This study aimed to assess parental willingness to vaccinate adolescent girls against human papillomavirus (HPV) for cervical cancer prevention.this was a descriptive cross-sectional study among 301 parents of adolescent girls who reside in Surulere Local Government Area in Lagos, Nigeria. A pretested, semi-structured interviewer-administered questionnaire was used to collect data and analysis was done using Epi-info™ version 7. The chi-square (or Fisher’s exact) test and the t-test were used to test for associations between categorical and continuous variables respectively. The level of significance was set at 0.05.over half (53.5%) of the respondents had heard of cervical cancer. Of these, two thirds (62.1%) were aware that it could be prevented, 19.0% had good knowledge of cervical cancer prevention, only 4% had their daughters vaccinated though 79.2% were willing to vaccinate. The poor vaccine uptake was mostly due to lack of awareness of vaccination centres and the high cost of the vaccine. Willingness was significantly associated with level of education (p = 0.047) and knowledge of HPV vaccination (p < 0.001), however once aware, most parents were willing to get their daughters vaccinated.awareness about cervical cancer prevention was high though uptake was low. A high level of education and good knowledge of cervical cancer prevention were facilitators of willingness to vaccinate, though once aware parents were willing. Creating awareness and educating parents about cervical cancer prevention is essential in improving the uptake of the vaccine. Cervicage of 40 . It is oge of 40 , where tHuman papillomavirus (HPV) is a common infection associated with genital skin to skin contact. Most women will have a transient infection only. Persistent infections are associated with integration of HPV DNA into the host cell genome, giving rise to premalignant and, less frequently, malignant change . High riThe HPV vaccination has the potential of reducing the incidence of cervical cancer worldwide by 70%; the remaining 30% of cancers can be prevented through regular cervical cancer screening . The sucBarriers to HPV vaccination include high monetary cost, uncertain length of vaccine effectiveness, low perceived risk of HPV infection (since their daughters were not engaging in sex at the time), no immediate perceived need (because of the slim chance of their daughter having sex in the very near future) and the anticipated family disapproval and fear of the pain of injection. Facilitators to HPV vaccination on the other hand include having the family support needed to get one's daughter vaccinated, peer support and medical reassurance on safety and efficacy of vaccine . StudiesThis was a community-based cross-sectional descriptive survey conducted in July-Sept 2018, involving parents of adolescent girls in Surulere Local Government Area (LGA), Lagos, south-western Nigeria. At the last census in the year 2006, the population of Surulere was 503,975 (Lagos State Population growth rate at 3.2% per annum). With a population density of 21,864 inhabitants per square kilometre, the major occupation of the people of Surulere LGA is trading. Surulere LGA is divided into 23 administrative wards. Using the Cochrane formula, a sample size of 274 was calculated. This was increased by 10% to correct for attrition and non-response to achieve a sample size of 301. The multi-stage sampling technique was used to select the respondents for this study. In the first stage, six of the administrative wards were selected by simple random sampling using balloting. In the second stage five streets were selected from each of the six selected wards by simple random sampling also by balloting. Ten out of about 40 houses on each street were selected by systematic sampling thus, fifty houses were selected per ward. In each house, if there was more than one eligible parent present, one parent  was selected by balloting, to participate in the study.Data were collected with the use of a pre-tested, semi-structured, interviewer-administered questionnaire developed from those used in previous studies. The questionnaire was designed to collect data on the socio-demographic characteristics of the respondents, their awareness, knowledge and attitude towards cervical cancer and cervical cancer prevention, their willingness to have their daughters receive HPV vaccination and the uptake of HPV vaccination. Data entry and analysis were done using Epi-info™ version 7 statistical software. The quantitative data was analysed as descriptive frequencies, percentages and cross tabulations. Knowledge and attitude were scored and categorised into ‘good’ or ‘poor’ and ‘positive’ or ‘negative’ respectively. The Chi-square and Fisher's exact tests were used to test for associations between categorical variables as applicable, while the t-test was used to test for associations between continuous variables. Associations were considered statistically significant if the two-tailed probability was less than 5% (0.05).Ethical approval was obtained from the Health Research Ethics Committee (HREC) of the Lagos University Teaching Hospital (HREC Assigned NO: ADM/DCST/HREC/APP/372) prior to the commencement of the study. Permission was obtained through the Medical Officer of Health in charge of Surulere Local Government Area. A written informed consent was taken from each participant prior to their enrolment into the study. Confidentiality was ensured by keeping the data anonymous; using numbers rather than names to identify the respondents and the questionnaires. Participation in the study was purely voluntary, with no consequences for non-participation.The age of the respondents in this study ranged from 28 to 65 years with a mean of 43.9 ± 7.3 years. More than two-thirds (69.1%) of the respondents were mothers and a third (30.9%) of them were fathers. More than half (59.1%) of the respondents were from the Yoruba ethnic group with 64.8% belonging to the Christian religion. Majority of the respondents (84.4%) were married, the mean age of their daughters being 13.5 ± 3.0 years. Over half (50.2%) of the respondents had attained tertiary education. Of the parents that participated in this study, 46.4% had one adolescent girl in their care, 39.9%, 12% and 1.7% had two, three and more than three adolescents in their care, respectively. A small proportion (4.0%) knew that their youngest adolescent daughter had experienced their sexual debut, 15.9% did not know whether or not she had, while the majority (80.1%) were certain that their daughters were virgins . Only abA very small proportion (4.0%) of the parents who were aware of HPV vaccination for cervical cancer prevention actually had their daughters vaccinated, 96.0% had not vaccinated their daughters. Of those who actually did have their daughters vaccinated, 75.0% vaccinated their daughter because they were following the doctor's request. Only 1 parent (25.0%) voluntarily had their daughter vaccinated. Not being aware of how to get their daughter vaccinated (41.7%), the vaccine not being available (11.5%), the high cost of the vaccine (17.7%) and being unsure of the safety of the vaccine (11.5%) were the reasons given for not having their daughters vaccinated. Some parents (17.7%) had no reason at all for not vaccinating their daughters. Of those who had not vaccinated their daughters, a large proportion (79.2%) of the parents were willing to have their daughters vaccinated if it was provided free of charge . RespondCervical cancer is an important disease that requires attention even at the time of adolescence, keeping prevention in view. Not many parents know about the vaccines nor are getting their daughters vaccinated. The analysis of the demographic data showed a higher percentage of females among the parents, reflecting the fact that mothers are usually the parent available to care for children even at adolescence. This study demonstrated that an average proportion of the parents were aware of cervical cancer, this can be compared to the findings of a study conducted in North West Ethiopia where 69.3% had heard about cervical cancer . A studyIn this study, almost half of the respondents were aware of HPV infection. This is in contrast to a study in Bamako, Mali where awareness about HPV was much lower, with only 8.6% knowing about HPV as an STI . This coIn this study, only 1.3% of the respondents had adolescent daughters who had received HPV vaccine despite the fact that they were aware of the vaccine. However, 80.9% of the parents were willing to have their daughters vaccinated. This is similar to a study carried out in Lagos where only 2.2% of the respondents had HPV vaccine given to their female teenage children and this was despite the acceptance rate of HPV vaccination being 76.2% among the respondents . In anotThe high level of willingness shown by the respondents in this study (80.9%) to accept HPV vaccination for their daughters is consistent with the reports from previous studies in Poland among parents where a major proportion of the total respondents (85.1%) expressed their willingness to vaccinate their daughters against HPV infection . This isIn another similar study carried out in Bangladesh, similar but additional factors influencing willingness to vaccinate against HPV were found which included lack of awareness (78.4%), doctors not recommending the vaccine (13.6%), worries about safety (6.8%), considering the recipient as being too old for vaccination (5.7%), not needing a vaccine (3.4%), not being sexually active (3.4%) and the vaccine being too expensive (2.3%) . In thisThe parents had good attitudes towards cervical cancer prevention, despite poor knowledge. The uptake of HPV vaccination was very poor mostly due to not knowing the vaccination centres, the high cost of the vaccine and the fear of side effects. Willingness was however high especially if vaccines were to be made available free of charge. Though having good knowledge was important, parents once aware of cervical cancer prevention were willing to vaccinate their daughters, hence improving public awareness about the vaccines and the vaccination centres, and reducing the cost of the HPV vaccine is key to improving vaccine uptake. Further studies, qualitative in nature, are required to identify targeted worries and expectations of potential users and parents/caregivers.Cervical cancer, the commonest gynaecological cancer in women worldwide and the second most common cancer in women living in less developed regions, is preventable;Awareness and access to HPV vaccination is poor in Nigeria.There is a low level of uptake of adolescent HPV vaccine, even though most parents are willing to have their daughters vaccinated;Awareness even without having good knowledge is sufficient in improving parental willingness to vaccinate their daughters;Taking steps to ensure public awareness about cervical cancer prevention and reducing the cost of the vaccine could improve uptake of HPV vaccination.


