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Mary Applegate, MD MPH
Interim Dean UAlbany School of Public Health February 15, 2007
• Cervical cancer 101
– Cause: Human Papilloma Virus (HPV) – “Natural history” – Treatment
• Preventing cervical cancer – Avoiding exposure to HPV – Current screening guidelines – The new HPV vaccines
Cervical Cancer 101 • Abnormal cell growth on cervix (lowest part of the uterus) • Caused by HPV infection. especially during the first years after puberty • Pre-cancerous changes long before invasive cancer develops • Rarely fatal in this country • A major cause of death worldwide 3 .
200.000 new cases annually 80% of women have HPV by age 50 50% of college students are infected 4 . but 15-20 can cause cancers • Very common – – – – 20.000.000 current cases in US 6.Human Papillomavirus (HPV) • Long known to cause warts • Found in many cancers too • Over 100 types identified • Most benign.
1996 – World Health Organization/European Research Organization on Genital Infection and Neoplasia.HPV & Cervical Cancer • HPV recognized as the underlying cause of cervical cancer since 1996 – NIH Consensus Conference on Cervical Cancer. 1996 5 .
58. 44. 82 Precancer cervical changes Cervical cancer Anal and other cancers 1.9:1. 70. Cox. 35. Munoz et al. 39. 54. 11. 51.348:518. 33. Baillière’s Clin Obstet Gynaecol. 68. 59. 43. 73.Common HPV Types and their effects HPV Types Low-Risk HPV 6. 56. 2003. 81 Lead to: Benign cervical changes Genital warts High-Risk HPV 16. 72. 2. 61. 40. 42. 1995. 52. 31. N Engl J Med. 6 . 18. 45.
Y. . CA Cancer J Clin 2005. 55:74-108. Cancer of penis Cancer of throat Cancer of mouth Cancer of esophagus Cancer of skin Cancer of X. .Z….Human Papillomavirus Cancer of cervix Cancer of anus Cancer of vulva. . vagina 100% 90% 40% 40% 12% 3% . 7 Parkin DM et al.
Natural History of HPV Infections • Sexually transmitted • Usually no symptoms • No treatment for HPV infection before symptoms • Immune system clears most cases. . some persist • HPV present in >99% of cervical cancers • High risk types (16. 105: 905-18. 2005. ACOG Practice Bulletin No. 11) are associated with genital warts • All can cause abnormal Pap tests 8 Human Papillomavirus. 61. 18) associated with cancer • Low risk types (6.
Modern Colposcopy.Co-factors for HPV Infection •Smoking •HIV infection •Other immune system defect •Pregnancy •Oral contraceptive use 9 Ferris et al. . 2004.
1973-1997. 2000.163:503. Epidemiology and End Results (SEER) Cancer Stats NCI. Sellors et al. Ries et al.000 10 25 20 15 10 25 20 15 10 5 0 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 5 0 Age (Years) 1.HPV and Cervical Cancer Rates by Age 30 HPV Prevalence (%) 30 Cancer incidence per 100. 2. Surveillance. CMAJ. 2000. .
HPV Infections: Summary • • • • Most people are infected by HPV at some time Immune system usually clears HPV. but not always Persistent low-risk HPV can lead to genital warts Persistent high-risk HPV can lead to pre-cancer Long persistence of HPV can lead to cancer HPV 11 .
Preventing Cervical Cancer • Screening for precancerous changes (and treatment if problems found) • Vaccination against HPV 12 .
49.History of the Conventional Pap Smear • Developed by Dr. Ferris et al. George N.org/Cytopaths/1998/cytoFall98. Modern Colposcopy.htm 13 . Papanicolaou in 1940’s • Most common cancer screening test • Key part of annual gynecologic examination • Has greatly reduced cervical cancer mortality in U.S. Photo accessed from http://www.cytology-iac. 2004: 2-4.
Screening with the Conventional Pap Smear • Widely available • Inexpensive • But not perfect – Screening test – not diagnostic – 7-10% of women need further evaluation – Low sensitivity – need regular repeats 14 Cervical Cytology Screening. 45. 102:417-27. . ACOG Practice Bulletin No. 2003.
. Arch Pathol Lab Med. et al. uniform layer of cells – Screening errors reduced by half • Screening needed less often • Can test for HPV with same specimen if abnormal cells found • Expensive 15 Linder J.New Liquid Pap Tests • More accurate test – Thin. 122: 139-144. 1998.
