HPV16 Drives Highest Cancer Risk Among Women With High-Grade Cervical Cytology

Women whose cervical screening shows high-grade abnormalities face sharply different risks depending on which high-risk human papillomavirus genotype is active in their cells, according to a retrospective study of 330 Chinese women published in Frontiers in Oncology. Among women with ASC-H or HSIL cytology, HPV16-positive individuals carried the heaviest burden of both precancerous lesions and invasive squamous cell carcinoma, while the two cases of adenocarcinoma in situ in the cohort both occurred in the small group positive for HPV18/45. Crucially, when the researchers adjusted for genotype, neither age nor menopausal status remained independently associated with the risk of cervical intraepithelial neoplasia grade 2 or worse, despite clear differences in the unadjusted data.

The study, conducted at the Second Hospital of Hebei Medical University in Shijiazhuang, drew on 511 women recorded in the hospital’s ThinPrep cytology database between January 2021 and February 2024 with cytological results of atypical squamous cells, cannot exclude high-grade lesion, or high-grade squamous intraepithelial lesion. After excluding 181 women for reasons including missing Aptima HPV testing, absent biopsy or histopathological diagnosis, prior hysterectomy or malignancy, previous pelvic radiotherapy or chemotherapy, and autoimmune disease, 330 women aged 20 to 84 years remained for analysis. All had undergone the Aptima HPV assay, which detects transcriptionally active E6/E7 messenger RNA from 14 high-risk HPV types, followed by colposcopy-guided biopsy and histopathological examination interpreted by two experienced gynecological pathologists.

The molecular distinction underlying the assay matters for interpreting the findings. Unlike DNA-based HPV tests, the Aptima assay detects E6/E7 mRNA, the transcripts of the viral oncogenes that drive malignant transformation, which the authors note offers higher specificity for clinically significant lesions. Positive specimens were further genotyped into three categories: HPV16, HPV18/45, and a pooled group of the other 11 high-risk types. Because the genotype assay cannot distinguish HPV18 from HPV45 or establish co-infection, the HPV18/45 category is inherently composite, a limitation that shaped some of the study’s most tentative conclusions.

The overall burden of disease in this high-risk cytology population was substantial. Histopathology revealed precancerous lesions, defined as CIN2, CIN3, or adenocarcinoma in situ, in 38.2 percent of the women, and malignant lesions, squamous cell carcinoma or adenocarcinoma, in 24.5 percent. Overall high-risk HPV positivity was 82.1 percent, rising from 70.4 percent among women with ASC-H cytology to 94.4 percent among those with HSIL cytology. The distribution of outcomes also differed significantly between the two cytology categories: 38.5 percent of HSIL cases harbored malignant lesions compared with 11.2 percent of ASC-H cases.

Genotype stratification revealed a striking pattern. HPV16 was the dominant genotype, detected in 42.1 percent of the cohort, and HPV16-positive women showed the highest proportions of CIN3, at 38.8 percent, and squamous cell carcinoma, at 41.7 percent. Women positive for the other 11 high-risk types, who made up 36.1 percent of the sample, had a CIN2/3 prevalence of 44.5 percent, statistically comparable to the 43.9 percent seen in the HPV16 group. By contrast, among the 59 women who tested negative for high-risk HPV, benign findings predominated, with normal histology accounting for 59.3 percent of cases and a CIN2/3 prevalence of only 13.6 percent.

The glandular findings, though suggestive, rest on very thin numbers. Only 13 women were HPV18/45-positive, and both adenocarcinoma in situ cases in the entire cohort occurred in this group, yielding a group-level prevalence of 15.4 percent that differed significantly from the other genotype groups. An exploratory multivariable analysis linked HPV18/45 positivity to AIS or adenocarcinoma with an odds ratio of 15.60, but the confidence interval stretched from 1.42 to 171.32, reflecting just two events. The authors explicitly frame this as hypothesis-generating and caution that it does not support genotype-specific diagnostic or interventional recommendations until confirmed in larger cohorts.

