
==== Front
Ann Med
Ann Med
Annals of Medicine
0785-3890
1365-2060
Taylor & Francis

39298375
10.1080/07853890.2024.2404548
2404548
Version of Record
Research Article
Pregnancy, Childbirth & Women's Health
Prevalence of human papillomavirus and cervical lesions among elderly women: an unignored challenge to cervical cancer prevention
J. Huiyun et al.
Huiyun Jiang
Yuebo Yang
Xiaomao Li
Department of Gynecology, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
Supplemental data for this article can be accessed online at https://doi.org/10.1080/07853890.2024.2404548.

CONTACT Li Xiaomao lixmao@mail.sysu.edu.cn Department of Gynecology, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong Province, China
19 9 2024
2024
19 9 2024
56 1 240454829 1 2024
8 4 2024
10 6 2024
KnowledgeWorks Global Ltd.19 9 2024
published online in a building issue19 9 2024
© 2024 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group
2024
The Author(s)
https://creativecommons.org/licenses/by-nc/4.0/ This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial License (http://creativecommons.org/licenses/by-nc/4.0/), which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. The terms on which this article has been published allow the posting of the Accepted Manuscript in a repository by the author(s) or with their consent.

Abstract

The prevalence of human papillomavirus (HPV) genotype and cervical neoplasia in women older than 64 years, who are outside the age demographic of cervical cancer screening in China, has been under-researched. This study conducts a retrospective analysis of women from a tertiary hospital in Guangzhou, with the aim to offer valuable insights for cervical cancer prevention and control in elderly women. The study incorporated 876 women, all aged 64 and above. In this age bracket, the prevalence rate of any HPV genotype was found to be 19.27%. The top six HR HPV genotypes were HPV 16, HPV 52, HPV 58, HPV 31, HPV 33, and HPV 18. The persistence rate of any HPV type over a 24-month period in this age group was as high as 33.33%. Among women over 64, around 16.47% of HPV-positive patients were diagnosed with cervical cancer. HPV 58 infection was the most substantial risk factor for histological CIN2+ (OR 3.556; 95% CI, 1.107–11.415; p = 0.032) in women over 64 years of age with HPV-positive/NILM status. In conclusion, the burden of HPV infection is significant among women over 64 years in Guangzhou. Re-evaluation of cervical cancer screening strategies for women after the age of 64 is imperative. Moreover, the HPV 16/18/52/58 genotype model could serve as an alternative triage approach to identify histological CIN2+ among elderly women with HPV-positive/NILM status.

KEY MESSAGES

Elderly women exhibit an elevated risk of contracting HPV infection and developing cervical lesions.

HPV 58 is notably associated with the progression of CIN2+ among women aged above 64 years with HPV-positive/NILM status.

HPV 16/18/52/58 genotype model presents an alternative triage approach for identifying CIN2+ among women aged above 64 years with HPV-positive/NILM status.

Keywords

Human papillomavirus
elderly women
cervical cancer screening
genotyping model
NILM
cervical intraepithelial neoplasia
HPV genotyping
Scientific Research Project of Guangdong Provincial Bureau of Traditional Chinese Medicine Science and Technology Planning Project of Guangzhou Municipal Science and Technology Bureau This work was supported by the Scientific Research Project of Guangdong Provincial Bureau of Traditional Chinese Medicine under Grant (20231066); the Science and Technology Planning Project of Guangzhou Municipal Science and Technology Bureau under Grant (2023A04J1097).
==== Body
pmc1. Introduction

The complication of cervical cancer continues to pose a heavy burden in China [1].

Persistent human papillomavirus (HPV) infection is a root cause closely tied to cervical cancer. HPV vaccination and cervical screening programs are main strategies in cervical cancer prevention [2]. Women aged above 64 are not covered in current cervical screening program in China. However, our previous studies have illuminated an age-specific prevalence of HPV that displays a bimodal curve, exhibiting a secondary peak within the elderly population [3]. HPV vaccination proves beneficial in countering HPV infection and associated cervical neoplasia, irrespective of age or HPV infection status [4]. Nonetheless, the HPV vaccine, initially approved in China in 2017, was authorized for women aged between 9 and 45 years, consequently maintaining an unaltered cancer risk for elderly women.

Elderly patients diagnosed with cervical cancer make up a meaningful subpopulation [5,6]. The onset age of cervical cancer is increasing over time [6]. Regrettably, elderly women are often identified with advanced-stage cervical cancer and the prognosis is poor [7,8]. With life expectancy in China rising appreciably [9], and with many elderly women maintaining active sexual lives [10], the population aged above 64 is expected to constitute 24% of the total by 2050 [11]. As a result, HPV infection and associated cervical lesions in elderly women will undoubtedly persist as a challenge to the prevention and control of cervical cancer.

