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Summary: Background: The standard for reading cervical cytology is for a cytoscreener to manually search across an entire slide for abnormal cells using a conventional microscope. Automated technology can select fields of view to assess abnormal cells, which allows targeted reading by cytoscreeners. In the Manual Assessment Versus Automated Reading In Cytology (MAVARIC) trial, we compared the accuracy of these techniques for the detection of underlying disease. Methods: For this randomised controlled trial, women aged 25–64 years undergoing primary cervical screening in Manchester, UK, were randomly assigned (1:2) to receive either manual reading only or paired reading (automation-assisted reading and manual reading), between March 1, 2006, and Feb 28, 2009. In the paired arm, two automated systems were used—the ThinPrep Imaging System and the FocalPoint GS Imaging System. General practices and community clinics were randomised to either ThinPrep or to SurePath (for the FocalPoint system) liquid-based cytology with block randomisation stratified by deprivation index. Samples were then individually randomised to manual reading only or paired reading only. Laboratory staff were unaware of the allocation of each slide and concealment was maintained until the end of the reporting process. The primary outcome was sensitivity of automation-assisted reading relative to manual reading for the detection of underlying cervical intraepithelial neoplasia grade 2 or worse (CIN2+) in the paired arm. This trial is registered, number ISRCTN66377374. Findings: 73 266 liquid-based cytology samples were obtained from women undergoing primary cervical screening; 24 688 allocated to the manual-only arm and 48 578 to the paired-reading arm. Automation-assisted reading was 8% less sensitive than manual reading (relative sensitivity 0·92, 95% CI 0·89–0·95), which was equivalent to an absolute reduction in sensitivity of 6·3%, assuming the sensitivity of manual reading to be 79%. Specificity of automation-assisted reading relative to manual reading increased by 0·6% (1·006, 95% CI 1·005–1·007). Interpretation: The inferior sensitivity of automation-assisted reading for the detection of CIN2+, combined with an inconsequential increase in specificity, suggests that automation-assisted reading cannot be recommended for primary cervical screening. Funding: National Institute for Health Research Health Technology Assessment programme. [Copyright &y& Elsevier]

Potential roles for HPV testing in cervical screening.The most important clinical value of HPV testing in thelower genital tract is to distinguish women at very low riskof malignancy from those at some risk.In cervical screening, the principal roles that HPV testingmay play are(i) in primary screening,(ii) in following up the treatment of cervical abnormalities,(iii) triage of mild abnormalities.Study findingsThe ASCUC-LSIL triage study (ALTS) investigated the sensitivityof HPV testing using HC II combined with repeat cytologyin detecting CIN3+ lesions (Table 1) [11].Further results from the ALTS study, in which 897 cases oflow-grade squamous intraepithelial lesion (LSIL) and 1193cases of HPV DNA-positive ASCUS were followed for 2 years,suggested that LSIL lesions and HPV-positive ASCUS areclinically equivalent [12]. Initial colposcopic detection of obviouslyprevalent CIN2+ reduces risk. However, for the remainingwomen who have CIN ≤ 1 on colposcopy and directedbiopsy, the risk for subsequent CIN grade 2 or 3 isapproximately 12% over 2 years.The HPV in addition to routine testing (HART) studylooked at the management of women who tested positivefor high-risk types of HPV, but had negative or borderlinescreening abnormalities [13]. HPV testing was more sensitivethan borderline-or-worse cytology (97.1% versus 76.6%,P = .002), but less specific (93.3% versus 95.8%, P < .0001)for detecting CIN2+. Surveillance at 12 months was as effectivefor monitoring progression as immediate colposcopy.From study results to clinical practiceA meta-analysis to assess the accuracy of HPV DNA testingas an alternative to repeat cytology in women who had equivocalresults on a previous Pap smear suggests thatHC II assayhas higher sensitivity and similar specificity than the repeatPap smear (ASCUS as threshold) for CIN2+ among womenin this patient group [14].HPV testing has a high negative predictive value and althoughthe positive predictive value is lower, it offers considerablebenefits in triaging patients. It can also assist decisionmaking on behalf of women with mild cytological abnormalities. [ABSTRACT FROM AUTHOR]