Cervical Cancer-Free
America Initiative Overview
Changing the Dialogue about
Cervical Cancer Prevention
Jennifer S. Smith
University of North Carolina
JenniferS@unc.edu
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
HPV Type Specific Prevalence in All Cases
HPV Types by Cervical Status:
Potential Impact of 16/18 Vaccine
100%
80%
60%
40%
~70%
~50%
20%
~14-25%
0%
Invasive Cancer
HSIL
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
LSIL
Optimal to Vaccinate Adolescent Girls
before Sexual Debut
35 %
Estimated start
of sexual life
30
25
Frequency
Papillomavirus
20
Infection (all types)
15
10
5
0
5
10
15
20
25
30
35
40
45
50
Age (years)
1- Hypothetical distribution of HPV prevalence in EU modeled after data available in the US and Canada
55
60
65
70
75
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
HPV Vaccine Coverage
National Immunization Survey-Teen
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 Type Specific Prevalence in All Cases
Continued Need for Screening
Following HPV Vaccination
100%
80%
60%
40%
~70%
~50%
20%
~14-25%
0%
Invasive Cancer
HSIL
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
LSIL
Decrease in Cervical Cancer Mortality
Following Introduction of Pap Test in the
United States
Number of Deaths
30,000
25,000
20,000
15,000
10,000
5,000
0
1941
1995
1999
2003
Years
2006
2009
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
Endpoint ≥CIN 2
Screening method
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.
Pap Smear Guidelines: 2009 American
College of Obstetrics and Gynecology
<21 Years
No routine
Pap smear
*History
21-29 Years
Bi-annual
Pap smear
of cervical cancer or DES in utero, HIV
positive, immunosuppression, or other risk factors
for acquiring STDs.
30-64 Years
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.*
≥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.*
ACOG Practice Bulletin No. 109. Obstet Gynecol. 2009;114:1409-20.
We can Change the Dialogue
We can End Cervical Cancer
Policy Makers
Vaccination
Screening
We can Effect Real Change at the State-Level
Age-adjusted Mortality Rates
per 100,000, 2001-2005 SEER Data
Indiana
Kentucky
California
DC
North Carolina
Age-adjusted Death Rates per
100,000 Quantile Interval
3.0 – 3.7
2.8 – 2.9
2.5 – 2.7
Alabama
HAWAII
ALASKA
Texas
SEER = Surveillance, Epidemiology, and End Results
2.2 – 2.4
1.9 – 2.1
1.5 – 1.8
US Rate 2.5
1. Surveillance, Epidemiology and End Results (SEER) Cancer Stats NCI, 2001-2005.
Cervical Cancer Free America
Common 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 Alabama
University of Alabama
Mona Fouad, Warner Huh,
Theresa Wynn
Cervical Cancer Free Kentucky
University of Kentucky
Baretta Casey, Rick Crosby,
Robin Vanderpool
Cervical Cancer Free Indiana
University of Indiana
Gregory Zimet
Kirk Forbes
Cervical Cancer Free North Carolina
University of North Carolina
Noel Brewer, Pamela Entzel,
Jennifer Smith
How Can We Work
Actively Together?
January:
Cervical Cancer Awareness Month
is right around the corner.