Women infected with the HIV face a higher risk of squamous cervical lesions than uninfected women.1 They also have higher rates of infection with human papillomavirus, the causative agent of cervical cancer2; of cervical intraepithelial neoplasia (CIN),3,4 and of cervical cancer,5–7 although cancer risk may be attenuated among women in cancer prevention programs.8
Cervical cancers also can arise from glandular cells lining the endocervical canal. Premalignant changes in these cells are reflected cytologically as atypical glandular cells (AGC) or adenocarcinoma in situ (AIS). In the general population, AGC is an uncommon cytologic diagnosis, accounting for about 0.3% of Pap tests.9 However, AGC is associated with a high risk of preinvasive and invasive disease; paradoxically, most of these are squamous, including a 9% risk of low-grade lesions, an 11% risk of high-grade CIN, a 3% risk of histologic AIS, a 1% risk of endometrial hyperplasia, and a 5% risk of cancer.9 Current and past guidelines recommend colposcopy for all women with AGC and AIS, with further investigation dependent on colposcopic findings and the severity of the cytologic abnormality.10,11
Cervical adenocarcinoma and adenocarcinoma in situ have been linked to infection with the human papillomavirus (HPV) and like squamous disease should be more common among immunosuppressed women.12 Unfortunately, rates of cytologic AGC and AIS and the associated risk for glandular neoplasia have not been well studied among women with HIV. In part, this is because glandular lesions are less common than squamous lesions, and accruing sufficient numbers of HIV-seropositive women in screening programs across time has been challenging. Lehtovirta and colleagues13 found that atypical glandular cells were found in 4% of HIV-seropositive women undergoing cytologic screening, but they studied only 108 women and did not describe histologic findings.
Our objectives were to estimate the frequency of cytologic atypical glandular cells, AIS, and adenocarcinoma among women with HIV; to present histologic correlates of these cytologic abnormalities among women who subsequently had colposcopy, to assess compliance with current management recommendations, and to estimate whether HIV-seropositive women were at higher risk for cytologic and histologic glandular abnormalities than seronegative women.
PATIENTS AND METHODS
This investigation was part of the Women’s Interagency HIV Study (WIHS), an ongoing multicenter cohort study of the natural history of HIV infection and related health conditions among HIV-seropositive women and at-risk HIV-uninfected comparison women. The protocols, recruitment processes, procedures, and baseline results of the WIHS have been previously described; seropositive WIHS participants are representative of U.S. women with HIV.14 Women’s Interagency HIV Study enrollment began October 1, 1994, at six study consortia and over time enrolled 3,766 women, with expansion during 2001–2002.15 Written informed consent for study was obtained after local human subjects committee approval from six sites. Follow-up continues, but this analysis includes information obtained before October 1, 2007.
Every 6 months, participants had structured medical, social, and sexual histories taken by trained interviewers, followed by a physical examination that included gynecologic evaluation and Pap testing. According to study-wide protocol, single-slide Pap samples were obtained using a spatula and brush. Human immunodeficiency virus status was established by Western blot, and women who seroconverted during follow-up were classified according to visit-specific serostatus. Pap tests were interpreted centrally at Dianon (New York, NY, formerly Kyto or Kyto Meridien) according to the 1991 Bethesda system for classification of cervicovaginal cytology,16 updated in 2001. Glandular abnormalities were classified as atypical glandular cells, subclassified as not otherwise specified or favor neoplastic, as adenocarcinoma in situ, and as adenocarcinoma. All Pap tests were screened by two cytotechnologists blinded to HIV status, with 10% of all negative tests and all abnormal tests reviewed by a cytopathologist. Study protocol recommended referral for colposcopy for glandular abnormalities of any grade, although decisions on biopsy and treatment were individualized. At some sites, women were referred externally for colposcopy, especially early in the study, and women may have had Pap tests outside study centers that led to colposcopy. Although women were asked whether they had cervical biopsies externally in the 6 months before each visit, with affirmative answers leading to medical records retrieval, we could not confirm negative responses. Histology results were interpreted locally and were not centrally reviewed.
Of the 3,766 women in WIHS (2,791 HIV+, 975 HIV–), 3,522 women (2,593 HIV+, 929 HIV–) were excluded because they did not have an index Pap test showing glandular abnormalities during the study period. One HIV-seropositive woman was excluded because she had undergone hysterectomy before her index AGC Pap test. Another 95 women (78 HIV+, 17 HIV-) were excluded because they did not have colposcopy done within 6 months of the index abnormal Pap test. Finally, 29 women (25 HIV+, 4 HIV–) were excluded because they had no histologic results, leaving 119 women (94 HIV+, 25 HIV–) for analysis.