2003.Cervical Cancer Screening Guidelines • First screen 3 years after first intercourse or by age 21 • Screen annually with regular Paps or every 2 years with liquid-based tests • After three normal tests. can go to every three years • Stop at 65-70 years with history of negative tests • Still need annual check-ups 16 Cervical Cytology Screening. 45. . 102:417-27. ACOG Practice Bulletin No.
6.NEW! The HPV Vaccine Gardasil ® (Merck) • • • • • • • • Protects against types 16. 18. 2003. 11 FDA approved for use in females 9-26 years of age Prevents HPV infection. Cancer. doesn’t treat existing infection Virus-like particles (VLP) Highly effective Safe.53(1): 27-43. . RA et al. few serious adverse side effects Requires 3 injections Expensive ($360 + administrative fees) 17 Smith.
108: 699-705. regardless of sexual activity • Less potential benefit with increasing age & number of sexual partners Special populations – vaccine less effective • Previous abnormal Pap tests or genital warts • Immunocompromised Continue screening with Pap tests! 18 Human Papillomavirus Vaccination. 2006. 344. ACOG Committee Opinion No.HPV Vaccine ACOG Recommendations VACCINATE all females 9-26 years old. .
. 344. 2006. ACOG Committee Opinion No. 108: 699-705. give remaining dose(s) post-partum • Breastfeeding women • Men 19 Human Papillomavirus Vaccination.HPV Vaccine ACOG Recommendations NOT CURRENTLY RECOMMENDED (Awaiting more evidence) Continue screening with Pap tests! • Women over age 26 • Pregnant women – If vaccine started before pregnancy.
. 344.HPV Vaccine Important Considerations Continue screening with Pap tests! • Vaccine is most effective before first sexual intercourse – less effective in sexually active women • HPV testing before vaccine not recommended • Vaccine is not a treatment for current HPV infection. genital warts. 108: 699-705. or pre-cancer 20 Human Papillomavirus Vaccination. ACOG Committee Opinion No. 2006.
ACOG Committee Opinion No. 108: 699-705. 344. but limited data • Most side effects are minor – Injection site reaction • Potentially effective in preventing cervical cancer (and other HPV-related cancers) – BUT not all cancer-causing HPV types are covered by the vaccine Continue screening with Pap tests! 21 Human Papillomavirus Vaccination.HPV Vaccine FAQ • Vaccine will not cause HPV – Virus-like particle vaccine (not live virus) • HPV vaccines appear to be very safe – Few major adverse events. 2006. .
2005. ACOG Practice Bulletin No. “ThinPrep Papanicolaou testing to reduce false -negative cervical cytology.”Arch Pathol Lab Med. 1994. Lacey CJN. Pa: Lippincott-Raven. Iowa: Kendall/Hunt. 4th ed. 2004.” J Clin Virol. “The 2001 Bethesda System Terminology. 1995. Apgar BS. 102:417-27. Obstet Gynecol 2005. Ferris et al. Dubuque.9:571–578. 1999. Jansen KU. 108: 699-705. Obstet Gynecol 2005. 2006.334:1030–1038. and the American Social Health Association Panel. Niloff JM. Howley PM. ACOG Committee Opinion No. Human Papillomavirus.gov/nip/recs/provisional_recs/hpv. Howley PM. Cancer facts and figures 2003. “Management of genital warts. Management of Abnormal Cervical Cytology and Histology. Modern Colposcopy: Textbook and Atlas. Fields Virology.org/downloads/STT/CAFF2003PWSecured. Cox.cdc. Cannistra SA. “Therapy for genital human papillomavirus-related disease. American College of Obstetricians and Gynecologists. 105: 905-18. Available at http://www. Roy M.pdf. eds. “Cancer of the Uterine Cervix. 66. American College of Obstetricians and Gynecologists. Accessed from http://www.” Annu Rev Med. Philadelphia. Maw RD. 78-82. 45. Shaw AR. Centers for Disease Control and Prevention. American College of Obstetricians and Gynecologists. 61. 2004. et al. Obstet Gynecol 2003.” Am J Clin Pathol. 