Urine as sample for primary cervical cancer screening
Quote this article as:
E van den Borst et al. (July 2024). Urine as sample for primary cervical cancer screening. www.HPVWorld.com, 269
Even though a population-wide screening program is organised for cervical cancer in most European countries, there is still a remarkable proportion of the eligible population that remains un(der)screened, ranging from 21% in Sweden to 96% in Romania1. Yet, cervical cancer remains a significant problem in this un(der)served group due to the discovery of more advanced cases, greatly affecting mortality. Therefore, it is important to increase the screening uptake. A potential approach is the implementation of non-invasive samples that can be self-collected at home. Urine sampling serves great interest in this regard. Especially the first part of the urine stream, the first-void urine (FVU), is of importance owing to its ability to non-invasively capture cervical secretions built up around the external female genitalia (Figure 1). Likewise, higher concentrations of human but also viral DNA were detected in FVU as compared to subsequent fractions2.
Costa et al. (2023) performed a meta-analysis on screening response when using different self-sampling approaches such as mail-to-all or opt-out (mailing a self-sampling kit directly to the women) and opt-in (inviting identified non-responders to request a self-sampling kit), which caused an increase of 13.2% and 4.4% respectively among underscreened women in the intention-to-treat scenario3. Despite that this meta-analysis only included studies using cervicovaginal self-samples, the same principles apply to urine sampling. In fact, urine is expected to be more accessible in several cultural settings as well as for people with a disability, previous (sexual) trauma, or trans- and gender-neutral people. Correspondingly, the CapU studies in France found participation rates of 13.7% to 15.4% when directly sending urine collection kits (mail-to-all) to non-responders4,5, and are awaiting results from their CapU4 trial6. Currently, our research team at the University of Antwerp is performing a population-wide study (ScreenUrSelf, NCT05996783) investigating the impact of urine versus vaginal self-sampling in 48.000 un(der)screened women, both in opt-in and mail-to-all arms. Together, these results will enhance our knowledge of the (cost-)effectiveness of urine in reaching the un(der)screened.
Moreover, urine allows the detection of the human papillomavirus (HPV) which is associated with a higher clinical sensitivity than cytology-based screening in cervical samples. Forty-eight countries worldwide (17 of them European) have accordingly decided to implement primary HPV DNA-based screening in their programs, including self-sampling for 17 countries (35%). In Europe, The Netherlands and Albania have implemented self-sampling for all women, whereas France, Denmark, Sweden, and Finland only employ it for the underscreened7. Other countries are performing pilot studies for its evaluation. For future implementation of urine self-sampling, sufficient data concerning the clinical sensitivity and specificity of HPV DNA testing in urine are crucial. Within the VALHUDES framework, similar clinical accuracy for the detection of high-grade cervical intraepithelial neoplasia (CIN2+) by high-risk HPV (hrHPV) testing in FVU compared to cervical samples was demonstrated8. Furthermore, hrHPV-testing on FVU (collected with the Colli-Pee® and prefilled with urine conservation medium) reached a pooled relative sensitivity of 0.98 [95% CI 0.93-1.03] (CIN2+) and sensitivity of 0.98 [95% CI 0.90-1.06] (<CIN2+) compared to clinician-collected samples9.
Nonetheless, data on clinical accuracy in a screening population is still required (Figure 2). For this purpose, depending on the local context, different ‘rule-in’ study designs are recommended to accept a test after studies in referral populations alike VALHUDES10. In addition, long-term data on the clinical accuracy in a screening population are required to give an estimate of cumulative risk after a negative HPV test on urine. However, studies using urine sampling are heterogeneous in terms of HPV detection method as well as pre-analytical factors (volume, storage, buffer,…) which are important but often underreported in urinary biomarker research11. Yet, urine sampling offers practical advantages in the lab, considering the high-throughput, objective, automated, and direct testing possibilities. Although this needs more optimisation, these tests are expected within the next three years12.
