The Future Control of

Cervical Cancer
Hazel Lewis
Public Health Physician
Wellington
Cartwright Forum, 7 August 2015
 History of cervical screening in New Zealand
2008 Guidelines
incorporating HPV testing,
Cartwright LBC conversion
Report 1999 Guidelines
1st Parliam
NCSP established Gisborne Inquiry NCSP research: Review
HPV prevalence,
(CSI) Legislation
modelling primary
In 14 AHB amended HPV, Compass study
McGoogan
NCSP-R review Monitoring indicators
Screening reviewed and 2ndParliam
Trials centralised CCA implemented Review
In Thames, NSU Policies,
Wanganui, NCSP-R stds reviews
Otago, outsourced Cancer case
Lab Audits
Waikato audits
automation

146 recs implemented

1965 1988 19901996 2000 2001 2004 2008 2011 2015

Global Cervical Cancer Incidence,
2012
Global Cervical Cancer Mortality, 2012
 Cervical cancer incidence trends
(ASR (W) per 100,000)

Globocan, 2012
 The next 10 years: Dual
Prevention

We now have two powerful technologies to

dramatically reduce cervical cancer incidence:
- Screening for HPV infection
-Immunisation against HPV
Success will depend on using both technologies
together to achieve effective coverage in all groups
This will require better technologies, better
guidelines, better information systems and better
partnerships with all communities

-
 Dual prevention has its pitfalls
In principle, dual prevention should increase
effective coverage and reduce gaps
Two concerns:
-Perception of protection
-Impact on cytology screening laboratories
Response:
-Education
-Change screening test from cytology to HPV
 Challenges to implementing
dual prevention
Increase cervical screening coverage

Co-ordinate components of the screening programme, close gaps

(Who will do what? How much will communities be involved?)

Improve quality of the screening programme

Increase HPV vaccination coverage (2 doses?)

Reduce inequalities between socio-economic and ethnic groups

Minimise cost barriers free in primary care

Improve co-ordination between screening and immunisation

programmes

Media involvement (change behaviours, minimise risks)

Programmes must be: easily affordable, effective, equitable

 Screening for HPV
infection
Cervical cancer is caused by infection with specific
high-risk types of HPV (hrHPV)
15 hrHPV types identified in cervical cancers (16, 18,
31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 68, 73, 82)
Infection is common only a few of infected women
will develop cancer. Persistent infection (>2 years)
more likely to lead to cervical cancer
Cancer slowly develops over a period of years from
precursor lesions CIN, making screening possible
hrHPV testing has been shown to provide a much
better protection against CIN3 and cervical cancer
than cytology
 Natural history of HPV infection

Schiffman M, Castle P. N Engl J Med 2005, 353:2101-2104

 Primary HPV screening
Screening tests (cervical Pap smear, HPV) identify an existing pre-invasive cervical
lesion

Pap smear (ie cytology) has been the mainstay of cervical screening for past 60 years

However, increased awareness of limitations of cytology:

- Interpretation subjective, potential sources of error (lesion not sampled, abnormal cells
may not be transferred, preservation of cells may be inadequate, may be reading errors)

- Single Pap low sensitivity (44-65%)

- Poor in preventing adenocarcinoma

- Poor PPV unnecessary colposcopy

- Requires at least 3 yearly repeats

Effects of new HPV vaccines

Key clinical question that has informed change is the reduction in the burden of CIN3
and cervical cancer incidence and mortality by the combination of hrHPV testing and
cytology (60-70% greater efficacy than cytology alone)
 Primary HPV screening continued

- Impact on inequalities, as can self test with HPV

- Extending the screening interval from 3 to 5
years

- Education
- Effects on laboratories
- Transition phase, for safety reasons, given NZ
cervical screening, should be considered
 HPV tests
Two types:
- those that report pooled hrHPV types
- those that report the presence of HPV 16 and 18
HPV can be detected via DNA testing, RNA testing and
testing of cellular markers of HPV
Specimens can be obtained using a swab, broom, brush
or tampon which is then placed in a transport medium
Over 100 tests available worldwide but not comparable
A test can be falsely negative important to standardise
the quality of test used
New clinical guidelines for cervical screening

Key clinical questions must inform change:

What are the benefits and potential harms of
HPV screening with cytology triage?
What are the benefits and harms of starting
screening at 20, 25 or 30 years and when to stop?
What is the best screening interval?
Accuracy of self collected specimens?
Immunisation against HPV
Introduced on 1 September 2008

Provided for year 8 (11-12 year old girls)

Programme targeted and tailored implementation to achieve equity

Mixed school based and primary care delivery

Vaccine uptake higher when evidence of integration and information

sharing across components of the Programme (community
engagement, primary care and school based delivery systems)

Improvements should address misinformation about HPV vaccine,

integration of delivery systems, possible health equity mechanisms
(role of and levers available to primary health organisations locally)
 HPV vaccine current
issues
Full HPV vaccine coverage (3 doses) well below target
Coverage falls after 1st dose
Girls only, offered free vaccine
Impact on current cytology based screening (high grade
lesions)
Absence of data linkage - Immunisation Register with NCSP
Register, therefore unable to monitor effectively
HPV immunised women may not be screened, and will be at
risk for cervical cancer
Key health education messages (HPV vaccine and screening)
should be part of ongoing communication strategy
 Future developments in HPV
immunisation
Nonavalent vaccines (CE studies)
FDA approved Gardasil 9, Dec 2014 with HPV types
6/11/16/18/31/33/45/52/58
Two dose regimens should be explored
Better integration of HPV vaccine with screening
- Information systems (data linkage)

- Education

- Workforce
Greater involvement / empowerment of communities
Summary: Future Control of Cervical Cancer
Dual prevention
Better technologies
- Screening test (hrHPV)

- Vaccine (nonavalent)
Better implementation
- New clinical guidelines

- New register for cervical screening (Integrated Data Infrastructure)

- Data linkage of two registers (NCSP-R and NIR within IDI)

- Community Partnerships
Timely analysis and publication