title: Use of p16-INK4A overexpression to increase the specificity of human papillomavirus testing: a nested substudy of the NTCC randomised controlled trial.
abstract: BACKGROUND
  Human-papillomavirus (HPV) testing is more sensitive, but less specific, than conventional cytology for detecting high-grade cervical intraepithelial neoplasia (CIN). We assessed whether HPV testing with triage by p16-INK4A overexpression can increase specificity while maintaining sensitivity.
  
  
  METHODS
  HPV-positive women were enrolled between June 10, 2003, and Dec 31, 2004 in a multicentre randomised controlled trial, which compared stand-alone HPV testing by Hybrid Capture 2 (experimental group) with conventional cytology, were referred for colposcopy. In seven of nine centres, cytospin preparations from these women were tested for p16-INK4A overexpression by immunostaining. The sensitivity and specificity for CIN grade 2 or more, determined at blind review of histology, were calculated for these women. We also estimated the relative sensitivity and relative referral to colposcopy that would have been obtained by HPV testing with p16-INK4A triage compared with conventional cytology. This trial is registered as a Standard Randomised Controlled Trial, number ISRCTN81678807.
  
  
  RESULTS
  24 661 women were randomly assigned to the experimental group. 1137 women (74% of those undergoing colposcopy in relevant centres), including 50 with CIN2 and 42 with CIN3 or cancer, had valid p16-INK4A immunostaining. For the endpoint of CIN2+, sensitivity and specificity of p16-INK4A (deemed positive with any number of stained cells-except endocervical, metaplastic, and atrophic cells if morphologically normal) in HPV-positive women of any age were 88% (81 of 92; 95% CI 80-94) and 61% (633 of 1045; 57-64), respectively. In the 35-60-year age group, the relative sensitivity of HPV testing and p16-INK4A triage versus conventional cytology for CIN2+ was 1.53 (95% CI 1.15-2.02) and relative referral was 1.08 (0.96-1.21). In the 25-34-year age group, relative sensitivity was 3.01 (1.82-5.17) and relative referral was 1.15 (0.96-1.37). In the latter age group, when 5% or more stained cells were deemed positive, the corresponding values were 2.06 (1.20-3.68) and 0.58 (0.46-0.73), respectively.
  
  
  CONCLUSIONS
  HPV testing with p16-INK4A triage produces a significant increase in sensitivity compared with conventional cytology, with no substantial increase in referral to colposcopy.
authors.affiliation: Centre for Cancer Study and Prevention, Florence, Italy.
authors.forename: Francesca
authors.initials: F
authors.lastname: Carozzi
authors.forename: Massimo
authors.initials: M
authors.lastname: Confortini
authors.forename: Paolo
authors.initials: P
authors.lastname: Dalla Palma
authors.forename: Annarosa
authors.initials: A
authors.lastname: Del Mistro
authors.forename: Anna
authors.initials: A
authors.lastname: Gillio-Tos
authors.forename: Laura
authors.initials: L
authors.lastname: De Marco
authors.forename: Paolo
authors.initials: P
authors.lastname: Giorgi-Rossi
authors.forename: Giovanni
authors.initials: G
authors.lastname: Pontenani
authors.forename: Stefano
authors.initials: S
authors.lastname: Rosso
authors.forename: Cristina
authors.initials: C
authors.lastname: Sani
authors.forename: Catia
authors.initials: C
authors.lastname: Sintoni
authors.forename: Nereo
authors.initials: N
authors.lastname: Segnan
authors.forename: Manuel
authors.initials: M
authors.lastname: Zorzi
authors.forename: Jack
authors.initials: J
authors.lastname: Cuzick
authors.forename: Raffaella
authors.initials: R
authors.lastname: Rizzolo
authors.forename: Guglielmo
authors.initials: G
authors.lastname: Ronco
mesh_terms: D000328:Adult; D052685:Alphapapillomavirus / Q000235:genetics / Q000302:isolation & purification*; D000911:Antibodies, Monoclonal; D003127:Colposcopy; D019941:Cyclin-Dependent Kinase Inhibitor p16 / Q000235:genetics / Q000378:metabolism*; D004279:DNA, Viral / Q000302:isolation & purification*; D005260:Female; D005786:Gene Expression Regulation; D006801:Humans; D008390:Markov Chains; D008403:Mass Screening / Q000379:methods; D008875:Middle Aged; D030361:Papillomavirus Infections / Q000175:diagnosis*; D012680:Sensitivity and Specificity; D002583:Uterine Cervical Neoplasms / Q000175:diagnosis* / Q000378:metabolism / Q000821:virology; D002578:Uterine Cervical Dysplasia / Q000175:diagnosis* / Q000378:metabolism / Q000821:virology
chemical_list: D000911:Antibodies, Monoclonal; D019941:Cyclin-Dependent Kinase Inhibitor p16; D004279:DNA, Viral