Histology and cytology results were tabulated. Differences in demographic and clinical characteristics between HIV seropositive and seronegative women were compared using Fisher exact test. Multivariate logistic regression models that incorporated generalized estimating equation models were used to compare the proportions of patient visits in HIV seropositive and HIV seronegative group with glandular abnormality, adjusting for repeated measures across visits for the same women over time.17 The variables adjusted for were age (divided into four groups: younger than 30, 30–40, 40–50, older than 50 years), ethnicity, smoking status, and whether the patient had been sexually active in the last 6 months. To further investigate the association of HIV serostatus and glandular abnormality, the model was refitted with an HIV serostatus variable, categorized as HIV seronegative, HIV seropositive/CD4 lymphocyte count less than 250/mm3, HIV seropositive/CD4 250–500, HIV seropositive/CD4 more than 500. A test for trend was applied: as parameters, we made HIV serostatus and CD4+ lymphocyte count as a continuous variable with four levels for HIV seronegative women and HIV seropositive women with CD4 counts more than 500, 250–500, and less than 500/mm3 and determined the significance of this variable in generalized estimating equation models. The Wald test was used to determine the significance of all variables in these models.18
For comparing the association of cytologic status with histologic findings between HIV seropositive and HIV seronegative groups, the Pearson’s χ2 test of independence was applied. Only index glandular abnormalities were included in estimating the correlation of histologic and Pap test results. Median age was compared between groups of subjects using the Wilcoxon test.
During the study period, we found 341 (0.7%) Pap results showing a glandular abnormality among 48,362 collected during 24,948 person-years of observation. These occurred in 244 (6%, 95% confidence interval [CI] 5.7–7.3%) of 3,766 women. Of the 341 glandular Pap abnormalities studied, 271 were from 198 HIV seropositive women and 70 were from 46 seronegative women. One woman had a hysterectomy before her index glandular abnormality and was excluded from further analysis.
Glandular abnormalities were found in 341 (0.7%, 95% CI 0.6–0.8%) tests from 244 (6%) women, including 264 (0.8%, 95% CI 0.6–0.9%) of 3,5057 tests from HIV seropositive women and 70 (0.6%, 95% CI 0.4–0.8%) of 11,769 tests from seronegative women (P=.12 after adjustment for age, ethnicity, smoking, and sexual activity in the prior six months). The demographic characteristics of women with glandular abnormalities on Pap are presented in Table 1. The median age was 37 years among 198 HIV seropositive women and 39 years among 46 HIV seronegative women (P=.9). Compared with HIV seronegative women, seropositive women with glandular abnormalities were marginally less likely to be smokers and less likely to have multiple recent sexual partners.
Stratification by CD4 lymphocyte count showed the effect of immunosuppression on risk for glandular cytologic abnormality: glandular abnormalities were found in 93 (1.0%, 95% CI 0.8–1.3%) of 9,564 Pap tests among HIV-seropositive women with CD4 lymphocyte counts less than 250/mm3, 103 (0.8%, 95% CI 0.6–1.0%) of 13,023 tests among those with counts 250–500/mm3, 68 (0.6%, 95% CI 0.4–0.8%) of 12,470 tests among women with counts more than 500/mm3, and 70 (0.6%, 95% CI 0.4–0.8 of 11,769 tests among HIV-seronegative women (P for trend=.006). Seven women with glandular abnormalities did not have CD4 counts at the corresponding visit.
Despite a study-wide protocol recommending referral for colposcopy and despite intensive infrastructure at each site to promote compliance, colposcopy was documented to have been done within 6 months for only 148 (61%) of 244 index Pap tests with glandular abnormalities, 119 (60%) of 198 HIV seropositive and 29 (63%) of 46 HIV seronegative women. Endocervical curettings were obtained after 106 (43%) women with index abnormal tests, including 81 (41%) HIV seropositive women and 25 (54%) seronegative women. Cervical punch biopsies were done for 76 (38%) index tests, 60 (30%) in HIV seropositive women and 16 (35%) in seronegative women. Endometrial biopsies were done in only 19 (8%) index Pap cases, 13 in HIV seropositive and six in seronegative women. Excisional biopsies, including knife conization and loop excision, were done in 14 women. Overall, histologic findings were available for 119 (49%) of the 244 women within 6 months of an index Pap showing glandular abnormalities. Compliance improved as women were followed, because 212 (87%) of women with index glandular abnormalities had colposcopy and 192 (79%) had at least one biopsy at some subsequent point during the study.
