Colposcopy referrals and CIN3 detection after triage by host cell DNA methylation and/or HPV genotyping in HPV positive women with low-grade cytology from a population-based Dutch primary HPV screening trial

Lisanne Verhoef; Maaike C G Bleeker; Nicole Polman; Kelsi R Kroon; Renske D M Steenbergen; Renée M F Ebisch; Willem J G Melchers; Ruud L M Bekkers; Anco C Molijn; Folkert van Kemenade; Chris J L M Meijer; Daniëlle A M Heideman; Johannes Berkhof

doi:10.1002/ijc.35289

Colposcopy referrals and CIN3 detection after triage by host cell DNA methylation and/or HPV genotyping in HPV positive women with low-grade cytology from a population-based Dutch primary HPV screening trial

Int J Cancer. 2024 Dec 16. doi: 10.1002/ijc.35289. Online ahead of print.

Authors

Lisanne Verhoef^{1

2}, Maaike C G Bleeker^{1

2}, Nicole Polman^{1

2}, Kelsi R Kroon³, Renske D M Steenbergen^{1

2}, Renée M F Ebisch⁴, Willem J G Melchers⁵, Ruud L M Bekkers^{4

6

7}, Anco C Molijn⁸, Folkert van Kemenade⁹, Chris J L M Meijer^{1

2}, Daniëlle A M Heideman^{1

2}, Johannes Berkhof³

Affiliations

¹ Amsterdam UMC, location Vrije Universiteit Amsterdam, Pathology, Amsterdam, The Netherlands.
² Cancer Center Amsterdam, Imaging and Biomarkers, Amsterdam, The Netherlands.
³ Amsterdam UMC, location Vrije Universiteit Amsterdam, Epidemiology and Data Science, Amsterdam, The Netherlands.
⁴ Radboud University Medical Center, Obstetrics and Gynecology, Nijmegen, The Netherlands.
⁵ Radboud University Medical Center, Medical Microbiology, Nijmegen, The Netherlands.
⁶ GROW School for Oncology and Reproduction, Maastricht University, Maastricht, The Netherlands.
⁷ Catharina Hospital, Eindhoven, The Netherlands.
⁸ Eurofins NMDL-LCPL, Rijswijk, The Netherlands.
⁹ Erasmus MC University Medical Center, Department of Pathology, Rotterdam, The Netherlands.

PMID: 39686532
DOI: 10.1002/ijc.35289

Abstract

High-risk HPV (hrHPV)-based screening has led to many unnecessary colposcopy referrals, mainly because of direct referral after low-grade cytology (ASC-US/LSIL). DNA methylation and genotyping tests on ASC-US/LSIL samples have the potential to significantly improve the efficiency of screening. In this study, 12 triage strategies were constructed from FAM19A4/miR124-2 or ASCL1/LHX8 methylation, HPV16/18 or HPV16/18/31/33/45 genotyping and 1-year repeat cytology. The performance was evaluated on 215 hrHPV-positive ASC-US/LSIL samples from the IMPROVE trial (NTR5078). Performance was measured by colposcopy referral rate, positive predictive value (PPV) for detecting precancer (CIN3), and negative predictive value (NPV). To evaluate efficiency, strategies were ordered by the cumulative colposcopy referral rate after 1-year cytology and compared by the marginal PPV to detect one additional CIN3 (mPPV). The most conservative strategy (referral when HPV16/18 and FAM19A4/miR124 methylation results are positive) had a direct referral rate of 5.2%, a cumulative referral rate after 1-year cytology of 54.1%, and mPPV of 19.3%. Replacing HPV16/18 by HPV16/18/31/33/45 increased the cumulative 1-year referral rate to 54.6%, and yielded an mPPV of 10.0%. Similar results were obtained for strategies with ASCL1/LHX8 methylation. Of all strategies, referral after an HPV16/18/31/33/45 positive, ASCL1/LHX8 methylation-positive, and/or 1-year cytology-positive result yielded the highest direct and cumulative 1-year colposcopy referral rates of 64.4% and 79.1%, respectively. The NPVs after 1-year cytology varied between 98.1% and 99.4%, warranting a return to routine screening. Altogether, DNA methylation-based triage strategies are recommended as they are discriminative for CIN3 and control the number of immediate colposcopy referrals.

Keywords: ASC‐US/LSIL; DNA methylation; cervical cancer; colposcopy referrals; diagnostic markers.