While a lot of research has focused on HPV detection in FVU, 80% of infections are spontaneously cleared by our immune system and thus do not cause disease. Hence, an additional triage test is necessary to select only those infections that are worrisome. FVU also captures biomarkers for reflex testing, with DNA methylation showing great promise. DNA methylation is an epigenetic modification affecting both viral and human DNA and is believed to be an early sign of the carcinogenic process. Therefore, it has been examined as a triage marker in several (self-)sample types including urine. One of the advantages is the simultaneous detection of HPV and triage markers in one and the same sample,
While a lot of research has focused on HPV detection in FVU, 80% of infections are spontaneously cleared by our immune system and thus do not cause disease. Hence, an additional triage test is necessary to select only those infections that are worrisome. FVU also captures biomarkers for reflex testing, with DNA methylation showing great promise. DNA methylation is an epigenetic modification affecting both viral and human DNA and is believed to be an early sign of the carcinogenic process. Therefore, it has been examined as a triage marker in several (self-)sample types including urine. One of the advantages is the simultaneous detection of HPV and triage markers in one and the same sample, aiming to reduce drop-out and loss-to-follow-up. Furthermore, it is objective, reproducible, and offers high-throughput possibilities in contrast to cytology-based triage, which is not applicable to self-collected samples because of the low amount of intact cells.
In conclusion, urine sampling offers great potential for cervical cancer screening purposes due to its ability to extend the reach of screening programs, and provide simultaneous screening and triage. Yet, further research should focus on validating the (long-term) clinical accuracy of HPV DNA and methylation marker testing in urine
DISCLOSURE
Part of this work performed by EVDB, SVK, and AV was supported by the Research Foundation – Flanders (FWO), Belgium (T004921N; G077923N) and Eurostars R&D performing SME Grant CASUS (12396). EVDB is supported by a PhD fellowship of FWO (1SC9123N) and Eurostars R&D performing SME Grant CASUS (12396). The employer of EVDB, SVK, and AV (University of Antwerp) received funding in the framework of VALHUDES and CASUS, which are investigator-initiated studies that evaluate molecular tests on self-samples. EVDB, SVK, and AV did not receive financial or material benefits from these projects. Up hereto the following manufacturers contributed: Abbott Laboratories, Roche, BD, Cepheid, Liferiver, Euroimmun, Seegene, Self-Screen and Novosanis. The University of Antwerp received payment for the participation of SVK in an advisory board of Novosanis (Subsidiary of OraSure Technologies Inc, Wijnegem, Belgium), a spin-off company of the University of Antwerp. All funds are handled and managed by the University of Antwerp. AV is a co-founder of and former board member of Novosanis and was a minority shareholder until January 2019.
This research work has received funding from the European Union’s Horizon 2020 Research and Innovation Programme under grant agreement No.847845 (Project RISCC).
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This article is included in the HPW monograph Cervical cancer prevention in Europe
Scientific coordinators:
Johannes Berkhof, Kate Cuschieri, Clàudia Robles, Xavier Bosch
HPW editors:
Patricia Guijarro, Paula Peremiquel, Valentina Rangel
On behalf of the editorial team, we would like to thank all the authors who contributed to this special monograph
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M Poljak, A Oštrbenk Valenčak. Global overview of commercially available HPV molecular tests.
M Arbyn, SK Dhillon, M Poljak. Validated HPV tests usable in cervical cancer screening on clinician-collected cervical specimens.
J Bonde. A Silver bullet - HPV self-sampling in Denmark.
M Lehtinen, K Louvanto. Low progression potential of cervical HSIL among HPV-vaccinated women with persistent non-vaccine type HPV infections.
M Elfstrom, J Dillner. Evaluation of co-testing with cytology and human papillomavirus testing in cervical screening.
L Baandrup, SK Kjaer. Profile of HPV infections in vaccinated cohorts and implications for future screening.
IM de Kok, E E.L. Jansen, J A.C. Hontelez. Harms and benefits of cervical cancer screening and its future.
K Cuschieri, L Connor, S Arroyo Muhr. Key elements of quality assurance for practical HPV testing to support cervical screening.
T McGlacken, M Fitzgerald, N Russell. Allowing safe exit from cervical cancer screening – which strategy to use.
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