New screening techniques may affect the optimal approachesfor the prevention of cervical cancer. We evaluated the cost-effectiveness and accuracy of alternative screening strategies to provide evidence for cervical cancer screening guidelines in China.® high-risk human papillomavirus (HR-HPV) nongenotyping and cytology cotesting (Cervista® cotesting) was compared with PCR-reverse dot blot HR-HPV genotyping and cytology cotesting (PCR-RDB cotesting). All eligible participants were divided into Arm 1, in which both HR-HPV assays were performed, and Arms 2 and 3, in which the PCR-RDB HPV or Cervista® HR-HPV assay, respectively, was performed. Outcome indicators included the cases, sensitivity, negative predictive value (NPV), colposcopy referral rate and cost of identifying cervical intraepithelial neoplasia of grade 2/3 or worse (CIN2+/CIN3+).In total, 32,306 women were enrolled. The current screening with Cervista® HR-HPV-positive, which reflects good agreement (k = 0.73). PCR-RDB cotesting identified more CIN3+ cases than Cervista® cotesting in the first round of screening in Arm 1 (37 vs 32) and Arms 2/3 (252 vs 165). The sensitivity and NPV of PCR-RDB cotesting for identifying CIN3+ in Arm 1  and Arms 2/3  were higher than those of Cervista® cotesting, but the cost was similar.Among the eligible participants, 18.4% were PCR-RDB HR-HPV-positive, while 16.9% were Cervista® HR-HPV assay results were consistent. PCR-RDB cotesting possesses optimal cost-effectiveness for cervical cancer screening in China, which has the highest number of cases globally but low screening coverage.The PCR-RDB HR-HPV genotyping and Cervista Cervical cancer is the second most common cancer among women worldwide , and 85%Although cytologic screening has effectively reduced the incidence and mortality, the accuracy of cytological results varies widely, ranging from 55 to 94% . Cervica® , Cobas HPV , Aptima  and BD Onclarity™ HPV . The Cervista® HR-HPV assay . However, the PCR-RDB cotesting screening strategy cost less than the Cervista® cotesting strategy in terms of the cost of identifying each CIN2+ woman [PCR-RDB cotesting vs Cervista® cotesting = $2527 vs $2632 (in Arm 1) or $1654 vs $1867 (in Arms 2/3)]. Similar results were observed for CIN3+.Nearly 798 participants were lost to recall during the follow-up period. Finally, 24,819 women  had eligible follow-up results and valid pathology results and were included in the cost-performance analysis. As shown in Tables As the largest developing country, cervical cancer poses a significant health burden in China. The PCR-RDB HPV genotyping assay is a PCR-based method used to detect and identify viral DNA from 14 HR-HPV genotypes. Some studies have confirmed that HPV-16/18 genotyping has excellent triage performance in HPV-positive women . Therefo® cotesting as a reference screening strategy and compared the cost-effectiveness of PCR-RDB cotesting for cervical cancer screening in China. In Arm 1 and Arms 2/3, we found that PCR-RDB cotesting had a higher sensitivity for identifying CIN2+ in the first round of screening. PCR-RDB cotesting can result in the detection of more CIN2+ women than Cervista® cotesting in the first round of screening; thus, implementing the PCR-RDB cotesting screening strategy will result in earlier detection of precancerous lesions and cervical cancer. The discovery of CIN2+ lesions earlier can result in prompt intervention or treatment of patients, which can help prevent progression to severe cervical cancer and the subsequent loss of the chance for a cure [In this study, we used Cervistar a cure . Our resr a cure .® HR-HPV (16.9%) and higher than that reported by Xiumin Zhao et al. [® HR-HPV assays had two age peaks, 21–24 years and 50–65 years, which was similar to the findings from other studies from China [® HR-HPV assays (k = 0.73). However, the consistency among HPV test results was lowest in the cytology NILM group (k = 0.65). This finding may be explained by the very low viral load that is near the cutoff value of the HPV test, leading to poorly judged results in this subgroup [The positivity rate of 14 genotypes of HR-HPV was 18.4% with the PCR-RDB HR-HPV genotyping assay, which is slightly higher than that with the Cervistao et al.  (9.9%). om China , 27–29, om China  and Chilom China , but HR-om China , 33. Theom China . In our subgroup . Some stsubgroup , 37 have® and HC2 have similar properties in terms of HSIL identification, although their principles are different [® HR-HPV cotesting for predicting CIN2+/CIN3+, but the total cost of the two screening methods was similar for every 1000 women screened . However, the cost of PCR-RDB cotesting was lower than that of Cervista® cotesting for each CIN2+/CIN3+ patient identified . Cost is an important factor to consider when formulating screening strategies, especially in low- and middle-income countries where resources are scarce. This study revealed that PCR-RDB cotesting may be a more cost-effective alternative to cervical cancer screening strategies in low- and middle-income countries, which have low screening coverage and large populations.Previous studies have shown that Cervistaifferent . TherefoThe PCR-RDB HR-HPV genotyping cotesting strategy revealed a subgroup of HPV-16/18-positive but cytologically normal women. In this study, 25.3% (407/1609) of HR-HPV-positive but cytologically normal women were HPV-16/18-positive in Arm 1 and Arm 2/3, and all of them were directly referred for colposcopy. This procedure resulted in the detection of CIN2+ lesions in an additional 19.1% (81/425) of patients during the first round of screening, confirming the importance of a PCR-RDB genotyping cotesting program for early detection of cervical lesions. Many studies have confirmed that HPV-16/18 infection has a higher carcinogenicity than any other type . TherefoThe follow-up of cervical cancer screening is difficult in low- and middle-income countries. In this study, all women with serious abnormal screening results in the first round of screening were directly referred for colposcopy, while those with slight abnormalities will undergo repeat HR-HPV and TCT testing one year later. To increase the follow-up rate of women with abnormal screening results, we have established telephone follow-up and online follow-up for women with abnormal screening to detect the progression of cervical disease over time and reduce the rate of missed follow-up. All colposcopy and pathological examinations in this study were performed by two expert colposcopy physicians or pathologists. We also regularly provide technical training for colposcopy physicians and pathologists to improve the accuracy of colposcopy diagnosis and pathological diagnosis.There are some limitations of this study that should be noted. First, some women with HR-HPV (non-HPV-16/18)-positive or cytology-positive results alone were not referred for colposcopy; thus, the evaluation of the specificity and PPV of the HPV assay may have been affected. Second, some women were not followed up after receiving abnormal screening results, and the loss to follow-up rate in our study was 3.1% , which is similar to what has been reported in other studies . Althoug® HR-HPV assay are effective for detecting CIN2+ and CIN3+. Additionally, the strategy of PCR-RDB HPV cotesting for the 16/18 genotypes presents a higher sensitivity and NPV than the standard strategy of Cervista® HR-HPV cotesting without increasing the cost. The PCR-RDB HPV genotyping assay as a cotest for the 16/18 genotypes possesses optimal cost-effectiveness for screening and should be recommended for cervical cancer screening programs in China and other developing countries.In summary, the results of this study indicate that the PCR-RDB HPV genotyping assay and the CervistaAdditional file 1: Table S1. Clinical characteristics of women in different screening arms. (N = 25617).Additional file 2: Figure S1. Prevalence of HPV positivity in different age/cytology/pathology groups. A. Prevalence of HPV positivity in different age groups. B. Prevalence of HPV positivity in different cytology groups. C. Prevalence of HPV positivity in different pathology groups. PCR-RDB positivity, positive for any of the 14 HR-HPV types; PCR-RDB HPV-16/18 positivity, positive for either genotype 16 or 18, with or without positivity for other HPV types; Cervista positivity, positive for any of the three HR-HPV groups; Cervista A9 positivity, positive for the A9 group, with or without positivity for the two other groups; NILM, negative for intraepithelial lesion or malignancy; ASCUS, atypical squamous cells of undetermined significance; LSIL, low-grade squamous intraepithelial lesion; HSIL, high-grade squamous intraepithelial lesion; AGC, atypical glandular cells; ASC-H, atypical squamous cells without excluding high-grade squamous intraepithelial lesions; SCC, squamous cervical cancer; CIN, cervical intraepithelial neoplasia.Additional file 3: Table S2. Disagreement between PCR-RDB HPV genotyping and Cervista® HR-HPV assays in different cytology subgroups (n = 172)


