Minimal benefit of co-testing over HPV primary screening with cytology triage from resource-limited settings in China

Co-testing with human papillomavirus (HPV) DNA testing plus liquid-based cytology is still used in parts of China, although many screening programmes are moving toward HPV-based strategies. We aimed to compare co-testing with HPV-based and cytology-only approaches in routine county services in resource-limited areas.

We analysed a screening cohort of 33,387 women aged 35-64 years from four primary care sites. Because all women received both HPV testing and cytology, we reconstructed four strategies within the same population: co-testing, HPV primary screening with cytology triage, HPV-only, and cytology-only. For each strategy we estimated detection of cervical intraepithelial neoplasia grade 2 or worse (CIN2 + ), referrals for specialist examination of the cervix, and cytology workload per 1000 women screened.

Here we show that co-testing detects 6.7 CIN2+ cases per 1000 women screened, compared with 6.5 for HPV primary screening with cytology triage, 4.3 for HPV-only, and 4.9 for cytology-only. However, co-testing requires more resources than HPV primary screening with cytology triage, including 33.1 additional colposcopy referrals and 888.8 extra cytology slides per 1,000 women screened, with little gain in detection. Cytology-only increases referrals while detecting fewer CIN2+ cases, whereas HPV-only reduces referrals but detects fewer CIN2 + .

In resource-limited county programmes, HPV primary screening with cytology triage provides the most favourable balance between detecting cervical pre-cancer and limiting unnecessary procedures. These findings support transitioning from routine co-testing to HPV-based screening tailored to local capacity.