Urinary HPV testing accurate for cervical HPV detection

1. Urinary HPV testing showed a high sensitivity and specificity for detecting cervical HPV, and an especially high specificity for strains 16 and 18.

2. First void collection was more accurate than midstream or random collection methods.

Evidence Rating Level: 1 (Excellent)

Study Rundown: Screening for cervical cancer often relies on a smear test or cytology to detect pre-cancerous cervical intraepithelial neoplasia (CIN). However, the HPV detection based screening may serve as a secondary screening or even alternative screening measure for grade 3 CIN or invasive cervical cancer. Complete coverage of all patients is important for prevention, and current screening practices can present a barrier to access due to invasiveness, low convenience, and necessity for a physician. This systematic review and meta-analysis assessed the accuracy of urinary HPV testing, which may be more accessible for many patients, including those in developing nations. The study found a sensitivity of 87% and a specificity of 94% in detecting cervical HPV when compared to direct cervical sampling, and a 73% sensitivity and 98% specificity in detecting HPV 16 and 18. First void collection had a 22-fold increase in accuracy when compared with midstream or random collection mostly due to a higher sensitivity.

This study provides strong evidence for the use of urinary HPV testing as a reliable method for alternative HPV screening. Situations where this test may be useful include post-vaccination follow-up and remote clinics. While the methodology was sophisticated and complete, the authors caution that high heterogeneity between studies may overestimate or underestimate test accuracy. Still, this work provides a support for consideration of urinary HPV testing as a reliable and viable screening tool for cervical HPV infection.

Click to read the study, published today in the BMJ

Click to read an accompanying editorial in the BMJ

Relevant Reading: Detection of human papillomavirus DNA in urine. Review of the literature

In-Depth [systematic review and meta-analysis]: This study selected 23 research articles for systematic review that included studies where both urine and cervical HPV testing were compared and excluded studies with no reference standard. Only 14 studies, where 2×2 contingency tables could be constructed, were used for subsequent meta-analysis. Sensitivity and specificity for urinary HPV detection tests were 87% (CI_95% 78-92%) and 94% (CI_95% 82-98%), respectively. Detection of high risk HPV had a sensitivity of 77% (CI_95% 68-84%) and a specificity of 88% (CI_95% 58-97%). Detection of strain 16 and 18 had a sensitivity of 73% (CI_95% 56-86%) and a specificity of 98% (CI_95% 91-100%). Receiver Operating Curves demonstrated 95% confidence intervals in the upper left quadrant, suggesting high heterogeneity between studies. One source of heterogeneity was first void versus midstream or random collection which showed a 21.7-fold (CI_95% 1.3-376) odds increase in accuracy for first void collection. No other sources of significant heterogeneity were identified. Sensitivity analyses showed similar sensitivities and specificities when studies of narrow spectrums of patients were excluded.

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