Accurate surveillance of epidemiological data is of crucial importance when adapting disease prevention and control strategies, yet very few studies have focused on the prevalence of HPV infection and related cervical neoplasia among elderly women who are beyond the coverage of cervical screening programs.

Presently, primary HPV screening is commonly used in most screening strategies. If the HPV test is positive, cervical cytology tests are recommended as triage method [12]. Nevertheless, cervix atrophy and the retraction of the squamocolumnar junction brought difficulties to the attainment of adequate samples and subsequent microscopic evaluation, thereby impairing the sensitivity of cervical cytology [13]. An alarming 73.3% of elderly women were observed to have negative cytology results within the five years preceding their cervical cancer diagnoses [14]. Moreover, for women with a positive HPV status but exhibiting negative results for intraepithelial lesion or malignancy (HPV+/NILM), the prevalence of cervical cancer was higher in elderly women than in younger women [15]. This indicates that triage through cervical cytology testing may not effectively serve elderly women. Several additional techniques have been proposed as complementary tools to HPV DNA test. These encompass biospectroscopy, HPV typing, cytological p16 immunostaining, and mRNA E6 and E7 expression [16].

In light of these observations, this study aims to investigate the prevalence of HPV and associated cervical neoplasia in women aged over 64, and assess the efficacy of extended HPV genotypes (beyond 16/18) in detecting cervical intraepithelial neoplasia 2+ (CIN 2+) among elderly women with HPV+/NILM. Findings from this research could provide valuable insights for improving cervical cancer prevention and control strategies in Guangzhou, China [17].

2. Materials and methods

2.1. Data sources

This study involved a retrospective analysis of data obtained from women who visited the physical examination center and gynecological department of the Third Affiliated Hospital, Sun Yat-sen university between January 1, 2015, and December 31, 2019. The inclusion criteria were as follows: (1) participants aged 64 years or older; (2) those who had a history of sexual activity; (3) those who willingly participated in HPV DNA testing and/or cervical cytology. Exclusion criteria were as follows: (1) prior diagnosis of cervical intraepithelial neoplasia or cervical cancer; (2) a history of cervical surgery or hysterectomy; (3) a history of severe immunodeficiency disease; (4) a history of HPV vaccination.

Our study was approved by the ethics committee of the Third Affiliated Hospital, Sun Yat-sen University (No.[2022]02-042-01). And ethics committee has granted a waiver for the requirement of informed consent for this study. Our research strictly adheres to the principles of the Declaration of Helsinki.

2.2. Cervical samples collection and tests

A trained physician extracted sufficient cervical epithelial cells by inserting a speculum to expose the cervix and employing a cervical brush, rotating it in one direction five to six times. All cervical samples collected were immediately stored at 4 °C and tested within a 48-hour window.

Polymerase chain reaction-reverse dot blot (PCR-RDB) test was used to detect HPV DNA genotypes. This involved twenty-one HPV genotypes, comprising 15 high-risk (HR) HPV subtypes (HPV 16,18, 31, 33, 35, 39, 45, 51, 52, 53, 56, 58, 59, 66, and 68) and 6 low-risk (LR) HPV subtypes (HPV6, 11, 42, 43, 44, and CP8304). Through this period, the testing methods remained consistent.

Cervical cytology tests were carried out using the ThinPrep Imaging system (Hologic, Inc., San Diego, CA, USA). Findings from cervical cytological tests were reported according to the Bethesda system, which labels results as negative for intraepithelial lesion or malignancy (NILM), atypical squamous cells of undetermined significance (ASC-US), atypical squamous cells, cannot exclude high-grade squamous intraepithelial lesion (ASC-H), atypical glandular cells (AGC), low-grade squamous intraepithelial lesion (LSIL), high-grade squamous intraepithelial lesion (HSIL), and squamous-cell carcinoma (SCC)/adenocarcinoma (Aca) [18].

2.3. Histological pathology

The abnormal histological findings were categorized into three levels: cervical intraepithelial neoplasia grade 1 (CIN 1), cervical intraepithelial neoplasia grade 2/3 (CIN 2/3), and cervical cancer.

2.4. Statistical analysis

Each HPV genotype was individually evaluated to determine its prevalence. Women who underwent multiple HPV tests within a single year were counted once. Persistence was defined as a positive result for a given HPV genotype on two separate tests. The odds ratio (OR) of different HPV genotypes was used to evaluate the risk of histological HSIL + among HPV-positive women with normal cytology. HR-HPV genotyping models were established by combining HR-HPV genotypes, based on the prevalence of HPV subtypes and respective ORs for histological HSIL + in women over 64 years with NILM. The efficiency of the different HR-HPV genotyping models, according to their sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV). A Chi-square test was utilized for comparing categorical variables. All statistical analyses were performed using SPSS version 27.0 (IBM Professional Concurrent User). P value less than 0.05 (two-sided) was considered as statistically significant.

