Compass - Randomised Controlled Trial of Primary HPV Testing for Cervical Screening in Australia (Compass)

Compass - Randomized Controlled Trial of 5-yearly Cervical Screening With Primary HPV Testing Versus Cervical Screening With 2.5-yearly Liquid Based Cytology Testing, in HPV-Unvaccinated and HPV-Vaccinated Women in Australia

Compass is a randomised controlled trial of primary HPV testing for cervical cancer screening in Australia. A pilot study involving 5,000 women was carried out in 2013-2014. The trial will involve recruiting 76,300 women from primary health clinics. Women aged 25-69, attending for cervical screening or for routine follow-up will be invited to participate in the 2-arm trial. A liquid-based cytology (LBC) sample will be taken from consenting women and sent to VCS Pathology. Women will be randomised in a 1:2 parallel group allocation to LBC and HPV arms using randomisation with the minimisation procedure, with stratification by birth cohort according to whether offered HPV vaccination in Australia's national publicly-funded HPV vaccination program (date of birth >=July 1st 1980 and <1st July 1980). In the LBC (active control) arm, women will undergo 2.5 yearly image read cytology screening with reflex HPV triage testing for low grade cytology. In the HPV (intervention) arm women will undergo 5 yearly HPV screening with partial genotyping enabling separate identification of HPV16 and HPV18 and referral of this group for diagnostic evaluation, and secondary randomisation of "intermediate risk" women testing positive for oncogenic HPV (but not HPV 16 or 18) to either image read LBC screening or dual-stained (DS) cytology testing with p16/Ki67. The laboratory reports issued to practitioners will specify the recommended management for women, according to study arm and test results.Participating women will be flagged and clinical outcomes will be tracked via the Compass Register. Data linkage between the Compass Register and HPV vaccination records held on the Australian Immunisation Register will be performed in order to integrate vaccination and screening histories for trial participants. Participants will be actively followed for an anticipated 5 years from the time of recruitment and the primary outcome is based on the total cumulative detection of CIN3+ after exit testing at 5 years. The anticipated study completion date of March 2027 takes into consideration the final migration of participants to the National Cancer Screening Register and allows for two years to follow-up any intermediate risk results occurring in the last of the recruited trial participants.

