J E N N I F E R L . Y O U N G , M D , M P H

G R A N D R O U N D S

D e p a r t m e n t o f O b s t e t r i c s a n d G y n e c o l o g y

M e d i c a l U n i v e r s i t y o f S o u t h C a r o l i n a

J a n u a r y 2 5 , 2 0 1 1

From Kilimanjaro to Charleston: How Cervical cancer screening in Africa

may impact our practice in the future

64,928Europe

67,078

AFRICA49,025

South America

14,845United States/

Canada

1,077Australia/

New Zealand

39,648Southeast

Asia

51,266Eastern Asia

21,596Central America

151,297Southcentral

Asia

Cervical Cancer: A Worldwide Problem

Prevalence: 2,274,000 women have cervical cancer1

Incidence: 510,000 new cases each year1

1. World Health Organization. Geneva, Switzerland: World Health Organization; 2003:1–74. 2. Bosch FX, de Sanjosé S. J Natl Cancer Inst Monogr. 2003;31:3–13. Modified after Merck & Co.

Objectives

Provide you with an understanding of the timeline and planning that goes into international research

Why does a study take 3 yrs to initiate and 3 wks to complete

Discuss types of HPV testing kits and differences between them

Why can’t we just use what we have here?

By the way, what test is that?

Review the data obtained from rapid HPV testing in rural Tanzania

How Arusha TZ is ahead of SC

Options for HPV testing in low resource settings

Pap smear Low sensitivity – requires repeat testing over years

High materials cost – requires use of slides (difficult to transport) or liquid media with expensive equipment

Low reproducibility – need expert pathologists

Visual inspection with acetic acid (VIA) Low sensitivity for small, early lesions

Requires expert examination and biopsies (with pathologist)

HPV testing High sensitivity

Limited expertise necessary

Method of testing determines expense

Sakaranarayanan R et al. NEJM 2009. 360:1385.

HPV testing decreases cervical cancer mortality

Tanzanian pilot study

•Plan to bring careHPV to rural mission hospital in Arusha, TZ

•Population of unscreened Masai women

•Pilot of 300 women for feasibility

Objectives of Tanzanian Pilot study

Aim 1: HPV genotyping to determine applicability of HPV vaccination in this area

Aim 2: Comparison of standard methods of cervical cancer screening

Aim 3: Comparison of careHPV to HC2 HPV testing for utilization in this low resource setting

Tanzania 2008

Building relationships

Hospice visits – dispensing medications and providing support

Study items established

Female providers preferred

Women know about cervical cancer and are interested in being screened

Cannot exclude the hospital staff

Exam remains very embarassing for women, even health care professionals

Hospice team has strong connections to community for recruitment

Tanzania 2009

A feasibility study

Its in the details

5 team members

2 nurses

1 translator

6 suitcases of equipment

One close call with import services

One not as close call with US customs

1 grand rounds on HPV and cervical cancer

Everybody has a different job…

Study items established

Protocol as it stands is feasible

Need community based consent process

Established core Selian staff for assistance

Cleaning and sterilization techniques acceptable to staff

Shipping paps for US testing feasible and consistent with expected results

3 outreach lectures to community and health care workers

HPV testing: aren’t they all the same?

All testing based on DNA amplification No utilize traditional PCR for this methodology Tests available include: Hybrid capture II Cervista Cervista 16,18 careHPV And others

Keep in mind the goal not to determine any presence of HPV but rather to determine the likelihood that the patient has a

dysplasia caused by HPV

PCR methodology

Method was devised by

Kary Mullis of Cetus

Corporation, Emeryville

• He recieved a $20,000

bonus and later a Nobel

Prize

• Later the patent was

sold to Hoffman-

LaRoche for

$300,000,000

PCR

1. Hologic. Cervista package insert. 2010

Hybrid capture II

Nucleic acid hybridization assay Target DNA hybridized with specific RNA probes In this case: 13 HPV types 16,18,33,35,39,45,51,52,58,59,68

DNA-RNA hybrids captured on a microplate with antibodies specific to these

Signal detection with labelled, conjugated antibodies Emitted light measured as relative light units where 1.0

consistent with 1 pg HPV DNA/mL

Receiver operating characteristic (ROC) curve of the Hybrid Capture I assay and the Hybrid

Capture II assay.

Kuhn L et al. JNCI J Natl Cancer Inst 2000;92:818-825

© Oxford University Press

CIN2+2

Sensitivity 80%Specificity 85.4%PPV 21.1%NPV 99.0%

2. Soderlund-Strand et al. J Clin Microbiol 2005: 43(7): 3260.

Cervista™

Utilizes patented Invader technology

Signal amplification of specific DNA sequences

14 HPV types tested

HPV16, 18, 31, 33, 35,39, 45, 51, 52, 56, 58, 59, 66, and 68

Clinical Performance Summary of Cervista: Compared to Colposcopy/Central Histology ≥ CIN2

among Women with ASC-US Cytology

Sensitivity 92.8% (64/69) 95% CI: (84.1% - 96.9%)

Specificity 44.2% (558/1263) 95% CI: (41.5% - 46.9%)

PPV 8.3% (64/769) 95% CI: (7.6% - 8.9%)

NPV 99.1% (558/563) 95% CI: (98.1% - 99.6%)

Disease Prevalence 5.2% (69/1332) Note: Among women with ASC-US cytology, there were 1.1% (15 out

1347) CervistaTM HPV HR indeterminate results with 95% CI: 0.7% to 1.8%.

