小柯机器人

澳大利亚悉尼大学Megan A Smith团队分析了HPV疫苗接种人群原发性人乳头瘤病毒（HPV）宫颈筛查前两年的全国经验。相关论文于2022年3月30日发表在《英国医学杂志》上。

为了回顾在HPV疫苗接种人群中进行原发性人乳头瘤病毒（HPV）宫颈筛查项目的头两年效果，研究组在澳大利亚进行了一项观察性研究。2017年12月1日至2019年12月31日，共有3745318名女性进行了原发性HPV检测；大多数年龄<40岁的女性以前都接种过HPV16和HPV18疫苗。

如果HPV16或HPV18（HPV16/18）阳性，则进行初级HPV筛查并转诊，并对16/18以外的高危HPV类型阳性的女性进行液基细胞学检查（非典型鳞状细胞阈值不能排除高级别鳞状上皮内病变）分诊。对于细胞学检查结果为阴性或低级别的分诊女性，建议进行12个月的随访HPV检测，如果她们在随访中检测出任何高危HPV类型呈阳性，则转诊。主要观察指标为参加第一次HPV筛查、检测呈阳性并被转诊进行阴道镜检查的女性比例；检测宫颈上皮内瘤变（CIN）2级或更差、CIN 3级或更差或癌症的短期风险。

截至2019年底，在年龄为25-69岁的6428677名合格女性中，有54.6%（n=3507281）接受了首次HPV检测。在参加常规筛查的人群中，25-69岁女性（n=3045844）的HPV16/18和非16/18型HPV阳性率分别为2.0%和6.6%，25-34岁女性（n=768362）的高度接种人群中的阳性率则分别为2.2%和13.3%。阴道镜检查转诊率（年龄25-69岁）为3.5%，考虑到尚未接受12个月复查的女性，这一比例上升至估计的6.2%。

在基线检查时HPV16/18阳性的女性中，宫颈癌检出率为0.98%（456/46330），其中HPV16/18阴性且细胞学检查阴性的女性中，宫颈癌检出率为0.32%（89/28003）。在基线检查和12个月时，HPV类型不是16/18且细胞学检查阴性或低级别的女性患严重疾病的风险较低（CIN 3级或更差为3.4%；癌症为0.02%），但人数估计占该筛查算法转诊的62.0%。

研究结果表明，阴道镜转诊阈值需要考虑潜在的癌症风险；在此基础上，无论细胞学结果如何，在第一轮HPV筛查中发现患有HPV16/18的女性风险更高，即使在之前筛查良好的人群中也是如此。HPV类型不是16/18、细胞学检查阴性或低级别的女性出现严重异常的风险较低，但构成大多数转诊，可以通过两轮重复而非一轮HPV检测进行安全管理。在接种HPV疫苗的队列中，HPV16/18驱动的转诊率较低。

附：英文原文

Title: National experience in the first two years of primary human papillomavirus (HPV) cervical screening in an HPV vaccinated population in Australia: observational study

Author: Megan A Smith, Maddison Sherrah, Farhana Sultana, Philip E Castle, Marc Arbyn, Dorota Gertig, Michael Caruana, C David Wrede, Marion Saville, Karen Canfell

Issue&Volume: 2022/03/30

Abstract:

Objective To review the first two years of the primary human papillomavirus (HPV) cervical screening programme in an HPV vaccinated population.

Design Observational study.

Setting Australia.

Participants 3745318 women with a primary HPV test between 1 December 2017 and 31 December 2019; most women aged <40 years had previously been offered vaccination against HPV16 and HPV18.

Interventions Primary HPV screening with referral if HPV16 or HPV18 (HPV16/18) positive and triage with liquid based cytology testing (threshold atypical squamous cells-cannot exclude high grade squamous intraepithelial lesion) for women who were positive for high risk HPV types other than 16/18. A 12 month follow-up HPV test was recommended in triaged women with a negative or low grade cytology result, with referral if they tested positive for any high risk HPV type at follow-up.

Main outcome measures Proportion of women who had attended for their first HPV screening test, tested positive, and were referred for colposcopy; and short term risk of detecting cervical intraepithelial neoplasia (CIN) grade 2 or worse, CIN grade 3 or worse, or cancer.

Results 54.6% (n=3507281) of an estimated 6428677 eligible women aged 25-69 had undergone their first HPV test by the end of 2019. Among those attending for routine screening, positivity for HPV16/18 and for HPV types not 16/18 was, respectively, 2.0% and 6.6% in women aged 25-69 (n=3045844) and 2.2% and 13.3% in highly vaccinated cohorts of women aged 25-34 (n=768362). Colposcopy referral (ages 25-69 years) was 3.5%, increasing to an estimated 6.2% after accounting for women who had not yet had a 12 month repeat test. Cervical cancer was detected in 0.98% (456/46330) of women positive for HPV16/18 at baseline, including 0.32% (89/28003) of women with HPV16/18 and negative cytology. Women with HPV types not 16/18 and negative or low grade cytology at both baseline and 12 months were at low risk of serious disease (3.4% CIN grade 3 or worse; 0.02% cancer; n=20019) but estimated to account for 62.0% of referrals for this screening algorithm.

Conclusions Colposcopy referral thresholds need to consider underlying cancer risk; on this basis, women with HPV16/18 in the first round of HPV screening were found to be at higher risk regardless of cytology result, even in a previously well screened population. Women with HPV types not 16/18 and negative or low grade cytology showed a low risk of serious abnormalities but constitute most referrals and could be managed safely with two rounds of repeat HPV testing rather than one. HPV16/18 driven referrals were low in HPV vaccinated cohorts.

DOI: 10.1136/bmj-2021-068582

Source: https://www.bmj.com/content/376/bmj-2021-068582

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