# Comparative performance of hrHPV testing and PAX1/ZNF671 methylation in triaging women with abnormal cytology: a study of paired urine, vaginal and cervical scrape samples

## TL;DR

This study compares hrHPV testing and PAX1/ZNF671 methylation for cervical cancer screening using cervical, vaginal, and urine samples.

## Contribution

The study introduces PAX1/ZNF671 methylation as a novel triage method for cervical lesions and compares its performance across sample types.

## Key findings

- PAX1 and ZNF671 methylation showed high sensitivity and specificity for detecting CIN3+ lesions in cervical scrapes.
- Cervical scrapes outperformed self-collected vaginal and urine samples in diagnostic accuracy for CIN2+ and CIN3+ lesions.
- PAX1/ZNF671 methylation effectively screens and excludes CIN2+ lesions in HPV-negative individuals.

## Abstract

The purpose was to evaluate the diagnostic effectiveness of High-risk human papillomavirus(hrHPV) testing, DNA methylation, PAX1/ZNF671 methylation in triaging patients with abnormal cytology and/or abnormal cervical biopsy pathology in cervical cancer screening; And the detection performance of different screening strategies was compared among clinician-taken cervical scrapes and paired self-collected urine and vaginal samples.

A total of 136 urine-based,137self-collected vaginal and 140 cervical scrapes samples were analyzed. Samples were tested for hrHPV DNA and six methylation markers. Various screening strategies from different samples were compared under the definitive histopathology for their diagnostic accuracy against two standards: cervical intraepithelial neoplasia grade 2 or more severe lesions (CIN2+) and cervical intraepithelial neoplasia grade 3 or more severe lesions (CIN3+).

For PAX1 and ZNF671, the areas under the ROC curve were 0.929 and 0.862 and the methylation-positive rate was 89.5% (77/86) and 80.2% (69/86) in CIN3+ lesions. The cutoff values were 7.95and 10.92, respectively, with the highest Youden index values being 0.763 and 0.684, respectively. The sensitivity of hrHPV testing for CIN2+ was 89.80% in cervical scrape to 92.63% in self-collected vaginal samples. And the optimal marker panel (PAX1/ZNF671) resulted in an 85.8% sensitivity and 5.8 PLR for CIN2+ detection in cervical scrapes, and reached a highest sensitivity for CIN3+ in cervical scrapes (91.9%), markedly exceeding that of vaginal (71.4%) and urine (48.1%) samples (P<0.001). The Negative Predictive Value (NPV) for cervical scrapes (85.7%) was higher than self-collected alternatives (P<0.001). As for hrHPV and DNA Methylation, a perfect sensitivity (96.51%), NPV (90.00%) and Negative Likelihood Ratio(NLR) (0.07) for CIN3+ were reached. For hrHPV negative population, trough PAX1/ZNF671 detection, Cervical scrapes showed a highest sensitivity (100.00%) and specificity (91.30%), a 77.78% PPV and 100% NPV were achieved for discriminating CIN3 +.

The prevalence of methylation for PAX1/ZNF671 genes exhibited a strong positive correlation with the severity of cervical lesions, and demonstrates a better diagnostic value for CIN2+ lesions. DNA methylation testing, especially PAX1/ZNF671 offers a promising strategy to detect CIN2/3 lesions or more serious disease. Cervical samples were the perfect candidates for DNA methylation. Furthermore, PAX1/ZNF671 methylation assays had a strong capacity in screening and excludingCIN2+ lesions among HPV-negative individuals.