Cervical Cancer and Other HPV-Related Studies

ASCUS/LSIL Triage Study (ALTS)

This project is a study of the clinical management of low-grade cervical cytologic abnormalities. The major hypothesis to be tested is whether HPV testing can reliably triage the common cytologic diagnoses of ASCUS (Atypical squamous cells of undetermined significance) and LSIL (Low-grade squamous intra-epithelial lesions), which represent the bulk of cervical abnormalities seen on Pap smears. Currently, the most aggressive standard of care is immediate colposcopy and biopsy of all suspected lesions. This type of aggressive management is expensive with some associated morbidity, and probably represents over-treatment, since evidence indicates that most cases of ASCUS and LSIL eventually regress. This clinical trial of management alternatives consists of three arms: immediate colposcopic referral of all patients; triage using HPV testing as an adjunct to cytology; and conservative management with repeat Pap smears. All participants are being followed every 6 months for two years. Over 5,000 women were randomized during enrollment that ended in December, 1998. The baseline data showed that HPV DNA testing is a viable strategy for clarifying ASCUS cytology. However, HPV DNA prevalence in cases of LSIL proved too uniformly high to permit use of HPV DNA testing for triage. More information, Philip Castle.

Assessment of Screening Modalities for Gynecologic Cancers

Currently, there are no convincing early detection approaches for endometrial and ovarian cancers. Although it is well established that some endometrial and ovarian tumors shed cytologically recognizable cells in routinely prepared Pap tests, it is clear that this approach rarely detects occult tumors. Accordingly, efforts to develop means of collecting biological samples that have high patient acceptability, good sensitivity for detecting early disease, and excellent specificity are needed. In this project, we want to assess the feasibility of using alternative sampling techniques in combination with molecular assays to detect endometrial and ovarian cancers. We will compare sampling using a Tampon and a sheathed endometrial brush, the Tao brush. We want to assess the quality of DNA extracted from the different samplers. We will assess the correlations between methylation of somatic DNA for a selected marker panel and cancer status. We wish to include 117 women age 45 years and older with suspected endometrial cancer or ovarian cancer, and 53 age-matched controls without malignancy, all of whom are referred to surgery at the Mayo clinic. We plan to conduct a pilot study of women with confirmed or suspected endometrial cancer or ovarian cancer, and women treated for benign conditions. DNA will be extracted from samples collected using a vaginal Tampon and an endometrial brushing using an FDA approved device (Tao brush) prior to surgery. A panel of methylation markers will be analyzed from samples yielding sufficient DNA. The results of the methylation analysis will be compared to the final histology for all patients in the study. We will set the detection of methylation at one or more loci in 50% of women in each arm as a technical success. More information, Nicolas Wentzensen.

Study to Understand Cervical Cancer Early Endpoints and Determinants (SUCCEED)

We now know that human papillomavirus (HPV) infection is the necessary but not sufficient cause of cervical cancer. Cervical pathogenesis evolves as follows: normal cervical tissue, to oncogenic HPV infection, to precancer and then to invasive cancer. The majority of women with oncogenic HPV infections will not develop cancer, and most HPV infections, even those with associated cellular changes, regress in 1-2 years, probably eradicated or controlled by cellular immune response. Moreover, while invasive cancer and precancer are histologically well-defined, the histological classification of low-grade lesions, now better defined as HPV infection, is very heterogeneous and poorly reproducible. Identifying women at highest risk for cancer prior to neoplastic progression is therefore a challenge. At present, we are unable to predict with any accuracy which HPV infections will progress and which are among the majority that regress. It is therefore of etiologic interest and of public health benefit to develop a method for identifying the HPV-infected women at risk for progressing to precancer and invasion. To develop an accurate and reproducible division of precursor lesions (HPV infection and precancer) will require gaining knowledge about the molecular distinctions at each progressive disease state. Our goal is to therefore comprehensively assess biomarkers of risk for progressive cervical neoplasia, and thus develop a new set of biomarkers that can distinguish those at highest risk of cervical cancer from those with benign infection. Specifically, we will initially implement a cross-sectional study to develop a comprehensive list of potential risk biomarkers by examining cervical tissues of 2000 women with HPV infection, precancer, and cancer. We will measure gene expression profiles to gain an accurate and comprehensive in vivo picture of cervical neoplasia carcinogenesis. We propose to then validate the most promising identified candidate biomarkers in a prospective design by assessing their predictive values for key outcomes related to progression (HPV persistence, diagnosis of precancer) or non-progression (HPV clearance). More information, Nicolas Wentzensen.

