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TRIAGE AND TREATMENT OF CERVICAL HPV

POSITIVE CASES IN THE COMMUNITY

DR. SIVAKAMI.K
DNB OBSTETRICS AND GYNAECOLOGY
8675762857
sivakami@gknmh.org
MONTH / YEAR OF ADMISSION – FEBRUARY 2022
 GUIDE
DR.LATHA BALASUBRAMANI
Consultant Gynae Oncosurgeon
MD, DGO , DNB(OG) , MRCOG,
G. Kuppuswamy Naidu Memorial Hospital,
Coimbatore.

TABLE OF CONTENTS
1.INTRODUCTION
2.REVIEW OF LITERATURE
3.AIMS AND OBJECTIVES
4.STUDY METHODOLOGY
5.SELECTION PROCESS
6.SAMPLE SIZE
7.REFERENCES
INTRODUCTION
Cervical cancer is one of the leading causes of mortality among
women. It is caused by Human Papilloma Virus (HPV). In 2020, an
estimated 604 000 women were diagnosed with cervical cancer
worldwide and about 342 000 women died from the disease. 90% of
these deaths occur in low- and middle-income countries . Cervical
cancer screening plays a vital role in prevention and treatment of
invasive cervical cancer. High risk HPV DNA is present in 99.7% of
cervical cancer specimens.[1] Molecular studies have shown that HPV-
16 and 18 are the two most common highly oncogenic types found in
invasive cervical cancer, causing about 70% of all invasive cervical
cancer in the world [2]. Persistent HPV infection is essential for cervical
cancer development. Cervical cancer screening programme includes
screening of target group ( HPV testing / cytology / VIA VILI /
combination of above) and referral to colposcopy and biopsy of
women who have a positive screening test. Cervical cancer screening
can reduce cervical cancer incidence and mortality [3]. Incorporation of
HPV testing into cervical screening strategies has the added advantage
of increased disease detection and increased screening intervals.
REVIEW OF LITERATURE
Global trends :
According to GLOBOCAN 2020 estimates of cancer published by the IARC
(International Agency for Research on Cancer ) in 185 countries, Cervical
cancer is the fourth most common cancer in terms of incidence and
mortality. (4). The incidence of cervical cancer is 3.4 % out of 9.2 million new
cases in females. Out of 4.4 million cancer related deaths in 2020, cervical
cancer accounts for 7.7%. (4)
 Cervical cancer is the leading cause of death in 36 countries. 85 % of the
deaths from cervical cancer occur in underdeveloped or developing
countries and the death rate is 18 times higher in low income and middle
income countries. ?
Trends in India :
Cervical cancer is the most common cancer in Indian women as the
screening tools and vaccination are not effectively practised compared to
the Western World. In India, the incidence of cervical cancer is 7.9/1,00,000
with the highest incidence in Mizoram (23.07/1,00,000) and lowest in
Dibrugarh(4.91/1,00,000).

Risk factors for developing cervical cancer :

