Colposcopy Versus HPV Testing to Identify Persistent Cervical Precancers
Colposcopy Versus HPV Testing to Identify Persistent Cervical Precancers
This trial will compare HPV testing to the routine colposcopy in the follow-up of women
 treated for cervical high grade lesions. Women will be assigned randomly (by chance) after
 treatment of cervical pre-cancer to be either (1) followed-up by colposcopy, or (2) undergo
 HPV testing. Women found to have disease by either strategy will be offered re-treatment. For
 the next 2 years participants will undergo yearly, in depth, evaluation to assess the cervix
 for precancer. We will then be able to compare which of the 2 follow-up strategies worked
 best.
Background and rational: Cervical cancer ranks twelfth in terms of cancer mortality in
 Canadian women, but remains the second most frequent cancer in Canadian women aged 20-44.
 Fortunately, its natural history makes it an ideal candidate for successful prevention.
 Cervical cancer and its precursors are caused by a persistent infection of the cervical
 epithelium by one of the 15 oncogenic (or high risk) types of human papillomaviruses (HPVs).
 The preinvasive changes of cervical intra-epithelial neoplasia (CIN) can be identified
 through cervical cytology (also known as the Pap test). When cellular abnormalities are
 identified, women are referred for diagnostic testing. High-grade precursor lesions (CIN2/3)
 carry a high risk of progression to invasive cancer and for this reason their treatment is
 recommended. Treatment success rates of CIN2/3 are 85%. However, those who fail treatment
 need to be identified promptly because their risk of invasive disease is increased more then
 10 fold. The current strategy used in Canada to identify treatment failures consists of a
 follow-up every 6 months in colposcopy clinics for 2 years. Recent research underlines the
 fact that routine colposcopy is unreliable and may miss significant lesions. The
 identification of oncogenic HPV DNA in the cervical secretions is known as HPV testing. A few
 studies have investigated the use of HPV testing in the identification of treatment failures.
 Although they point to a very good sensitivity (90-95%) there were methodological
 limitations: studies were small; the HPV test used was often not suitable for clinical
 laboratory use; endpoints were not assessed by histological confirmation. Most importantly,
 none compared HPV testing to colposcopy, the strategy used in Canada. Research question: Is
 HPV testing more sensitive than routine colposcopy to identify CIN2/3 treatment failures?
 Methodology: Design: We propose a parallel randomized controlled trial, where participants
 will be randomized 1:1 to routine colposcopy vs. HPV testing after treatment of CIN2/3
 lesions. Study Population: Women treated for high-grade precursor lesions. Exclusion criteria
 are: pregnancy, less than 18 years of age, known immunosuppression or immunodeficiency,
 unable to provide informed consent. Study interventions: (1) HPV testing with Hybrid Capture
 2. (2) Routine colposcopy. In order to evaluate the performance of the current follow-up
 strategy, there will be no standardized protocol for the colposcopy intervention, but
 documentation of procedures will be done. Patients will receive the study interventions 6
 months after treatment. All participants will undergo expert diagnostic assessment at 12 and
 24. Sample size calculation and recruitment rate. The sample size was calculated to have 80%
 power to detect an increase in sensitivity of 15%, with an alpha set at 0.05 (double sided
 test). Assuming a conservative baseline sensitivity of 70% for colposcopy, 134 cases of
 recurrent/persistent disease will be necessary in each study group. Assuming a 15% failure
 rate of treatment and a 20% drop out rate, a total of 2250 participants will need to be
 accrued. Recruitment will take place in high volume colposcopy clinics across Canada over 2
 years. Analysis: The primary analysis will consist of the comparison of the diagnostic
 indices of the 2 follow-up strategies: sensitivity, specificity, positive and negative
 predictive values (with their 95% asymptotic confidence intervals). Cumulative
 persistent/recurrent cases identified during the 2 year follow-up will make up the case
 group. Since all participants will undergo expert diagnostic assessment. No subgroup analysis
 will be performed. 4. Expected contribution: The result from this trial will provide high
 quality data on which to base management recommendation. If HPV testing is found to be more
 sensitive than routine colposcopy, follow-up of treated lesion may occur mainly in primary
 care physician's office with HPV testing, reducing costs, and making it possible to focus
 colposcopy activities on a group of women truly at risk of significant disease.
Inclusion Criteria:

 -  Woman ≥ 18 years old 19 in British Columbia, Nova Scotia and Newfoundland)

 -  Understands English or French (for sites where French speaking coordinator is
 available)

 -  Is treated for biopsy proven CIN II, III or AIS

 -  Understands study procedures, available alternatives treatment, risks related to
 study, and accepts voluntarily to participate by signing the ICF.

 Exclusion Criteria:

 -  has been treated for cervical cancer or pre-cancer in the past

 -  Participant has known immunosuppression or immunodeficiency

 -  Planned hysterectomy

 -  Participant is receiving or has received one of the following treatment :

 -  Immunosuppressive therapy in the three months prior to enrollment

 -  Corticosteroid therapy in the two weeks prior to enrollment

 -  Two or more courses of corticosteroids (orally or parenterally) lasting at least
 one week in duration in the year prior to enrollment (inhalation, nasal or
 topical corticosteroids are permitted)

 -  There is a strong probability that the participant will not follow the procedures of
 study, will not come to its appointment, or plans a delocalization throughout study.