hpv and cervical cancer, screening and prevention and cervical cancer, screening and prevention...
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HPV and Cervical Cancer, Screening and Prevention
John Ragsdale, MDJuly 12, 2018
CME Lecture SeriesPresenterPresentation NotesThis is a topic of medicine which is continuing to evolve we will look at the progresss we made around screening, vaccinations and look at cases
We have come a long WayPresenterPresentation NotesRates of cervical cancer have dropped to roughly of what they were in the seventies. In fact from the 1930s we have seen an 80% decline in the morbidity associated with cervical cancer
Prevalence HPV in Young Adults in U.SPresenterPresentation NotesYou will notice that happily, the rates are dropping due to increased rates of vaccination in the U.S. In fact you totaled the prevalence of all HPV serotypes from folks aged 18-59 anyone want to hazard a guess as to that %?
25% all cervical cancers
90-95% of warts
20% of all adeno-carcinomas
55-60% of All cancers
HPV genotypesPresenterPresentation NotesIf you know these statistics then you know why HPV 16 and 18 were originally the focus of so much energy and research So not all HPV is created equal most strains rarely if ever cause a problem And mostly they do not cause symptoms (hence the high prevalence)
- PresenterPresentation NotesDo you know what your vaccination rates are? Do you have system of reminders? What strategies are you using to motivate parents and kids to get vaccinated?we are not doing a very good job at vaccinating in NC we are below the national average Hep B discussion
HPV Vaccines Gardisil 9:
6, 11, 16, 18, 31, 33, 45, 52, and 58
Gardisil: 6, 11, 16, and 18
Cervarix: 16 & 18 For girls onlyPresenterPresentation Notes16 & 18 cause 70 % of all HPV mediated cancers do you know which you are offering in your clinicThese vaccines as we will see are effective but you have to use themThey will likely eventually cause a change in how we screen We do not know how long protection lasts that is a very active field of study
How Effective is the HPV vaccine? Answer very!!! Large RCT of 2392 women ages
16-23 split into two groups. All women were tested for HPV virus at enrollment One group was placebo
Rate of persistent HPV infection 3.8% One group got series of 3 HPV 16
vaccines at 0,2,and 6 months Rate of persistent infection 0%
A controlled trial of a human papillomavirus type 16 vaccine.Koutsky LA1, Ault KA, Wheeler CM, Brown DR, Barr E, Alvarez FB, Chiacchierini LM, Jansen KU; Department of Epidemiology, University of Washington, Seattle, USA. email@example.com
HPV vaccine: efficacy HPV Cancers U.S.
2008-12: 38,793 HPV-associated
cancers (11.7 per 100,000 persons)
23,000 (13.5) among females
15,793 (9.7) among males.
30,700/38,793 = HPV attributed
28,500/38793 = Preventable
Human PapillomavirusAssociated Cancers United States, 20082012 MMRW Weekly / July 8, 2016 / 65(26);661666
74% PreventablePresenterPresentation NotesTwo things on this slide caught my attention first the high number of preventable cancers and secondly the relatively high number of men that end up with HPV related cancers. What % of HPV is detected in all SCC and adenocarcs?: 99.7%
Risk FactorsPresenterPresentation NotesSmoking is assoc with SCC but NOT adenocarcRisk decreases by 50% after 10 yrs of quitting OCPs for 5-9 years assoc with hazard ratio of 2 effect is hormonal may be result of sex steroids on oncogenic expression BUT CIN is not a contraindication to OCPs
Cervical Cancer Screening
Being rarely or never screened is THE major contributing factor to the MOST cervical cancer deaths today.PresenterPresentation NotesAccording to the CDC Who is not screened?Minorities Low SESForeign born and has lived in the U.S. less than 10 yearsNo usual source of health care or fragmented healthcare
SC JunctionPresenterPresentation NotesSo the cervix is a busy place cytologically -cells are changing from columnar to squamous (column to plate)It is forever transforming and remodeling which is required for it to function normally So this is just a reminder about whats going on within the cervix anatomically and remember overtime the SC junction tends to migrate up into the OS making colposcopy more difficult
TZ: transformation zone
SCJ: squamo-columnar junction
SE: squamous epithelium
CE: columnar epitheliumPresenterPresentation NotesJust as a quick reminder about anotomyFrom central to peripheral
Review of Pap Nomenclature & Results
A bit of Context. Bethesda system
System for reporting cervical or vaginal cytologic diagnoses, used for reporting Pap smear results. It was introduced in 1988 and revised in 1991, 2001, and 2014.