Risk factor for cervical cancer development includes persistent HPV
infection with high risk types, multiple lifetime sexual partners, co infection
with HIV, immunosuppression and cigarette smoking.
Harold zur Hausen, a German virologist was the first one to demonstrate
the link between genital HPV infections and cervical cancer in early 1980s.
He was awarded the Nobel prize for the same. Since then, the link between
HPV and cervical squamous cell carcinoma has been well established. ?
HPV (Human Papilloma virus) infection is a necessary but not sufficient
cause for cervical cancer(5). HPV prevalence in cervical cancer patients in
India vary from 87.8 % to 96.67%(6).There are more than 100 types of HPV,
among them , HPV types 16,18,31,33,34,35,39,45,51,52,56,58,59,66,68 and
70 are high-risk types and others are low-risk types . HPV 16 and 18 are the
two most common highly oncogenic viruses found in invasive cervical cancer
and out of these two, HPV 16 is found more commonly. HPV type 16 account
for about half of the cases in the United States and Europe and types 18, 31, and
45 account for an additional 25 to 30% of cases .
HPV :
Human Papilloma viruses , members of Papavoviridae family are non
enveloped , small double stranded DNA viruses that infect skin and mucosa
of the anogenital tract. HPVs that infect genital tract are sexually
transmitted and two thirds of individuals who have sexual relationship with
infected partner will become infected. Majority of infections are subclinical.
Persistence of infection by high risk HPV is the greatest risk factor for
developing genital malignancies like squamous cell carcinoma and less
commonly adenocarcinoma of cervix.HPV is implicated in 99.7% of cervical
squamous cell cancer cases worldwide (5) Cervical Adenocarcinomas are also
related to HPV, but the correlation is less pronounced and is age dependent .
Pathogenesis of HPV infection :
Infection of the epithelium occurs through microwounds which exposes
cells in the basal layer to viral entry. Though the receptor for entry of virus
into cells is currently unknown, alpha 6 integrin has been proposed as the
epithelial cell receptor for HPV 6, but not obligatory for attachment of HPV
11 or HPV 33. Heparin sulfate mediates the initial attachment of virions to
cells. HPV infection of epithelial cells results in activation of a cascade of
viral gene expression which results in production of approximately 20 to 100
extrachromosomal copies of viral DNA per cell. Replication factors E1 and E2
are the first viral proteins to be expressed.
The HPV genome consists of approximately 7,900 bp associated with
histones. All open reading frame (ORF) protein-coding sequences are
restricted to one strand. The genome is functionally divided into three
regions . The first is a noncoding upstream regulatory region of 400 to 1,000
bp, which has been referred to as the noncoding region, the long control
region (LCR), or the upper regulatory region. This region contains the p97
core promoter along with enhancer and silencer sequences that regulate
DNA replication by controlling the transcription of the ORFs. This region also
contains the highest degree of variation in the viral genome .The second is
an early region, consisting of ORFs E1, E2, E4, E5, E6, and E7, which are
involved in viral replication and oncogenesis. The third is a late region, which
encodes the L1 and L2 structural proteins for the viral capsid.
In the basal layers, viral replication is considered to be nonproductive and the
virus establishes itself as a low-copy-number episome by using the host DNA
replication machinery to synthesize its DNA on average once per cell cycle . In the
differentiated keratinocytes of the suprabasal layers of the epithelium, the virus
switches to a rolling-circle mode of DNA replication, amplifies its DNA to high
copy number, synthesizes capsid proteins, and causes viral assembly to occur .
HPV replication starts when host cell factors interact with LCR region of the HPPV
genome and begin transcription of the viral E6 and E7 genes. E6 and E7 gene
products dysregulate host cell growth cycle by inactivating tumour suppressor
genes, cell cyclins and cyclin dependent kinases. The tumour suppressor protein
p53 and Retinoblastoma gene product pRB regulate the cell cycle growth. HPV E6
gene product binds to p53 and results in rapid degradation via ubiquitin ligase. E7
gene product binds to hypophosphorylated form of RB family of proteins and
disrupts the complex between pRB and the cellular transcription factor E2F-1. E2F
-1 is liberated which allows the trascription of genes whose products are required
for the cells to enter the S phase of cell cycle resulting in stimulation of cellular
DNA synthesis and cell proliferation.
Natural history of HPV infection :
The natural history of cervical cancer progress from mild cervical intraepithelial
neoplasia (CIN 1) to severe degrees of dysplasia and microinvasive lesions and to
invasive disease . This is the basis for diagnosis , therapeutic measures and
secondary preventive strategies.
The risk of progression of mild dysplasia to severe dysplasia is only 1% per year,
while the risk of progression of moderate dysplasia to severe dysplasia is 16%
within 2 years and 25% within 5 years. However, it is agreed that early detection
and subsequent early treatment of HPV infection in precancerous lesions can
prevent progression to cancer. The primary diagnostic tools are cytology and
histology. Recently, molecular methods to detect HPV DNA sequences have been
introduced.
Cervical cancer screening remains the mainstay to diagnose precancerous cervical
lesions and to effectively treat to prevent progression to invasive cancer.
Screening is done either with cytology alone or HPV testing alone or combined
HPV testing and cytology.
1.Pap smear :
The primary method of detection of cervical precancer is still the Pap smear
named after the pathologist George Papanicolaou. He introduced Pap smear in
1949 before the cause of cervical cancer was known. The pap smear has helped to
reduced the cervical cancer incidence and mortality rates by approximately half to
two – thirds. ?The current reporting system is Bethesda system, which classifies
squamous cell abnormalities into 4 types – ASC, LSIL, HSIL and invasive carcinoma.
The false negative rate of conventional pap smear is 20-30 % due to clumping of
cells, cell morphology not clearly made out due to blood and bacteria obscuring
the cellular details.
To overcome the difficulties in pap smear , liquid based cytology was introduced
where the contaminants were removed and automatic uniform monolayer is
prepared which is easier for the technician to read. The process also prevents
drying artefacts.FDA approved LBS systems are the Prepstain and Thinprep
methods.
Identification of precancerous lesions has been primarily by cytologic screening of
cervical cells. However cellular abnormalities may be missed or may not be
sufficiently distinct and patients with borderline or mildly dyskaryotic
cytomorphology might have high grade disease identified by colposcopy and
biopsy. Sensitive and specific molecular techniques to detect HPV DNA and to
distinguish high risk from low risk HPV types are introduced as an adjunct to
cytology.Early detection of high risk HPV types improve triage, treatment and
follow up in infected patients. Currently the clearest role for HPV testing is to
improve diagnostic accuracy.
2. Visual Inspection with Acetic acid (VIA) :
 VIA test uses dilute acetic acid on the cervix without magnification to identify
aceto-white areas. VIA cannot be done in women when the transformation zone
is not visible or after menopause.