Compass is a randomised controlled trial of primary HPV testing for cervical cancer screening versus cytology screening in Australia. A pilot study involving 5,000 women was carried out in 2013-2014. The main trial will involve recruiting 76,300 women from primary health clinics. Women aged 25-69, attending for cervical screening or for routine follow-up will be invited to participate in the 2-arm trial. A liquid-based cytology (LBC) sample will be taken from consenting women and sent to VCS Pathology, at VCS Foundation. On receipt of a woman's first Compass sample at VCS Pathology she will be randomised in a 1:2 parallel group allocation to LBC and HPV arms using randomisation with the minimisation procedure, with stratification by birth cohort according to whether offered HPV vaccination in Australia's national publicly-funded HPV vaccination program (date of birth >=July 1st 1980 and DOB <1st July 1980). The screening and management algorithms for the two study arms will be as follows: LBC Arm: 2.5 yearly image-read cytology screening with reflex HPV triage testing for low grade cytology. HPV Arm: 5 yearly HPV screening for potentially oncogenic types with partial genotyping enabling separate identification of HPV16 and HPV18 and referral of this group for diagnostic evaluation, and secondary randomisation of "intermediate risk" women testing positive for oncogenic HPV (but not HPV 16 or 18) to either image read LBC screening or dual-stained (DS) cytology testing with p16/Ki67. The laboratory reports issued to practitioners will specify the recommended management for women, according to study arm and test results. Participating women will be flagged on the Compass Register and invitation letters will be issued 3 months prior to the designated time for re-screening or follow-up. Clinical outcomes (screening test, colposcopy and histology results) will be tracked via the Compass Register. Data linkage between the Compass Register and HPV vaccination records held on the Australian Immunisation Register will be performed in order to integrate vaccination and screening histories for trial participants. Participants will be followed for an anticipated 5 years from the time of recruitment. Previous trials in unvaccinated populations have demonstrated increased detection of CIN2+ in HPV-screened (or co-tested) women vs. cytology-alone screened women in the baseline screening round, followed by decreased rates of incident CIN3+ in HPV-screened vs. Pap screened women thereafter. This potentially reflects (i) the increased detection of disease at the CIN2 (treatment) threshold at baseline in HPV-screened women, leading to increased prevention of future CIN3 in the group of women treated for CIN2 at baseline; and (ii) the association, demonstrated in multiple cohort studies, between HPV positivity (especially for types 16/18) and the development of CIN3+ in the future. In the Compass trial, HPV-positive women without verified disease at baseline undergo increased surveillance until testing HPV negative. A total of 36,300 women in the birth cohorts not offered vaccination and 40,000 women in the cohorts offered vaccination, who are presenting for routine screening, will be recruited, to bring the total number recruited to 76,300 (updated August 2019) (with the additional women representing those presenting for routine follow-up and those recruited for a safety monitoring sample). The sample size requirements for the trial are based on assessment of the cumulative proportion of CIN3+ (including CIN3 and invasive cervical cancer) in women who were screen-negative at baseline. A major impact of this study will be value of extended screening intervals in patients who are screen-negative at baseline. Logistically, it would be difficult to randomise patients after baseline screening and as such, the cumulative 5-year CIN3+ rates in baseline screen-negative patients may no longer be strictly comparative. However, this is a critical scientific question and so the trial is powered for this secondary outcome: the cumulative proportion of CIN3+ (including CIN3 and invasive cervical cancer) in screen-negative women, adjusted for censoring after CIN2+ treatment. The primary outcome is based on the total cumulative detection of CIN3+. Because the primary outcome includes precancer, there remains a potential benefit from early detection in the baseline screening round, and although this benefit is not explicitly factored into the primary outcome it will be highlighted in the assessment of outcomes in baseline screen-negative women (i.e. in the analysis for Secondary Outcome 1). When assessing total cumulative rates of CIN3+, including both the baseline round and longitudinal follow-up in each arm, the follow-up duration is a critical determinant of the expected relative outcomes for CIN3+ when the two arms are compared. A second critical determinant is the disease ascertainment process at trial exit, and a consistent process using a sensitive screening test followed by equivalent referral and management processes must be performed in both arms. Therefore all women enrolled in Compass will be offered HPV exit testing at 5 years (as the standard recommendation for cervical screening in Australia from December 2017, the HPV exit test will also act as a routine cervical screening test). A Scientific Advisory Committee will advise the investigator team on issues related to protocol, operations and any other issues brought by the investigators to the Committee. An Independent Data Safety and Monitoring Committee (IDSMC) has been configured to monitor the safety of participants in the trial. Compass is sponsored by the VCS Foundation, a government-funded health promotion charity. The VCS have received equipment and a funding contribution for the Compass trial from Roche Molecular Systems and Ventana Inc USA. Primary HPV testing is performed using the cobas 4800 HPV Test (Roche Molecular Systems Inc., Pleasanton, CA) (listed on the ARTG) and incorporating: cobas 4800 System, Sample Preparation Kit: c4800 SMPL PREP cobas 4800 System, Amplification/Detection Kit: c4800 HPV AMP/DET cobas 4800 System, Preparation Kit: c4800 LIQ CYT cobas 4800 System, Wash Buffer Kit: c4800 WB

Molecular testing for HPV with partial genotyping for types 16/18, with referral of the HPV16/18-positive group for diagnostic evaluation, and secondary randomisation of women testing positive for other oncogenic HPV infection (not 16/18), to either image-read cytology screening or dual-stained (DS) cytology testing with p16/Ki67 - the "HPV arm". Screening performed 5 yearly.

Image-read liquid based cytology (LBC) screening with reflex HPV triage testing for low grade smears, the "LBC arm." Screening performed 2.5 yearly.

Molecular testing for HPV with a test allowing partial genotyping for separate identification of types 16/18 from cervical samples. The technology used in this trial will be approved by the Therapeutic Goods Administration (TGA) Australia. It will identify the major HPV oncogenic genotypes in a pool and separately identify HPV 16 and 18. It will also satisfy performance criteria for relative sensitivity and specificity compared to Hybrid Capture 2 (HC2 ) as articulated by Meijer et al, 2009, Guidelines for human papillomavirus DNA test requirements for primary cervical cancer screening in women 30 years and older.

The liquid based cytology (LBC) used in this trial will be will be approved by the Therapeutic Goods Administration (TGA) Australia for LBC and appropriately validated and (TGA approved) to perform human papillomavirus testing from a cytology sample.