3. Results

3.1. Prevalence of HPV subtypes

The study encompassed a total of 876 women, with the median age was 67.00 (66.00, 71.00) years, ranging from 65 to 86 years. The prevalence of any HPV genotypes, HR HPV, 2v HPV, 4v HPV, and 9v HPV were 19.27% (170/876), 18.36% (161/876), 6.16% (54/876), 6.62% (58/876), and 14.48% (127/876), respectively. The top six HR HPV genotypes were HPV 16 (4.91%, 43/876), HPV 52 (4.22%, 37/876), HPV 58 (3.42%, 30/876), HPV 31 (1.71%, 15/876), HPV 33 (1.37%, 12/876), and HPV 18 (1.26%, 11/876) (Figure 1(a)).

Figure 1. Genotype distribution among women aged >64 years. (a) Infection quantity of different HPV genotypes. (b) Genotype proportion among women with single/multiple HPV infection.

3.2. Distribution of single and multiple HPV genotypes

Infections with a single HPV genotype accounted for 14.04% (123/876) of cases, while infections with multiple HPV genotypes accounted for 5.37% (47/876), among women over 64 years of age.

Different HPV genotypes exhibited varied prevalence, with HPV 16, HPV 31, HPV 45, HPV 58, and HPV 59 tending towards single infection. Conversely, HPV 18, HPV 33, HPV 35, HPV 51, HPV 52, HPV 53, HPV 56, HPV 66, HPV 68, HPV 6, HPV 11, HPV 42, HPV 44, and CP8304 displayed a propensity for co-infections (Figure 1(a), Table S1). Among single HPV infections, the most prevalent HR HPV subtype was HPV 16, followed by HPV 52 and HPV 58. For multiple HPV infections, HPV 52 emerged as the most prevalent HR HPV genotype, followed by HPV 58 and HPV 16 (Figure 1(b), Table S2).

Figure 2. Interaction among HPV genotypes in women aged >64 years, with two or more genotypes. The bottom row corresponds to HR-HPV genotypes tested in women aged >64 years. Each column shows the percentage of co-infection with other HPV genotypes.

Further analysis revealed that each HPV genotype demonstrated a preference for co-infection with specific HPV genotypes (Figure 2, Table S2). HPV 16 predominantly co-infected with HPV 52 (55.56%), followed by HPV 66 (22.22%) (Table S2: HPV 16 row), while HPV 18 frequently co-infected with HPV 56 (42.86%) (Table S2: HPV 18 row). HPV 52 frequently co-infected with HPV 16 (25.00%) and HPV 58 (25.00%) (Table S2: HPV 52 row). HPV 58 mainly co-infected with HPV 31(38.46%) and HPV 52 (38.46%) (Table S2: HPV 58 row). The most common co-infection combinations were between HPV 16 and HPV 52, HPV 31 and HPV 58, HPV 52 and HPV 58.

3.3. Persistence rates of HPV infection

Out of fifteen HPV-positive women, all received HPV retest at both 12-month and 24-month checkpoints. The persistence rate of any HPV genotype at 12 months amongst women over 64 years was 46.67% (7/15). And the equivalent persistence rate of any HPV genotype at the 24-month mark amongst the same demographic was 33.33% (5/15).

3.4. Cervical cytological results and pathological results among HPV-positive women

Among women above the age of 64 who tested positive for HPV, 108 underwent cervical cytological examinations (Figure 3). Of these, 35.18% (38/108) exhibited abnormal cytological results, including ASCUS (10.18%, 11/108), ASC-H (3.70%, 4/108), LSIL (5.56%, 6/108), HSIL (13.00%, 14/108), AGC (0.93%, 1/108), and the presence of cancer cell (1.86%, 2/108).

Figure 3. Flow chart for the selection of women >64 years with HPV+/NILM. ASCUS, atypical squamous cells of undetermined significance; LSIL, low-grade squamous intraepithelial lesion; HSIL, high-grade squamous intraepithelial lesion; AGC, atypical glandular cells; CIN1, cervical intraepithelial neoplasia grade 1; CIN2, cervical intraepithelial neoplasia grade 2.

Out of the 170 HPV-positive women, above 64 years, 4.12% (7/170), 17.06% (29/170), and 16.47% (28/170) were diagnosed with CIN 1, CIN 2/3, and cervical cancer, respectively.

The correlation between HPV infection status and histological diagnosis among women above 64 years was also examined (Table 1). Single HPV infection cases were found to have a significantly higher association with cervical cancer (24/27, 88.89%) compared to multiple HPV infections (3/27, 11.11%; p = 0.013). The prevalences of CIN 2/3, and cervicitis were higher in cases of single HPV infection than in multiple infections, although the difference was not statistically significant.

