STI Team Log Frame and Priorities

1
The Role of WHO in Control of Cervical Cancer
World Health Organization
Katharine Shapiro, PA, MPH Department of
Reproductive Health Research Cervical Cancer
Control Project Dr. Cecilia Sepulveda,
Coordinator, Program on Cancer Control
2
The Role of WHO in Control of Cervical Cancer
Acknowledgements Dr. Nathalie Broutet
Reproductive Health Research, Dr. Andreas
Ullrich, Program on Cancer Control, Dr. Sonia
Pagliusi, Initiative for Vaccine Research
3
Topics to be covered

• Magnitude of the problem
• Causes and natural history
• WHO - A comprehensive approach
• Prevention - vaccines
• Early detection - screening and treatment
• Treatment and palliative care
• Collaboration
• The challenges ahead

4
Magnitude of the problem

• Cervical cancer is of the leading causes of
  cancer among women
• 480,000 new cases per year
• 234,000 deaths per year
• 1.4 million prevalent cases (Globocan, 2000)

5
Magnitude of the problem
Incidence 452 000
6
Regional disparities in incidence trends
7
Magnitude of the problemMain reasons for
regional differences

• Lack of effective primary prevention
• Lack of effective early detection and treatment
  programmes
• Differences in prevalence of risk factors

8
(No Transcript)
9
WHO activities to control cervical cancerProgram
on cancer controlA comprehensive approach
10
WHO activities to control cervical cancerProgram
on cancer controlA comprehensive approach
Healthy
population
Prevention
Early
detection
and treatment
Exposed to
Risk
T
reatment
Early
Stages
Advanced
Stages
Palliation
Death
11
Parallel track approach to HPV vaccine development
Epidemiological studies in Asia
Epidemiological studies in Africa
HPV vaccine introduction world-wide
Phase III trials
Cost-effectiveness analyses
Qualitative research for vaccine introduction
Advocacy
Decision point
YEAR
2003
2004
2005
2006
2007
2008
12
Prophylactic vaccines against HPV
HPV Type and Antigen
Status
Organization
Phase III US, L. America Nordic countries, Asia
Merck
16-18-6-11 L1 VLP
16-18 L1 VLP
NCI (US), GSK
To start Phase III Costa Rica
Ph II-III L.America US
16-18 L1 VLP
GSK
13
Estimated incidence of cervical cancer cases
Ongoing clinical trials for prophylactic HPV
vaccines
64.900
14.900
245.600
67.200
77.300
2.100
Asia accounts for about half of all cases
adapted from Globocan 2000
14
WHO activities to control cervical cancerProgram
on cancer controlA comprehensive approach
Healthy
population
Prevention
Early
detection
and treatment
Exposed to
Risk
T
reatment
Early
Stages
Advanced
Stages
Palliation
Death
15
Efficacy of screening

• Site Reduction in mortality
• Breast (age 50-69) 30
• Cervix 90
• Colon 30
• Providing adequate compliance achieved at the
  population level

16
Failures of cervical screening

• At level of the national program
• At the level of the community
• At the level of the woman
• At the level of the primary care provider
• At the level of the laboratory
• At the level of the gynecologist

17
Cervical Cancer Alternatives for early detection
Available
Effective
Cost
Early diagnosis
Yes


Cytology Screening
Yes
?

VIA
Yes
?

HPV Screening
REF 1) National Cancer Control Programmes,
Policies and Managerial Guidelines, 2nd ed. 2)
Report on a WHO Consultation Cervical Cancer
Cancer in Developing Countries (in press)
18
2001 Consultation Cervical Cancer Screening -
Conclusions

• Central to the success of any screening
  programme is adequate organisation and
  functioning irrespective of which method of
  screening is used
• Currently Cervical cytology is the only test
  known to reduce cervical cancer incidence and
  mortality in programmes, particularly in
  organized ones. (Though never proven by RCT)

19
2001 Consultation Cervical Cancer Screening -
Conclusions

• At present there is not sufficient evidence to
  recommend VIA based screening programmes. The
  results from on going RCT are being analysed
  will be available after IARC April meeting
• At his point in time there is insufficient
  evidence to recommend HPV tests for primary
  screening. Further research is required (Cost
  benefit analysis and RCT)

20
(No Transcript)
21
WHO steps for screening in resource-limited
settings

• Screen every woman once at age 45
• Once resources permit, expand to screen every
  woman at ages 35, 45 and 55
• When that has been achieved, expand to screen
  every 5 years from age of 35 to 59
• Only when the coverage is adequate for women
  age 35-59, extend screening to age 25 or more

22
WHO activities to control cervical cancerProgram
on cancer controlA comprehensive approach
Healthy
population
Prevention
Early
detection
and treatment
Exposed to
Risk
Treatment
Early
Stages
Advanced
Stages
Palliation
Death
23
Elements of an organised program

• The target population is identifiable
• Measures are available to guarantee high coverage
  and attendance
• There are adequate facilities for performing high
  quality screening tests
• There is an effective referral system for
  diagnosis and treatment of abnormalities
• There are adequate facilities for diagnosis and
  treatment

24
Cervical Cancer Control
The Package
Programme Manager
Adaptation tools
Programmatic guides

• Adaptation and Evidence-Based guides
• Training tools

• Service Programme Guidance
• Review of Screening and Programmatic strategies

Generic Guidelines
Health care providers

• Comprehensive Cervical Cancer Control a Guide
  for Essential Practice (C4-GEP)

• Specific, practical guides adapted to health care
  setting

25
WHO Core FunctionsStimulating the development
and testing of new technologies and guidelines
for disease controlCollaboration

• Within WHO
• Reproductive Health Research (RHR)
• Program on Cancer Control (PCC)
• Initiative for Vaccine Research (IVR)
• International Agency for Research on Cancer
  (IARC)
• Regional Offices - PAHO
• UN Agencies
• International Atomic Energy Agency (IAEA)
• UN Fund for Population Activities (UNFPA)
• Other Organizations
• ACCP, Academic institutions

26
Challenges Ahead

• Advocating for evidence based policies
• Reinforcing cytology screening where feasible
• Promoting low cost screening technologies for low
  resource settings
• Stimulating early diagnosis (awareness of early
  signs symptoms)
• Accelerating the development dissemination of
  HPV vaccines in developing countries

27
Challenges Ahead

• Promoting integrated intervention for prevention,
  early detection, treatment and palliation)
• Assisting countries in implementing effective and
  efficient programmes using a systematic approach
  involving all levels of the health care system
• WHO Cancer website www.who.int/cancer
• RHR website http//www.who.int/reproductive-healt
  h/
• IVR website www.who.int/entity/vaccine_research/
  en
• IARC website www.who.int/entity/vaccine_research/
  en