HPV: How to prevent your patients from becoming my patients

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HPV How to prevent your patients from becoming
my patients

• Katina Robison, MD
• Assistant Professor, Department of Obstetrics
  Gynecology
• Director of Colposcopy
• Brown University / Women and Infants Hospital
• Program in Womens Oncology

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Cervical Cancer
Anal Cancer
Oropharyngeal Cancer
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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
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There are at least 14 oncogenic HPV genotypes in
the anogenital region
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Most Prevalent HPV Types Squamous Cervical Cancer
58
60
50
gt70 of cases of cervical cancerare associated
with HPV 16 or 18
40
All HPV-infected patients ()
30
20
13
10
5
4
3
0
HPV 16
HPV 18
Munoz et al. N Engl J Med. 2003348518-527
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Most Prevalent HPV Types Adenocarcinoma
HPV DNA was detected in 93 of patients with
cervical adenocarcinoma.
Prevalence of HPV type in cases of
adenocarcinonma ()
HPV 16
HPV 18
HPV 45
Multitype
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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

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Prevention
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HPV vaccines are 93 effective in preventing
cervical cancers secondary to HPV 16 and 18
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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

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HPV Vaccine 360
Cervical Cancer Treatment 40,000
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Screening
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Cervical PAPANICOLOU Smear
77 reduction in the incidence of invasive
cervical cancer
No RCTs have evaluated efficacy
Herrero R. Monogr Natl Cancer Inst 1996 211-6
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April 2014 FDA approves cobas HPV test for
primary cervical cancer screening in women over
25 years
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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 20033621871-76
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ACOG When to Start and Why?

• Age 21
• Cancer rarely seen prior to 19 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 132277-2 2Ho GY.
NEJM 1998 338423-42 3Moore K, et al. AJOG
2007 197141e1-141e6 4Fuchs, et al. J Pedi Adol
Gyn 200720269-274.
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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

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Can we screen for other HPV related cancers?
Anal Cytology
Formal guidelines are lacking Consider in HIV
positive, MSM, and studies underway in HIV
negative women
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Thank You
krobison_at_wihri.org 401-954-9811