CERVICAL CANCER CERVICAL CANCER PREVENTION AND CONTROLPREVENTION AND CONTROL

IN THE AMERICASIN THE AMERICAS

Silvana LucianiPan American Health Organization

May 2008

Presentation OutlinePresentation Outline

§§ Burden of cervical cancer in the AmericasBurden of cervical cancer in the Americas

§§ Recommendations for effective programsRecommendations for effective programs

§§ Challenges and opportunities Challenges and opportunities

§§ Proposal for a Regional Strategy and Plan Proposal for a Regional Strategy and Plan of Actionof Action

Source: Wright, TC. NEJM 2003

How cervical cancer developsHow cervical cancer developsHOW CERVICAL CANCER HOW CERVICAL CANCER DEVELOPSDEVELOPS

Estimated Number of Women with Estimated Number of Women with HPV, PreHPV, Pre--cancer and cancer and Cancer Cancer

in the Americas in the Americas

PrePre--cancerous lesionscancerous lesions

Cervical CancerCervical Cancer87,00087,000

1.5 -5 million

Source: Castellsagué X et al. Vaccine 2007WHO, C4GEP 2006

336 million

Women with HPV infectionWomen with HPV infection

Female population (15 years +)Female population (15 years +)

52 million

87,000 new cases87,000 new casesper yearper year

39,000 deaths 39,000 deaths per yearper year

Source: IARC, Globocan 2002Source: IARC, Globocan 2002

Cervical Cancer Cervical Cancer In The AmericasIn The Americas

Cervical Cancer Mortality Trends 1955-2003

0

5

10

15

20

25

1955

1961

1967

1973

1979

1985

1991

1996

2000

2003

Year

Rat

e pe

r 100

,000

Costa RicaChileMexicoColombiaCanadaUSACuba

Trends in Trends in Cervical Cancer Mortality Cervical Cancer Mortality

in in selected countriesselected countries

Source: WHO Mortality databaseSource: PAHO Mortality Database, 2007

§§ ScreeningScreening§§ high coverage of women at riskhigh coverage of women at risk§§ accurate screening test accurate screening test

§§ Treatment for women detected with Treatment for women detected with prepre--cancer and cancercancer and cancer

§§ High quality of treatment and careHigh quality of treatment and care

CERVICAL CANCER IS CERVICAL CANCER IS PREVENTABLEPREVENTABLE

WHO Policy RecommendationsWHO Policy Recommendations

§§ Screening test:Screening test: cytology cytology •• alternative screening tests in pilot settingsalternative screening tests in pilot settings

§§ Target age group:Target age group: 30 years +30 years +•• cover highest risk groups firstcover highest risk groups first•• once in lifetime screen, best age: 35once in lifetime screen, best age: 35--45 years45 years

§§ Frequency of screening:Frequency of screening: 3 year interval3 year interval

§§ PrecancerPrecancer treatment: outpatient basistreatment: outpatient basis•• cryotherapycryotherapy, LEEP, LEEP

§§ Cancer treatment: surgery and radiotherapyCancer treatment: surgery and radiotherapy

WHO Policy RecommendationsWHO Policy Recommendations

Cervical Cancer Prevention Cervical Cancer Prevention ProgramProgram

ChallengesChallenges withwith Cervical Cervical CancerCancerPreventionPrevention ProgramsPrograms

Women

Health Services Technology

coveragecoverage

qualityqualityfollowfollow upup

§§New screening testsNew screening tests

§§ Screen & treat approachScreen & treat approach

§§HPV vaccinesHPV vaccines

Opportunities to ImproveCervical Cancer Prevention

ScreeningScreening for cervical cancerfor cervical cancer

Pap Test Pap Test HPV DNA test

Visual inspection with acetic acid (VIA) FastHPV DNA test

Screening TestsScreening Tests

§§ Cost effective strategyCost effective strategy§§ Links screening to immediate Links screening to immediate

treatmenttreatment§§ One visit reduces loss to follow upOne visit reduces loss to follow up

§§ Easily integrated into routine Easily integrated into routine primary health care servicesprimary health care services

Screen & Treat ApproachScreen & Treat ApproachScreen and Treat ApproachScreen and Treat Approach

Screening in the HPV Vaccine Era

Improve country capacity for comprehensive Improve country capacity for comprehensive cervical cancer prevention and control:cervical cancer prevention and control:§§ Health educationHealth education

§§ Screening and preScreening and pre--cancer treatmentcancer treatment

§§ Cancer treatment and palliative careCancer treatment and palliative care

§§ HPV vaccine introductionHPV vaccine introduction•• analysis of evidence to support policy decisionanalysis of evidence to support policy decision•• when it can be sustainable, relying on affordable pricewhen it can be sustainable, relying on affordable price

Proposed Regional Strategy Proposed Regional Strategy & Plan of Action& Plan of Action

Cervical CancerCervical CancerMortality RatesMortality Rates

by subby sub--region, by ageregion, by age

0

20

40

60

80

100

120

0-14 15-44 45-54 55-64 65+

AGE GROUP [years]

Dea

th R

ate

N. AmericaCen. AmericaCaribbeanSo. America

Source: IARC, Globocan 2002

Incidence and MortalityIncidence and Mortality87.3

5553.252.4

48.247.347.245.6

38.736.4

3631.230.830.630.629.528.227.1

2725.824.923.423.2

21.520.218.816.7

8.87.77.7

48.130.4

26.12324.6

22.222.323.5

2118.2

16.812.2

17.317.217.2

14.112.9

10.714

10.99.410.2

7.812

8.376.2

2.82.52.3

10080604020020406080100

HAITÍBOLIVIA

PARAGUAYBELIZE

PERUGUYANA

NICARAGUAEL SALVADOR

ECUADORCOLOMBIA

VENEZUELAJAMAICA

DOMINICAN REPUBLICGUATEMALAHONDURAS

MÉXICOPANAMA

TRINIDAD & TOBAGOSURINAME

CHILEBARBADOS

BRASILARGENTINA

COSTA RICACUBA

URUGUAYBAHAMAS

PUERTO RICOCANADAE.E.U.U.

Age Standardized Rates per 100,000

ASIR ASMR

Source: IARC, Globocan 2002

Cervical Cancer Incidence & Cervical Cancer Incidence & Mortality Rates in the AmericasMortality Rates in the Americas

Source: IARC Globocan, 2002

05

101520253035

Caribbean Mexico &CentralAmerica

SouthAmerica

Canada/USA

Sub-Region

Age

-Sta

ndar

dize

d pe

r 100

,000

MortalityIncidence

%

69.8

38.132.8

57.7

31.426.3

32.535.6

0

20

40

60

80

Indígena Otro Mestizo Blanco Indígena Ladino

Ecuador 2004 Guatemala 2002Source: ENDEMAIN, ECUADOR-INEC 2004 ; DHS -2002 GUATEMALA

Inequities in Cervical Cancer Screening Coverage

Proportion of Women Never Having a Pap Test in Ecuador & Guatemala

Source: Ecuador INEC, 2004

Guatemala DHS, 2002

Single Visit Screen & TreatSingle Visit Screen & Treat Effect of visual screening on cervical cancer incidence and mortality in Tamil, Nadu, India

0

20

40

60

80

100

Cervical cancerincidence

Cervical cancer deaths

ASR

per 1

00,0

00

Control GroupIntervention Group

Source: Sankaranarayanan, The Lancet 2007