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