV testing reported by

clinical specialties
70

High risk HPV

60

High and low risk HPV

50

40

30

20

10

0
Family Practice

Int Med

ObGyn

Mid-level

Lee, Berkowitz, Zahava, Saralya. OG 2011;118:4-13

Low risk HPV testing

Screens for non-oncogenic HPV types.

Serves no purpose in the context of cervical cancer
screening.
Low risk testing should not be performed for genital
warts. Does not change management.

Bottom line: + low risk HPV test is clinically

insignificant but ..unnecessary follow-up is not.

Why order low risk HPV tests?

Clinician confusion.
It is on the lab req as a check-box option.
Financial gain to clinician or clinic or institution.
Low and high risk HPV billed the same (doubles the
cost.
Test marketing by industry.
2007: 45% of labs offered low risk HPV testing. (Arch
Pathol Lab Med 2008;132)

Need attributed to reimbursement and demand.

Requests to check HPV status

Direct to consumer advertising associated with

significant increases in HPV test use by clinicians.
(Price et al. Med Care 2011;49.)

Screening for HPV status outside cervical cancer

screening should be avoided.

Value of co-testing women < 30 yrs

50 % of clinicians and clinics do HPV co-testing in women

< 30 years (not adherent).
% of clinicians doing co-testing for this age group
doubled since 2004.
Despite significant rate of transient HPV infections
in this age group.

Problem: Women < age 30 referred to colposcopy after

co-testing.

Other issues with co-testing

About 6% prevalence of women with discordant results

will require additional follow-up.

Problems:
Repetition of co-testing annually or biannually rather
than triannually.
Repeating co-testing < 3 years if new sexual partner.
Berkowitz Z et al. Obstet Gynecol 2010;116.
Castle PE et al. Obstet Gynecol 2009;113.
Katki HA et al. Lancet Oncol 2012; 12: 663

Proportion of Co-Test Results in

331,061 Kaiser women > 30 years
3.7%

1.4%

2.4%

Discordant

92.5%

Katki HA, et al. Lancet Oncol 2012; 12: 663

Cumulative Risk Of Invasive Disease

Based on Initial Co-Test

Kaiser Study
N=331,818 women > 30
years in prospective cotesting study

Katki HA, et al. Lancet Oncol 2011;

12: 663

Conclusions of CDC Report 2011

Many clinicians report guideline-adherent HPV

testing.
Some also report inappropriate HPV testing (no
clinical indication).
Low risk HPV testing (33%).
HPV co-testing in women < age 30 (60%).
Consequences: increased medical costs,
unnecessary follow-up tests, patient anxiety and
alarm about HPV status.

Why use HPV testing for detection of CIN 2,3

and cancer?
Necessary role of persistent carcinogenic
HPV infections in the development
of serious lesions
Increased sensitivity of carcinogenic HPV testing for detection
of CIN 2,3 and cancer.
Increases the efficiency of cervical cancer screening by better
risk stratification than cytology alone.

Finding carcinogenic HPV types

does not
provide a diagnosis of CIN 3 or
cancer
It identifies a group of women in
whom CIN 3+ is more likely

Compensation for the limitations of

cytology, colposcopy, histology
Relied on repeated annual
or
biennial Pap screening

Used CIN 2 as a threshold for

treatment to provide an
additional margin of safety
even though CIN 2 can regress

Adopted an expanded role for the

detection of carcinogenic HPV DNA
in the clinical management of
cervical abnormalities

Triage of Postmenopausal Women

with LSIL

62 year old postmenopausal woman

with atrophy.
LSIL cytology. No HPV testing.
Always normal Pap tests.

HPV testing in postmenopausal women with

LSIL and no HPV test?

Prevalence of CIN 2,3 drops with increasing age.

Accuracy of LSIL as a marker for HPV drops in older
women.
Postmenopausal women can be managed less
aggressively than premenopausal women.
ASCCP: No HPV test: Acceptable options include reflex
HPV DNA testing, repeat cytology at 6 and 12 mos. and
colposcopy.

Postmenopausal women with LSIL

If the HPV is negative or no CIN identified at

colposcopy, repeat cytology in 12 months.

If either the HPV test is + or repeat cytology is >

ASCUS, colposcopy.

If 2 consecutive repeat cytology tests are

negative, routine screening.

There is something new on the horizon

What happens to HPV after tx for CIN 2,3 ?

Most women become HPV negative after treatment

of CIN 2,3 provided recurrent/persistent disease not

present.
Women who fail treatment have high rates of HPV

positivity.
HPV testing has high negative predictive value.
Useful in post-treatment surveillance.

HPV follow-up after treatment CIN 2.3

Systematic review
Paraskevaidis et al. Ca Treatment Rev 2004;30:205-11

HPV status

Treatment Outcome
Success
Failure
n=672
n=204

Negative

84%

17%

Positive

16%

83%

Clearance of HPV after treatment for CIN 2,3

or persistent CIN 1
1207 treated women prospectively studied.
Treated LEEP, cone, or laser ablation.
Followed with colpo, cytology 2-6, 12
months after tx, then annually until HPV
cleared.
Genotyping done.

45% had laser ablation

55% had excision.
Moore et al. Obstet Gynecol 2011;117:101-108

Time to clearance of HPV

HPV types

No. with HPV type at

baseline

No. (% cleared)

Median time to
clearance (months)

HPV 16

418

387(93)

5.9

HPV 18

99

96(97)

5.9

HPV 31

149

142(95)

5.4

HPV 39

89

79(89)

6.3

Almost all women with HPV types 16, 18 had clearance and 50%
cleared within 6 months.
Moore et al. Obstet Gynecol 2011;117:101-108

HPV testing post-tx predicting residual disease in

subsequent TAH specimens n=115
Sensitivity

Specificity

Accuracy*

Resection
Margin

75%

53%

61%

HPV Testing

85%

67%

73%

Predictive value of resection margin was much improved when used

in combination with HPV DNA testing
Park JY et al. Obstet Gynecol 2009;114:87-92