hpv: how to prevent your patients from becoming my patients katina robison, md assistant professor,...

HPV: How to prevent your

patients from becoming

my patientsKatina Robison, MD

Assistant Professor, Department of Obstetrics & GynecologyDirector of Colposcopy

Brown University / Women and Infants’ HospitalProgram in Women’s Oncology

Oropharyngeal Cancer

Oropharyngeal Cancer

Cervical CancerCervical Cancer

Anal CancerAnal Cancer

HPV Prevalence

• Koutsky LA, Am J med 1997 – estimated

prevalence• 1.4 million (1%) genital warts• 5 million (4%) detected by colposcopy• 14 million (10%) HPV positive – neg colpo• 81 million (60%) HPV negative with detectable

antibodies TOTAL INFECTED = 75% of population

TOTAL INFECTED = 75% of population

There are at least 14 oncogenic HPV

genotypes in the anogenital region

There are at least 14 oncogenic HPV

genotypes in the anogenital region

Most Prevalent HPV Types

Squamous Cervical Cancer

Munoz et al. N Engl J Med. 2003;348:518-527

58%

13%

5% 4% 3%

All

HPV

-infe

cted p

ati

ents

(%

)

60

50

40

30

20

10

0

>70% of cases of cervical cancerare associated with HPV 16 or 18

HPV 16 HPV 18

Most Prevalent HPV Types

Adenocarcinoma

Castellsague X et al. J Natl Cancer Inst. 2006;98:303-315.

Pre

vale

nce

of

HPV

typ

e in

ca

ses

of

ad

en

oca

rcin

on

ma

(%)

HPV DNA was detected in 93% of patients with cervical adenocarcinoma.

HPV 16 HPV 18 HPV 45 Multitype

HPV 16/18

One of highest oncogenic risks known!

• Male 40 pack-yr smoking hx vs nonsmoker• RR of lung cancer: 9.6

• Postmenopausal women on HRT vs no HRT• RR of breast cancer: 1.3

• HPV16+ vs negative• RR of cervical cancer: 434

Prevention

HPV vaccines are 93% effective in

preventing cervical cancers

secondary to HPV 16 and 18

How is Rhode Island doing?

• GIRLS • 39.9% IN KANSAS • 76.6% IN RHODE ISLAND

• BOYS •11.0% IN KANSAS •69.3% IN RHODE ISLAND

HPV Vaccine

$360

Cervical Cancer

Treatment

$40,000

Screening

Cervical PAPANICOLOU Smear

Herrero R. Monogr Natl Cancer Inst 1996; 21:1-6

77% reduction in the incidence of invasive cervical cancer

77% reduction in the incidence of invasive cervical cancer

No RCTs have evaluated efficacyNo RCTs have evaluated efficacy

April 2014: FDA approves cobas

HPV test for primary cervical cancer

screening in women over 25 years

Effectiveness For Screening

HPV versus Cytology

Detect CIN 2+

Sensitivity Specificity

HPV + 97.1% 93.3%

Cytology 76.6% 95.8%

Cuzick, J et al Lancet 2003;362:1871-76

ACOG: When to Start and Why?

• Age 21

• Cancer rarely seen prior to19 years

• Only 1.7% adolescents estimated to have HSIL

• 70-90% HPV regression rates within 3 years1,2

• 80-90% LSIL regression in 13-21 yo (50-80% in adult

women)1

• CIN 2 regresses 65% and 75% of the time after 18

months and 3 years3

1Moscicki AB. J Pediatr 1998; 132:277-2 2Ho GY. NEJM 1998; 338:423-42 3Moore K, et al. AJOG 2007; 197:141e1-141e6 4Fuchs, et al. J Pedi Adol Gyn 2007;20:269-274.

Frequency of screening

• 21 to 29 years• Cytology alone

• Every 3 years

• HPV testing should NOT be used to screen

• 30 to 65 years• Cytology alone (acceptable)

• Every 3 years

• Cytology and HPV testing (preferred)• Every 5 years

Can we screen for other HPV

related cancers?

Formal guidelines are lacking

Consider in HIV positive, MSM, and studies

underway in HIV negative women

Anal CytologyAnal Cytology

Thank You

krobison@wihri.org

401-954-9811