Postoperative ctHPV-DNA for Recurrence Prediction and Adjuvant Treatment Decision-Making in Cervical Cancer

This is a prospective, single-center, observational cohort study designed to evaluate the prognostic value of serial circulating tumor human papillomavirus DNA (ctHPV-DNA) monitoring after radical surgery for HPV-associated cervical cancer and to explore its potential role in postoperative adjuvant treatment decision-making.

Eligible patients will have histologically confirmed HPV-associated cervical cancer and will undergo radical hysterectomy with pelvic lymph node assessment, with or without para-aortic lymph node assessment as clinically indicated. Adjuvant treatment will not be assigned by the study. Decisions regarding postoperative radiotherapy, chemoradiotherapy, systemic therapy, or observation will be made according to current clinical guidelines, postoperative pathological risk factors, and multidisciplinary clinical assessment.

Peripheral blood will be collected at three predefined time points: before surgery; TP#1, 2-4 weeks after surgery and before initiation of adjuvant therapy when adjuvant treatment is planned; and TP#2, 12-16 weeks after surgery for patients not receiving adjuvant therapy or 12-16 weeks after completion of adjuvant therapy for patients receiving postoperative treatment. ctHPV-DNA will be assessed using a tumor-informed HPV-specific detection approach based on droplet digital polymerase chain reaction (ddPCR) or next-generation sequencing (NGS), depending on HPV genotype and platform applicability. Both qualitative detection status and quantitative ctHPV-DNA levels will be recorded.

The primary analysis will focus on patients who are ctHPV-DNA negative at TP#1 and who are alive and free of radiologically evident recurrence at TP#2. According to ctHPV-DNA status at TP#2, these patients will be classified into two major dynamic groups: persistently negative (negative at TP#1 and negative at TP#2) and molecular conversion to positive (negative at TP#1 and positive at TP#2). Patients who are ctHPV-DNA positive at TP#1 will be followed as a separate high-risk molecular residual disease cohort and analyzed descriptively.

The primary outcome is disease-free survival (DFS), assessed from the TP#2 landmark date to the first occurrence of radiologically or pathologically confirmed recurrence, death, or last follow-up. Secondary outcomes include overall survival, locoregional recurrence-free survival, distant metastasis-free survival, the interval between ctHPV-DNA conversion to positivity and clinically or radiologically detected recurrence, the association between quantitative ctHPV-DNA levels and DFS, and ctHPV-DNA clearance after adjuvant treatment.

The study will further assess whether postoperative ctHPV-DNA dynamics provide incremental prognostic information beyond established clinicopathological risk factors, including Sedlis- and Peters-based risk stratification. Exploratory analyses will compare outcomes according to receipt of adjuvant therapy within ctHPV-DNA-defined subgroups. Because treatment is not randomized, these analyses will be considered hypothesis-generating, and multivariable regression and propensity score-based methods may be used to reduce confounding.

The overall aim is to determine whether serial postoperative ctHPV-DNA monitoring can improve recurrence-risk stratification after radical surgery for cervical cancer and provide prospective evidence to support future interventional trials of ctHPV-DNA-guided escalation or de-escalation of adjuvant therapy.

Inclusion criteria

• Age ≥18 years.
• Histologically confirmed cervical cancer, including squamous cell carcinoma, HPV-associated adenocarcinoma, or adenosquamous carcinoma.
• FIGO 2018 stage IB1-II cervical cancer undergoing radical surgical treatment; selected patients with postoperative pelvic lymph node metastasis may also be included.
• Undergoing radical hysterectomy with pelvic lymph node dissection, with or without para-aortic lymph node dissection, including sentinel lymph node assessment when applicable.
• A high-risk or intermediate-risk HPV genotype detectable in baseline tumor tissue or plasma, allowing establishment of a trackable ctHPV-DNA target.
• Ability and willingness to undergo serial blood collection and clinical follow-up according to the study protocol.
• Written informed consent.
• For patients who received neoadjuvant chemotherapy, pretreatment ctHPV-DNA information must be available and a trackable HPV target must remain identifiable before surgery or during the early postoperative period.

Exclusion criteria

• HPV-independent cervical cancer, including gastric-type adenocarcinoma or confirmed HPV-negative squamous cell carcinoma.
• Pelvic radiotherapy administered before radical surgery.
• No residual cervical tumor after conization and inability to establish a reliable baseline HPV target for ctHPV-DNA monitoring.
• Concurrent active HPV-associated malignancy other than cervical cancer.
• Inability to comply with the scheduled blood collection or follow-up procedures.