Jennifer S. Smith University of North Carolina JenniferS@unc

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 Dea

ths

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 methodEndpoint ≥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 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: January: Cervical Cancer Awareness Month Cervical Cancer Awareness Month is right around the corner.is right around the corner.