3.HPV testing :
HPV testing looks for the presence of high risk HPV subtypes. HPV testing alone or
HPV / PAP cotesting has higher sensitivity compared to Pap smears alone. Thus
someone with negative HPV testing has very low risk of developing precancerous
cervical lesions over the next few years. ?So the recommended screening interval
is 5 years rather than 3 years as for Pap smear.
Eventhough there are several cervical cancer campaigns carried out in India,
there are certain barriers in the attitude of women towards screening and follow
up. HPV self sampling kits may increase screening and early detection of cervical
cancer , thus reducing the burden globally.
Screen positive Women:
Patients with abnormal cytologic findings or positive HPV testing and with no
gross cervical lesion are evaluated by colposcopy and colposcopy directed biopsy.
5 % acetic acid solution is applied and cervix examined with a bright filtered light
under 10-15 fold magnification. Acetowhitening and vascular patterns typical of
dysplasia or carcinoma can be seen. Colposcopy detects low grade and high grade
dysplasias but not microinvasive disease. The characteristic histopathological
features of HPV infection in biopsy include Epithelial hyperplasia (acanthosis) and
degenerative cytoplasmic vacuolization(koilocytosis) in terminally differentiated
keratinocytes with atypical nuclei.Immunostaining can also be used to detect HPV
antigen.

Treatment strategies :
There are two screening and treatment approaches namely “ screen and treat
approach “ and “ screen, triage and treat approach”. In screen and treat approach
, the decision to treat is based on a positive primary screening test only. In the
screen, triage and treat approach, the decision to treat is based on a positive
primary screening test followed by a positive second test (a triage test) with or
without histologically confirmed diagnosis.
WHO recommends screening approach to start at the age of 30 years with regular
screening every 5 to 10 years. After the age of 50 years, WHO suggests to stop
screening after two consecutive negative tests.
WHO recommends retesting with HPV DNA testing after 24 months if HPV DNA
primary screening is positive and then negative on triage test. WHO also suggests
that women from the general population to be retested with HPV DNA testing at
12 months if primary cytology screening is positive and have normal results on
colposcopy. If retesting is negative, then the women can be moved on to the
regular screening interval.
The modality of treatment of HPV positive cases is cryotherapy of transformation
zone. Cryotherapy is the use of low temperatures locally to crystallise the cytosol
thereby killing the cells.Liquid nitrogen is the most popular cryogen due to the
low temperatures achievable (-197 degree celcius). Carbon di oxide can also be
used.

AIMS AND OBJECTIVES

⮚ To screen the women in the community for cervical cancer using ‘care HPV
kit’
⮚ To study the prevalence of HPV positive cases
⮚ To treat HPV positive cases
⮚ To understand barriers to treatment.

STUDY METHODOLOGY
STUDY POPULATION:
Women in the age group of 30 -60 years in the community
STUDY DESIGN:
A Prospective Observational study
STUDY PERIOD:
September 2022 to December 2023

PLACE OF STUDY:
Department of Oncology, G.Kuppuswamy Naidu Memorial Hospital, Coimbatore
SELECTION PROCESS:
INCLUSION CRITERIA:
Womem from 30-60 years willing to be screened using HPV test..
EXCLUSION CRITERIA:
⮚ HPV positive women who do not consent for treatment.

SAMPLE SIZE:
Sample Size Calculation formula:

n = 60

n = required sample size

z= confidence level of 95% (standard value of 1.96)
p = Expected HPV positive cases in cervical cancer – 96 %
d = margin of error of 5% .
METHODS:
HPV testing is done as a screening tool in the community set up in all women of
reproductive age group(30 – 60 years) using ‘Care HPV kit’. Women who are HPV
positive are advised to come to Oncology Dept, GKNMH. Colposcopy is done in all
HPV positives and women with normal colposcopy findings are treated with
cryotherapy ablating the transformation zone. In colposcopy , if high grade
changes are noted, then biopsy is done and LEEP carried out .

REFERENCES:

1.Walboomers J. M. M., Jacobs M. V., Manos M. M., et al. Human papillomavirus is a necessary cause of
invasive cervical cancer worldwide. The Journal of Pathology. 1999;189(1):12–19.

2.Reid R., Stanhope C. R., Herschman B. R., Booth E., Phibbs G. D., Smith J. P. Genital warts and cervical
cancer. I. Evidence of an association between subclinical papillomavirus infection and cervical
malignancy. Cancer. 1982;50(2):377–387.

3.International Agency for Research on Cancer. IARC Handbooks of Cancer Prevention. Vol. 10. Lyon,
France: IARC Press; 2005. Cervix cancer screening. International agency for research on cancer; pp. 1–
302

4.Sung H, Ferlay J. Siegel RL, Laversanne M, Soerjomataram I, Jemal A, et al,Global cancer statistics 2020:
GLOBOCAN Esimates of incidence and Mortality worldwide for 36 cancers in 185 countries. CA Cancer J
Clin 2021;71(3):209-49

5.Walboomers, J. M. M., M. V. Jacobs, M. M. Manos, F. X. Bosch, J. A. Kummer, K. V. Shah, P. J. F.

Snijders, J. Peto, C. J. L. M. Meijer, and N. Munoz. 1999. Human papillomavirus is a necessary cause of
invasive cervical cancer worldwide. J. Pathol. 189:12-19.