Table 1. Correlation between histological diagnosis and HPV infection status (single HPV infection and multiple HPV infection).

Histological results	No.	Multiple HPV infection	Single HPV infection	p Value	
No.	Frequency (%)	No.	Frequency (%)	
Cervicitis	26	7	26.92	19	73.08	0.760	
CIN 1	7	4	57.14	3	42.86	0.187*	
CIN 2/3	29	12	41.38	17	58.62	0.079	
Cervical cancer	27	3	11.11	24	88.89	0.013	

In women diagnosed with cervical cancer, HPV 16 (79.17%, 19/24) was the most prevalent HR HPV genotype encountered in single HPV infection, followed by HPV 58 (8.33%, 2/24), HPV 52(4.17%, 1/24), HPV 31(4.17%, 1/24), and HPV 33(4.17%, 1/24). Notably, HPV 52 (66.67%, 2/3) and HPV 58 (66.67%, 2/3) were the most common HR HPV genotypes among the multiple HPV infections, followed by HPV 18 (33.33%, 1/3), HPV 31(33.33%, 1/3), and HPV 33(33.33%, 1/3).

3.5. Odds ratio for CIN2+ with different HR-HPV genotypes among elderly women with HPV+/NILM

Among women aged over 64 with HPV+/NILM, HPV 58 was the most prevalent HR-HPV genotype (20.00%, 14/70), followed by HPV 16 (12.86%, 9/70), HPV 52 (12.86%, 9/70), HPV 56 (12.86%, 9/70), and HPV 51(10.00%, 7/70). Out of the twenty-two women with HPV+/NILM who underwent colposcopy and received biopsy, 31.82% (7/22) were identified as having CIN2+. As detailed in Table 2, the primary risk factor associated with the emergence of CIN2+ among older women with HPV+/NILM was HPV 58 infection (OR 3.556; 95% CI, 1.107–11.415; p = 0.032). Other HR-HPV genotypes related to the development of CIN2+ include HPV 18 (OR 3.500; 95% CI, 1.780–6.883; p = 0.318), HPV 66 (OR 3.500; 95% CI, 1.780–6.883; p = 0.318), HPV 31 (OR 1.800; 95% CI,0.526–6.164; p = 0.388), HPV 16 (OR 1.667; 95% CI, 0.358–7.768; p = 0.563), HPV 33 (OR 1.667; 95% CI, 0.358–7.768; p = 0.563), and HPV 52 (OR 1.056; 95% CI, 0.187–5.965; p = 0.952). The remaining HR-HPV genotypes (HPV 35, 39, 45, 51, 56, 59, and 68) demonstrated no apparent connection with the evolution of CIN2+.

Table 2. Odds ratio of histological HSIL + according to different HR-HPV genotypes among women >64 years with HPV+/NILM.

HR-HPV genotype	No. of women	Pathological results	OR (95% CI)	p Value	
 	 	≤LSIL	≥HSIL	 	 	
HPV 16	 	 	 	 	 	
 Positive	2	1	1	1.667(0.358, 7.768)	0.563	
 Negative	20	14	6	 	 	
HPV 18	 	 	 	 	 	
 Positive	1	0	1	3.500(1.780, 6.883)	0.318	
 Negative	21	15	6	 	 	
HPV 31	 	 	 	 	 	
 Positive	4	2	2	1.800(0.526, 6.164)	0.388	
 Negative	18	13	5	 	 	
HPV 33	 	 	 	 	 	
 Positive	2	1	1	1.667(0.358, 7.768)	0.563	
 Negative	20	14	6	 	 	
HPV 35	 	 	 	 	 	
 Positive	1	1	0	 	 	
 Negative	21	14	7	 	 	
HPV 39	 	 	 	 	 	
 Positive	2	2	0	 	 	
 Negative	20	13	7	 	 	
HPV 45	 	 	 	 	 	
 Positive	0	0	0	 	 	
 Negative	22	15	7	 	 	
HPV 51	 	 	 	 	 	
 Positive	1	1	0	 	 	
 Negative	21	14	7	 	 	
HPV 52	 	 	 	 	 	
 Positive	3	2	1	1.056(0.187, 5.965)	0.952	
 Negative	19	13	6	 	 	
HPV 56	 	 	 	 	 	
 Positive	4	3	1	0.750(0.122, 4.623)	0.746	
 Negative	18	12	6	 	 	
HPV 58	 	 	 	 	 	
 Positive	6	2	4	3.556(1.107, 11.415)	0.032	
 Negative	16	13	3	 	 	
HPV 59	 	 	 	 	 	
 Positive	0	0	0	 	 	
 Negative	22	15	7	 	 	
HPV 66	 	 	 	 	 	
 Positive	1	0	1	3.500(1.780, 6.883)	0.318	
 Negative	21	15	6	 	 	
HPV 68	 	 	 	 	 	
 Positive	2	2	0	 	 	
 Negative	20	13	7	 	 	
HPV16/18	 	 	 	 	 	
 Positive	3	1	2	2.533(0.845, 7.598)	0.227	
 Negative	19	14	5	 	 	
HPV 16/58	 	 	 	 	 	
 Positive	8	3	5	8.750(1.228, 62.334)	0.011	
 Negative	14	13	1	 	 	
HPV 18/58	 	 	 	 	 	
 Positive	7	2	5	5.357(1.358, 21.138)	0.014	
 Negative	15	13	2	 	 	
HPV 16/18/58	 	 	 	 	 	
 Positive	9	3	6	8.667(1.247, 60.244)	0.007	
 Negative	13	12	1	 	 	
HPV 16/18/52/58	 	 	 	 	 	
 Positive	10	4	6	 	0.003	
 Negative	12	12	0	 	 	
HPV 16/18/31/52/58	 	 	 	 	 	
 Positive	12	5	7	 	0.005	
 Negative	10	10	0	 	 	