A Study to Distinguish HPV infection from precancer- The Biopsy Study

A new NCI-funded, collaborative study on colposcopic biopsy is conducted at the University of Oklahoma, as part of an already established project on cervical cancer risk-marker discovery. The aims of the study are to study cervical disease on the lesion level, to optimize criteria for biopsy placement, and to analyze the incremental benefit of taking multiple biopsies. The study is conducted in close collaboration with the ASCCP represented by a colposcopy and pathology expert group.

Following a standardized protocol for biopsy placement based on decreasing order of lesion severity as judged by colposcopic impression, up to 4 biopsies, including one randomly taken, will be performed on 1000 women referred to colposcopy. ECC will be restricted to women 30 and older. Colposcopic impression, acetowhitening, and biopsy placement will be documented using a digital imaging system. All biopsies taken from a woman will be analyzed separately using conventional histology, HPV typing, and biomarkers.

We will study the topographic distribution and functional relation of multiple lesions on the cervix using HPV genotyping and biomarkers for viral transformation. The incremental benefit of taking additional targeted and random biopsies will be calculated. We will study the predictive value of candidate biomarkers against an improved gold standard. The results of the study will impact colposcopy and cervical cancer screening procedures in general. Making colposcopy more effective is important in a time of extensive screening (smaller lesions are detected) and vaccination against HPV (leading to an overall reduction of high grade lesions). More information, Nicolas Wentzensen.

Mississippi Delta Project

Mississippi Delta region is a region along the southern portion of the Mississippi River with one of the highest incidence rates of cervical cancer in the U.S. High incidence rates are due in part to poor access to, and limited resources for, Pap screening. The Mississippi Delta Project (MDP) is a community-based demonstration project to examine whether self-collection of cervicovaginal specimens in combination with HPV DNA testing in women aged 30 and older might be a viable and acceptable method of cervical cancer screening in this population. MDP is the first in series of demonstration projects in underserved U.S. regional and international populations to develop, evaluate, and implement alternative, cost-effective approaches to cervical cancer screening with the long-term goal of establishing self-sustaining, community-based, screening programs. More information, Philip Castle

The HPV Persistence and Progression (PaP) Cohort

The carcinogenicity of the 15 HPV types with carcinogenic potential varies greatly. We wish to increase the already proven clinical utility of carcinogenic HPV DNA testing in women 25 and older by understanding the unique properties of individual HPV types for viral persistence and progression. Specifically, we seek to understand the timing and determinants of viral clearance versus persistence and, given persistence, the risk of progression to CIN3/cancer (=CIN3) among women infected with each type of carcinogenic HPV at the ages when cancer occurs. The relevant natural history data are lacking. There are no NCI or other cohorts in which these and other questions are being adequately addressed.

Kaiser Permanente Northern California (KPNC) routinely uses a FDA-approved pooled-type DNA test for carcinogenic HPV (Hybrid Capture 2 [HC2], Digene Corporation, Gaithersburg, MD) as an adjunct to cytology for cervical cancer screening in women 25 and older. We are teaming with KPNC to create a carcinogenic HPV-positive cohort (HPV Persistence and Progression Cohort or PaP Cohort) for investigating the natural history of HPV genotypes. Specifically, we are targeting 1) 32,000 HPV-positive women and 4,000 HPV-negative women aged 30 and older and 2) 4,000 HPV-positive women and 7,000 HPV-negative women aged 25-29. Our initial enrollment targets have almost been met; we are also planning additional enrollment of women 50 and older, women <25 years of age, and women with incident HPV infections. We will use efficient sampling designs to achieve high power with minimal laboratory analyses, with specimens selected for testing based on clinical outcomes ascertained by linkage to the Kaiser cytology and histology databases and KPNC’s active yearly follow-up of all HC2-positive women. We plan to “follow” women for three years after their enrollment in 2007-8 by banking their residual specimens collected at their return visits; longer follow-up might be biased by extensive censoring due to treatment. More information, Philip Castle