To evaluate the 9-year incidence of cervical intraepithelial neoplasia grade 2 or worse (CIN2+) and cumulative adherence to perform a next test in a cohort of women aged 40+ years with no cervical screening cytology within a window of 5 years (underscreened women), after baseline cervical cytology and HPV tests.In Catalonia, Spain, co-testing with cytology and HPV test has been recommended in the Public Health system since 2006 for underscreened women. In 2007, 1,594 women with underscreened criteria were identified and followed through medical records form Pathological Department. 9-year cumulative incidence of histologically confirmed CIN2+ and cumulative adherence to perform a next test were estimated using Kaplan-Meier statistics.Follow-up was available for 1,009 women (63.3%) resulting in 23 women with. CIN2+ (2.3%). Of them, 4 women (17%) had both tests negative at baseline (3CIN2 and 1CIN3) with cumulative incidence of CIN2+ of 0.4% (95% CI: 0.1–1.4) at 5-years and 1.3% (95% CI: 0.4–3.7) at 9-years. During the first year, the prevalence among women with both tests positive was 27.0% (95% CI: 13.0–50.6) for CIN2+. Lost to follow-up was higher among women with both tests negative compared to those with both positive tests . 40.5% of the women HPV-/cyto- had a re-screening test during the 4 years following the baseline, increasing until 53.5% during the 6 years of follow-up.HPV detection shows a high longitudinal predictive value at 9-year to identify women at risk to develop CIN2+. The data validate a safe extension of the 3-year screening intervals  to 5-year intervals in underscreened women that had negative HPV result at baseline. It is necessary to establish mechanisms to ensure screening participation and adequate follow-up for these women. The implementation of screening programs for cervical cancer prevention, using cervical cytology with a high coverage, has led to a reduction in the incidence and mortality of cervical cancer up to 80%, due to the detection and treatment of precancerous lesions and incipient cancers –3. UnforThe recognition of the viral aetiology of cervical cancer has allowed the design of new approaches for the screening of the disease with the aim of improving cytological screening programs –6. Data However, the absence of screening, ranging from in 23 to 71%, is associated with an increased mortality –18. Our Aiming to reduce these preventable cases, the Autonomic Catalan government approved in June 2006 a cervical cancer screening guidelines, aiming to identify women with suboptimal screening history. This screening program was opportunistic. The guidelines recommended co-testing with HPV DNA and cervical cytology in women aged 40 years or older having no previous screening registered test in a window of 5 years, so called underscreened women . In 2007The objective of this study was to estimate the predictive value of the co-test of histologically confirmed CIN2+ lesions. A previous analysis evaluating 3-year follow-up showed that this strategy identified women at risk of CIN2+ that would have been missed by using cytology alone . We haveThis study is part of periodical evaluation reports on cervical cancer screening activities in the public health system in Catalonia (Spain) carried out by the Catalan Institute of Oncology ,23.This retrospective cohort includes 1,831 women with underscreened criteria identified in 2007. These women were offered a co-testing with cytology and HPV test at baseline and had been follow-up for subsequent screening visits up to 2016. If the baseline result was negative for both tests, a subsequent cytology test, as guidelines at the time recommended, was indicated every 3 years until the age of 65 . When cyThe overall project was approved by the ethical committee of the Bellvitge University Hospital (PR271/11). Any information regarding the identification of patients was anonymized before analysis.Follow-up was available through the computerized clinical history of the pathology laboratories of the reference hospitals. During the follow-up period (2007–2016), date and results of subsequent cytologies, biopsies and HPV test registered in clinical records were collected for all participants. The participant laboratories included were: Hospital Universitari Dr. Josep Trueta, Consorci hospitalari de Vic, Hospital Universitari Joan XXIII, Hospital del Mar, Hospital Universitari de Bellvitge, Hospital General de Granollers, Hospital d’Althaia and Hospital Germans Trias i Pujol.If further concomitant tests were available, the highest cytological or histological grade of abnormality was taking into account. Women with no more tests apart of those obtained at the baseline were considered “lost to follow-up”.st January 2007 to 31st of December 2016 were retrieved regularly every 18 months approximately.Clinical records on pathology diagnosis and gynecological visits registered from 1Cervical cytology was largely based on conventional Pap smears and HC2 transport media was used for HPV evaluation. If liquid based cytology was available, HPV and cytology tests were performed using the same sample. All cytological results were classified according to the 2001 Bethesda system by the institution’s pathology teams . AbnormaThe HPV test was performed with the Hybrid Capture 2 test technology  which detects 13 high-risk HPV types: 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59 and 68. A positive result was considered if attained or exceeded the FDA-approved threshold of 1.0 relative light unit (RLU/CO). All HPV reference laboratories were part of a quality control with kappa values over 90% .All abnormal cytology results at the level of HSIL+ had to be histologically confirmed and were classified according to the CIN classification .All women identified during 2007 with underscreened criteria, who had been screened by co-test were included. Included laboratories were health area referent for cytology, HPV and histology data and were able to provide follow-up information on the study population.We estimated:Cumulative and annual incidence of CIN2+ and CIN3+. The main event of interest was the development of CIN2+ or CIN3+ along the follow-up period. CIN2+ result included all histologically confirmed diagnoses of CIN2, CIN3, adenocarcinoma and invasive cervical carcinoma. In CIN3+ result, CIN2 is not included. A variable called “final diagnosis” was created including three categories: 1) women who had developed a CIN2+ or CIN3+ throughout the follow-up period, 2) women with a diagnosis other than CIN2+ or CIN3+, and 3) women with only the baseline tests that were considered lost to follow-up because of missing data. A woman was censored for follow-up if a CIN2+ lesion was identified, or when there was a surgical treatment for a CIN1 lesion, or in case of hysterectomy for non-cervical causes. In these cases, the woman contributed time until the diagnosis of CIN2+ or until time of surgical treatment or hysterectomy. Remaining women or in case of death for causes other than cervical cancer, the contributing time was accounted for until the last recorded test. For women with a baseline positive test, at least two negative tests (either HPV or cytology) were necessary to be registered as having a negative final diagnosis. For women with a negative result of the two tests at baseline, they were coded as negative at the end of follow-up if they had subsequent negative test results.Cumulative adherence to perform a next test. Among women with HPV-/cyto- at baseline, any test performed after 180 days following baseline tests including HPV test, cytology or cervical biopsy were all taken into account. This was done to avoid including additional tests not related to screening that could have been performed before . Among women HPV+/cyto-, tests performed at least 45 days after baseline were considered to not interfere with other tests performed concomitantly with the baseline ones. Among women HPV-/cyto+ and HPV+/cyto+, all subsequent tests performed, after baseline ones were considered without restriction.A woman was censured at the time that she had the next cytology, HPV test or cervical biopsy (event) registered after baseline according to the established criteria. The contribution time of that woman was time between baseline tests and the performance of next test. Women did no additional tests were censored on the date of baseline. In case of hysterectomy not due to cervical cancer, or death not related to cervical cancer, women was censored at the date of that event and considered of non-related event. If no date of death was available, the last date of woman's test was used. If none was available, it was considered the date of baseline.Results for continuous variables were given as mean values, and for categorical variables as percentages. We used chi-square test to compare proportions between groups. The percentage of cumulative incidence of histologically confirmed CIN2+ and CIN3+ lesions and its 95% confidence intervals (CI) as well as the cumulative adherence to perform a next test were estimated and graphically represented using the Kaplan-Meier curves at 1, 3, 5 and 9 years. Data are presented according to the combination of baseline results of cytology and HPV tests up to 9 years follow-up. Incidence rates were calculated in person-years per 100 women. Pairwise comparisons between cumulative incidence curves were evaluated using log-rank test. Also, annual incidence rates of CIN2+ and CIN3+ lesions were calculated at 3, 5 and 9 years, as the number of cases per 100 women/year, according to all combinations of baseline test results, with their 95% CI . In all To estimate number of women at risk during the study period and accounting for variability, person-years were estimated as number of years from baseline date of initial screening tests (HPV/cytology) to date of censorship or until end of follow-up period.https://www.R-project.org/).Data analyses were carried out with R software version 3.3.2 (R Core Team (2015). R: A language and environment for statistical computing. R Foundation for Statistical Computing, Vienna, Austria. URL At baseline1,831 women were included in the study, with a mean age of 54.4 years old at baseline (range 40–88). Double negative tests results were detected in 92.4% of women  while 1.3% (n = 24) had both tests positive. 