Age and menopausal status told a more nuanced story. In unadjusted analyses, CIN2/3 prevalence fell steadily with advancing age, from 50.6 percent among women aged 25 to 34 to 12.5 percent among those 65 and older, while squamous cell carcinoma prevalence climbed from 8.6 percent to 58.3 percent across the same span. Premenopausal women had significantly higher CIN2/3 prevalence than postmenopausal women, 44.1 percent versus 21.3 percent, whereas postmenopausal women had far higher SCC prevalence, 45.7 percent versus 14.0 percent. Exploratory sensitivity analyses using alternative age cut-offs at 30, 40, 50, and 60 years showed broadly consistent patterns, though the authors note these P values were not adjusted for multiple comparisons.

Yet when all three variables entered a multivariable logistic regression model simultaneously, the picture changed. HPV16 positivity carried an adjusted odds ratio of 23.79 for CIN2 or worse, HPV18/45 an odds ratio of 5.51, and the other 11 high-risk types an odds ratio of 4.26, all relative to HPV-negative women. Age, modeled as a continuous variable, and menopausal status showed no significant independent association. The authors report that variance inflation factors of 2.35 and 2.37 indicated no problematic multicollinearity between the correlated age and menopause variables, allowing both to be retained as prespecified covariates. Secondary models reinforced the genotype signal: younger age, HPV16, and the other high-risk types independently predicted CIN2/3, while increasing age and HPV16 independently predicted squamous cell carcinoma.

One clinically consequential finding concerns the HPV-negative minority. Among the 59 women with high-grade cytology but negative Aptima results, histopathology still identified squamous HSIL or worse in 12 women, 20.3 percent, and one glandular lesion, for an overall prevalence of clinically significant disease of 22.0 percent. Among the nine HPV-negative women with HSIL cytology specifically, six, or 66.7 percent, were confirmed to have CIN2 or worse. The authors propose possible explanations, including inadequate sampling, E6/E7 mRNA expression below the assay’s detection threshold, infection with genotypes outside the assay’s target panel, or persistence of established lesions after viral clearance, but they emphasize that none of these mechanisms were directly evaluated and remain hypothetical. Their conclusion is that a negative HPV result must not override high-grade cytology, and that colposcopy with targeted biopsy remains mandatory for this population regardless of molecular status.

The authors acknowledge the constraints of their design. The retrospective, single-center structure limits generalizability, and requiring both Aptima testing and histopathological confirmation may have preferentially selected women with more concerning clinical findings, a selection and verification bias that could inflate lesion prevalence. Excisional or surgical specimens were available for 47.0 percent of participants, and while the highest grade across all specimens defined the final diagnosis, reliance on biopsy alone in the remainder may have underestimated CIN2+ lesions. Centralized rereview of slides was not performed, leaving some interobserver variability unquantified. With these caveats in place, the study’s central message stands on firmer ground: in women whose cytology already signals high-grade disease, the active viral genotype, above all HPV16, refines immediate histopathological risk, while age and menopause, though visible in crude comparisons, add little once genotype is accounted for.

Subject of Research: Associations of Aptima HPV E6/E7 mRNA genotype, age, and menopausal status with immediate histopathological outcomes in women with high-grade cervical cytology

Article Title: Immediate histopathological outcomes according to Aptima HPV E6/E7 mRNA genotype, age, and menopausal status in women with ASC-H/HSIL cytology

Article References: Liu, P., Liu, Z., Yang, Y., Du, B., & Zuo, H. (2026). Immediate histopathological outcomes according to Aptima HPV E6/E7 mRNA genotype, age, and menopausal status in women with ASC-H/HSIL cytology. Frontiers in Oncology, 16, Article 1952454. https://doi.org/10.3389/fonc.2026.1952454

Image Credits: AI Generated

DOI: 10.3389/fonc.2026.1952454

Keywords: HPV16, Aptima HPV E6/E7 mRNA, ASC-H, HSIL, CIN2+, cervical cancer screening, colposcopy, squamous cell carcinoma, adenocarcinoma in situ, HPV18/45, menopausal status, retrospective study