Title: Predicting the Risk of High-grade Precancerous Cervical Lesions Based on High-risk
HPV Typing in Changsha China
Version: 0 Date: 22 Sep 2024
Reviewer:  Sveinung Wergeland Sørbye
Reviewer's report:
Xiau et al. have conducted a retrospective analysis to predict the risk of low-grade and high-grade
precancerous cervical lesions based on high-risk HPV typing in Changsha, China. The study
analyzed HPV typing data from 158,565 women, with a subset undergoing ThinPrep cytologic
testing (19,707) and colposcopy (7,539). The results showed that HPV types 52, 58, and 53 were
the most prevalent, detecting over 50% of low- and high-grade lesions, surpassing the sensitivity
of HPV16/18. The authors propose individualized screening strategies based on regional HPV
prevalence.
Comments
1. The authors have utilized cervical cytology as an endpoint to calculate the sensitivity for
various HPV types. However, it is imperative to note that cervical cytology should not be
considered a gold standard or endpoint in research due to its limited sensitivity, accuracy, and
reproducibility. Particularly, the ASC-US diagnosis is contentious. If any cytological diagnosis
must be employed, only HSIL should be considered, as it correlates with a significant risk of
high-grade lesions (CIN2+) and cervical cancer.
Sørbye SW, Suhrke P, Revå BW, Berland J, Maurseth RJ, Al-Shibli K. Accuracy of cervical
cytology: comparison of diagnoses of 100 Pap smears read by four pathologists at three hospitals
in Norway. BMC Clin Pathol. 2017 Aug 29;17:18. doi: 10.1186/s12907-017-0058-8. PMID:
28860942; PMCID: PMC5576325.
2. The authors have used low-grade colposcopic lesions as an endpoint to calculate the sensitivity
for various HPV types. However, research by Castle et al. (2011) indicates that CIN1 does not
substantially increase the risk of developing CIN3 beyond that posed by the genotype-specific
HPV infection itself. Thus, CIN1 should not be the primary focus of screening or treatment
efforts, as it often resolves spontaneously. Supporting this, Sørbye et al. (2011) demonstrated
that the risk of developing high-grade lesions (CIN2+) is comparable between women with
a negative cervical biopsy and those with CIN1. This evidence advocates for a conservative
approach, treating CIN1 similar to a positive HPV test with a normal biopsy, focusing on
monitoring rather than immediate intervention.
Castle PE, Gage JC, Wheeler CM, Schiffman M. The clinical meaning of a cervical
intraepithelial neoplasia grade 1 biopsy. Obstet Gynecol. 2011 Dec;118(6):1222-1229. doi:
10.1097/AOG.0b013e318237caf4. PMID: 22105250; PMCID: PMC3229199.
Sørbye SW, Arbyn M, Fismen S, Gutteberg TJ, Mortensen ES. HPV E6/E7 mRNA testing
is more specific than cytology in post-colposcopy follow-up of women with negative cervical
biopsy. PLoS One. 2011;6(10):e26022. doi: 10.1371/journal.pone.0026022. Epub 2011 Oct 6.
PMID: 21998748; PMCID: PMC3188582.
3. In the manuscript, terms such as "cervical biopsies," "histology," "LEEP," and "CIN3+" are
notably absent. This omission is critical as the authors have employed colposcopy to determine
the sensitivity of various HPV types for detecting both low-grade and high-grade lesions. It
is essential to recognize that colposcopy, without concurrent histological biopsy, has limited
sensitivity, specificity, and reproducibility, and thus should not be used as a gold standard or
definitive study endpoint. Only histologically confirmed high-grade lesions (CIN2+ or CIN3+)
should be regarded as valid endpoints or gold standards for evaluating screening tests.
4. In their discussion, the authors suggest following up on the histopathology and clinical
treatment of patients to compare the progression and treatment efficacy of cervical cancer by
different HPV types. However, this study lacks hard endpoints, as it does not include any
histopathology results. For meaningful outcomes, only histologically confirmed high-grade
lesions (CIN2+ or CIN3+) should be regarded as a gold standard for assessing the efficacy of
cervical cancer screening tests.
5. The concept of extended genotyping in cervical cancer screening for women with a positive
HPV test is focused on risk stratification, not sensitivity. The crucial metric is the positive
predictive value (PPV) for CIN3+, rather than the prevalence of different HPV types or
their sensitivity for detecting CIN3+. While HPV testing without genotyping offers excellent
sensitivity, its specificity is low, necessitating further triage measures. Currently, many countries
employ partial genotyping (HPV 16/18) and cervical cytology as triage tools for women
with a positive HPV test. However, extended genotyping is increasingly adopted in various
countries to minimize unnecessary colposcopies and biopsies, thereby enhancing specificity,
while necessarily reducing sensitivity.
