title: Protecting the underscreened women in developed countries: the value of HPV test.
abstract: BACKGROUND
  Poor attendance to cervical cancer (CC) screening is a major risk factor for CC. Efforts to capture underscreened women are considerable and once women agree to participate, the provision of longitudinal validity of the screening test is of paramount relevance. We evaluate the addition of high risk HPV test (HPV) to cervical cytology as a primary screening test among underscreened women in the longitudinal prediction of intraepithelial lesions grade 2 or worse (CIN2+).
  
  
  METHODS
  Women were included in the study if they were older than 39 years and with no evidence of cervical cytology in the previous five years within the Public Primary Health Care System in Catalonia (Spain). 1,832 underscreened women from eight public primary health areas were identified during 2007-2008 and followed-up for over three years to estimate longitudinal detection of CIN2+. Accuracy of each screening test and the combination of both to detect CIN2+ was estimated. The risk of developing CIN2+ lesions according to histology data by cytology and HPV test results at baseline was estimated using the Kaplan-Meier method.
  
  
  RESULTS
  At baseline, 6.7% of participants were HPV positive, 2.2% had an abnormal cytology and 1.3% had both tests positive. At the end of follow-up, 18 out of 767 (2.3%) underscreened women had a CIN2+, two of which were invasive CC. The three-year longitudinal sensitivity and specificity estimates to detect CIN2+ were 90.5% and 93.0% for HPV test and 38.2% and 97.8% for cytology. The negative predictive value was >99.0% for each test. No additional gains in validity parameters of HPV test were observed when adding cytology as co-test. The referral to colposcopy was higher for HPV but generated 53% higher detection of CIN2+ compared to cytology.
  
  
  CONCLUSIONS
  Underscreened women had high burden of cervical disease. Primary HPV screening followed by cytology triage could be the optimal strategy to identify CIN2+ leading to longer and safe screen intervals.
authors.forename: Raquel
authors.initials: R
authors.lastname: Ibáñez
authors.forename: Josefina
authors.initials: J
authors.lastname: Autonell
authors.forename: Montserrat
authors.initials: M
authors.lastname: Sardà
authors.forename: Nayade
authors.initials: N
authors.lastname: Crespo
authors.forename: Pilar
authors.initials: P
authors.lastname: Pique
authors.forename: Amparo
authors.initials: A
authors.lastname: Pascual
authors.forename: Clara
authors.initials: C
authors.lastname: Martí
authors.forename: Montserrat
authors.initials: M
authors.lastname: Fibla
authors.forename: Cristina
authors.initials: C
authors.lastname: Gutiérrez
authors.forename: Belén
authors.initials: B
authors.lastname: Lloveras
authors.forename: Judit
authors.initials: J
authors.lastname: Moreno-Crespi
authors.forename: Anna
authors.initials: A
authors.lastname: Torrent
authors.forename: Núria
authors.initials: N
authors.lastname: Baixeras
authors.forename: María
authors.initials: M
authors.lastname: Alejo
authors.forename: Francesc Xavier
authors.initials: FX
authors.lastname: Bosch
authors.affiliation: Unit of Infections and Cancer; Cancer Epidemiology Research Programme, IDIBELL, Catalan Institute of Oncology (ICO), 08908 L'Hospitalet de Llobregat, Barcelona, Spain. raquelip@iconcologia.net.
authors.forename: Silvia
authors.initials: S
authors.lastname: de Sanjosé
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D019049:Developed Countries; D055088:Early Detection of Cancer / Q000379:methods*; D005260:Female; D006801:Humans; D008137:Longitudinal Studies; D008403:Mass Screening; D008875:Middle Aged; D065006:Papanicolaou Test / Q000379:methods; D030361:Papillomavirus Infections / Q000175:diagnosis*; D012680:Sensitivity and Specificity; D002583:Uterine Cervical Neoplasms / Q000175:diagnosis / Q000473:pathology* / Q000821:virology*; D014626:Vaginal Smears / Q000379:methods
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