6.7% (n = 123) of women were HPV positive irrespective of cytology result, and 2.2% (n = 40) had a positive cytology regardless of HPV result .At baseline, 231 women out of 1,831 were over 65 years of age with negative result in both tests (HPV/cytology) and were informed, consequently, to stop further cervical cancer screening. Six women died for reasons other than cervical cancer before the performance of a new test, so they were excluded, leaving a total of 1,594 women for being followed-up. Of these, 1,009 (63.3%) women had a complete follow-up during the study period . In 36.7During the 9 years of follow-up, a total of 23 women with histologically confirmed CIN2+ lesions were diagnosed, including 9 CIN3, 3 squamous carcinomas and one adenocarcinoma. The mean age of women at CIN2+ diagnosis was 49.3 years (range 40–67 years old). Eleven women (47.8%) out of the 23 CIN2+ cases were diagnosed among women with negative cytology but HPV positive test . Four caAmong CIN2+ cases, 70% (n = 16) were diagnosed within the first 3 years of follow-up, and all of them were positive for HPV, but only 7 had an abnormal cytology. Of the remaining 30% of cases (n = 7) diagnosed after 3 years of follow-up, one case had an abnormal cytology (14.3%) and the HPV test identified 3 cases (43%). Among women with both tests being negative, 4 had a CIN2+ with an average time until diagnosis of 5.7 years (range of 4.4–7.5 years).Annual incidence rates of CIN2+ and CIN3+ lesions at 3, 5 and 9 years were detailed in the supporting information .Differences between the combination of screening test results and having a CIN2+ or CIN3+ lesion were statistically significant according to the log-rank test  an explained by the impact of HPV test and not by cytology results. When HPV negative women with negative and positive cytology were compared, these differences were not statistically significant . Thus, HPV test was crucial in the CIN2+ risk stratification.HPV testing in cervical cancer screening among underscreened women over age 39 has shown an excellent longitudinal predictive value for the detection of CIN2+ and CIN3+ lesions at 9 years of follow-up, in both HPV positive and HPV negative women. The inclusion of HPV test in addition to cervical cytology in women at risk of cervical cancer identified all CIN3+ cases but one, at year 9 since baseline, while cytology missed 6 cases of CIN3+. These results are consistent with our evaluation at 3 years and with the literature, supporting HPV as a standalone primary screening test , and thaWomen with HPV negative results, regardless of cytology result had a low risk for CIN2+ and CIN3+, remaining low over time. In our study, no cases with CIN3+ were observed among HPV negative women at 5 years and the risk increased still a very low level to 0.3%  at 9 years. Additionally, among all women with a positive cytology, only those with a concomitant HPV positive test developed cervical pathology. In the RCT Athena Study, a study conducted in US among women aged 25 years or older attending routine cervical screening, the cumulative incidence of CIN3+ after 3 years for women with double negative tests (cytology + HPV) was 0.3%  comparable to that observed among women having been tested with HPV only, and more than twice among women with negative cytology . In anotOn the other hand, in our study, the average time to final diagnosis of a CIN2+ lesion in women with both negative tests at baseline was 5.7 years (range 4.4–7.5) and 6.5 years for a CIN3+ diagnosis (for the only one case). Our results support that HPV can be an excellent primary test that provides security to go beyond a 3-year screening interval, also in underscreened women. In the European RCTs, risk of CIN3+ among women with a negative screening test at baseline was found to be about the same after six years with HPV screening than after three years with cytology screening , suggestHowever, having a screening test with a higher sensitivity but a lower specificity leads to overdetection and needs to be balanced by the benefits of an early detection. To avoid detection of HPV positive cases that are unlikely to develop cervical cancer, several authors have proposed to restrict the number of HPV types included in the HPV assays, given that the risk of developing a CIN3+ is very low for some genotypes such as 39, 51, 56, 59, 68 ,34. ReceOn the other hand, a certain proportion of women, 17.2% of HPV positive and negative cytology and in 25% HPV negative women with a positive cytology, had no record of a second screening visit. A poor information or full understanding of a positive test could affect follow-up visit as has been seen elsewhere ,43. GoodThis is an evaluation of the implementation of screening guidelines and data are thus limited to that available at the health information system of public health sector. Any additional information such as socioeconomic profile or individual characteristics that could affect participation in screening activities was not available. The yield of disease among the subgroup of women with HPV-/cyto+, at baseline (only 16 women), should be considered with caution, due to the low number of women under this stratum.A strong point of our study lies in the monitoring over a period of 9 years the use of pathology laboratory registries. Although there could be some sub-registration if women decided after a given test, to go to a private services, this is however, suspected to be minimal among those having had a baseline visit although no routine registration exist. The HPV test used (HC2) is a robust test with high interlaboratory reproducibility among all reference laboratories in Catalonia .HPV test in cervical cancer screening, among underscreened women over age 39, shows a high longitudinal predictive value at 9 years to identify women at risk to develop CIN2+, in both HPV+ and HPV- women. The data validate a safe extension of the 3-year screening intervals  to 5-year intervals in underscreened women with a negative HPV result. Underscreened women had persistently poor adhesion to screening recommendations, so it is necessary to establish mechanisms to ensure re-screening participation within the established intervals in women with negative tests and compliance with adequate follow-up in women with positive tests.S1 TableCIN2+ included cervical intraepithelial neoplasia grade 2 and 3 and cervical carcinoma. CIN3+ included cervical intraepithelial neoplasia grade 3 and cervical carcinoma. The CIN2+ and CIN3+ incidence rate was calculated in person-year per 100 women.(PDF)Click here for additional data file. 12 May 2020PONE-D-20-10012Long-term protection of HPV test in women at risk of cervical cancerPLOS ONEDear Dr. Ibañez,Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. 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Thank you for stating the following in the Competing Interests section:"I have read the journal's policy and the authors of this manuscript have the followingcompeting interests:RI, ER, LM, LB and FXB: Cancer Epidemiology Research Programme runs someresearch projects funded by MSD and Seegene.RI: has collaborated in a consultancy for Hologic and received HPV tests free of chargeby Roche.FXB:has received travel/speaking grants from MSD, Seegene and Roche.The rest of the authors reported having no conflict of interest."http://journals.plos.org/plosone/s/competing-interests).  If there are restrictions on sharing of data and/or materials, please state these. 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Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented. Reviewer #1: PartlyReviewer #2: YesReviewer #3: Yes**********2. Has the statistical analysis been performed appropriately and rigorously? Reviewer #1: NoReviewer #2: YesReviewer #3: Yes**********3. Have the authors made all data underlying the findings in their manuscript fully available?PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. 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Reviewer #1: The paper is interesting as it describes the incidence of cervical diseases  in a cohort of under-screened women , who had been invited to screening with both HPV test and Pap Smear test. The follow-up is very long (9 years), therefore, the study results indicate the long protective effect of a negative HPV test, also in under-screened women.Major comments- There is a crucial error in Table 1: the cumulative incidence at 9 years is not reported for the HPV+/cyto+ group. It could be a typo, but the value is not reported neither in the text, therefore, I suggest a revision of all the statistical analysis.- Please uniform the Kaplan-Meier figures with the time span reported in Table 1 . Add also censored women  in the curves. It seems strange that the end of the line (last available data) for the 4 groups is not equal to 9 years. Maybe a complete 9-year follow-up has not been reached by some group of women? The time span used for the calculation seems to be months, please specify in the methods.- Please better specify the difference between censoring for follow-up and censoring as it is usually intended in the Kaplan-Meier estimates. Please describe in details in the methods which are the events of interest: I suppose that HSIL/CIN2+ is an event of interest, but also death from cervical cancer should be one, and hysterectomy for cervical diseases (if possible).- I wonder if in Spain you are able to distinguish between deaths due to ‘uterus n.o.s.’ and deaths due to cervical cancer. I know this is a challenging issue in several countries. The same questions arise with regard to the possibility of identifying the reason of hysterectomy.Minor comments- Please better specify what do you mean for “predictive value”, i.e., both positive and negative predictive values?- Methods, lines 122-124 death and end of follow-up should be included among the censoring times.- Please add the total for each group in Table 1.- The study could be underpowered  to detect incidence of cervical lesions among the subgroup of women with HPV-/Cyto+ at baseline (only 16 women). Therefore, the results (incidence =0) in this group should be considered with caution. Please add this limitation to the discussion.- Pg. 10 lines 194-196. I do not understand the meaning of this paragraph.- pg. 11, lines 225-229. I do not understand the meaning this comparison between groups.Typos/languagePg. 