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Konsep Terkini Pencegahan Kanker Serviks

Dwiana Ocviyanti

Departemen Obstetri dan Ginekologi

Fakultas Kedokteran Universitas Indonesia, Jakarta

Infeksi HPV dan Kanker Serviks

Infeksi HPV ditemukan pada 99.7% penderita Kanker Serviks

Walboomers JMM et al. 1999. Journal of Pathology 189(1): 12 19.

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HPV Natural History-Infeksi HPV

HPV Natural History-Infeksi HPV

75/100

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Global Prevalence of HPV

USA

11.4% 8ad

41.1% 4b

16.8% 2a

16.8%

2a

British Columbia, Canada

British Columbia, Canada

6.5% 910b

6.5%

910b

USA

50.8% 6a

17.1% 3b

17.1%

3b

Texcoco Sanitary

Texcoco Sanitary

District, Mexico

District, Mexico

Estimated global prevalence is between 9% and 13%, or ~630 million people 1

Estimated prevalence of HPV infection in selected geographic areas:

Conakry, Guinea

5a

6a

4b

8ad

Indonesia

Indonesia

Rio de Janeiro, Brazil

Rio de Janeiro, Brazil

South Wales, UK

South Wales, UK

7ac

Conakry, Guinea

Zhejiang Province, China

Zhejiang Province, China

13.3%

41.1%

11.4%

50.8%

13.5%

13.3% 7ac

13.5% 5a

^a Includes female data only; ^b Includes male and female data; ^c No visual cervical lesions or history of abnormal cytology or HPV; ^d Only married, widowed, or divorced women.

1. World Health Organization. Vaccine research and development. www.who.int/vaccines/en/hpvrd/shtml. Accessed December 10, 2010. 2. Moore RA et al. Cancer Causes Control. 2009;20:1387–1396. 3. Parada R et al. BMC Infect Dis. 2010;10:223. 4. Carestiato FN et al. Braz J Infect Dis. 2006;10:331–336. 5. Hibbitts S et al. Br J Cancer. 2008;99:1929–1933. 6. Keita N et al. Br J Cancer. 2009;101:202–208. 7. Ye J et al. Virol J. 2010;7:66. 8. Vet JNI et al. Brit J Cancer. 2008;99:214–218. 9. Centers for Disease Control and Prevention (CDC). Fact Sheet: Genital HPV. www.cdc.gov/std/HPV/STDFact-HPV.htm. Accessed March 1, 2011. 10. US Census Bureau. US population estimates. http://factfinder.census.gov/servlet/DTTable?_bm=y&-geo_id=01000US&-ds_name=PEP_2009_EST&-mt_name=PEP_2009_EST_G2009_T001. Accessed March 1, 2011.

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HPV Natural History- Lesi PraKanker

75/1000

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HPV Natural History

6/10.000

HPV Natural History

1.2/10.000

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Insidens Kanker Serviks di Indonesia

13.6-20.6/100.000

Kematian akibat Kanker Serviks di

Indonesia 5.8-9.8/100.000 (7800/tahun)

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WHO (2013) Guidance note: comprehensive cervical cancer prevention and control: a healthier future for girls and women

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Program Skrining didasarkan pada Natural History infeksi HPV

Untuk mendeteksi apakah seorang perempuan:

saat diperiksa terinfeksi oleh HPV onkogenik (hrHPV)

Atau • Memiliki lesi prakanker • Menderita Kanker Serviks stadium awal

TES PAP/PAP SMIR

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SKRINING DENGAN TES PAP/PAP SMIR

•	Dilakukan pada pasien sehat (tidak ditemukan lesi / kecurigaan kanker pada serviks)
•	Bila hasil positif (ditemukan sel yang dicurigai lesi prakanker atau kanker ASCUS/+) harus dilakukan kolposkopi dan bila ditemukan lesi dilakukan biopsi pada lesi tersebut

• Diagnosis akhir didasarkan pada hasil biopsi, dan tindakan lebih lanjut hanya dilakukukan bila Lesi Derajat Tinggi ( NIS 2/+)

Colposcopy

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WHO 2013. WHO guidelines for screening and treatment of precancerous lesions for cervical

cancer prevention.

