jennifer s. smith university of north carolina [email protected] cervical cancer-free america...
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Jennifer S. Smith University of North
Carolina [email protected]
Cervical Cancer-Free America Initiative Overview
Changing the Dialogue about Cervical Cancer Prevention
Carolina Framework for Action against Cervical Cancer
There are four key challenges to eradication of cervical cancer that a comprehensive public health strategy can address:
• HPV infection• Lack of screening• Screening errors• Not receiving follow-up care for abnormal Pap smear
results
Brewer and Smith
HPV virus-like particles (VLPs): Basis of HPV vaccination
For Prevention of Cervical Cancer:• Persistent HPV 16/18 infections • HPV 16/18 abnormal pap smear
0%
20%
40%
60%
80%
100%
Invasive Cancer HSIL LSIL
HPV Types by Cervical Status: Potential Impact of 16/18
Vaccine
~70%~50%
~14-25%
HP
V T
ype
Spe
cific
Pre
vale
nce
in A
ll C
ases
ICC data: Smith et al. Int Journal of Cancer, 2007, 121 (3), 621-32.HSIL data: Smith et al. Int Journal of Cancer, 2007, 121 (3), 621-32.LSIL data: Clifford et al. Cancer Epidemiol Biomarkers. 2005;14:1157-1164
Optimal to Vaccinate Adolescent Girls
before Sexual Debut
1- Hypothetical distribution of HPV prevalence in EU modeled after data available in the US and Canada
35
30
25
20
15
10
5
Age (years)
%Estimated start of sexual life
0 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75
Frequency
Papillomavirus
Infection (all types)
Prophylactic HPV Vaccine Approved for Adolescent Girls
Vaccine HPV Types FDA approved Age range
Bivalent 16/18 2009 10-25* yrs
Quadrivalent 6/11/16/18 2006 9-26* yrs
*Routine vaccination for 11-12 year old females
Females aged 13-17 years
US 2009: 44.3% (42.4%-46.1%) for 1+ dose 26.7% (25.2%-28.3%) for 3 doses completed
August 20, 2010 / 59(32);1018-1023
HPV Vaccine Coverage National Immunization Survey-
Teen
0%
20%
40%
60%
80%
100%
Invasive Cancer HSIL LSIL
Continued Need for Screening Following HPV Vaccination
~70%
~50%
~14-25%
HP
V T
ype
Spe
cific
Pre
vale
nce
in A
ll C
ases
ICC data: Smith et al. Int Journal of Cancer, 2007, 121 (3), 621-32.HSIL data: Smith et al. Int Journal of Cancer, 2007, 121 (3), 621-32.LSIL data: Clifford et al. Cancer Epidemiol Biomarkers. 2005;14:1157-1164
Decrease in Cervical Cancer Mortality Following Introduction of Pap Test in
the United States
0
5,000
10,000
15,000
20,000
25,000
30,000
1941 1995 1999 2003 2006 2009
Num
ber o
f D
eath
s
Years
1. OBGYN.net. Available at: http://www.obgyn.net/displayarticle.asp?page=/yw/articles/braun_PAP 2. American Cancer Society. Cancer Facts & Figures. Available at: http://www.cancer.org/
Sensitivity of Cervical Cancer Screening Methods
Screening method
Endpoint ≥CIN 2
Sensitivity % (95% CI)
Pap smear only 71 (61-81)
HPV DNA test only 95 (89-99)
Pap smear with HPV DNA test 100 (96-100)
Naucler P, et al. JNCI. 2009;101:88-99.
30-64 Years21-29 Years<21 Years
No routine Pap smear
Pap Smear Guidelines: 2009 American College of Obstetrics and
Gynecology
Pap smear every 3 years
..if patient has had 3 or more
normal Pap results in a row,
no abnormal test results in 10 years, and
lacks other risk factors.*
*History of cervical cancer or DES in utero, HIV positive, immunosuppression, or other risk factors for acquiring STDs.
Bi-annual Pap smear
ACOG Practice Bulletin No. 109. Obstet Gynecol. 2009;114:1409-20.
≥65 Years
Consider discontinuing
Pap smear at 65 or 70 years
..if patient has had 3 or more
normal Pap results in a row,
no abnormal test results in 10 years, and
lacks other risk factors.*
We can Change the Dialogue
We can End Cervical Cancer
Policy Makers
Vaccination
Screening
We can Effect Real Change at the State-Level
ALASKAHAWAII
DC
Age-adjusted Death Rates per 100,000 Quantile Interval
3.0 – 3.7
2.8 – 2.9
2.5 – 2.7
2.2 – 2.4
1.9 – 2.1
1.5 – 1.8
US Rate 2.5
Age-adjusted Mortality Rates per 100,000, 2001-2005 SEER
Data
SEER = Surveillance, Epidemiology, and End Results 1. Surveillance, Epidemiology and End Results (SEER) Cancer Stats NCI, 2001-2005.
California
Indiana
Texas
North Carolina
Alabama
Kentucky
Cervical Cancer Free AmericaCommon State Goals
To increase HPV vaccination among young female adolescents ages 10-18
To increase cervical cancer screening among women ages 25-70 who have not been screened in the last four years
.
Cervical Cancer Free California
California Medical Association Foundation
Sara Cook, Carol Lee, Elissa Maas
Cervical Cancer Free North Carolina
University of North Carolina
Noel Brewer, Pamela Entzel,Jennifer Smith
How Can We Work Actively Together?
January: January:
Cervical Cancer Awareness Month Cervical Cancer Awareness Month
is right around the corner.is right around the corner.