3.6. The effectiveness of HR-HPV genotyping models in triaging women older than 64 years with HPV+/NILM

We conducted a risk-assessment for CIN2+ in HPV+/NILM women by employing different HR-HPV genotyping models. As demonstrated in Table 3, the sensitivities and NPVs increased proportionately with the incorporation of additional HR-HPV subtypes. The highest detection efficacy for underlying CIN2+ was observed with extended HPV 16/18/52/58 and HPV 16/18/31/52/58. However, compared to HPV 16/18/52/58 with a specificity of 75.0%, the HPV 16/18/31/52/58 model had a lower specificity (66.7%). Furthermore, the extended HPV 16/18/31/52/58 model also resulted in a higher colposcopy referral rate at 54.5%, compared to 45.5% with the HPV 16/18/52/58 model.

Table 3. The accuracy of different HR-HPV genotyping to triage women >64 years with HPV+/NILM to detect underlying CIN2+.

HR-HPV genotyping models	Sensitivity (%)	Specificity (%)	PPV (%)	NPV (%)	Referral rate (%)	
HPV 16/58	83.3(40.5, 126.2)	81.3(59.8, 102.7)	62.5(19.2, 105.8)	92.9(77.4, 108.3)	40.9	
HPV 16/18/58	85.7(50.8, 120.7)	80.0(57.1, 102.9)	66.7(28.2, 105.1)	92.3(75.5, 109.1)	40.9	
HPV 16/18/52/58	100.0(100.0, 100.0)	75.0(51.2, 98.8)	60.0(23.1, 96.9)	100.0(100.0, 100.0)	45.5	
HPV16/18/31/52/58	100.0(100.0, 100.0)	66.7(39.6, 93.7)	58.3(25.6, 91.1)	100.0(100.0, 100.0)	54.5	

4. Discussion

The challenge of HPV infection and related cervical lesions, particularly among elderly women, remains significant in the context of cervical cancer prevention and control. The prevalence rates among this age group, in large part, remain a gray area, owing to the limited number of comprehensive studies addressing it.

Indeed, in our investigation, the prevalence of any HPV genotypes among women aged more than 64 years was quantified at 19.27%, a rate surpassing premenopausal women’s rates reported in other studies[6, 19,20]. This outcome is potentially attributed to post-menopausal hormone changes, instigating immunological disorders and causing continued viral presence and latent HPV reactivation. Further studies affirmed the highest persistence of any HPV genotypes within this age group[21]. In our context, an alarming 46.67% persistence rate was registered across a 12-month period among the same demographic. In Poland, HPV 31 was found to be the most prevalent genotype among elderly women[22], whereas in our study, HPV 16 was identified as the most commonly occurring genus, with HPV 31 ranking fourth. This observed disparity could potentially be attributed to regional influences and racial variations.

Most cervical cancers cases beyond 65 years of age were found among unscreened women[23]. However, it is reported that the proportion of abnormal pap-smears in women aged over 65 years remained relatively high, even in women who had a regular gynecological follow-up history[24]. Indeed, our research demonstrated a significant 35.18% proportional rate of abnormal cytological results among HPV-positive women aged more than 64 years. Despite the fact that not all HPV-positive women in this study underwent cytological screening, casting some doubt on the exactness of the data, these findings do highlight the increase risk faced by elderly HPV-positive women. This underscores the urgent need to intensify cervical screening measures specifically for women over 64 years, and especially those with patchy screening history. Moreover, the cry for additional research, targeting the most appropriate age to halt cervical screening, couldn’t be more imperative. Furthermore, enhancing the acceptance of cervical cancer screening among elderly women remains a pertinent tissue. It has been found that self-sampling for HPV testing is well-received in this demographic. Consequently, this method could be deployed to boost the coverage of cervical cancer screening services[25].

