title: Improving the performance of reflex Human Papilloma Virus (HPV) testing in triaging women with atypical squamous cells of undetermined significance (ASCUS): A restrospective study in a tertiary hospital in United Arab Emirates (UAE).
abstract: BACKGROUND
  Cervical cancer is the second commonest cancer in women worldwide. Infection with oncogenic types of human Papillomavirus (HPV) is the most important risk factor for developing cervical cancer. Reflex High risk HPV (HR-HPV) testing is of significant value in the assessment of Papanicolaou (Pap) smear results where ASCUS are identified.
  
  
  OBJECTIVE
  To improve the performance of reflex HR-HPV testing in triage of ASCUS and analyze the factors impacting it.
  
  
  METHODS
  In this study, we generated a database of 9641 women who had cervical smears collected during the study period from the cytopathology record in a large tertiary hospital in UAE. These included 297 smears with ASCUS diagnosis. All cases were retrospectively followed up with a mean duration of 2.44 years. We analyzed data according to the outcome based on several follow-up Pap smear analysis as the reference assessment.
  
  
  RESULTS
  We detected HR-HPV infection in 17.9% of cases. 9.1% <25, 28.8% 25-34 and 62.1% ≥35 years old. HR-HPV prevalence was higher among premenopausal women (20.7%) compared to postmenopausal women (9.5%) (P-value=0.044). The rate of progression to high grade lesions was also higher (28.7%) in the premenopausal group compared to (12.8%) in the postmenopausal group. Reflex HPV testing had an overall sensitivity of 41.1%, specificity of 88.2%, positive predictive value (PPV) of 62.1%, and negative predictive value (NPV) of 75.9% in detection of cervical lesions. These figures were higher on combining premenopausal status and complaint of abnormal bleeding or discharge/itching (66.7%, 93.3%, 66.8% and 93.3% respectively).
  
  
  CONCLUSIONS
  The sensitivity, specificity and NPV of reflex HPV testing in the triage of ASCUS cases can be more accurate in premenopausal women upon adding age group and presenting complaint as a triage item. This improves the performance of reflex HPV testing and the subsequent selection of high risk patients for colposcopy.
authors.affiliation: Department of Obstetrics and Gynecology, Corniche Hospital, Abu Dhabi, United Arab Emirates. Electronic address: marwa.maher84@gmail.com.
authors.forename: Marwa
authors.initials: M
authors.lastname: Fakhreldin
authors.affiliation: Department of Obstetrics and Gynecology, Mafraq Hospital, Abu Dhabi, United Arab Emirates.
authors.forename: Karim
authors.initials: K
authors.lastname: Elmasry
mesh_terms: D000328:Adult; D000368:Aged; D065309:Atypical Squamous Cells of the Cervix; D005260:Female; D006801:Humans; D008875:Middle Aged; D065006:Papanicolaou Test / Q000592:standards*; D027383:Papillomaviridae / Q000145:classification; D030361:Papillomavirus Infections / Q000175:diagnosis*; D017698:Postmenopause; D017697:Premenopause; D015995:Prevalence; D012680:Sensitivity and Specificity; D062606:Tertiary Care Centers; D014479:United Arab Emirates; D002583:Uterine Cervical Neoplasms / Q000175:diagnosis / Q000821:virology; D014626:Vaginal Smears
keywords: Atypical squamous cells of undetermined significance; Cervical screening; High Risk Human Papilloma Virus; Reflex HPV testing; Triage of ASCUS; United Arab Emirates