Anal Cancer Screening Study

I am conducting a screening cohort study of 1,000 HIV-positive MSM participating in the Kaiser Permanente Northern California (KPNC) health maintenance program. Under written, informed consent, participating KPNC members will respond to a self-administered risk factor questionnaire and will undergo two anal specimen collections into liquid-based cytology (LBC) medium prior to a digital exam and high resolution anoscopy. Subjects will be followed annually for two years to collect follow-up clinical data related to outcomes. Baseline clinician-collected specimens will be tested in a masked fashion for the following clinical biomarkers: 1) carcinogenic HPV DNA in aggregate and individual carcinogenic HPV genotypes; 2) carcinogenic HPV RNA and HPV16/18 RNA; 3) cytogenetic changes (3q, 5p, and 20q amplification); and 4) p16INK4a and Ki-67 immunocytochemical staining. For reference, clinician-collected specimens will be used to make LBC slides and evaluated by an expert cytopathology laboratory. We will estimate the HPV genotype-specific risk and the clinical performance (sensitivity, specificity, positive and negative predictive values, and referral rates) of individual tests and combinations of tests for detection of prevalently-detected, one-year cumulative, and two-year cumulative histologically-confirmed anal precancer (anal intraepithelial neoplasia grade 3) or worse (=AIN3). All MSM will undergo diagnostic procedures at all visits and independent of testing results, which will result in unbiased disease ascertainment.More information, Philip Castle

Low-Cost Molecular HPV Screening Study

Low-cost, molecular human papillomavirus (HPV) testing may offer a more robust alternative to Pap smears and visual inspection with acetic acid (VIA) for cervical cancer screening and prevention in underserved populations. Two low-cost molecular tests for human papillomavirus (HPV) have been developed: 1) AVantage HPV E6 Test (Arbor Vita Corporation, Sunnydale, CA) that detects E6 proteins from 7 carcinogenic HPV genotypes and 2) careHPV (Qiagen, Gaithersburg, MD) that detects the DNA for pool of 14 carcinogenic HPV genotypes. A prototype E6 Test just being completed and will be ready for the first clinical evaluations in 2009. The HPV E6 Test works like an ELISA in strip format such that it takes less than two hours to run and may provide point-of-care (diagnostic testing at or near the site of patient care) use for immediate decision making. careHPV, a small-batch DNA test for pool of 14 carcinogenic HPV genotypes that takes 2.5 hours, already has been developed and is currently being used in demonstration projects. The results to date for careHPV are promising. I am evaluating both tests, and to evaluate the best low-cost triage strategies for careHPV in areas of high prevalence of carcinogenic HPV DNA. We propose a study of 7,500 women, ages 25-65, in an age-stratified, region-stratified sample of women living in rural China. Women will be screened at enrollment and at the one-year follow-up by the HPV E6 Test, careHPV and careHPV16/18/45 (for triage), second test for carcinogenic HPV with separate detection of HPV16/18/45 (for triage), and visual inspection with acetic acid (VIA). A subgroup of composed of all screen-positive women and random samples of screen-negative women will be evaluated at both time points by colposcopy using a rigorous diagnostic protocol. The primary goals are 1) to evaluate the clinical performance of these tests for detection of cervical precancer and cancer and 2) to determine the positive predictive value of VIA, the HPV E6 Test, and HPV16/18/45 detection among careHPV-positive woman for cervical precancer and cancer.More information, Philip Castle