10: line 203, “3-years stablished” should be “3-year established”; line 212 “anormal”, should be “abnormal”Pg. 11: Line 215 “CIN2+” should be “HSIL/CIN2+”; line 220 “cero”, should be “zero”; line 225 “statistical significantly” should be “statistically significant”Pg. 12: Line 240: “baseline” 2 times; Line 241 “an HPV positive tests” should be “a HPV positive test”Pg. 14: line 273 “accumulative” should be “cumulative”Pg. 15: line 303 “To avoid detection of positive cases, that are unlikely to develop disease,” should be “To avoid detection of HPV positive cases that are unlikely to develop cervical diseases,”Pg. 16: line 323 “least”, should be “at least”.Reviewer #2: The paper is very well written and reports in a sound, original way the results of a cohort including under-screened women tested for HPV and cytology. The small number of women does not allow to infer too much about outcomes in interesting subgroups as cyto+/HPV- women at baseline. There are many other retrospective and prospective studies that analyzed similar cohorts around the world, thus the study can add very little to what is already known on a biological, natural history of the disease and screening effectiveness point of view. Nevertheless, the nature of thee cohort and thee length of follow up makes the study interesting.I suggest to focus the results and the discussion on the specific issues related to the high risk group and in particular on the compliance to follow up and screening appointments in the following nine years. Now there is a paragraph in the results about timing of rescreening, maybe a figure with survival curves for having a test or the frequency of first and second test during follow up, separately for negative and positive women could be more informative.Also in the discussion, most of the issues afforded are general and many other studies and secondary literature already has treated these topics. What is specific of this study is the underscreened population over 40. I suggest to discuss points linked to this: I see two issues, but other can be interesting that I do not see: 1) compliance to follow up and acceptability; 2) co-testing is not recommended in Europe, but some researchers argue that for women not screened before 40, where the prevalence of cancer may be high, including cytology in the first screening episode could be useful, given that the cytology vs HPV relative sensitivity for cancer seems to be similar, cytology could add something. For the second point your study cannot give an answer, but you can confirm the high prevalence of cancers in this population, all HPV+/cyto+...I have some minor commentsLine 193 the lost to follow up seem different from those reported in the abstract.Line 187 and line 194 the same results are reported with different indicators, thus it gives an impression of inconsistency and it is difficult to follow. I suggest to report the two measures in the same paragraph.Line 199 the average age at diagnosis is reported, but given the length of follow up it is difficult to manage this information. May be better to say how many in women below and over a certain age and to report it also for the whole cohort.Lines 225-28: there is something not clear to me in the sentence: “Not statistical significantly differences were detected among women HPV positive and cytology negative at baseline at 9 years and women HPV positive and cytology positive at 5 years .” Is the comparison between baseline or 9yy in HPV+/cyto- and HPV+/cyto+ at 5yy?In general, I suggest to shorten the text of the results: tables and figures are much clearer…DiscussionSee general commentsReviewer #3: This article attests to the sensitivity of HPV testing for cervical screening and its ability to justify extended screening rounds beyond 3 years. It is well written and the data support the conclusions drawnCommentsThe data support the conclusions drawn although the sample size is relatively small - the authors should avoid overstatement/extrapolation from their data - e.g. while I accept that the risk of developing CIN3 in HPV negative women "regardless of cytology result at 5 years was 0" - this is likely to be influenced by power-limitationsAn important element of this work is that the cohort are "underscreened " women - we get to know what is meant by this in the introduction but underscreened is not defined in abstract, and arguably should beA review of the English is recommended; there are some minor lapses in vocabulary and tenses eg line 83 "arouse" should be "arise" and for line 273 "accumulative" should be "accumulated"The data will be of importance locally and serve as key audit and service evaluation, with the potential to influence wider policy. However, as the authors describe - there are several larger published studies which describe longitudinal performance of HPV either as a stand alone test or as a co-test with cytology for the detection of cervical disease. The authors should try to describe the novelty/importance of these findings for the international community more clearlyEnd of review**********what does this mean?). If published, this will include your full peer review and any attached files.6. PLOS authors have the option to publish the peer review history of their article  digital diagnostic tool,  14 Jul 2020Dear editor and reviewers,Please find enclosed the revised version of the manuscript entitled “Long-term protection of HPV test in women at risk of cervical cancer” for publication, as a research article, in PLoS One.We have considered all the suggestions provided by the editor and reviewers. We thank them all for this as we believe have contributed to improve our manuscript. Below, you can see our responses point by point. We hope the manuscript is suitable now for publication.Response to editor: 1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. Response: It has been revised and adapted to the PLOS ONE's style requirements.2. In the ethics statement in the manuscript and in the online submission form, please provide additional information about the patient records used in your retrospective study, including: a) whether all data were fully anonymized before you accessed them; b) the date range (month and year) during which patients' medical records were accessed; and c) the source of the medical records analyzed in this work . Response:a) Any information regarding the personal identification of patients was anonymized before analysis. This is already included in the manuscript in the methods section, at the end of the study population partb) It was included in the methods section, follow-up part through the next paragraph: “Clinical records on pathology diagnosis and gynaecological visits registered from 1st January 2007 to 31st of December 2016 were retrieved regularly every 18 months approximately”.c) This information was already included in the methods section, follow-up part. Specifically, it says: “Follow-up was available through the computerized clinical history of the pathology laboratories of the reference hospitals. During the follow-up period (2007-2016), date and results of subsequent cytologies, biopsies and HPV test registered in clinical records were collected for all participants. The participant laboratories included were: Hospital Universitari Dr. Josep Trueta, Consorci hospitalari de Vic, Hospital Universitari Joan XXIII, Hospital del Mar, Hospital Universitari de Bellvitge, Hospital General de Granollers, Hospital d’Althaia and Hospital Germans Trias i Pujol.”3. In the ethics statement in the manuscript and in the online submission form, please provide the ethics approval number that was issued by the ethical committee of the Bellvitge University Hospital. Response: Sorry for not adding the reference before. Please see the approval number PR271/11. It was included in the manuscript in methods section, study population part. 4. To comply with PLOS ONE submission guidelines, in your Methods section, please provide additional information regarding your statistical analyses, including the specific threshold set to judge statistical significance in your study. Response: Please see the additional information included in methods section, statistical analysis part: “Results for continuous variables were given as mean values, and for categorical variables as percentages. We used chi-square test to compare proportions between groups. The percentage of cumulative incidence of histologically confirmed CIN2+ and CIN3+ lesions and its 95% confidence intervals (CI) as well as the cumulative adherence to perform a next test were estimated and graphically represented using the Kaplan-Meier curves at 1, 3, 5 and 9 years. Data are presented according to the combination of baseline results of cytology and HPV tests up to 9 years follow-up. Incidence rates were calculated in person-years per 100 women. Pairwise comparisons between cumulative incidence curves were evaluated using log-rank test. Also, annual incidence rates of CIN2+ and CIN3+ lesions were calculated at 3, 5 and 9 years, as the number of cases per 100 women/year, according to all combinations of baseline test results, with their 95% CI . In all cases, time was expressed in years. All statistical tests were two tailed, and p-values below 0.05 were considered statistically significant”.5. We note that you have indicated that data from this study are available upon request. PLOS only allows data to be available upon request if there are legal or ethical restrictions on sharing data publicly. In your revised cover letter, please address the following prompts:a) If there are ethical or legal restrictions on sharing a de-identified data set, please explain them in detail  and who has imposed them . Please also provide contact information for a data access committee, ethics committee, or other institutional body to which data requests may be sent.b) If there are no restrictions, please upload the minimal anonymized data set necessary to replicate your study findings as either Supporting Information files or to a stable, public repository and provide us with the relevant URLs, DOIs, or accession numbers. Response: ja.espinas@iconcologia.net, arguing the reason why they are requested.These are sensitive data that are part of the evaluation activities for cervical cancer screening in Catalonia commissioned by the Oncology Master Plan and the Health Department of the Generalitat of Catalonia. Requests to access this data can be addressed to Josep Alfons Espinàs, from the Oncology Master Plan, using the following email address: 6. Thank you for stating the following in the Competing Interests section: "I have read the journal's policy and the authors of this manuscript have the following competing interests: RI, ER, LM, LB and FXB: Cancer Epidemiology Research Programme runs some research projects funded by MSD and Seegene. RI: has collaborated in a consultancy for Hologic and received HPV tests free of charge by Roche. FXB: has received travel/speaking grants from MSD, Seegene and Roche.The rest of the authors reported having no conflict of interest."Please confirm that this does not alter your adherence to all PLOS ONE policies on sharing data and materials, by including the following statement:http://journals.plos.org/plosone/s/competing-interests). If there are restrictions on sharing of data and/or materials, please state these. Please note that we cannot proceed with consideration of your article until this information has been declared."This does not alter our adherence to PLOS ONE policies on sharing data and materials.”  