The primary outcome will be cumulative CIN3+ at 5 years following a 5 year HPV exit testing round in both arms, in women randomised to the HPV arm vs. women randomised to the LBC arm, adjusted for censoring after CIN2+ treatment. For the primary outcome, intention to treat analysis will be performed with closed loop testing for non-inferiority and superiority if non-inferiority is declared. Assuming a total average CIN3+ rate in the LBC arm (across unvaccinated and vaccinated women) of 0.94%, and an absolute non-inferiority margin of 0.22%, the trial will have 78% power with 97.5% confidence to detect non-inferiority for the HPV arm, allowing for a 15% non-compliance rate.

Cumulative CIN3+ in women presenting for routine screening randomised to the HPV arm who were HPV-negative at baseline, vs. CIN3+ in those randomised to the LBC arm and who were LBC-negative at baseline, adjusted for censoring after CIN2+ treatment and stratified by recruitment group (date of birth >=July 1st 1980 and <1st July 1980). Intention to treat analysis will be performed with closed loop testing for non-inferiority and superiority if non-inferiority is declared.

Cumulative CIN3+ in women presenting for routine screening randomised to the HPV arm who were HPV-negative at baseline, vs. CIN3+ in those randomised to the LBC arm and who were LBC-negative at baseline and at 2.5 years, adjusted for censoring after CIN2+ treatment and stratified by recruitment group (date of birth >=July 1st 1980 and <1st July 1980). Per-protocol analysis will be performed in women screened and followed up within a defined tolerance period according to protocol recommendations.

Cumulative CIN2+ in women randomised to the HPV arm who were HPV-negative at baseline, vs. CIN2+ in women who were randomised to the LBC arm and were LBC-negative at baseline, adjusted for censoring after CIN2+ treatment and stratified by recruitment group (date of birth >=July 1st 1980 and <1st July 1980).

Cross-sectional outcomes for CIN 2+ and CIN3+ detection in each arm, stratified by recruitment group (date of birth >=July 1st 1980 and <1st July 1980).

CIN2+ in women randomised to HPV testing at baseline who have other HPV (not 16/18), stratified by recruitment group (date of birth >=July 1st 1980 and <1st July 1980).

CIN2+ and CIN3+ in women who have an abnormal test result at baseline, adjusted for censoring after CIN2+ treatment and stratified by recruitment group (date of birth >=July 1st 1980 and <1st July 1980).

CIN2+ and CIN3+ in women who were in follow-management for a previous abnormality at baseline, adjusted for censoring after CIN2+ treatment and stratified by recruitment group (date of birth >=July 1st 1980 and <1st July 1980).

Inclusion Criteria: Australian residents with a cervix, aged 25-69 years who are attending for routine cervical screening. (Note: since April 2016 recruitment has been confined to the younger strata, i.e. women age-eligible for HPV vaccination aged at least 25 and born on or after 1st July 1980, as the recruitment target of the older cohort was met). Participants may have been previously enrolled in the Compass Pilot but must have been discharged to routine screening. Women may also be in follow-up management for a previous abnormality or unsatisfactory cytology. Exclusion Criteria: Previous total hysterectomy (uterus and cervix). The presence of symptoms or signs for which cervical cancer must be excluded. Currently undergoing treatment for cervical cancer. Currently enrolled in the Compass Pilot Study.

Canfell K, Saville M, Caruana M, Gebski V, Darlington-Brown J, Brotherton J, Heley S, Castle PE. Protocol for Compass: a randomised controlled trial of primary HPV testing versus cytology screening for cervical cancer in HPV-unvaccinated and vaccinated women aged 25-69 years living in Australia. BMJ Open. 2018 Jan 26;8(1):e016700. doi: 10.1136/bmjopen-2017-016700. Erratum In: BMJ Open. 2018 Mar 8;8(3):e016700corr1.

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Sarich P, Canfell K, Egger S, Banks E, Joshy G, Grogan P, Weber MF. Alcohol consumption, drinking patterns and cancer incidence in an Australian cohort of 226,162 participants aged 45 years and over. Br J Cancer. 2021 Jan;124(2):513-523. doi: 10.1038/s41416-020-01101-2. Epub 2020 Oct 11.

Smith MA, Gertig D, Hall M, Simms K, Lew JB, Malloy M, Saville M, Canfell K. Transitioning from cytology-based screening to HPV-based screening at longer intervals: implications for resource use. BMC Health Serv Res. 2016 Apr 26;16:147. doi: 10.1186/s12913-016-1375-9.

Guidelines for human papillomavirus DNA test requirements for primary cervical cancer screening in women 30 years and older