key: cord-0729729-j5fd6wf3 authors: Goldstein, Andrew; Lei, Yang; Goldstein, Lena; Goldstein, Amelia; Bai, Qiao Xu; Felix, Juan; Lipson, Roberta; Demarco, Maria; Schiffman, Mark; Egemen, Didem; Desai, Kanan T.; Bedell, Sarah; Gersten, Janet; Goldstein, Gail; O’Keefe, Karen; O’Keefe, Casey; O’Keefe, Tierney; Sebag, Cathy; Lobel, Lior; Zhao, Anna; Lu, Yan Ling title: A rapid, high-volume cervical screening project using self-sampling and isothermal PCR HPV testing date: 2020-10-22 journal: Infect Agent Cancer DOI: 10.1186/s13027-020-00329-0 sha: 905b4a6c82eae2c7990e51780e5efaf1ddc21850 doc_id: 729729 cord_uid: j5fd6wf3 OBJECTIVE: Rapid, high-volume screening programs are needed as part of cervical cancer prevention in China. METHODS: In a 5-day screening project in Inner Mongolia, 3345 women volunteered following a community awareness campaign, and self-swabbed to permit rapid HPV testing. Two AmpFire™ HPV detection systems (Atila Biosystems) were sufficient to provide pooled 15-HPV type data within an hour. HPV+ patients had same-day digital colposcopy (DC) performed by 1 of 6 physicians, using the EVA™ system (MobileODT). Digital images were obtained and, after biopsy of suspected lesions for later confirmatory diagnosis, women were treated immediately based on colposcopic impression. Suspected low- grade lesions were offered treatment with thermal ablation (Wisap), and suspected high-grade lesions were treated with LLETZ. RESULTS: Of 3345 women screened, 624 (18.7%) were HPV+. Of these, 88.5% HPV+ women underwent same-day colposcopy and 78 were treated. Later consensus histology results obtained on 197 women indicated 20 CIN2+, of whom 15 were detected and treated/referred at screening (10 by thermal ablation, 4 by LLETZ, 1 by referral). CONCLUSIONS: Global control of cervical cancer will require both vaccination and screening of a huge number of women. This study illustrates a cervical screening strategy that can be used to screen-and-treat large numbers of women. HPV self-sampling facilitates high-volume screening. Specimens can be tested rapidly, promoting minimal loss-to-follow-up. Specifically, the AmpFire™ system used in this study is highly portable, simple, rapid (92 specimens per 65 min per unit), and economical. Visual triage can be performed on HPV+ women with a portable digital colposcope that provides magnification, lighting, and a recorded image. Diagnosis and appropriate treatment remain the most subjective elements. The digital image is under study for deep-learning based automated evaluation that could assist the management decision, either by itself or combined with HPV typing. Infection with human papillomavirus (HPV) is a leading cause of cancer among women worldwide with approximately 500,000 new cervical cancer cases and 250,000 deaths each year [1] . Cervical cancer is caused by persistent infection with a group of carcinogenic HPV genotypes (HPV16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59 , and probably HPV68) [2] . The importance of cervical cancer is accentuated by the relatively young average age at incidence and death. Cervical cancer screening strategies have evolved from cytology-based to HPV-based [3] . Following the identification of HPV as the cause of cervical cancer and the development of sensitive HPV tests, HPV-based screening permits the extension of screening intervals and increased impact per number of lifetime screens [3] . Without compromising yield of disease, selfsampling can increase participation and reach of cervical cancer screening programs. Self-sampling is comparable to clinician-obtained sampling for HPVbased screening, is well accepted in many populations, and has been incorporated into screening programs to improve coverage [4, 5] . Currently, there are no national cervical cancer screening programs in China and only 10-30% of Chinese women report having ever had cervical cancer screening [6] . Although incidence and mortality rates (15.3/100, 000 and 4.6/100,000, respectively) are moderately high, the population is so large that every year, there are approximately 100,000 new cervical cancer cases and 30, 000 deaths in China [7] . In general, women living in rural areas are less likely to report ever having had cervical cancer screening and mortality rates from cervical cancer are up to 48% higher [6, [8] [9] [10] . The Inner Mongolia Minority Autonomous Region (Inner Mongolia), is a vast territory that stretches in a great crescent for 1500 miles across northern China. Inner Mongolia was part of the ancient Silk Road region and is bordered to the north by Mongolia and Russia. Inner Mongolia is a geographically diverse and relatively underdeveloped province, with a population of over 24 million in the 2010 census. Forty-nine ethnic groups live in Inner Mongolia though the majority are Mongolian or Han. Additional ethnicities include Manchu, Hui, Daur, Ewenki, Oroqen, and Korean. More than 58% of the population lives in rural areas. Due to the level of development, complex geography, and dispersed population across the rural parts of the majority of Inner Mongolia, the conventional, multi-step screening process for cervical cancer is not feasible. The traditional process of screening with cytology, colposcopy, biopsy and subsequent treatment of women diagnosed with cervical precancer is too resource and expertise-intensive for low-income, vast regions such as Inner Mongolia. Accordingly, techniques such as visualization with