to include author Belén Lloveras.Response: Thank you very much. It must have been a mistake. We have added the co-author Belen Lloveras. 8. Please amend your list of authors on the manuscript to ensure that each author is linked to an affiliation. Authors’ affiliations should reflect the institution where the work was done .Response: Authors' affiliation has been completed and reviewed.  Response to Reviewers: Reviewer #1: Major comments1. There is a crucial error in Table 1: the cumulative incidence at 9 years is not reported for the HPV+/cyto+ group. It could be a typo, but the value is not reported neither in the text, therefore, I suggest a revision of all the statistical analysis.Response: We apologize for this omission. In the HPV+ /cytology+ category, all women at risk developed CIN2+ or CIN3+ or had a hysterectomy during follow-up by year 5, so they were censored. No woman within this category was at risk for the period 5-9 years. The table has been updated, in the manuscript, for further understanding.2. Please uniform the Kaplan-Meier figures with the time span reported in Table 1 . Add also censored women  in the curves. It seems strange that the end of the line (last available data) for the 4 groups is not equal to 9 years. Maybe a complete 9-year follow-up has not been reached by some group of women? The time span used for the calculation seems to be months, please specify in the methods.Response: We thank the reviewer for this observation. The figures have now been modified, adding the years on the X axis according to the periods of time in table 1. We have modified the Y axis to put it in % by 100 and not in % by 1 as it was originally, also, in concordance with Table 1. In the figures do not include the number of censored women as they are in Table 1. The follow-up time period was set up to a year periods up to 9 years. Finally, the time span used for the calculation is not in months, but in years. It was already specified in methods section and in the graph on the X axis . We have expanded the statistical analysis description on the methods section, based on the reviewer's comments as follows: “The percentage of cumulative incidence of histologically confirmed CIN2+ and CIN3+ lesions and its 95% confidence intervals (CI) as well as the cumulative adherence to perform a next test were estimated and graphically represented using the Kaplan-Meier curves at 1, 3, 5 and 9 years. Data are presented according to the combination of baseline results of cytology and HPV tests up to 9 years follow-up. Incidence rates were calculated in person-years per 100 women. Pairwise comparisons between cumulative incidence curves were evaluated using log-rank test. Also, annual incidence rates of CIN2+ and CIN3+ lesions were calculated at 3, 5 and 9 years, as the number of cases per 100 women/year, according to all combinations of baseline test results, with their 95% CI . In all cases, time was expressed in years. All statistical tests were two tailed, and p-values below 0.05 were considered statistically significant”.3. Please better specify the difference between censoring for follow-up and censoring as it is usually intended in the Kaplan-Meier estimates. Please describe in details in the methods which are the events of interest: I suppose that HSIL/CIN2+ is an event of interest, but also death from cervical cancer should be one, and hysterectomy for cervical diseases (if possible).Response: Thank you for the comment. We have now expanded this important information. The main event of interest was the development of CIN2+ or CIN3+ along the follow-up period including death of cervical cancer. In the methods section, it was specified that a woman was censored for follow-up if a CIN2+ lesion was identified, or when there was a surgical treatment for a CIN1 lesion, or in case of hysterectomy for non-cervical causes. We have expanded the text as follows:“The main event of interest was the development of CIN2+ or CIN3+ along the follow-up period. CIN2+ result included all histologically confirmed diagnoses of CIN2, CIN3, adenocarcinoma and invasive cervical carcinoma. In CIN3+ result, CIN2 is not included. A variable called “final diagnosis” was created including three categories: 1) women who had developed an CIN2+ or CIN3+ throughout the follow-up period, 2) women with a diagnosis other than CIN2+ or CIN3+, and 3) women with only the baseline tests that were considered lost to follow-up because of missing data. A woman was censored for follow-up if a CIN2+ lesion was identified, or when there was a surgical treatment for a CIN1 lesion, or in case of hysterectomy for non-cervical causes. In these cases, the woman contributed time until the diagnosis of CIN2+ or until time of surgical treatment or hysterectomy. Remaining women or in case of death for causes other than cervical cancer, the contributing time was accounted for until the last recorded test”.4. I wonder if in Spain you are able to distinguish between deaths due to ‘uterus n.o.s.’ and deaths due to cervical cancer. I know this is a challenging issue in several countries. The same questions arise with regard to the possibility of identifying the reason of hysterectomy.Response: Thanks for the observation that had been a relevant issue when looking at routine death certificates several decades age but we think the issue is now minimized. In all instances we extracted the available information from pathology laboratory or recorded case of death. Uterus n.o.s is now a minor cause of death within deaths from cancer of the uterus. We did not have any that were uterine cancer or uterus n.o.s. There were 3 gynaecological cancer-related deaths: one died from endometrial cancer, one from ovarian cancer, and another one from squamous cell cervix carcinoma.Hysterectomy cases were also identified through the medical history. If the hysterectomy was for cervical malignancy, the woman was censored at the time of diagnosis of the cervical pathology and not the time of the hysterectomy. Further we identified several cases of hysterectomy for uterine prolapse. In these cases, when the report of the hysterectomy piece was available, if the cervix was normal, the women contributed up to the time of the hysterectomy, and the same when the hysterectomy was caused by other cancers. Hysterectomies for ovarian and endometrial cancer were recorded in our study.Minor comments5. Please better specify what do you mean for “predictive value”, i.e., both positive and negative predictive values? Response: We apologize for this unclarity. Yes, we refer to both, since in our study HPV test was able to distinguish women with a higher risk of developing cervical pathology (positive HPV) and, however, in negative women, HPV test confirmed prolonged protection during the study period. 6. Methods, lines 122-124 death and end of follow-up should be included among the censoring times.Response: Thanks for the comment. We included an explanation in Statistics analysis part of the manuscript. Please see the paragraph included in the response of the question 3. 7. Please add the total for each group in Table 1. Response: Please see the modification of Table 1 in our response comment to the question 1.8. The study could be underpowered  to detect incidence of cervical lesions among the subgroup of women with HPV-/Cyto+ at baseline (only 16 women). Therefore, the results (incidence =0) in this group should be considered with caution. Please add this limitation to the discussion.Response: We agree with the reviewer and we are aware of the limited number of events. A paragraph in the limitations of the study was added with this appreciation: “The yield of disease among the subgroup of women with HPV-/cyto+, at baseline (only 16 women), should be considered with caution, due to the low number of women under this stratum”.9. Pg. 10 lines 194-196. I do not understand the meaning of this paragraph.Response: We apologize for it. We have modified the text as follows. We hope it is better understood:“In 36.7% of women, there was no evidence of a new test during the 9-year follow-up period. Most of these women classified as "lost to follow-up" were women with both baseline negative tests instead of women with both positive results ”.10. pg. 11, lines 225-229. I do not understand the meaning this comparison between groups.Response: We apologize if we were not clear enough. We aimed to emphasize that cytology did not add any risk differences in the incidence of CIN2+ provided women were HPV positive. The 5-year incidence of the double positives at baseline was very similar to those HPV positives and cytology negative, emphasizing that it is the HPV test that defines the risk and not the cytology. Finally, the paragraph has been removed, as suggested by another reviewer to reduce the text of the results section.Typos/languagePg. 