Histology results from these 94 HIV seropositive women and 25 seronegative women with available histologic results after index glandular Pap abnormalities are shown in Tables 2 and 3. Overall, the severity of results did not differ significantly by HIV serostatus (P=.16). For both HIV-infected and uninfected women, most abnormalities were squamous. Approximately 40% of biopsies in both groups were negative, and the risk of CIN or cancer was greater than 50%. However, high-grade disease, including high-grade squamous lesions, glandular atypia, or cancer, was found in 20 of 94 (21%) HIV seropositive women and 9 of 25 (36%) HIV seronegative women (P=.12). Although glandular abnormalities on Pap testing raise concern for adenocarcinoma, only one HIV seropositive woman and none of the HIV seronegative women had adenocarcinoma, whereas none of the HIV seropositive women and one of the seronegative women had glandular atypia.
Our results show that the risk of cervical glandular cytologic abnormalities, like that of squamous Pap abnormalities1 and HPV in general,19 is increased by immunosuppression among women with HIV. These findings are qualitatively similar to those of Lehtovirta and colleagues,13 who reported a 4% risk of abnormal glandular cytology in their patients with HIV, although the absolute frequency of abnormality was lower in our cohort, at 0.8% of all HIV seropositive women.
In our study, the rate of biopsy-proven cervical cancer precursors among HIV seropositive women with glandular cytologic abnormalities was substantial. Among those with HIV, more than one half had CIN or cancer, although only 21% had high-grade disease. These results are consistent with rates reported in HIV seronegative women,9 and we did not find a difference in risk for high-grade disease between HIV seropositive and seronegative women once glandular abnormalities were reported on Pap testing. Although the 3% risk of cancer that we found among HIV-seropositive women is small in absolute terms, it does reflect a substantial risk. Although WIHS is the largest U.S. cohort study of women with HIV, we had too few events to stratify histologic results by CD4 count; studies from other national cohorts may help to determine whether the most severely immunosuppressed women have an increased risk of biopsy-proven cervical disease after glandular Pap abnormalities.
For now, our results suggest that women with HIV and glandular abnormalities on Pap testing should be managed according to guidelines for the general population from the American Society for Colposcopy and Cervical Pathology.10 These recommend colposcopy with endocervical curettage for all women, with endometrial assessment for those aged older than 35 years or with risk factors for endometrial cancer, such as obesity or irregular vaginal bleeding. Risks for cervical disease and cancer are too high to justify either triage using HPV DNA testing without colposcopy or surveillance with serial cytology, as can be done for women with atypical squamous cells of uncertain significance. One exception to the management of glandular abnormalities according to American Society for Colposcopy and Cervical Pathology guidelines involves testing for high-risk HPV types at initial colposcopy to minimize follow-up for women with negative initial evaluation. This strategy has not been tested in women with HIV, whose high prevalence of high-risk HPV may limit the specificity of this approach.
Women with HIV are at risk to default from colposcopy appointments.20 The discrepancy between the number of glandular Pap abnormalities and the number of colposcopies indicates that substantial opportunities for improved compliance with follow-up guidelines can be achieved for women with glandular Pap abnormalities. Unfortunately, our low rates of colposcopy and endocervical and endometrial sampling parallel those in the general cytology literature on glandular abnormalities, although many of our patients were evaluated before national guidelines were promulgated in 2001. Our data are too limited to allow us to distinguish between missed colposcopy because of patient noncompliance or clinician failure to recall women with glandular abnormalities on Pap for colposcopy. According to protocols developed soon after study launch, colposcopy referral was recommended after any study Pap showing a glandular abnormality. It is possible that women failed to report some colposcopies and biopsies that occurred outside study sites, but the low rate of endocervical curettage and endometrial biopsy in our study suggests that providers’ lack of familiarity with Pap management guidelines and patients’ reluctance to undergo these somewhat invasive and painful procedures contribute. Clinicians who care for women with HIV should be familiar with Pap management guidelines and should educate patients about the potential cancer prevention benefits of compliance.
1. Massad LS, Seaberg EC, Wright RL, Darragh T, Lee YC, Colie C, et al. Squamous cervical lesions in women with human immunodeficiency virus: long-term follow up. Obstet Gynecol 2008;111:1388–93.
