Open Access Research article

Protecting the underscreened women in developed countries: the value of HPV test

Raquel Ibáñez1, Josefina Autonell2, Montserrat Sardà2, Nayade Crespo3, Pilar Pique3, Amparo Pascual3, Clara Martí4, Montserrat Fibla5, Cristina Gutiérrez6, Belén Lloveras7, Judit Moreno-Crespi8, Anna Torrent9, Núria Baixeras10, María Alejo11, Francesc Xavier Bosch1 and Silvia de Sanjosé112*

Author Affiliations

1 Unit of Infections and Cancer; Cancer Epidemiology Research Programme, IDIBELL, Catalan Institute of Oncology (ICO), 08908 L’Hospitalet de Llobregat, Barcelona, Spain

2 Pathology Department, Consorci Hospitalari de Vic, 08500 Vic, Barcelona, Spain

3 Sexual and Reproductive Health Centre of Bages-Solsonès, 08240 Manresa, Barcelona, Spain

4 Pathology Department, Hospital General de Granollers, 08402 Granollers, Barcelona, Spain

5 Pathology Department, Hospital Universitari Joan XXIII de Tarragona, 43005 Tarragona, Spain

6 Clinical Laboratory ICS Tarragona, Molecular Biology Section, Hospital Universitari Joan XXIII de Tarragona. IISPV Rovira i Virgili University, 43005 Tarragona, Spain

7 Pathology Department, Hospital del Mar, 08003 Barcelona, Spain

8 Pathology Department, Hospital Universitari Dr. Josep Trueta de Girona. Catalan Institute of Oncology, 17007 Girona, Spain

9 Sexual and Reproductive Health centre of Mollet del Vallés 08100 Mollet del Vallès, Barcelona, Spain

10 Pathology Department, Hospital Universitari de Bellvitge, IDIBELL, Catalan Institute of Oncology d’Oncologia 08908 L’Hospitalet de Llobregat, Barcelona, Spain

11 Pathology Department, Hospital General de L’Hospitalet. 08906 L’Hospitalet de Llobregat, Barcelona, Spain

12 CIBER Epidemiology and Public Health, Barcelona, Spain

For all author emails, please log on.

BMC Cancer 2014, 14:574  doi:10.1186/1471-2407-14-574

Published: 8 August 2014



Poor attendance to cervical cancer (CC) screening is a major risk factor for CC. Efforts to capture underscreened women are considerable and once women agree to participate, the provision of longitudinal validity of the screening test is of paramount relevance. We evaluate the addition of high risk HPV test (HPV) to cervical cytology as a primary screening test among underscreened women in the longitudinal prediction of intraepithelial lesions grade 2 or worse (CIN2+).


Women were included in the study if they were older than 39 years and with no evidence of cervical cytology in the previous five years within the Public Primary Health Care System in Catalonia (Spain). 1,832 underscreened women from eight public primary health areas were identified during 2007–2008 and followed-up for over three years to estimate longitudinal detection of CIN2+. Accuracy of each screening test and the combination of both to detect CIN2+ was estimated. The risk of developing CIN2+ lesions according to histology data by cytology and HPV test results at baseline was estimated using the Kaplan–Meier method.


At baseline, 6.7% of participants were HPV positive, 2.2% had an abnormal cytology and 1.3% had both tests positive. At the end of follow-up, 18 out of 767 (2.3%) underscreened women had a CIN2+, two of which were invasive CC. The three-year longitudinal sensitivity and specificity estimates to detect CIN2+ were 90.5% and 93.0% for HPV test and 38.2% and 97.8% for cytology. The negative predictive value was >99.0% for each test. No additional gains in validity parameters of HPV test were observed when adding cytology as co-test. The referral to colposcopy was higher for HPV but generated 53% higher detection of CIN2+ compared to cytology.


Underscreened women had high burden of cervical disease. Primary HPV screening followed by cytology triage could be the optimal strategy to identify CIN2+ leading to longer and safe screen intervals.

Human papilloma virus; Cervical cytology; Pap smear; Cervical cancer screening; HC2 testing; HPV test; Sensitivity; Specificity; Underscreened women