The variability of single and multiple HPV infections prevalence globally seems influenced by an array of factors, including immune status, socioeconomic factors, regional factors, and age[26]. Our findings suggest that multiple HPV infections in women aged over 64 are less frequent than single HPV infection, aligning with previous Chinese studies[20, 27]. It’s been previously noted that individuals infected with a single HPV genotype could possibly harbor additional HPV genotypes[28]. Some studies found that certain HPV genotype appear to co-infect with specific other HPV genotypes. For instance, the co-infection of HPV 51 and HPV 52 was most prevalent in Mexican population[29], and HPV 16/18 were found likely to co-infect with HPV 31, 52, and 58 in Chinese population[27]. Remarkably, our studies revealed different patterns of co-infection among women over 64 years, with HPV 16 and 52, HPV 31 and 58, and HPV 52 and 58 emerging as the most frequent combinations, deviating from earlier reports. This discrepancy could be interpreted in light of regional and age factors.

The connection between multiple HPV infection and cervical carcinogenesis remains a contentious issue. Some studies propose a significant role of multiple HPV infections in cervical cancer development[30,31], while others suggest a heightened risk from single HPV infection[32–34]. Our results favor the latter, indicating a stronger association between cervical cancer and single HPV infection, especially in women above the age of 64. This supports the clonal development concept of invasive carcinoma deriving from the persistent infection of a single HPV type[35].

In women exceeding 64 years of age, the transformation zone retracts into the cervical canal, which is a deviation from premenopausal women. Concurrently, guidelines for managing abnormal cervical cancer screening tests in this age group are insufficient. Our study indicates an evidently higher prevalence of CIN2+ in HPV+/NILM women above the age of 64, as compared to those aged between 25 and 64. The cervix’s atrophy reduces cytology’s sensitivity in elderly women, yet limited studies focus on identifying risk factors for developing CIN2+ in HPV+/NILM women of this age group.

Among HPV+/NILM women >64 years, our study identified HPV 58 and HPV 16 as the most prevalent HR-HPV genotype. Stoler et al. reported that HPV 16 and 31 were the most prevalent HR-HPV in HPV+/NILM women above the age of 25[36]. Another study in Korea reported HPV 16 and HPV 58 were the most prevalent HR-HPV in NILM cytology population[37]. Studies have reported varying HPV genotype distributions among HPV+/NILM women, presumably due to differing target population ages. Furthermore, our study seeming aligns with Song et al.’s results, demonstrating HPV 58 possessing the highest risk for CIN2+ in HPV+/NILM women aged >64 years[37]. Another study found that HPV 31 and 52 are frequently present in CIN 2/3 lesions[22]. These findings emphasize the need for increased focus on the management of non-16/18 HPV infections.

We also evaluated the triage efficiency of various HR-HPV genotype models for HPV+/NILM women aged over 64 years. Both HPV 16/18/52/58 and HPV 16/18/31/52/58 models showed the highest sensitivity, but HPV 16/18/52/58 model demonstrated superior specificity. And the referral rate of HPV 16/18/52/58 was lower than HPV 16/18/31/52/58. Consequently, the HPV 16/18/52/58 genotype model emerges as a viable alternative triage strategy for identifying CIN2+ cases in HPV+/NILM women aged >64 years of age in Guangdong, China.

There are, however, limitations to our study: it centered on data primarily from a hospital-based population and was conducted in a single center, which may challenge the wider applicability of our conclusions.

5. Conclusion

In summary, elderly women are highly susceptible to HPV infection and cervical lesions—an issue that demands immediate attention. A significant association is evident between HPV 58 and the development of CIN2+ in HPV+/NILM women over 64 years of age. HPV 16/18/52/58 genotype model suggests an alternative triage strategy to detect CIN2+ among HPV+/NILM women above 64 years.

Supplementary Material

Supplemental Material

Ethics approval

This study was approved by the ethics committee of the Third Affiliated Hospital, Sun Yat-sen University (No.[2022]02-042-01).

Authors contributions

Jiang Huiyun and Li Xiaomao designed the study. Jiang Huiyun collected and analyzed the data. Yang Yuebo participated in the acquisition of data and manuscript writing. Li Xiaomao revised the manuscript. All authors given approval of the final version of the manuscript.