10: line 203, “3-years stablished” should be “3-year established”; line 212 “anormal”, should be “abnormal”Pg. 11: Line 215 “CIN2+” should be “HSIL/CIN2+”; line 220 “cero”, should be “zero”; line 225 “statistical significantly” should be “statistically significant”Pg. 12: Line 240: “baseline” 2 times; Line 241 “an HPV positive tests” should be “a HPV positive test”Pg. 14: line 273 “accumulative” should be “cumulative”Pg. 15: line 303 “To avoid detection of positive cases, that are unlikely to develop disease,” should be “To avoid detection of HPV positive cases that are unlikely to develop cervical diseases,”Pg. 16: line 323 “least”, should be “at least”.Response: Thank you for detecting the typos and edits that we have duly corrected. Reviewer #2: 1. I suggest to focus the results and the discussion on the specific issues related to the high risk group and in particular on the compliance to follow up and screening appointments in the following nine years. Now there is a paragraph in the results about timing of rescreening, maybe a figure with survival curves for having a test or the frequency of first and second test during follow up, separately for negative and positive women could be more informative.Response: We appreciate the comment and we have modified our text. In fact, we have done a whole new analysis of cumulative adherence to perform a next cytology, HPV test, or biopsy, throughout the follow-up time stratified by baseline results. Tables and survival curves are now included. Also, in methods, results and discussion sections, we have included the data from this new analysis. The paragraphs are as follows, according to each section:“Methods section: Cumulative adherence to perform a next test. Among women with HPV-/cyto- at baseline, any test performed after 180 days following baseline tests including HPV test, cytology or cervical biopsy were all taken into account. This was done to avoid including additional tests not related to screening that could have been performed before . Among women HPV+/cyto-, tests performed at least 45 days after baseline were considered to not interfere with other tests performed concomitantly with the baseline ones. Among women HPV-/cyto+ and HPV+/cyto+, all subsequent tests performed, after baseline ones were considered without restriction. A woman was censured at the time that she had the next cytology, HPV test or cervical biopsy (event) registered after baseline according to the established criteria. The contribution time of that woman was time between baseline tests and the performance of next test. Women did no additional tests were censored on the date of baseline. In case of hysterectomy not due to cervical cancer, or death not related to cervical cancer, women was censored at the date of that event and considered of non-related event. If no date of death was available, the last date of woman's test was used. If none was available, it was considered the date of baseline.Results section: Table 2 and figure 3 show the cumulative adherence to perform a next cytology, HPV test or cervical biopsy, along time by results of baseline screening tests. We observed that among women with both negative tests at baseline, in which the recommended interval for re-screening was after 3 years, only 40.5% had a next test registered during the 4 years from the baseline and 53.5% returned to perform a test along the following 6-years after baseline. Only 60.2% of these women had a next test recorded during the 9-years follow-up period, evidencing a poor adherence of these women to screening protocol recommendations. According to screening protocol recommendations, in HPV+/cyto- women, a cytology and colposcopy should be performed between 6 and 12 months or an HPV test at 12 months as follow-up. We observed that the 67.3% of these women had a follow-up test during the following 2 years from baseline, increasing to 74.5% before 3 years. However, in 16.3% of women there was no additional test recorded during the 9-year follow-up. Most women with a positive cytology at baseline and regardless of the HPV result had a follow-up test in the following year. Discussion section: In our study, we found that one third of total women did not return to screening after baseline tests. Among double negative women, only 40.5% had a re-screening before the next 4 years and 53.5% before the 6 years of follow-up, demonstrating that despite having participated in the screening activities, they did not meet the established intervals and most of those who returned, they did so at longer than recommended intervals. Unfortunately, we do not know if these women have searched care elsewhere. Under opportunistic screening approaches, loss to follow-up is common. We have shown that inviting these women can quickly revert the situation [36]. The use of personal reminders increased significantly screening participation even if only an invitation letter with a scheduled visit was used . Generally, in organized programs, higher adherence to the screening programs is attained [37–39]. As well, women may perceive themselves to be at low risk of cervical cancer, and thus delay their attendance at screening as occurred in a Norwegian study [40]. A study carried out in Sweden also pointed out that women have a comprehensive rationale for postponing cervical screening, yet they do not view themselves as non-attenders [41]. On the other hand, a certain proportion of women, 17.2% of HPV positive and negative cytology and in 25% HPV negative women with a positive cytology, had no record of a second screening visit. A poor information or full understanding of a positive test could affect follow-up visit as has been seen elsewhere . Good and comprehensive information remains a special need, particularly when the HPV test is positive, but the cytology does not detect any abnormality. The fact of having a negative cytology, associated with a lack of knowledge about the superiority of HPV tests in predicting disease, can give a false sense of security as observed also by others . Some studies have shown that attendance at repeated tests is poor, particularly after a normal cytological test, reaching losses of 40% within the established one-year follow-up intervals . Adequate communication is necessary to improve adequate management of screen positive women. For women who find it difficult to attend appointments, there may be substantial advantage to being able to self-collect at home”.2. Also in the discussion, most of the issues afforded are general and many other studies and secondary literature already has treated these topics. What is specific of this study is the underscreened population over 40. I suggest to discuss points linked to this: I see two issues, but other can be interesting that I do not see: 1) compliance to follow up and acceptability; 2) co-testing is not recommended in Europe, but some researchers argue that for women not screened before 40, where the prevalence of cancer may be high, including cytology in the first screening episode could be useful, given that the cytology vs HPV relative sensitivity for cancer seems to be similar, cytology could add something. For the second point your study cannot give an answer, but you can confirm the high prevalence of cancers in this population, all HPV+/cyto+...Response: We appreciate the thoughtful reviewer comment on how best direct the discussion. We agree that both points are critical in our data. Regarding point 1), we have modified the results text and discussion. Please see the paragraphs included in the response of the question 1.Regarding point 2), according to the data from our study, cytology does not risk assessment in the co-test scenario. In our data, HPV test alone would provide the best risk estimate. This conclusion was already introduced in the discussion of the manuscript: “The inclusion of HPV test in addition to cervical cytology in women at risk of cervical cancer identified all CIN3+ cases but one, at year 9 since baseline, while cytology missed 6 cases of CIN3+. These results are consistent with our evaluation at 3 years and with the literature, supporting HPV as a standalone primary screening test, and that HPV testing is more accurate than cytology to predict disease also among underscreened women.”Minor comments3. Line 193 the lost to follow up seem different from those reported in the abstract.Response: The abstract compared women with a negative co-test (HPV- and cyto-) with women with at least one positive result, either cyto and/or HPV test. However, in the results section, women with both tests negative are compared with those who have both tests positive at baseline.Noting that it can be confusing, we have modified the information in the abstract to compare double positives with double negatives, as follows: “Lost to follow-up was higher among women with both tests negative compared to those with both positive tests ”.4. Line 187 and line 194 the same results are reported with different indicators, thus it gives an impression of inconsistency and it is difficult to follow. I suggest to report the two measures in the same paragraph.Response: As a new analysis of cumulative adherence to perform a next test has been done, these data have been modified. Please see the paragraphs included in the response to the question 1 part results.5. Line 199 the average age at diagnosis is reported, but given the length of follow up it is difficult to manage this information. May be better to say how many in women below and over a certain age and to report it also for the whole cohort.Response: We included the mean age at CIN2+ cases occur, and not by age group, since there were only 23 cases within an age range of 40 to 67 years. Stratifying the information further would result in groups with very low numbers and would not provide much additional information. However, below you have the table with the age at diagnosis of CIN2+ and the time (in months) between baseline test and CIN2+ diagnosis. If you think it may be interesting, we could include it in supplemental material. 