101:215-219. et al. Hutchinson ML. Human Papillomavirus Vaccination. Md: CDC National Prevention Information Network. Cervical Cytology Screening. ACIP provisional recommendations for the use of quadrivalent HPV vaccine. 22 .References Advisory Committee on Immunization Practices. “An international survey of patients with genital warts: perceptions regarding treatment and impact on lifestyle.70:2335–2342.” Int J STD AIDS. Rockville. Nasraty S. 1998. 2004: 2-4. American Cancer Society.9:1. Cates W Jr. 122: 139-144. 1998. American College of Obstetricians and Gynecologists. et al. 344. Kodner CM.pdf.68:1992–1998.55:319–331.” Sex Transm Dis. ”Human Papillomavirus Vaccines and prevention of cervical cancer.” N Engl J Med. Atlanta (GA): ACS 2003. “Estimates of the incidence and prevalence of sexually transmitted diseases in the United States. Baillière’s Clin Obstet Gynaecol. 49. 2003. 106: 645-64. ACOG Practice Bulletin No. 1996. “Homogeneous sampling accounts for the increased diagnostic accuracy using the ThinPrep Processor. August 14.32(suppl):S82–S90. Linder J.” Am Fam Physician. Knipe DM. Reitano M. 2nd ed.cancer. In: Fields BN.” Am Fam Physician. 2004. Obstet Gynecol 2006. 2001:2197–2229.26(suppl):S2–S7. ACOG Practice Bulletin No.
T. Evaluation of Cervical Cytology. Philadelphia. et al. Epidemiology and End Results (SEER) Cancer Stats NCI. Castle PE. “Human papillomavirus: Epidemiology and public health. A. AG. “Global cancer statistics 2002. 2006.52:342-362. Pisani P.” CA Cancer J Clin. Canada. Pa: Lippincott Williams & Wilkins. Wiley DJ. Ferlay J. Kurman R. “Genital human papillomavirus infection: Incidence and risk factors in a cohort of female university students. 24S3. 2003. Davey D.” Vaccine.) McCrory DC. 2003. Spitzer M.” CA Cancer J Clin 2005. “American Cancer Society Guidelines for the Early Detection of Cancer. 13th ed. Johnson C. 2002.” CMAJ. Schiffman M ASCCP 2002 Biennial Orlando. Philadelphia. “2001 Consensus Guidelines for the Management of Women with Cervical Cytological Abnormalities. Available at http://www. 2003. 157:218-226. Novak’s Gynecology. Beutner K.B. Soper DE. 2002:453– 470.” N Engl J Med. Ostor. Evidence Report/Technology Assessment No. Winer RL et al. 2003.163:503-8. 2003. et al.” Int J Gynecol Pathol 1993.348:518.53(1): 27-43. “Updating the natural history of HPV and anogenital cancer. 23 .C.127:930–934. USPSTF.287:2114–2119. 287: 2120-2129. treatment and prevention. 1973-1997. JAMA. 42-51.” Arch Pathol Lab Med. Parkin DM. et al. Douglas J. Sellors et al.” Clin Infect Dis. Fl. Surveillance. February 1999. “Natural history of cervical intraepithelial neoplasia: a critical review. In: Berek JS. “Prevalence and predictors of human papillomavirus infection in women in Ontario. Wright.” JAMA. 2003. 55:74-108. Saslow D et al. MD: Agency for Health Care Policy and Research. Schiffman M. 2002. 2002.htm. Ries et al. RA et al. et al “External genital warts: diagnosis. “Epidemiologic classification of human papillomavirus types associated with cervical cancer.ahrq. Smith. 2002:41–72.35(suppl 2):S210–S224. Moscicki.” Cancer.” Am J Epidemiol. Rockville. Bastian L. 2002. for the Forum Group Members and the Bethesda 2001 Workshop. 99-E010. 5. et al. Solomon D. ed. AHCPR Publication No. 2000. “American Cancer Society Guideline for the Early Detection of Cervical Neoplasia and Cancer. 2000.References (Cont. 12(2): 18692. Bray F. Munoz et al.gov/clinic/uspstf/uspscerv. Pa: WB Saunders Co. Matchar DB.
Cancer Services Program Please take a few moments to complete the evaluation! 24 . Kim Noyes Preventive Medicine Resident. School of Public Health Information provided by the New York State Department of Health.Questions? Program sponsored by Middle Earth Slide set developed with help from Dr.
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