Disclosure statement

The authors declare no conflict of interest.
==== Refs
References

1 Singh D, Vignat J, Lorenzoni V, et al. Global estimates of incidence and mortality of cervical cancer in 2020: a baseline analysis of the WHO Global Cervical Cancer Elimination Initiative. Lancet Glob Health. 2023;11 (2 ):e197–e206. doi: 10.1016/S2214-109X(22)00501-0.36528031
2 Cohen PA, Jhingran A, Oaknin A, et al. Cervical cancer. Lancet. 2019;393 (10167 ):169–182. doi: 10.1016/S0140-6736(18)32470-X.30638582
3 Huiyun J, Jie D, Huan W, et al. Prevalence and characteristics of cervical human papillomavirus genotypes and cervical lesions among 58630 women from Guangzhou, China. J Infect Public Health. 2023;16 (10 ):1531–1536. doi: 10.1016/j.jiph.2023.07.013.37562080
4 Pruski D, Millert-Kalińska S, Łagiedo M, et al. Effect of HPV vaccination on virus disappearance in cervical samples of a cohort of HPV-positive polish patients. J Clin Med. 2023;12 (24 ):7592. doi: 10.3390/jcm12247592.38137661
5 Chen W, Zheng R, Baade PD, et al. Cancer statistics in China, 2015. CA Cancer J Clin. 2016;66 (2 ):115–132. doi: 10.3322/caac.21338.26808342
6 Huiyun J, Huixia Y, Xiaomao L, et al. Time trends assessment of cervical cancer characteristics in Guangzhou, 2010-2021: is the age at diagnosis increasing over time? J Geriatr Oncol. 2023;14 (1 ):101389. doi: 10.1016/j.jgo.2022.10.004.36428177
7 Guo M, Xu J, Du J. Trends in cervical cancer mortality in China from 1989 to 2018: an age-period-cohort study and Joinpoint analysis. Bmc Public Health. 2021;21 (1 ):1329. doi: 10.1186/s12889-021-11401-8.34229639
8 Darlin L, Borgfeldt C, Widén E, et al. Elderly women above screening age diagnosed with cervical cancer have a worse prognosis. Anticancer Res. 2014;34 (9 ):5147–5151.25202106
9 Chen H, Qian Y, Dong Y, et al. Patterns and changes in life expectancy in China, 1990-2016. Plos One. 2020;15 (4 ):e231007. doi: 10.1371/journal.pone.0231007.
10 Li T, Luo Y, Meng Y, et al. Sexual activity and related factors of older women in Hunan, China: a cross-sectional study. J Sex Med. 2022;19 (2 ):302–310. doi: 10.1016/j.jsxm.2021.11.020.34973899
11 O’Meara S. How health research will support China’s ageing population. Nature. 2020;578 (7793 ):S1–S3. doi: 10.1038/d41586-020-00279-y.32025021
12 Perkins RB, Guido RS, Castle PE, et al. 2019 ASCCP risk-based management consensus guidelines for abnormal cervical cancer screening tests and cancer precursors. J Low Genit Tract Dis. 2020;24 (2 ):102–131. doi: 10.1097/LGT.0000000000000525.32243307
13 Gyllensten U, Lindell M, Gustafsson I, et al. HPV test shows low sensitivity of Pap screen in older women. Lancet Oncol. 2010;11 (6 ):509–510. doi: 10.1016/S1470-2045(10)70064-4.20522375
14 Hammer A, Soegaard V, Maimburg RD, et al. Cervical cancer screening history prior to a diagnosis of cervical cancer in Danish women aged 60 years and older-a national cohort study. Cancer Med. 2019;8 (1 ):418–427. doi: 10.1002/cam4.1926.30600650
15 Liu Q, Zhou X, Zhang X, et al. HPV genotype specific and age stratified immediate prevalence of cervical precancers and cancers in women with NILM/hrHPV+: a single center retrospective study of 26,228 cases. Cancer Manag Res. 2021;13 :6869–6877. doi: 10.2147/CMAR.S328279.34512026
16 Purandare NC, Trevisan J, Patel II, et al. Exploiting biospectroscopy as a novel screening tool for cervical cancer: towards a framework to validate its accuracy in a routine clinical setting. Bioanalysis. 2013;5 (21 ):2697–2711. doi: 10.4155/bio.13.233.24180508
17 Xiaomao L, Huiyun J, Yang Y. Prevalence of human papillomavirus and cervical lesions among women older than 64 years and outside the Chinese cervical cancer screening age in Guangzhou. Authorea. 2023;10 :1–17. doi: 10.22541/au.168112991.13555619/v1.
18 Nayar R, Wilbur DC. The Bethesda System for Reporting Cervical Cytology. Definitions, Criteria, and Explanatory Notes; 2015.