2. Palefsky JM, Minkoff H, Kalish LA, Levine A, Sacks HS, Garcia P, et al. Cervicovaginal human papillomavirus infection in human immunodeficiency virus-1 (HIV)-positive and high-risk HIV-negative women. J Natl Cancer Inst 1999;91:226–36.
3. Cubie HA, Seagar AL, Beattie GJ, Monaghan S, Williams AR. A longitudinal study of HPV detection and cervical pathology in HIV infected women. Sex Transm Infect 2000;76:256–61.
4. Delmas MC, Larsen C, van Benthem B, Hamers FF, Bergeron C, Poveda JD, et al. Cervical squamous intraepithelial lesions in HIV-infected women: prevalence, incidence and regression. European Study Group on Natural History of HIV Infection in Women. AIDS 2000;14:1775–84.
5. Serraino D, Carrieri P, Pradier C, Bidoli E, Dorrucci M, Ghetti E, et al. Risk of invasive cervical cancer among women with, or at risk for, HIV infection. Int J Cancer 1999;82:334–7.
6. Patel P, Hanson DL, Sullivan PS, Novak RM, Moorman AC, Tong TC, et al. Incidence of types of cancer among HIV-infected persons compared with the general population in the United States, 1992–2003. Ann Intern Med 2008;148:728–36.
7. Engels EA, Biggar RJ, Hall HI, Cross H, Crutchfield A, Finch JL, et al. Cancer risk in people infected with human immunodeficiency virus in the United States. Int J Cancer 2008;123:187–94.
8. Massad LS, Seaberg EC, Watts DH, Minkoff H, Levine AM, Henry D, et al. Long-term incidence of cervical cancer in women with human immunodeficiency virus. Cancer 2009;115:524–30.
9. Schnatz PF, Guile M, O’Sullivan Sorosky JI. Clinical significance of atypical glandular cells on cervical cytology. Obstet Gynecol 2006;107:701–8.
10. Wright TC, Massad LS, Dunton CJ, Spitzer M, Wilkinson EJ, Solomon D, et al. 2006 consensus guidelines for the management of women with abnormal cervical screening tests [published erratum appears in J Low Genit Tract Dis 2008;12:255]. J Low Genit Tract Dis 2007;11:201–22.
11. Kurman RJ, Henson DE, Herbst AL, Noller KL, Schiffman MH. Interim guidelines for management of abnormal cervical cytology. The 1992 National Cancer Institute Workshop. JAMA 1994;271:1866–9.
12. Herzog TJ, Monk BJ. Reducing the burden of glandular carcinomas of the uterine cervix. Am J Obstet Gynecol 2007;197:566–71.
13. Lehtovirta P, Finne P, Nieminen P, Skogberg K, Savonius H, Paavonen J, et al. Prevalence and risk factors of squamous intraepithelial lesions of the cervix among HIV-infected women—a long-term follow-up study in a low-prevalence population. Internat J STD AIDS 2006;17:831–4.
14. Barkan SE, Melnick SL, Preston-Martin S, Weber K, Kalish LA, Miotti P, et al. The Women’s Interagency HIV Study. WIHS Collaborative Study Group. Epidemiology 1998;9:117–25.
15. Bacon M, von Wyl V, Alden C, Sharp G, Robison E, Hessol N, et al. The Women’s Interagency HIV Study: an observational cohort brings clinical sciences to the bench. Clin Diagn Lab Immunol 2005;12:1013–9.
16. Kurman RJ, Solomon D, editors. The Bethesda System for reporting cervical/vaginal cytologic diagnoses: definitions, criteria, and explanatory notes for terminology and specimen adequacy. New York (NY): Springer-Verlag; 1994.
17. Zeger SL, Liang KY, Albert PS. Models for longitudinal data: a generalized estimating equation approach [published erratum in Biometrics 1989;45:347]. Biometrics 1988;44:1049–60.
18. Hosmer D, Lemeshow S. Applied logistic regression. New York: John Wiley and Sons, 2000.
19. Strickler HD, Burk RD, Fazzari M, Anastos K, Minkoff H, Massad LS, et al. Natural history and possible reactivation of human papillomavirus in human immunodeficiency virus–positive women. J Natl Cancer Inst 2005;97:577–86.
© 2009 by The American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. All rights reserved.
20. Cejtin H, Komaroff E, Massad LS, Korn A, Schmidt JB, Eisenberger-Matiyahu D, et al. Adherence to colposcopy among women with HIV infection. J Acquir Immune Defic Syndr 1999;22:247–52.