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Evaluasi metode skrining Kanker Serviks di Amerika saat ini

•	Bila pemeriksaan tes hrHPV negatif, ternyata kemungkinan kejadian CIN3/+ akan lebih rendah dibandingkan hasil tes sitologi/Pap Smir
•	Karena efektifitas pemeriksaan skrining dengan tes hrHPV lebih baik atau setidaknya setara dengan pemeriksaan sitologi/Pap Smir, maka saat ini tes hrHPV dapat dijadikan pemeriksaan primer untuk skrining

• Pap Smir saja atau kombinasi Pap Smir dengan hrHPV tetap dapat digunakan sebagai pilihan

Warner K Huh. et.al. In:Gynecologic Oncology 136 (2015) 178 182

Warner K Huh. et.al. In:Gynecologic Oncology 136 (2015) 178 182

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Program Pencegahan Kanker Serviks di negara lain di dunia

Berdasarkan pada:

•	Sitologi Pap smir, atau
•	Inspeksi Visual dengan Aplikasi Asam Asetat (IVA), atau
•	Tes Human Papilloma Virus (HPV)
Tatalaksana:
•	Pap Smir positif or tes HPV positif kolposkopi biopsi histopatologi terapi , or
•	Pap Smir positif or tes HPV positif kolposkopi eksisi dengan eksisi diatermi / loop dan histopatologi(see and treat)
•	IVA positif (?) terapi Bedah Krio
•	Tes hrHPV positif (?) terapi Bedah Krio

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WHO 2013. WHO guidelines for screening and treatment of precancerous lesions for cervical

cancer prevention.

Skrining Kanker Serviks

• Sitologi dan kolposkopi tidak boleh digunakan sebagai teknik skrining tunggal, sehingga harus dilanjutkan dengan kolposkopi +biopsi dalam program skrining Kanker Serviks

• Di negara dengan fasilitas pelayanan kesehatan terbatas maka IVA atau tes HPV dapat digunakan sebagai teknik skrining tunggal dalam program skrining Kanker Serviks

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Suggestion from WHO 2013

• Use a strategy of screen with an HPV test and treat, over a strategy of screen with VIA and treat

• In resource-constrained settings, where screening with an HPV test is not feasible, the panel suggests a strategy of screen with VIA and treat

WHO guidelines for screening and treatment of precancerous lesions for cervical cancer prevention. 2013

Effective cervical cancer prevention programs in low-resource settings

Can be implemented and should focus on three critical factors:

• achieving high screening coverage • offering an effective and acceptable test • ensuring appropriate treatment of test- positive women.

WHO guidelines for screening and treatment of precancerous lesions for cervical cancer prevention. 2013

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HPV in Indonesia

• 4.0% of women in the general population are estimated to harbour cervical HPV- 16/18 infection at a given time

• 87.7% of invasive cervical cancers are attributed to HPVs 16 or 18

Bruni L, Barrionuevo-Rosas L, Albero G, Aldea M, Serrano B, Valencia S, Brotons M, Mena M,

Cosano R, Muñoz J, Bosch FX, de Sanjosé S, Castellsagué X. ICO Information Centre on HPV and

Cancer (HPV Information Centre). Human Papillomavirus and Related Diseases in Indonesia.

Summary Report 2015-03-20. [Data Accessed]

Cervical Cancer Prevention in Indonesia

•

Over the course of the 5-year project began at 2007, a total of 45 050 women received VIA screening. They represented 24.4% of the total female population aged 30 50 in the catchment area of the 17 health centers.

•A total of 145 women, or 0.3% of those screened over the 5-year period, were suspected of having cervical cancer.

•

1.8% tested positive for cervical dysplasia (VIA positive)

83.1% of VIA-positive women sought cryotherapy

•

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HPV Vaccine in Indonesia

• HPV vaccine licensure:

– Bivalent vaccine (Cervarix) – Quadrivalent vaccine (Gardasil)

• Cost of the vaccine:

– one injection Rp. 700.000,- ( 50 USD)

• Government pilot program in Jakarta

–Girl 10-13 years Rp. 1.000.000,- (70 USD) for 2 (two) injection

HPV Vaccine acceptance in Indonesia

Methods: 746 parents, with at least 1 daughter aged 0 14, were interviewed using questionnaires based on published and adjusted interviews. Interviews were done in sub district public health centers, general governmental hospitals, and via house-visits, in 5 Indonesian provinces.

Results: Parental HPV vaccine acceptance was 96.1%.

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HPV Vaccine Program in Indonesia

Indonesia Adolescent data until 2013

31 million girls age 10-24 years

11.3 miilion girls age 10-14 years (450 thousands in Jakarta)

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Join the Indonesian forum at AOGIN!

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