New Tools for Cervical Cancer Prevention Jose Jeronimo, MD June 11, 2009
Theta Eta Kappa Mu Lambda Nu A10 Lota A13 A1 Zeta A8 Delta A9 Epsilon A11 A7 Alpha A5 Beta A6 A2 A15 A4 New Genus Pi A3 Gamma Xi Omikron Human Papillomavirus (HPV) Condyloma Neoplastic Vaginal ≥100 HPV genotypes ~40 mucotropic HPV genotypes ~15 Carcinogenic HPV genotypes
Natural History of HPV infection and Cervical Cancer Peak Ages: 15-25 25-35 45-50 Schiffman, et al., Lancet, 2007
Primary prevention Secondary Prevention
Cervical Cancer Incidence1 Europe 59,931 North America 14,670 Asia 265,884 Central and South America 71,862 Africa 78,897 1. Ferlay J, Bray F, Pisani P, Parkins DM; International Agency for Research on Cancer (IARC). GLOBOCAN 2002: Cancer Incidence, Mortality, and Prevalence Worldwide. Lyon, France: IARCPress; 2004. CancerBase No. 5, version 2.0.
Current menu of options for screening. PAP smear VIA HPV testing
Trends in age-standardized incidence rates of cervical cancer in four Nordic countries Parkin DM. Bray F. Vaccine. 2006 Aug 31;24 Suppl 3:S3/11-25
Limitations of cytology-based programs: • Deficit of trained cyto-technologists. • Delay of results. • Multiple visits: lack of follow-up. • Cost. • Sub-optimal sensitivity.
Pap smear sensitivity 100% of Pre-cancer cases
VIA “VIA is a good alternative for settings where conventional cytology is not well implemented.” –IARC/WHO, 2005 IARC, WHO. IARC Handbooks of Cancer Prevention: Cervical Cancer Screening. Volume 10. IARC Press; 2005.
HPV DNA testing CIN 2+ HART Tuebingen Hannover Jena French Public French Private Seattle Canada Combined 0% 10% 30% 50% 70% 90% 100% HPV sensitivity Cuzick et al., IJC, 2006 Mayrand et al., NEJM, 2007
HPV16+ HPV18+ HPV+ HPV- Follow-up according to HPV result Khan et al., JNCI, 2005; Castle et al., AJOG, 2007
A new HPV-DNA test for low- resource settings hc2 CareHPV test
Accuracy of CareHPV, hc2, and VIA in China n=2,382 (Shanxi Province, China) Reference standard: directed, four-quadrant biopsy and ECC (>CIN 2) externally read.
careHPV A new HPV test for low-resource settings. Affordable price for public-health programs in low- and middle-income countries. First regulatory filing expected in late 2009 Commercially available in late 2010. Currently used in demonstration projects.
START-UP* demonstration projects *Screening Technologies to Advance Rapid Testing for Cervical Cancer Prevention—Utility and Program Planning (START-UP) project.
Challenges in HIV infected women • Higher prevalence of HPV infected women.* Performance of screening tests different than general population: - Higher positive rates.* Need for intervention.* PATH evaluation options in countries with high HIV prevalence.
Conclusions: • There is no screening test 100% effective for detecting cervical pre-cancer. • There are more affordable options forsecondary prevention in low-resource settings. • Screening for cervical cancer in HIV infected women seems to be more challenging than HIV negative women.
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Next session: June 18th, 2009 Christina Marra HIV and Neurology
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