Monitoring of Cell-free Human Papillomavirus DNA in Metastatic or Recurrent Cervical Cancer: Clinical Significance and Treatment Implications

Reviewer #1 (Public review):

Summary:

The study "Monitoring of Cell-free Human Papillomavirus DNA in Metastatic or Recurrent Cervical Cancer: Clinical Significance and Treatment Implications" by Zhuomin Yin and colleagues focuses on the relationship between cell-free HPV (cfHPV) DNA and metastatic or recurrent cervical cancer patients. It expands the application of cfHPV DNA in tracking disease progression and evaluating treatment response in cervical cancer patients. The study is overall well-designed, including appropriate analyses.

Strengths:

The findings provide valuable reference points for monitoring drug efficacy and guiding treatment strategies in patients with recurrent and metastatic cervical cancer. The concordance between HPV cfDNA fluctuations and changes in disease status suggests that cfDNA could play a crucial role in precision oncology, allowing for more timely interventions. As with similar studies, the authors used Droplet Digital PCR to measure cfDNA copy numbers, a technique that offers ultrasensitive nucleic acid detection and absolute quantification, lending credibility to the conclusions.

Weaknesses:

Despite including 28 clinical cases, only 7 involved recurrent cervical cancer, which may not be sufficient to support some of the authors' conclusions fully. Future studies on larger cohorts could solidify HPV cfDNA's role as a standard in the personalized treatment of recurrent cervical cancer patients.

Reviewer #2 (Public review):

Summary:

The authors conducted a study to evaluate the potential of circulating HPV cell-free DNA (cfDNA) as a biomarker for monitoring recurrent or metastatic HPV+ cervical cancer. They analyzed serum samples from 28 patients, measuring HPV cfDNA levels via digital droplet PCR and comparing these to squamous cell carcinoma antigen (SCC-Ag) levels in 26 SCC patients, while also testing the association between HPV cfDNA levels and clinical outcomes. The main hypothesis that the authors set out to test was whether circulating HPV cfDNA levels correlated with metastatic patterns and/or treatment response in HPV+ CC.

The main claims put forward by the paper are that:

(1) HPV cfDNA was detected in all 28 CC patients enrolled in the study and levels of HPV cfDNA varied over a median 2-month monitoring period.
(2) 'Median baseline' HPV cfDNA varied according to 'metastatic pattern' in individual patients.
(3) Positivity rate for HPV cfDNA was more consistent than SCC-Ag.
(4) In 20 SCC patients monitored longitudinally, concordance with changes in disease status was 90% for HPV cfDNA.

This study highlights HPV cfDNA as a promising biomarker with advantages over SCC-Ag, underscoring its potential for real-time disease surveillance and individualized treatment guidance in HPV-associated cervical cancer.

Strengths:

This study presents valuable insights into HPV+ cervical cancer with potential translational significance for management and guiding therapeutic strategies. The focus on a non-invasive approach is particularly relevant for women's cancers, and the study exemplifies the promising role of HPV cfDNA as a biomarker that could aid personalized treatment strategies.

Weaknesses:

While the authors acknowledge the study's small cohort and variability in sequential sampling protocols as a limitation, several revisions should be made to ensure that (1) the findings are presented in a way that aligns more closely with the data without overstatement and (2) that the statistical support for these findings is made more clear. Specific suggestions are outlined below.

(1) The authors should provide source data for Figures 2, 3, and 4 as supplementary material.

(2) Description of results in Figure 2: Figure 2 would benefit from clearer annotations regarding HPV virus subtypes. For example, does the color-coding in Figure 2B imply that all samples in the LR subgroup are of type HPV16? If that is the case, is it possible that detection variations are due to differences in subtype detection efficiency rather than cfDNA levels? The authors should clarify these aspects. Annotation of Figure 2B suggests that the p-value comes from comparing the LR and LN+H+DSM groups. This should be clarified in the legend. If this p-value comes from comparing HPV cfDNA copies for the (LR, LNM, HM) and (LN+HM, LN+HM+DSM) groups, did the authors carry out post-hoc pairwise comparisons? It would be helpful to include acronyms for these groups in the legend also.

(3) Interpretation of results in Figure 2 and elsewhere: Significant differences detected in Figure 2B could imply potential associations between HPV cfDNA levels (or subtypes) and recurrence/metastasis patterns. Figure 2C shows that there is a difference in cfDNA levels between the groups compared, suggesting an association but this would not necessarily be a direct "correlation". Overall, interpretation of statistical findings would benefit from more precise language throughout the text and overstatement should be avoided.

(4) The authors state that six patients showed cfDNA elevation with clinically progressive disease, yet only three are represented in Figure 3B1 under "Patients whose disease progressed during treatment." What is the expected baseline variability in cfDNA for patients? If we look at data from patients with early-stage cancer would we see similar fluctuations? And does the degree of variability vary for different HPV subtypes? Without understanding the normal fluctuations in cfDNA levels, interpreting these changes as progression indicators may be premature.

(5) It would be helpful if where p-values are given, the test used to derive these values was also stated within parentheses e.g. (P < 0.05, permutation test with Benjamini-Hochberg procedure).