Welcome to I-TECH HIV/AIDS
Clinical Seminar Series
9 September 2010
Cervical cancer screening in resourcelimited settings
Jose Jeronimo, MD
Cervical cancer screening in
resource-limited settings
Jose Jeronimo, MD
I-Tech distance learning sessions
September 9, 2010
1
Cervical Cancer Incidence
Europe
59,931
North America
14,670
Central and
South America
71,862
Africa
78,897
Asia
265,884
1. Ferlay J, Bray F, Pisani P, Parkins DM; International Agency for Research on Cancer (IARC).
GLOBOCAN 2002: Cancer Incidence, Mortality, and Prevalence Worldwide. Lyon, France:
IARCPress; 2004. CancerBase No. 5, version 2.0.
Human Papillomavirus (HPV)
Epsilon
FPV
PePV
TmPV1
Condyloma
25
19
20
14D
21
5
36
47
RTRX7
12
8
93
24
96
92
76
75
49
23
22
38
37
17
A8
7 2
5
67
33
58
31 R
16
A9
35
73
34 PV
Rh
97
45
18R
68
39
70
85
59
69
26
82a
51
53
30
66
56
78
10
94
28
A11
Neoplastic
A7
Alpha
A5
A6
A2
A15
84
86
87
BPV4
BPV935
BPV6
PsPV
50
48
60
65
3
29
7771a
90 6
0
1
57
27
2a
62
81
61
72
89
83
102
8
15 0
Vaginal
Ha 1 0 9
O1P 3
0V
1
Beta
Eq
O PV
v
Ov PV 1
PV 2
1
R
EE PV
PV
DP
B V
BP PV
V
BPV 2
5
A13
A1
6
1
741a
44
55
1C3h
PC PV
PV
54
a
32
42
43
9
40 1
Delta
PV
RO V
P
CR
63
PV1
Fd PV
CO
11
PV4
Ed PPVV
n
Muin
Eq
Theta
Eta
Mu Kappa
Lambda
A10
Nu
Lota
Zeta
New
A3
Pi
Genus
GammaXi
Omikron
A4
≥100 HPV genotypes
~40 mucotropic HPV genotypes
~15 Carcinogenic HPV genotypes
Natural History of HPV infection
and Cervical Cancer
Peak Ages:
15-25
25-35
45-50
Schiffman, et al., Lancet, 2007
Primary
prevention
Secondary Prevention
Current screening options
Visual inspection
PAP smear with acetic acid HPV testing
(VIA)
CervicalIncidencia
Cancer
Incidence,
England
de cáncer cervical invasor
1971-95
estandarizada por edad, Inglaterra 1975-95
100
18
90
80
70
14
60
Invasive cervical cancer
50
40
10
30
National call-recall introduced
20
10
0
Quinn et al, BMJ 1999
95
19
91
19
87
19
83
19
79
19
19
19
71
75
06
Percentage
Incidence rate / 100,000
Coverage
Sensitivity of Cytology: CIN2+
CIN 2+
HART
Tuebingen
Hannover
Jena
French Public
French Private
Seattle
Canada
Combined
0%
Cuzick et al., IJC, 2006
Mayrand et al., NEJM, 2007
10%
30%
50%
70%
90%
100%
VIA
“VIA is a good alternative
for settings where
conventional cytology is
not well implemented.”
–IARC/WHO, 2005
IARC, WHO. IARC Handbooks of Cancer Prevention: Cervical Cancer Screening.
Volume 10. IARC Press; 2005.
VIA
Negative
Positive
Unmagnified view
Alternatives for screening: HPV DNA
testing
The
digene®HC2
HPV DNA
Test
The
careHPV™
Test
HPV DNA testing
CIN 2+
HART
Tuebingen
Hannover
Jena
French Public
French Private
Seattle
Canada
Combined
0%
10%
30%
50%
70%
HPV sensitivity
Cuzick et al., IJC, 2006
Mayrand et al., NEJM, 2007
90%
100%
Follow-up time and HPV result
25%
HPV16
+
HPV18
+
Acumulate Incidence ≥CIN3
20%
15%
10%
5%
HPV
+
0%
0.0
4.5
15.0
27.0
39.0
51.0
63.0
75.0
Follow-up (months)
Khan et al., JNCI, 2005; Castle et al., AJOG, 2007
87.0
99.0 111.0 119.5
HPV-
The careHPV™ Test: a new HPV DNA
test for low-resource settings
The careHPV™ Test: an alternative for
developing countries
START-UP* demonstration projects
*Screening Technologies to Advance Rapid Testing for Cervical Cancer
Prevention—Utility and Program Planning.
Preliminary results
Screening method
Vaginal careHPV
Cervical careHPV
VIA
Pap (ASCUS+)
Sensitivity*
Specificity*
(95% CI)
(95% CI)
87.8%
83.9%
(73.8, 95.9)
(82.3, 85.4)
85.4%
88.8%
(70.8, 94.4)
(87.4, 90.1)
73.2%
78.5%
(57.1, 85.8)
(76.8, 80.2)
48.9%
98.2%
(32.9, 64.9)
(97.6, 98.7)
*Clinical sensitivity and specificity estimates.
Based on results from 2,239 women with screening and final diagnosis completed in Nicaragua and Hyderabad.
41 cases of CIN2+.
Cervical cancer in HIV infected women
Higher prevalence of HPV infected women.
Performance of screening tests is different than in
general population:
- Higher positive rates.
Need for intervention.
Need for evaluation of screening and treatment
strategies in countries with high HIV prevalence.
Conclusions
• There is no screening test that is 100%
effective for detecting cervical precancer.
• There are more affordable options for
secondary prevention in low-resource
settings.
• Screening for cervical cancer and treatment
in HIV-infected women seems to be more
challenging than screening and treating HIVnegative women.
Thank you
jjeronimo@path.org
www.path.org
www.rho.org
Thank you!
Listserv: itechdistlearning@u.washington.edu
Email: DLinfo@u.washington.edu
Welcome to I-TECH HIV/AIDS
Clinical Seminar Series
Next session: 23 September 2010
Mystery Opportunistic Infections
Shireesha Dhanireddy MD