6. The authors have employed an HPV test that detects both high-risk and certain low-risk HPV
types ('HPV qualitative testing was performed for 23 HPV types, including high-risk types 16,
18, 26, 31, 33, 35, 39, 45, 51, 52, 53, 56, 58, 59, 66, 68, 73, 82 and low-risk types 6, 11, 42, 43,
81'). A Norwegian study with 30 years of follow-up demonstrated that the incidence of CIN3+
among women with a negative HPV test was comparable to those infected with low-risk HPV
genotypes, specifically noting that low-risk HPV types such as 6 and 11 do not predict high-
grade lesions (CIN3+) (Riibe 2021). These findings are corroborated by Thomsen (2014), which
supports the notion that including low-risk HPV types in cervical cancer screening protocols is
unnecessary and does not contribute to the effective prediction or prevention of cervical cancer.
Riibe MØ, Sørbye SW, Simonsen GS, Sundsfjord A, Ekgren J, Maltau JM. Risk of
cervical intraepithelial neoplasia grade 3 or higher (CIN3+) among women with HPV-test in
1990-1992, a 30-year follow-up study. Infect Agent Cancer. 2021 Jun 22;16(1):46. doi: 10.1186/
s13027-021-00386-z. PMID: 34158090; PMCID: PMC8220730.
Thomsen LT, Frederiksen K, Munk C, Junge J, Castle PE, Iftner T, Kjaer SK. High-risk
and low-risk human papillomavirus and the absolute risk of cervical intraepithelial neoplasia
or cancer. Obstet Gynecol. 2014 Jan;123(1):57-64. doi: 10.1097/AOG.0000000000000056.
PMID: 24463664.
7. The ultimate goal of cervical cancer screening is to reduce both the incidence and mortality
of cervical cancer. The primary objective of these screenings is not merely to detect invasive
cervical cancers but to identify and treat high-grade lesions (CIN2+) to prevent the development
of cervical cancer. When deciding which HPV types to include in an extended genotyping
HPV test, the focus should be on cervical cancer prevention. Therefore, the types most
prevalent in cervical cancer should be prioritized over those commonly found in women with
abnormal cytology or colposcopy results. Because a significant proportion of CIN2 and CIN3
lesions may regress without treatment, addressing all CIN2+ lesions can lead to overtreatment.
Consequently, screening programs should focus on the HPV genotypes most prevalent in
cervical cancer, rather than those found in CIN2 or CIN3 lesions.
Significant research supports this approach: A study by Arbyn (2014) found that 20 HPV types
were notably more prevalent in cases of cervical cancer compared to women with normal
cytology. Nygård et al. (2021) suggest that in the post-vaccination era, concentrating screening
on the HPV types included in the nonavalent vaccine could optimize test performance, as
extending beyond these types might create an imbalanced trade-off between risks and benefits.
Additionally, Sundström (2021) in Sweden and a recent Norwegian study (Sørbye 2023) showed
that a substantial majority of screen-detected cervical cancers were attributed to HPV types 16,
18, 31, 33, 45, or 52, with the inclusion of other types contributing minimally to cancer detection.
This evidence suggests a targeted approach in HPV screening could enhance efficacy and reduce
unnecessary interventions.
Arbyn M, Tommasino M, Depuydt C, Dillner J. Are 20 human papillomavirus types causing
cervical cancer? J Pathol. 2014 Dec;234(4):431-5. doi: 10.1002/path.4424. PMID: 25124771.
Sundström K, Dillner J. How Many Human Papillomavirus Types Do We Need to Screen For?
J Infect Dis. 2021 May 20;223(9):1510-1511. doi: 10.1093/infdis/jiaa587. PMID: 32941611.
Nygård, M., Hansen, B. T., Kjaer, S. K., Hortlund, M., Tryggvadóttir, L., Munk,
C., ... Dillner, J. (2021). Human papillomavirus genotype-specific risks for cervical
intraepithelial lesions. Human Vaccines & Immunotherapeutics, 17(4), 972-981. DOI:
10.1080/21645515.2020.1814097.
