Single-round HPV testing reduced the rate of cervical cancer, death in rural Indian population

In rural India, an area with limited resources, a single round of HPV testing led to a significant decrease in the incidence of stage-II or higher cervical cancer and associated death among women aged 30 to 59, according to data from a cluster-randomized trial.

“The implications of the findings of this trial are immediate and global,” Mark Schiffman, MD, MPH, and Sholom Wacholder, PhD, of the division of cancer epidemiology and genetics at the National Cancer Institute, wrote in an accompanying editorial.

Schiffman and Wacholder wrote that in place of establishing large cytologic-testing programs, where repeated screening is required for effectiveness, low-resource countries “should now adapt HPV testing for widespread implementation.”

The study included 52 clusters of villages with 131,746 healthy women. Participants were randomly assigned to four groups of 13 clusters each, according to the researchers. Groups were randomly assigned to screening with HPV testing (n=34,126), cytologic testing (n=32,058), visual inspection of the cervix with acetic acid (n=34,074) or standard care (n=31,488).

Cervical cancer was diagnosed in 127 women in the HPV-testing group compared with 157 in the visual inspection group, 152 in the cytologic group and 118 from the control group. However, women in the HPV-testing group had a decreased risk for being diagnosed with stage II or higher cervical cancers (HR=0.47; 95% CI, 0.32-0.69) and death (HR=0.52; 95% CI, 0.33-0.83) compared to the other screening groups and the control group.

The incidence rates for stage-II or higher cervical cancer were higher in the visual inspection (HR=1.04; 95% CI, 0.72-1.49) and cytologic groups (HR=0.75; 95% CI, 0.51-1.10) compared with the HPV-testing group, and these groups had no significant reductions in the number of advanced cancers detected or deaths compared with the control group.

According to the researchers, although HPV testing is fairly costly, an accurate and inexpensive test evaluated in China (careHPV test, Qiagen) may provide an opportunity for primary screening in low-resource settings. – by Stacey L. Adams

Sankaranarayanan R. N Engl J Med. 2009;360:1385-1394.

Unlike Western countries, cervical cancer is one of the most common causes of death from cancer in women in developing countries. Therefore, finding a low-cost, easy way of screening is important. This study is important because it shows that HPV testing may provide effective (and superior) screening compared with other commonly used techniques such as Pap smear screening and visual inspection with acetic acid or VIA. VIA is the cheapest method and has been effective in other studies. Obviously, Pap smear screening has a long record of effectiveness. So, it is unclear why these other two methods showed no reduction in cancer deaths as compared with no screening at all. There may have been some impediment to follow-up for these other two methods (as suggested in the paper), but it is not clear what they were. It also may be that the HPV testing only requires one screening test (not repeated ones) and more frequent visits are not always possible in this setting.

The method of screening for HPV used, Hybrid Capture II, is expensive and requires sophisticated laboratory infrastructure, so the authors hope that a new, cheaper and simpler method, the careHPV test, may soon be available, which would make HPV testing more suitable for resource-poor countries. Regardless, this is a well-designed study in a resource-poor setting that demonstrates a new, potentially effective method to reduce deaths from cervical cancer.

– Mark Morgan, MD

Chief of Gynecologic Surgical Oncology
Fox Chase Cancer Center, Philadelphia