6. Lines 225-28: there is something not clear to me in the sentence: “Not statistical significantly differences were detected among women HPV positive and cytology negative at baseline at 9 years and women HPV positive and cytology positive at 5 years .” Is the comparison between baseline or 9yy in HPV+/cyto- and HPV+/cyto+ at 5yy?Response: We apologize if we were not clear enough. We aimed to emphasize that cytology did not add any risk differences in the incidence of CIN2+ provided women were HPV positive. The 5-year incidence of the double positives at baseline was very similar to those HPV positives and cytology negative, emphasizing that it is the HPV test that defines the risk and not the cytology. Bu finally, the paragraph has been removed, as suggested.7. In general, I suggest to shorten the text of the results: tables and figures are much clearer…Response: We have tried to reduce unnecessary text all over the manuscript.8. Discussion: see general comments. Response: please see the paragraphs included in the response of the question 1 part results. Reviewer #3: 1. The data support the conclusions drawn although the sample size is relatively small - the authors should avoid overstatement/extrapolation from their data - e.g. while I accept that the risk of developing CIN3 in HPV negative women "regardless of cytology result at 5 years was 0" - this is likely to be influenced by power-limitationsResponse: We appreciate the comment and a paragraph in the limitations of the study was added with this appreciation, especially emphasizing the number of women in the HPV-/cyto+ category. The new paragraph is the following: “The yield of disease among the subgroup of women with HPV-/cyto+, at baseline (only 16 women), should be considered with caution, due to the low number of women under this stratum”.2. An important element of this work is that the cohort are "underscreened " women - we get to know what is meant by this in the introduction but underscreened is not defined in abstract, and arguably should beResponse: We apologize if we were not clear enough. We have added emphazised definition in the abstract as suggested. We have moved the definition to the objective part as follows: “To evaluate the 9-year incidence of cervical intraepithelial neoplasia grade 2 or worse (CIN2+) and cumulative adherence to perform a next test in a cohort of women aged 40+ years with no cervical screening cytology within a window of 5 years (underscreened women), after baseline cervical cytology and HPV tests”3. A review of the English is recommended; there are some minor lapses in vocabulary and tenses eg line 83 "arouse" should be "arise" and for line 273 "accumulative" should be "accumulated"Response: Thanks for appreciation. We have revised the language.4. The data will be of importance locally and serve as key audit and service evaluation, with the potential to influence wider policy. However, as the authors describe - there are several larger published studies which describe longitudinal performance of HPV either as a stand alone test or as a co-test with cytology for the detection of cervical disease. The authors should try to describe the novelty/importance of these findings for the international community more clearly. Response: Overall, the article has been completed and greatly improved. One of the reviewers proposed a new analysis that was performed and included about cumulative adherence to perform a next test stratified by the baseline results. Now a new table and survival curve are also included. We believe that this new data puts more emphasis on underscreened women's behaviour in participating in screening programs and how HPV based screening can be better for these women with a high risk of developing cervical disease. We think now the discussion has improved. We have added the following new paragraphs below: “In our study, 86% of CIN2+ diagnosed among women those with both positive tests were detected during the first year and in most cases, screening tests were part of the diagnosis of CIN2+. In addition, having both positive tests generates a much higher risk during the first year than having one of them negative (27.0% vs. 6.5%). But above all, according to the data from our study, the risk increased if the positive test was the HPV test. Subsequently, the risk of diagnosis of these lesions decreases in later years. In fact, in our study, the cumulative risk of having CIN2+ lesions had a steep rise between the first 12 months and the third year, followed by stabilization or slow increase between the third and fifth year of follow-up. RCTs have also shown a reduction in detection of high grade lesions in the second rounds compared with the first round, highlighting the impact of using the HPV test in screening when it is compared with cytological screening . This benefit of the HPV test could be critical for underscreened women that have persistently poor adhesion to recommendations. In our study, we found that one third of total women did not return to screening after baseline tests. Among double negative women, only 40.5% had a re-screening before the next 4 years and 53.5% before the 6 years of follow-up, demonstrating that despite having participated in the screening activities, they did not meet the established intervals and most of those who returned, they did so at longer than recommended intervals. Unfortunately, we do not know if these women have searched care elsewhere. Under opportunistic screening approaches, loss to follow-up is common. We have shown that inviting these women can quickly revert the situation [36]. The use of personal reminders increased significantly screening participation even if only an invitation letter with a scheduled visit was used . Generally, in organized programs, higher adherence to the screening programs is attained [37–39]. As well, women may perceive themselves to be at low risk of cervical cancer, and thus delay their attendance at screening as occurred in a Norwegian study [40]. A study carried out in Sweden also pointed out that women have a comprehensive rationale for postponing cervical screening, yet they do not view themselves as non-attenders [41]. On the other hand, a certain proportion of women, 17.2% of HPV positive and negative cytology and in 25% HPV negative women with a positive cytology, had no record of a second screening visit. A poor information or full understanding of a positive test could affect follow-up visit as has been seen elsewhere . Good and comprehensive information remains a special need, particularly when the HPV test is positive, but the cytology does not detect any abnormality. The fact of having a negative cytology, associated with a lack of knowledge about the superiority of HPV tests in predicting disease, can give a false sense of security as observed also by others . Some studies have shown that attendance at repeated tests is poor, particularly after a normal cytological test, reaching losses of 40% within the established one-year follow-up intervals . Adequate communication is necessary to improve adequate management of screen positive women. For women who find it difficult to attend appointments, there may be substantial advantage to being able to self-collect at home.”Thank you very much for all the comments suggested by the editor and reviewers. We hope our manuscript is now more complete and suitable for publication and we look forward to hearing from you.With kind regards,Raquel Ibáñez PérezInformation and Interventions in Infections and Cancer Unit. Cancer Epidemiology Research ProgramCatalan Institute of Oncology. IDIBELL Gran Via de l’Hospitalet, 199 – 203. 08907 L’Hospitalet de Llobregat, Spainraquelip@iconcologia.netPhone: +34 260 78 12 | Fax: +34 260 77 87 | E-mail:  7 Aug 2020Long-term protection of HPV test in women at risk of cervical cancerPONE-D-20-10012R1Dear Dr. Ibañez,We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.http://www.editorialmanager.com/pone/, click the 'Update My Information' link at the top of the page, and double check that your user information is up-to-date. If you have any billing related questions, please contact our Author Billing department directly at authorbilling@plos.org.An invoice for payment will follow shortly after the formal acceptance. To ensure an efficient process, please log into Editorial Manager at onepress@plos.org.If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact Kind regards,Maria Lina TorneselloAcademic EditorPLOS ONEAdditional Editor Comments :Reviewers' comments:Reviewer's Responses to QuestionsComments to the Author1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.Reviewer #1: All comments have been addressedReviewer #2: All comments have been addressed**********2. Is the manuscript technically sound, and do the data support the conclusions?The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented. Reviewer #1: YesReviewer #2: Yes**********3. Has the statistical analysis been performed appropriately and rigorously? 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Is the manuscript presented in an intelligible fashion and written in standard English?PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.Reviewer #1: YesReviewer #2: Yes**********6. Review Comments to the AuthorPlease use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. Reviewer #1: The authors have fully addressed all the Reviewers' comments. The paper has been improved and it is now suitable for publication.Reviewer #2: Please check some typos in the new text, for example in line 273 I think "an" should be "and".Line 153 and 355 "an CIN" should be "a CIN".regarding answer to question 5, I think it would be useful to add these figures in the supplementary materials, this info could be used in meta-analyses.**********what does this mean?). If published, this will include your full peer review and any attached files.7. PLOS authors have the option to publish the peer review history of their article (If you choose “no”, your identity will remain anonymous but your review may still be made public.Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.Reviewer #1: NoYes: paolo giorgi rossiReviewer #2:  17 Aug 2020PONE-D-20-10012R1 Long-term protection of HPV test in women at risk of cervical cancer Dear Dr. Ibáñez:I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department. onepress@plos.org.If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact plosone@plos.org. If we can help with anything else, please email us at Thank you for submitting your work to PLOS ONE and supporting open access. Kind regards, PLOS ONE Editorial Office Staffon behalf ofDr. Maria Lina Tornesello Academic EditorPLOS ONE