title: Triage by methylation-marker testing versus cytology in women who test HPV-positive on self-collected cervicovaginal specimens (PROHTECT-3): a randomised controlled non-inferiority trial.
abstract: BACKGROUND
  Cytology is a widely used method of triaging women who test positive for human papillomavirus (HPV). However, self-sampled specimens, which can substantially increase participation in screening programmes, are not suitable for accurate cytological assessment. We investigated whether direct DNA methylation-based molecular triage on self-sampled cervicovaginal specimens was non-inferior to cytology triage on additional physician-collected cervical samples in the detection of cervical intraepithelial neoplasia grade 2 (CIN2) or worse in women who did not attend cervical screening programmes.
  
  
  METHODS
  In this randomised controlled non-inferiority trial, we invited women (aged 33-63 years) registered as non-attendees of cervical screening in the Netherlands in 2007 to submit a self-collected cervicovaginal sample for HPV testing. Using a computer-generated sequence, we randomly allocated women who tested positive for high-risk hrHPV on a self-sample to either triage by cytology on an additional physician-taken smear or direct triage on the self-sample by methylation analysis of MAL and miR-124-2 genes (1:1; stratified by age and region, with block sizes by age group). Triage-positive women in either group were referred for colposcopy. The primary endpoint was detection of CIN2 or worse, analysed by intention to treat. The non-inferiority margin was 0·80. This study is registered in the Primary Trial Register of the Netherlands, number NTR6026.
  
  
  RESULTS
  We invited 46,001 women to participate, 12,819 of whom returned self-sampled material; 1038 samples tested positive for high-risk HPV. Between Nov 1, 2010, and Dec 31, 2011, after exclusion of women who were ineligible, we enrolled and randomly allocated 515 women to methylation triage and 509 to cytology triage. The detection of CIN2 or worse with methylation triage was non-inferior to that with cytology triage (90 [17%] of 515 women vs 75 [15%] of 509 women; relative risk 1·19, 95% CI 0·90-1·57). Referral for colposcopy was more common in the molecular group (284 [55%] women) than in the cytology group (149 [29%] women; p<0·0001). Mean time to CIN2 or worse diagnosis was shorter in the molecular triage group (96 days, range 44-101) than in the cytology triage group (158 days, 71-222; p=0·00084).
  
  
  CONCLUSIONS
  DNA methylation analysis of MAL and miR-124-2 genes on HPV-test-positive self-samples is non-inferior to cytology triage in the detection of CIN2 or worse, opening the way to full molecular screening.
  
  
  BACKGROUND
  Midden-West and Oost Screening Organisations and Stichting Achmea Gezondheidszorg.
authors: Department of Pathology, VU University Medical Centre, Amsterdam, Netherlands.
authors: Viola M J
authors: VM
authors: Verhoef
authors: Department of Obstetrics and Gynaecology, Radboud University Nijmegen Medical Centre, Nijmegen, Netherlands.
authors: Remko P
authors: RP
authors: Bosgraaf
authors: Department of Pathology, VU University Medical Centre, Amsterdam, Netherlands; Department of Pathology, Erasmus MC University Medical Centre Rotterdam, Netherlands.
authors: Folkert J
authors: FJ
authors: van Kemenade
authors: Department of Pathology, VU University Medical Centre, Amsterdam, Netherlands.
authors: Lawrence
authors: L
authors: Rozendaal
authors: Department of Pathology, VU University Medical Centre, Amsterdam, Netherlands.
authors: Daniëlle A M
authors: DA
authors: Heideman
authors: Department of Pathology, VU University Medical Centre, Amsterdam, Netherlands.
authors: Albertus T
authors: AT
authors: Hesselink
authors: Department of Obstetrics and Gynaecology, Radboud University Nijmegen Medical Centre, Nijmegen, Netherlands.
authors: Ruud L M
authors: RL
authors: Bekkers
authors: Department of Pathology, VU University Medical Centre, Amsterdam, Netherlands.
authors: Renske D M
authors: RD
authors: Steenbergen
authors: Department of Obstetrics and Gynaecology, Radboud University Nijmegen Medical Centre, Nijmegen, Netherlands.
authors: Leon F A G
authors: LF
authors: Massuger
authors: Department of Medical Microbiology, Radboud University Nijmegen Medical Centre, Nijmegen, Netherlands.
authors: Willem J G
authors: WJ
authors: Melchers
authors: Department of Pathology, Radboud University Nijmegen Medical Centre, Nijmegen, Netherlands.
authors: Johan
authors: J
authors: Bulten
authors: PALGA, Houten, Netherlands.
authors: Lucy I H
authors: LI
authors: Overbeek
authors: Department of Epidemiology and Biostatistics, VU University Medical Centre, Amsterdam, Netherlands.
authors: Johannes
authors: J
authors: Berkhof
authors: Department of Pathology, VU University Medical Centre, Amsterdam, Netherlands.
authors: Peter J F
authors: PJ
authors: Snijders
authors: Department of Pathology, VU University Medical Centre, Amsterdam, Netherlands. Electronic address: cjlm.meijer@vumc.nl.
authors: Chris J L M
authors: CJ
authors: Meijer
mesh_terms: D000328:Adult; D003127:Colposcopy; D019175:DNA Methylation; D005260:Female; D006801:Humans; D035683:MicroRNAs / Q000235:genetics; D008875:Middle Aged; D062806:Myelin and Lymphocyte-Associated Proteolipid Proteins / Q000235:genetics; D027383:Papillomaviridae / Q000302:isolation & purification*; D013048:Specimen Handling; D014218:Triage; D002583:Uterine Cervical Neoplasms / Q000175:diagnosis*; D014626:Vaginal Smears / Q000379:methods*; D002578:Uterine Cervical Dysplasia / Q000175:diagnosis*
chemical_list: C569026:MAL protein, human; C509207:MIRN124 microRNA, human; D035683:MicroRNAs; D062806:Myelin and Lymphocyte-Associated Proteolipid Proteins