Cervista™: Limitations

Does not detect DNA of HPV low-risk types (6,11,42,43,44)

Exhibits cross-reactivity to two HPV types of unknown risk

An HPV positive result was observed with 5000 copies/reaction of HPV type 67

50,000 copies/reaction of HPV type 70.

Does not exclude the possibility of HPV infection because very low levels of infection or sampling error may cause a false-negative result

Interference was observed in cervical specimens contaminated with high levels (2%) of contraceptive jelly and/or anti-fungal creams

The test has been validated for use only with cervical cytology specimens

Cervista vs HC2

SHENCCAST II study – China

8,435 women

By ROC curves, tests are clinically equivalent

Cervista Hybrid Capture II

p-value

Disease prevalence

11.1% 13.6%

Sensitivity for CIN2+

92.9% 95.5%

Specificity 91.1% 88.6% <0.05

careHPV compared to Hybrid Capture 2

careHPV Hybrid Capture 2 (HC2)

DNA amplification DNA amplification

Solution surfactants Solution toxic chaotropic salts

Assay time 2.5 hours Assay time 6 hours

Capture magnetized beads coated with monoclonal antibody

Capture microplates

Cost $4 Cost $100

Qiao Y et al. Lancet Oncol 2008; 9: 929-936.

careHPV Test: New rapid HPV test developed by QIAGEN (Gaithersburg, MD)

2388 women tested in rural China

70 diagnosed with ≥ CIN2

Using diagnosis of CIN2+ as the standard

Qiao Y et al. Lancet Oncol 2008; 9: 929-936.

Test Sensitivity Specificity

careHPV 90% 84.2%

VIA 41.4% 94.5%

Hybrid Capture 2 97.1% 85.6%

Team Tanzania 2010

15 team members

3 female health care providers

3 excellent pap smear cleaners

1 study coordinator

1 scientist

2 Hospice nurses

2 nursing assistants

2 lab assistances

1 driver

The details

4 boxes of testing equipment

20 boxes of gloves

15 tubes of KY jelly

325 thin prep paps

325 Digene careHPV tests

600 consents and 300 study intake forms

1000 glass slides

324 patients enrolled

2 facilities

1 truck

A note on approval, consent, and recruitment

IRB approval took 2 years

Cancer center protocol review comm

UVA IRB

Selian IRB

Tanzanian Government IRB (wait 4-6 months…)

Edits made

Repeat………………..x3!

Consent

Education first!

Translation only or a true connection to the community

Recruitment

Mama Makule with Dr. Peyton Taylor (Babu)

Meetings held with regional pastors association

Significant education regarding cervical ca and screening

Screening study annouced in congregations for 3 weeks

Each day brought one congretation of women

Transportation provided

Study population

324 women enrolled

Average age 42 years (30-60 years)

Majority in monogamous relationships

21% postmenopausal

Nonsmokers

HPV and Pap Testing results

42/324 (12.8%) were HPV positive

7 of 42 or 16.7% were positive for ≥ CIN2

No cancers were diagnosed

1 patient diagnosed with CIN3 was negative for HPV

Comparison of careHPV to HC2

Specimens careHPV HC2 HR HPV DNAor CIN2/3

True positives 31 + + +

2 - + +

2 + - +

True Negatives 278 - - -

9 - + -

Indeterminate 1 - - +

•careHPV agreement with HC2•Positive agreement 94% (95% CI 80.4, 98.3)•Negative agreement 99.3% (95% CI 97.4, 99.8)•Total agreement 98.7% (95% CI 96.8, 99.5)

Comparing Testing Methods

Test Sensitivity Specificity PPV NPV

VIA 34% 81.8% 21.9% 89%

Pap smear 48.7% 99% 95% 92.9%

HC2 96.9% 94% 78.6% 99.2%

careHPV 99.6% 94% 97% 99.3%

Note that disease is defined as HPV infection not dysplasia based on currentrecommendiations for treatment in low resource settings.

Most frequent HPV genotypes

6

1 1

4

2

4

1 1

4

1

3

1

2

1

0

1

2

3

4

5

6

7

Number of Specimens

16 18 26 31 33 35 39 45 51 52 56 58 66 68

High risk HPV genotypes

HPV genotyping implications

HPV 16/18 offered in current HPV vaccinations

7/42 or 16.7% positive for HPV 16 or 18

Much lower than the anticipated 70% reduction in cervical HPV disease quoted for HPV vaccine in developed countries

Conclusions

HPV testing remains the best option for cervical cancer screening in low resource setting

careHPV shows excellent agreement with current sophisticated HPV testing methods

Low prevalence of HPV types covered by current vaccination

Acknowledgements

Dr. Peyton Taylor

Dr. Mark Stoler

Dr. Paul Eder

QIAGEN

Ms. Barbara Badman

Mrs. Asha Nyanga’nyi

Dr. Gweneth Lazenby

Dr. Emil Mchaki

Mrs. Elizabeth Makule

Selian and ALMC staff