Sørbye SW, Falang BM, Antonsen M. Distribution of HPV Types in Tumor Tissue from Non-
Vaccinated Women with Cervical Cancer in Norway. Journal of Molecular Pathology. 2023;
4(3):166-177. https://doi.org/10.3390/jmp4030015
8. The authors have employed the term 'pathogenicity' in their analysis ('The most prominent
high-risk HPV16/18 did not show a higher degree of pathogenicity compared with other high-
risk types after the infection rates were discounted'). However, without any hard endpoints such
as histologically confirmed lesions, the use of 'pathogenicity' is not substantiated and could be
misleading. Given the well-documented evidence that HPV types 16 and 18 are responsible for
more than 70% of all cervical cancer cases worldwide, it is inaccurate and potentially misleading
for the authors to suggest that these types do not confer the highest risk of cervical cancer
development. A more accurate assessment of risk should align with established epidemiological
data.
9.  In their conclusion, the authors state: 'In Changsha, China, the most prevalent HPV52/58/53
detected 50.5% of low-grade lesions and 50.6% of high-grade lesions, significantly exceeding
the sensitivity of HPV16/18 (34.0%/27.7%).' However, this statement could lead to
misinterpretation in clinical practice. Firstly, targeting low-grade lesions (CIN1) with such
high sensitivity implies a decreased specificity for more clinically relevant high-grade lesions.
Importantly, we typically avoid biopsies for CIN1 due to their potential for spontaneous
resolution. Secondly, the focus of triage should not be on sensitivity alone but on risk
stratification based on the positive predictive value (PPV) for histologically confirmed high-
grade lesions (CIN3+), which is more indicative of the potential for cancer development. The
manuscript's emphasis on sensitivity overlooks these critical aspects of cervical cancer screening
and management.
10. The authors conclude that 'colposcopy should be performed directly for the positive cases of
HPV52/58/53/16/18, in order to increase the efficiency of cervical cancer screening.' However,
this recommendation prompts several critical questions: What is the positive predictive value
(PPV) for CIN3+ using this strategy? Additionally, what proportion of cervical cancer cases
would be detected by these five genotypes? Studies from Europe commonly identify HPV types
16, 18, 45, 33, and 31 as the most prevalent in cervical cancer, suggesting that a broader scope of
high-risk HPV types, typically including 16, 18, 45, 33, 31, 52, and 58, might be more effective
in triage tests for women with positive HPV results in primary screening. This broader approach
might enhance both the detection and the management of cervical cancer risk more effectively
than the strategy suggested by the authors.
Stoler MH, Parvu V, Yanson K, Andrews J, Vaughan L. Risk stratification of HPV-positive
results using extended genotyping and cytology: Data from the baseline phase of the Onclarity
trial. Gynecol Oncol. 2023 Jul;174:68-75. doi: 10.1016/j.ygyno.2023.04.022. Epub 2023 May
5. PMID: 37149907.
Sørbye SW, Falang BM, Antonsen M. Performance of a 7-Type HPV mRNA Test in Triage of
HPV DNA Primary Screen Positive Women Compared to Liquid-Based Cytology. Journal of
Molecular Pathology. 2023; 4(2):69-80. https://doi.org/10.3390/jmp4020008
11. In the introduction, the authors state: 'Cancer screening can detect tumors in the early stages
for patients, and greatly improve their chances of survival and cure.' However, this statement
overlooks the primary goal of cervical cancer screening, which is not to detect invasive cervical
cancer per se, but rather to identify and treat high-grade lesions (CIN2/3), also known as
precancers, to prevent the development of cervical cancer. The occurrence of invasive cervical
cancer in women who have participated timely in screening programs is considered a screening
failure. It is essential to clarify that the success of cervical cancer screening hinges on preventing
cancer through the early detection and treatment of precancerous conditions, not just the early
detection of cancer itself.
12.  In the introduction, the authors claim, 'There are over 400 different types of HPV that
persist within the human population.' This figure appears to be overstated. According to the latest
data from the International Human Papillomavirus Reference Center in Sweden, the number of
officially established HPV types is 231. It would be more accurate and scientifically valid to
state: 'More than 200 distinct HPV types have been identified.'
de Villiers EM. Cross-roads in the classification of papillomaviruses. Virology.
2013;445(1-2):2–10. doi: 10.1016/j.virol.2013.04.023.
Doorbar J, Quint W, Banks L, et al. The biology and life-cycle of human papillomaviruses.
Vaccine. 2012;30(Suppl 5):F55–70. doi: 10.1016/j.vaccine.2012.06.083.