19 Tang SY, Liao YQ, Hu Y, et al. HPV prevalence and genotype distribution among women from Hengyang district of Hunan Province, China. Front Public Health. 2021;9 :710209. doi: 10.3389/fpubh.2021.710209.34805062
20 Luo G, Sun X, Li M, et al. Cervical human papillomavirus among women in Guangdong, China 2008-2017: implication for screening and vaccination. J Med Virol. 2019;91 (10 ):1856–1865. doi: 10.1002/jmv.25520.31206752
21 Li M, Liu T, Luo G, et al. Incidence, persistence and clearance of cervical human papillomavirus among women in Guangdong, China 2007-2018: a retrospective cohort study. J Infect Public Health. 2021;14 (1 ):42–49. doi: 10.1016/j.jiph.2020.11.011.33341483
22 Przybylski M, Pruski D, Wszołek K, et al. Prevalence of HPV and assessing type-specific HPV testing in cervical high-grade squamous intraepithelial lesions in Poland. Pathogens. 2023;12 (2 ):350. doi: 10.3390/pathogens12020350.36839622
23 Kissel M, Rambeau A, Achkar S, et al. Challenges and advances in cervix cancer treatment in elder women. Cancer Treat Rev. 2020;84 :101976. doi: 10.1016/j.ctrv.2020.101976.32006796
24 Meyer R, Lemay AL, Guy X, et al. Is there a benefit to continue pap smear screening for cervical cancer after 65 years of age? A retrospective study on 53,644 women. Bull Cancer. 2012;99 (4 ):409–415.22450525
25 Hermansson RS, Olovsson M, Gustavsson C, et al. Elderly women’s experiences of self-sampling for HPV testing. BMC Cancer. 2020;20 (1 ):473. doi: 10.1186/s12885-020-06977-0.32456679
26 Crow JM. HPV: the global burden. Nature. 2012;488 (7413 ):S2–S3. doi: 10.1038/488S2a.22932437
27 Liao G, Jiang X, She B, et al. Multi-infection patterns and co-infection preference of 27 human papillomavirus types among 137,943 gynecological outpatients across China. Front Oncol. 2020;10 :449. doi: 10.3389/fonc.2020.00449.32318343
28 Chaturvedi AK, Katki HA, Hildesheim A, et al. Human papillomavirus infection with multiple types: pattern of coinfection and risk of cervical disease. J Infect Dis. 2011;203 (7 ):910–920. doi: 10.1093/infdis/jiq139.21402543
29 Gallegos-Bolaños J, Rivera-Domínguez JA, Presno-Bernal JM, et al. High prevalence of co-infection between human papillomavirus (HPV) 51 and 52 in Mexican population. Bmc Cancer. 2017;17 (1 ):531. doi: 10.1186/s12885-017-3519-7.28789619
30 Fife KH, Cramer HM, Schroeder JM, et al. Detection of multiple human papillomavirus types in the lower genital tract correlates with cervical dysplasia. J Med Virol. 2001;64 (4 ):550–559. doi: 10.1002/jmv.1085.11468743
31 Kim M, Park NJ, Jeong JY, et al. Multiple human papilloma virus (HPV) infections are associated with HSIL and persistent HPV infection status in Korean patients. Viruses. 2021;13 (7 ):1342. doi: 10.3390/v13071342.34372548
32 Bruno MT, Scalia G, Cassaro N, et al. Multiple HPV 16 infection with two strains: a possible marker of neoplastic progression. BMC Cancer. 2020;20 (1 ):444. doi: 10.1186/s12885-020-06946-7.32429930
33 Li M, Du X, Lu M, et al. Prevalence characteristics of single and multiple HPV infections in women with cervical cancer and precancerous lesions in Beijing, China. J Med Virol. 2019;91 (3 ):473–481. doi: 10.1002/jmv.25331.30281807
34 Lagheden C, Eklund C, Lamin H, et al. Nationwide comprehensive human papillomavirus (HPV) genotyping of invasive cervical cancer. Br J Cancer. 2018;118 (10 ):1377–1381. doi: 10.1038/s41416-018-0053-6.29559733
35 Quint W, Jenkins D, Molijn A, et al. One virus, one lesion–individual components of CIN lesions contain a specific HPV type. J Pathol. 2012;227 (1 ):62–71. doi: 10.1002/path.3970.22127961
36 Stoler MH, Wright TJ, Parvu V, et al. Stratified risk of high-grade cervical disease using on clarity HPV extended genotyping in women, ≥25 years of age, with NILM cytology. Gynecol Oncol. 2019;153 (1 ):26–33. doi: 10.1016/j.ygyno.2018.12.024.30638767
37 Song JS, Kim EJ, Choi J, et al. Significance of HPV-58 infection in women who are HPV-positive, cytology-negative and living in a country with a high prevalence of HPV-58 infection. Plos One. 2013;8 (3 ):e58678. doi: 10.1371/journal.pone.0058678.23505548
