CINtec PLUS and the Pap smear: a co-testing alternative

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1 CINtec PLUS and the Pap smear: a co-testing alternative Rosemary Tambouret MD

2 p16/ki67 (CINtec PLUS) and the Pap smear Rosemary Tambouret MD

3 CINtec PLUS dual stain: p16 and Ki67 p16 is anti-proliferative marker cell cycle regulator by inhibition of CDK4/ CDK6 leading to cell cycle arrest in epithelial cells undergoing cellular differentiation. In response to transforming hrhpv, levels of p16 rise; p16 over expression is considered to be a surrogate marker for transforming hrhpv infection Ki67 is a marker of cycling cells

4 CINtec PLUS p16 in normal squamous cells: no staining or brown cytoplasmic staining and no red stain of Ki67as the cell is in G0 Clone E6H4 Ki67 nuclear stain if normal cell is cycling but no p16 staining is identified Clone AC3 Dual staining for p16 and Ki67 correlates with cell cycle dysregulation and with the presence of high risk HPV in women at risk for HSIL (independent of morphology)

5 Screening for cervical cancer Single test: Pap, hrhpv Single test with triage: Pap -> hrhpv hrhpv -> Pap or genotyping hrhpv-> CINtec PLUS or other tests Co-testing: Pap and hrhpv Pap and CINtec PLUS

6 Studies evaluating use of dual p16/ki67 stain in cervical cancer screening Co-testing with cytology and hrhpv Ikenberg H et al. J Natl Cancer Inst 2013;105: Cytology negative, hrhpv positive Petry KU et al. Gynecol Oncol 2011; 121:505-9 Wentzensen N et al JNCI 2015:107: (12) Abnormal cytology, hrhpv positive Schmidt D et al. Cancer Cytopathol 2011;119: Uijterwaal MH et al BJCancer 2014; 110: Bergeron C et al Cancer Cytopathol 2015;123: Wentzensen N et al J Natl Cancer Inst 2015;107 (12)

7 Screening for cervical cancer precursors with p16/ki67 dual-stained cytology: PALMS 25,577 women >18 years at 196 centers Screening with hrhpv (HC2), cytology (CS, TP or SP), dual stain 21,909 all negative (86%) Positive tests 5.4% dual stain 5.2% cytology ASC-US+ 10.7% HC2 Ikenberg H et al. J Natl Cancer Inst 2013;105:1550-7

8 Screening for cervical cancer precursors with p16/ki67 dual-stained cytology: PALMS Colposcopy done following any positive test except in women <30 years old with only HPV positive Cervical biopsies taken as clinically indicated When no biopsy taken, the patient was considered to have no clinical disease Ikenberg H et al. J Natl Cancer Inst 2013;105:1550-7

9 PALMS: Test results

10 Sensitivity, specificity, predictive value

11 PALMS: Diagnostic performance for CIN2+

12 PALMS: Conclusions Because 3 tests applied to all women, can tease out Pap-dual stain co-testing results hrhpv testing is most sensitive test, suggesting may be used as primary screen Dual stain has higher sensitivity than Pap but nearly equivalent specificity Confirmed that hrhpv prevalence too high in women <= 30 years

13 PALMS: Dual stain triage for abnormal cytology Bergeron C et al Cancer Cytopathol 2015;123: Large prospective study, >1100 women with ASCUS/LSIL cytology ASCUS triage: DS sensitivity near or same as HPV, but specificity higher for DS Women < 30 with ASCUS would have almost 50% less referral to colposcopy LSIL triage: HPV more sensitive than DS but much less specific; referral rates for DS slightly >50% and risk CIN3+ <2% in DS neg group Results in LSIL group vary by cytology method

14 PALMS: Dual stain triage for abnormal cytology Bergeron C et al Cancer Cytopathol 2015;123:373-81

15 Triage cytology negative hrhpv positive results with dual stain Petry KU et al. Gynecol Oncol 2011;121:505-9 Prospective Pap (TP)/HPV (HC2) co-testing trial of women >= 30 years In subgroup of 425 women negative TP/pos HC2, the dual stain was used Usual follow up for this group is by HPV and/or Pap in 6-12 months 147 colposcopy results (1/3 of cohort), biopsy in 132, 64 no follow-up visit

16 Triage cytology negative hrhpv positive results with dual stain Petry KU et al. Gynecol Oncol 2011;121: samples dual stain positive with 34 CIN samples dual stain negative with 3 CIN2+ Sensitivity of dual stain for CIN % Specificity of dual stain for CIN % Conclusion: Use of dual stain to triage Pap negative/hpv positive women will identify >90% of underlying CIN2+

17 p16/ki67 dual stain cytology for detection of precancer in HPV-positive women Wentzensen N et al JNCI 2015;107 (12) Prospective trial of HPV/cytology co-testing begun 2003 in women >=30 yrs Evaluated performance of dual stain in all HPV positive women and in a cohort of HPV positive/cytology negative women Samples collected over 3 months in 2012, dual stain on HPV pos samples from 1509 women

18 p16/ki67 dual stain cytology for detection of precancer in HPV-positive women Wentzensen N et al JNCI 2015;107 (12) ASCUS 383 (25.4%) LSIL 319 (21.1%) ASC-H 36 ( 2.4%) HSIL 49 ( 3.3%) DS positivity increased with lesion severity All women with cancer were DS positive

19 Performance of DS compared to ASCUS+ Wentzensen N et al JNCI 2015;107 (12)

20 Test performance of dual p16/ki67 stain in HPVpositive/cytology-negative women Wentzensen N et al JNCI 2015;107 (12)

21 Risk of cervical precancer for DS results in relation to clinical mgt thresholds

22 Risk of cervical precancer for DS results in relation to clinical mgt thresholds

23 p16/ki67 dual stain cytology for detection of precancer in HPV-positive women: Conclusions DS had lower positivity and higher sensitivity and specificity than cytology at ASCUS threshold despite better than most cytology screening performance at KPNC Using established risk thresholds to HPV+/cyto- DS+ surpassed the colposcopy risk level DS- was below risk level for one year f/u Wentzensen N et al JNCI 2015;107 (12)

24 European Equivocal of Mildly Abnormal Pap Cytology Study (EEMAPS) and dual stain Schmidt D et al Cancer Cytopathol 2011;119: Dual stain on TP from prior retrospective study using p16 ASCUS and LSIL 5 European cytology labs HPV testing by HC2 Biopsy within 6 months into 2 categories Disease = CIN2+ No disease = CIN1 or negative for dysplasia Cases enriched for CIN2+

25 EEMAPS and dual stain results ASCUS DS identifies about same proportion of HSIL as HPV testing but reduces number of women referred to colposcopy, most evident in group of women aged 18-29

26 EEMAPS LSIL Pap and dual stain results DS in LSIL has about the same sensitivity for CIN2+ but with a much higher specificity, DS could be used to triage LSIL

27 p16/ki67 dual stain in screening for cervical cancer Mounting evidence for a role in Triage of ASCUS and LSIL Triage of co-testing results: cytology negative/hrhpv positive Triage of primary hrhpv test positive women Future developments Cost analysis Automation