HPV Screening With Triage by HPV Genotyping Versus Visual Inspection With Acetic Acid

Prof. Patrick Petignat

Status: Enrolling

Conditions: Cervical Cancer

Treatments: Diagnostic Test: Visual inspection after application of acetic acid; Diagnostic Test: HPV genotyping

Study type: Interventional

Funder types: Other

Identifiers

NCT05385406

AO_2021-00066

Details and patient eligibility

About

Cervical cancer is the leading cause of cancer death among women in sub-Saharan Africa, despite the existence of effective prevention and screening methods. Because vaccination rates against human papillomavirus (causing nearly all cervical cancers) are still insufficient in some low-resource countries, early detection and treatment of cervical lesions at risk of progressing to cancer are crucial components of cervical cancer control. Therefore, it is essential to find the most reliable and appropriate screening strategy in the context of low-resource countries in order to identify women in need of treatment and thus prevent the development of cervical cancer. The objective of our study is to compare two different methods of cervical cancer screening adapted to low-resource settings, in two study centers in Cameroon.

Full description

HPV used as a stand-alone test has a limited specificity and positive predictive value and as a consequence, a significant number of HPV-positive women have no cervical precancerous lesions or cancer and receive unnecessary workup and treatment. For this reason, the WHO has recommended visual inspection with acetic acid (VIA/VILI) as a triage test of HPV-positive women to identify women requiring treatment. Nevertheless, VIA is a highly subjective procedure dependent on the health care provider's experience, with diagnostic accuracy varying from setting to setting. Triage by HPV genotyping has recently emerged as an alternative to triage by VIA, with immediate treatment of women with a subset of high-risk HPV genotypes only, thus reducing overtreatment rates. However, to date, the triage of HPV-positive women by VIA versus HPV genotyping has not yet been compared. This project aims to implement primary HPV-based screening in Cameroon followed by an immediate offer for treatment by thermal ablation after randomization for triage by HPV genotyping or VIA. More specifically, we aim to determine if triage by HPV genotyping (with immediate treatment of women with HPV types 16, 18, 45, 31, 33, 35, 52 or 58) allows better targeting of women needing treatment and allocation of resources to women at-risk than triage by VIA, as recommended by the WHO.

Primary objective: To identify the most efficient screening strategy for cervical cancer in Cameroon, more specifically to determine whether triage by a pool of eight genotypes (HPV types 16, 18, 45, 31, 33, 35, 52 or 58) is more effective than triage by visual inspection with acetic acid for detection of precancerous lesions. ¨

Secondary objectives:

• To determine the overtreatment rate in each screening group (HPV genotyping and VIA/VILI)
• To determine the rate of adverse events (e.g. hemorrhage, infection, hospitalization) in each screening group
• To determine which participant characteristics may be associated with better prediction of CIN2+ for each screening group
• To assess patient and health care provider acceptability of both screening strategies
• To create a sustainable structure for the promotion of women health with a priority made in the prevention of cervical cancer West Region of Cameroon
• To treat all precancerous or cancerous lesions discovered during the screening
• To inform women and their families about gynecological pathologies, including cervical cancer, sexually transmitted diseases (STD) and HIV
• To create a database of cervical images for continuous clinical education
• To develop an Automated VIA/VILI Classifier (AVC) that can help identify cervical precancerous lesions based on a 2-minute video of the cervix during VIA/VILI
• To assess women's, the community's and healthcare providers' acceptability of the AVC test

Study Design: National multicentric open-label two-arm randomized controlled trial

Qualitative and quantitative studies for participants and health care providers will be included during the study period addressing preferences and attitudes toward the screening process and treatment.

Enrollment: 5,500 estimated patients

Sex: Female

Ages: 25 to 49 years old

Volunteers: Accepts Healthy Volunteers

Inclusion criteria

• HIV-negative women aged 30-49 and HIV-positive women aged 25-49 years old
• Ability to understand study procedures and accepting voluntarily to participate by signing an informed consent form (ICF).

Exclusion criteria

• Pregnancy at the time of screening
• Previous hysterectomy
• Known cervical cancer
• Symptoms of cervical cancer (e.g. metrorrhagia, known pelvic mass)
• Conditions that can interfere with visualization of the cervix
• Severe pre-existing medical conditions (e.g. advanced cancer, terminal renal failure)
• Women who are not able to comply with the study protocol.

Trial design

Primary purpose: Diagnostic

Allocation: Randomized

Interventional model: Parallel Assignment

Masking: Single Blind

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5,500 participants in 2 patient groups

Triage by genotyping

Experimental group

Description:

The study intervention will consist in applying HPV genotyping as a triage method of HPV-positive women for cervical cancer screening. After primary screening with the Xpert HPV test, positive women will be sorted according to two groups of genotypes: group 1 (HPV types 16,18,45, 31, 33, 35, 52 and/or 58 obtained from channels 1, 2 and 3) and group 2 (HPV types 51, 59, 39,56, 66 and/or 68 obtained from channels 4 and 5). Women of group 1 will immediately treated, while those of group 2 will not receive immediate treatment and will be followed-up at 12 months. An exception will be made for participants with lesions suspicious of invasive cancer upon examination, which will be referred for further investigations regardless of the HPV type.

Treatment:

Diagnostic Test: HPV genotyping

Triage by visual inspection after application of acetic acid (VIA)

Active Comparator group

Description:

The control arm will consist in triage of HPV-positive women by VIA, as currently recommended by the WHO. Women with a positive VIA will be treated immediately, while VIA-negative women will not be treated and will be followed-up at 12 months.

Treatment:

Diagnostic Test: Visual inspection after application of acetic acid