acetic acid (VIA) and HPV testing have been studied as alternative methods. The prevalence of HPV varies amongst different ethnic and geographic regions [11, 12] . In China, the prevalence and genotype distributions of HPV are well documented. HPV genotypes 16, 18, 52 and 58 are the most common cancer-causing types amongst Chinese women, with differing distribution rates throughout the country. The prevalence of high-risk HPV within Inner Mongolia ranges from 14.5-36.0%, and this varies significantly between different ethnicities [13] [14] [15] . This study demonstrates the feasibility of a rapid, high-volume screening approach that combines selfsampled HPV testing and digital colposcopy triage to reach unscreened populations, as exemplified by Inner Mongolia, China. This is a cross-sectional analysis using data from women attending a same-day, high-volume screening demonstration in Inner Mongolia, China. Women were contacted and, following an awareness campaign, 3345 agreed to participate and provided consent (Fig. 1) . Participants were female, 30-65 years old, who provided consent to participate in the study. We excluded women who: knew or thought they might be pregnant, were unable to provide informed consent, were seriously ill, had a gross cervical mass, history of previous treatment for cervical cancer, or complete hysterectomy, or had cervical cancer screening in the past 5 years. During a 6-day period in May 2019 that consisted of 4 clinic days and 2 travel days, 3345 Chinese women aged 30 to 65 were screened in three different medical clinics in the Inner Mongolia Minority Autonomous Region. IRB approval was obtained from United Family Hospitals Investigational Review Board, Beijing, China. Local health officials notified and registered potential participants in the preceding weeks. The vast majority of women had never been screened for cervical cancer. After obtaining informed consent, participants received a brief explanation of HPV and cervical cancer via a prerecorded video, as well as instructions on how to obtain a self-sampled vaginal specimen. We screened 460-990 women per day (Fig. 2 ). The first 79 arrivals were referred directly to colposcopy after self-sampling, without awaiting the test results, to make best use of the physicians' time. This provided a subset of 69 HPV-negative referrals. Subsequently, only HPVpositive women were referred for colposcopic examination. Self-collected vaginal specimens were collected using dry brushes and tested for 15 high-risk HPV (HPV16, HPV18, or a pool of 13 types including HPV31, 33, 35, 39, 45, 51, 52, 53, 56, 58, 59, 66, 68) on site using two AmpFire™ (Atila Biosystems, California) machines running concurrently. While waiting for test results, women participated in a joint breast cancer screening effort. All women positive for high-risk HPV (hrHPV+) results were contacted via text message and returned for colposcopic examination the same day or the following day. Digital Colposcopy (DC) was performed with the EVA system 90 s after the application of acetic acid. All DC was performed by one of six physicians and the EVA system was used to obtain 1-3 DC images per patient. Thin acetowhite lesions were considered suspicious for CIN1. Thick acetowhite lesions, rapidly appearing lesions, lesions with course mosaicism or punctuation, and lesions with sharp borders were considered suspicious for CIN2 + . [27] The limitations of visual assessment for grading are acknowledged and discussed below. If DC was positive for cervical abnormalities (suspected CIN1+), patients underwent cervical biopsy of the exocervix using a SoftBiopsy™ (Histologics, California) brush for subsequent confirmatory diagnosis, but were treated presumptively with thermocoagulation or loop electrosurgical excision procedure (LLETZ) the same day. The SoftBiopsy™ (Histologics, California) brush obtains tissue from the entire exocervix to be processed in a single slide. Compared with multiple biopsies from biopsy forceps, it is faster to obtain tissue from multiple areas of the exocervix and it causes less trauma and bleeding, making it easier to perform thermocoagulation (if needed) immediately after biopsy. Thermocoagulation was performed when DC findings were suspicious for CIN1 lesions using one of two different thermocoagulation systems: C3 thermo-coagulator (WISAP, Germany) or TC thermocoagulator™ (Cure Medical, Utah). A LLETZ was performed when findings were highly suspicious for CIN2+ or when thermal ablation was not technically possible. If no acetowhite changes were seen and the entire transformation zone was visible, the patients were informed of the findings and not immediately treated. Repeat HPV testing in 1 year was advised; although the availability of such follow-up was recognized not to be Overall, at colposcopy, clinician colposcopic impression led to 216 women biopsied and, of those, 84 immediately treated. Immediate treatment included thermal ablation, LLETZ, and none (including women who refused treatment and those treated later, based on histologic results). All biopsy specimens were subsequently processed, and read twice, by two pathologists (QXB, JF). The original histopathologic diagnoses included CIN1, CIN1-2, CIN2, CIN2-3, CIN3, and inadequate. For this research analysis, precancer case status among the HPV-positive women was defined as follows: CIN3 by either pathologist or CIN2 by both pathologists. The remaining adequate samples were considered