ASCCP: Governing body Devised rationale cytological definitions
then correlated with pathologic definitions Established Guidelines:
Based on data from 1.4 million women followed from Jan 2003 December 31st 2010 at KaiserPresenterPresentation NotesStandardization began in the 80s when physicians began to realize there was no standard way of discussing pap abnormalities, and consequently, no standard parameters for treatment
Reflecting our evolving understanding HPV pathology
The ASCCP will no longer be referenced as the American Society for Colposcopy and Cervical Pathology but rather now simply as the ASCCP, with a mission to improve lives through the prevention and treatment of ano-genital and other HPV-related diseases.PresenterPresentation NotesFrom their webpageMission for the ASCCP recently updated to reflect our increasing understanding of the role HPV plays in the development of cervical pathology and more importantly and a rising emphasis on non cervical based HPV pathology we will be looking at slides later on of the broader disease burden the HPV is responsible for I think you will be surprised at the %s
HPV testing: a game changer
An increased detection of CIN3
Concomitant decrease in
CIN3+ or cancer
detected in subsequent screening
increased diagnostic lead time
Longer screening intervalsPresenterPresentation Notes40% more sensitive at detecting CIN3+ however they have a lower specificity
HPV testing: a game changer
Enhanced detection of women with adenocarcinoma of the cervix and its precursors
Bethesda System CIN System Dysplasia
ASCUS Cellular Atypia Unspecified Changes
ASC-H Cannot r/o high grade Variable
LGSIL CIN 1 Mild Dysplasia
Moderate Dysplasia/Severe Dysplasia
PhenotypicPresenterPresentation NotesThe bottom two are cancer equivalents It was the conferences with the ASCCP with the foundational work by the Bethesda group that began to bring
ASCUS ASCUS H nuclear enlargement in Pap tests is due to reactive change
About 4% of total pap results
Not a cancer equivalent but evidence of infection
First exclude moderate/severe cervical intraepithelial neoplasia or carcinoma in-situ (CIN3/HSIL)
A rare but significant finding of a cancer equivalent
2% have cancer at time of pap
20% will go on to get cancer without proper carePresenterPresentation NotesNo cellular designation was originally more problematic than ASCUS during the first Bethesda meeting in 1988Colposcopist dont like ASCUS H
LGSIL / CIN 1 What % of low grade pap smears progress to CIN2 or greater?
A)12-16%B)Less than 3%C)18-22%
Mildly increase nuclear/cytoplasmic ratioMild/moderate staining
What happens to LGSIL?
60% of CIN 1 regresses
30% of CIN 1 persists
10% progress to CIN 3
1% may ultimately go on to invasive cancer
Increased nucleoplasm to cytoplasm ratio
Moderately to severely abnormal morphology
Chromatin is more granular
Nuclear notches and folds
Nucleus is more hyper chromic
Care for contraception of STI screening / treatment is paramount
NO pap test NO speculum exam
for asymptomatic women
STI screening can be done using urine
Treatment Saves Lives, but there is a cost.
After LEEP women are more likely to have Preterm birth (O.R 1.7 Low birth weight (O.R. 1..8) PPROM (O.R. 2.7
Increased risk (small) with perinatal death from incompetent cervix
Risk rises with depth and number of LEEPs Conization vs. laser treatment risks
essentially the same Absolute risk is quite small
A 21 year-old G0P0 presents to your office for her first gynecologic examination.
She has no symptoms or complaints and does not report chronic medical conditions.
She does not smoke or use illicit drugs.
She has had two male sexual partners in her lifetime and has been using combination oral contraceptive pills for the past 14 months.
She has completed her HPV immunization series
What is the screening interval for a 21 year old female?
Pap and co-testing every three years
Pap only every three years Pap only every 5 years Annual pap smear
Cervical Cancer Screening Women under 30
HPV testing should not be used to screen
NOT as a function of co-te