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, 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.

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, Nicolas Wentzensen

Intramural-to-India (‘I-to-I’) Study on ‘Improving Cervical Cancer Prevention among HIV-infected women using novel HPV-based biomarker assays’

Traditional cytology-based screening programs for cervical cancer prevention have failed everywhere other than resource-abundant settings. In resource constrained settings, while tests such as visual inspection with acetic acid (VIA) provide a suitable platform for clinical evaluation and are very cheap, they are highly rater-dependent and suffer from substantial false positivity. Carcinogenic HPV DNA detection [e.g., HPV DNA testing by Hybrid Capture-2 (hc2) assay] is less specific than cytology and cannot differentiate between the great majority of benign infections and the few persistent infections linked to cervical pre-cancer. A reliable and robust test that improves both the sensitivity and specificity of screening may provide better alternatives for HIV-infected women than conventional cytology screening or VIA. This study [funded through the NIH Office of AIDS Research (OAR) ‘Intramural-to-India’ initiative] will be conducted in collaboration with the National AIDS Research Institute (NARI), a permanent institute of the Indian Council of Medical Research (ICMR) in Pune, India. A cohort of 1000 HIV-infected women will undergo evaluation using two novel and potentially sustainable, lower-cost tests for accurate screening for cervical cancer. These tests include detection of HPV E6 oncoprotein (using a low-cost, rapid, strip test that detects HPV E6 oncoprotein and can be performed without complex machinery or a cold chain) and immunocytochemical staining using p16INK4a/Ki-67 (a biomarker correlated with the oncogenic transformation of cervical cells following persistent carcinogenic HPV infection). This study involves simultaneous and independent evaluation of these novel biomarkers along with confirmation by colposcopy/histopathology for all participants. Linear Array HPV polymerase chain reaction (PCR) assay will measure carcinogenic HPV-DNA for comparison purposes. This observational study will permit us to describe the sensitivity and specificity of any of the tests or combinations with reasonable precision for a wide range of prevalence of cervical pre-cancer and cancer. This study will allow evaluation of the field adoption and efficacy of these newer assays as well as permit validation of collection, transport, storage, and evaluation protocols. More information, Vikrant Sahasrabuddhe.