International Human Papillomavirus Reference Center. Reference clones. Stockholm:
Karolinska Institutet. Available from: https://www.hpvcenter.se/human_reference_clones/
13.  In the introduction, the authors state, 'Most HPV infections are transient and will be cleared
within a couple of years, about 10–20% of infections persist latently and lead to ultimately
invasive cancer.' This assertion suggests a misunderstanding of the epidemiology of HPV and
cervical cancer. While it's true that 70-80% of women may be infected with HPV at some
point in their lives, the 10-20% persistence rate does not directly translate to cervical cancer
development. If it did, the lifetime risk of cervical cancer would be 7-16%. However, the actual
lifetime risk is much lower—about 1% in countries with organized screening programs and
potentially 2-3% without screening. For instance, in the US, only about 0.6% of women are
diagnosed with cervical cancer during their lifetime, according to 2018–2021 data. It would
be more accurate to clarify that while persistent HPV infections increase the risk, only a small
fraction of these lead to cervical cancer.
In the UK, the lifetime risk of developing cervical cancer is less than 1% for women and
people with a cervix, with over 99% not expected to develop the disease. This low incidence
reflects significant advancements in healthcare, including cervical screening (smear tests) and
treatment for abnormal cervical cells. Without the benefits of the HPV vaccine and regular
cervical screening, research suggests the lifetime risk would approximately double to about 2%.
https://www.jostrust.org.uk/information/cervical-cancer/causes-risks
https://seer.cancer.gov/statfacts/html/cervix.html
14.  In the introduction, the authors state: 'In this study, women of the appropriate age in
Changsha are screened for cervical cancer with HPV testing, and if HPV positive, cytology
is performed to assess the risk of cervical lesions and to determine the need for colposcopy
and biopsy or treatment.' However, it is important to clarify that most countries that utilize
cervical cytology in primary screening or as triage for women with a positive HPV test do
not recommend treatment such as LEEP based solely on cytological diagnoses. Treatment
is typically recommended only for women with histologically confirmed high-grade lesions
(CIN2+).
https://www.gov.uk/government/publications/cervical-screening-programme-and-colposcopy-
management/3-colposcopic-diagnosis-treatment-and-follow-up
15. Table 1 identifies HPV58, HPV33, HPV82, HPV31, and HPV26 as the five HPV types
with the highest risk of cytological HSIL. This supports the inclusion of HPV33 and HPV31 in
genotyping tests aimed at identifying women at high risk for cytological HSIL. However, despite
their association with high HSIL rates, the infrequent causation of cervical cancer by HPV82 and
HPV26 argues against using cervical cytology alone as an endpoint in cervical cancer prevention
studies. Such an endpoint may not adequately reflect the true oncogenic potential of different
HPV types.
HPV58: 5.6% (173/3096)
HPV33: 5.5% (65/1190)
HPV82: 4.8% (11/229)
HPV31: 4.7% (32/686)
HPV26: 4.6% (5/108)
HPV52: 3.0% (198/6611)
HPV51: 2.3% (40/1723)
HPV35: 2.3% (9/392)
HPV45: 2.3% (6/257)
HPV59: 1.7% (15/893)
HPV56: 1.4% (18/1273)
HPV66: 1.4% (16/1114)
HPV73: 1.3% (3/223)
HPV53: 1.1% (32/2904)
HPV39: 1.1% (20/1849)
HPV68: 1.0% (18/1740)
16. Table 2 lists HPV26, HPV45, HPV68, HPV53 ,and HPV35 as the five HPV types with
the highest risk of colposcopic impressions of high-grade lesions. However, the methodology
underlying these results is potentially confounding, as the women were selected based on both
HPV type and abnormal cytology (ASC-US+). Relying solely on colposcopic impressions of
high-grade lesions as an endpoint may not provide an accurate reflection of the true oncogenic
potential of different HPV types, possibly skewing the perceived risk associated with these types.
HPV26: 41.3% (19/46)
HPV45: 37.8% (37/98)
HPV68: 37.3% (179/480)
HPV53: 36.6% (333/910)
HPV35: 36.4% (48/132)
HPV59: 36.3% (103/284)
HPV73: 34.3% (24/70)
HPV39: 34.0% (175/514)
HPV66: 33.9% (122/360)
HPV52: 33.1% (706/2131)
HPV31: 32.4% (80/247)
HPV56: 32.1% (146/455)
HPV51: 31.8% (177/557)
HPV82: 31.4% (27/86)
HPV33: 29.8% (137/460)
HPV58: 29.3% (335/1145)
HPV16: 28.4% (523/1839)
HPV18: 25.5% (167/654)