Robyn Moxley MD CCFP Assistant Professor Department of Family Medicine Victoria Family Medical Centre Faculty Presenter Disclosure Faculty Robyn Moxley Relationships with commercial interests ID: 775010
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Slide1
Updates in HPV
Grand Rounds, May 1, 2019
Robyn Moxley MD CCFP
Assistant Professor, Department of Family Medicine
Victoria Family Medical Centre
Slide2Faculty/ Presenter Disclosure
Faculty:
Robyn Moxley
Relationships with commercial interests:
Grants/Research Support:
None
Speakers Bureau/Honoraria:
None
Consulting Fees:
None
Other:
None
Slide3Disclosure of Commercial Support
This program has received no in-kind support.
Potential for conflict(s) of interest
:
None
This program has received no commercial financial support.
Slide4Mitigating Potential Bias
N/A
Slide5Learning objectives
Discuss currently available HPV vaccines, indications, and funding
Describe the role of HPV testing in screening for cervical cancer – current and future recommendations
Review recommendations for follow up in primary care after discharge from colposcopy
Discuss recommendations for screening for anal intraepithelial neoplasia and anal cancer, including anal pap tests and high resolution
anoscopy
Human Papilloma Virus
In the absence of vaccination, an estimated 75% of sexually active Canadians will be infected with HPVPersistent infection with high-risk HPV types can lead to the development of pre-cancerous lesions These can progress to cancers of the cervix, vulva, and vagina in females, penile cancer in males, and anal and oropharyngeal cancer in both females and malesThe total burden of HPV-associated cancers among both genders is estimated at 5.2% of all cancers worldwide
Slide7HPV Vaccination
Slide8HPV Vaccination
In Canada, immunization against HPV types 16 and 18 can prevent approximately 70% of anogenital cancers and 60% of high-risk precancerous cervical lesions
HPV9
can prevent up to an additional 14% of anogenital cancers and up to 30% of high-risk precancerous cervical lesions caused by the additional five HPV types (31, 33, 45, 52 and 58)
Slide9Available Vaccines Against HPV
Gardasil 4 – authorized for use in Canada since 2006 for prevention of HPV types 6, 11, 16, 18Cervarix – authorized in 2010, for prevention of HPV 16, 18Gardasil 9 –3 dose schedule authorized in 2015, to prevent HPV 6, 11, 16, 18, 31, 33, 45, 52 and 58, For prevention of anogenital cancers, related pre-cancerous lesions, and AGWs
Slide10Who should be vaccinated
Cervarix
, Gardasil 4, and Gardasil 9 are all indicated for girls and women age 9-46
Gardasil 4 and 9 are indicated for boys and men age 9-26
No evidence of immunogenicity before age 9
Slide11Dose Schedule
2 dose schedule - if age younger than 15 at time of first dose and immunocompetent
Cervarix
– 0, 6 months
Gardasil 4 – 0 and 6-12 months
Gardasil 9 – 0 and 5-13 months
3 dose schedule – if age 15 or older at time of first dose or immune compromised or HIV infected
Cervarix
– 0, 1, 6 months
Gardasil 4 and 9 – 0, 2, 6 months
Slide12Publicly Funded HPV vaccines In Ontario
Female students in grade 8 were offered Gardasil 4 starting in 2007
Since 2017,
Gardasil 9
has been offered to
male and female
students in
grade 7
(born in 2004 or after)
If a student misses the grade 7 immunization clinic, they may receive the vaccine the next time the public health nurse is at the school, in the Immunization Clinic at the MLHU, or in their family doctor’s office (if they stock the vaccine)
Slide13Publicly Funded HPV vaccines In Ontario
Students who miss the vaccine are eligible for catch up at the health unit
until the end of grade 12
Cost at health unit is $175 per dose
Not required for school attendance
Slide14High risk HPV immunization Program
Gardasil 9 is offered to men who have sex with men (MSM) age 26 or youngerAvailable at the MLHU immunization clinicAmong MSM, the risk of persistent HPV infection and genital warts are about 3 times higher than heterosexual malesRisk of anal cancer is 20 times higher in MSM compared to heterosexual males
Nine-valent Human Papillomavirus (HPV9) Vaccine for Ontario’s High-Risk HPV Immunization Program: Information for Patients. MOHLTC. http://
health.gov.on.ca
/
en
/pro/programs/immunization/docs/hpv9_patient_fact_sheet.pdf
Slide15Which one should I prescribe?
Gardasil 9
–
can prevent up to an additional 14% of anogenital cancers and up to 30% of high-risk precancerous cervical lesions caused by the additional five HPV types (31, 33, 45, 52 and 58)
NACI has no current recommendations to re-vaccinate people who have previously had Gardasil 4 or
Cervarix
Slide16Should mid-adult women receive the vaccine?
Risk of high risk HPV (hrHPV) decreases with ageThere is a significant portion of mid-adult women (>25) with hrHPV infection, with a second peak of HPV infection in the 4th and 5th decades of life Risk increases with lifetime number of sexual partners, number of male sexual partners, and number of male partners the met onlineImmunosenescence - the natural physiological process in which the ability of the immune system declines with aging
Meghan
Plotnick
, MSc1; Catherine Craig, MD. Should HPV Vaccination Be Offered to Mid-adult Women? J
Obstet
Gynaecol
Can 2017;39(5):361e365 https://
doi.org
/10.1016/j.jogc.2017.01.015
Slide17Should mid-adult women receive the vaccine?
Four phase III clinical trials examined seroconversion for HPV-16 and HPV-18 in women >25. Seropositivity appears to last longer for HPV-16 than HPV-18, and longer if divalent vs quadrivalent vaccine is given.Two clinical trials examined the efficacy of the HPV vaccine in preventing persistent HPV infection with HPV- 16 or HPV-18 in women older than 25 years More research is needed for women >45
Meghan Plotnick, MSc1; Catherine Craig, MD. Should HPV Vaccination Be Offered to Mid-adult Women? J Obstet Gynaecol Can 2017;39(5):361e365 https://doi.org/10.1016/j.jogc.2017.01.015
Slide18Effectiveness of HPV4 in Canada
Systematic review of studies published between 2006 and 2016 (publicly funded HPV4 immunization for girls was introduced in 2007-2009)Prevalence of HPV types 6, 11, 16, and 18 was lower in qHPV-vaccinated than unvaccinated individuals (1.5% vs. 11.0%)Risk of AGW incidence decreased by up to 45% Incidence of CIN 2 + was reduced by up to 86%
Steben M, et al. A Review of the Impact and Effectiveness of the Quadrivalent Human Papillomavirus Vaccine: 10 Years of Clinical Experience in Canada Obstet Gynaecol Can 2018;40(12):1635–1645
Slide19HPV and cervical cancer screening
Slide20Papanicolaou smears
George N. Papanicolaou, “father of cytology”Also a PhD in zoology, studied cells from vaginal walls of guinea pigsDiscovered cancer cells from a vaginal sample of a hospital volunteer; presented findings at a meeting in 1928In 1939, worked with gynecologist and pathologist Herbert F Traut and gynecologist Andrew Marchetti to further develop the Pap testAll women admitted to the obs/gyne service at the New York Hospital routinely had a Pap testCancer could be diagnosed in asymptomatic women
Slide21Papanicolaou Smears
Initially the test consisted of collecting fluid from the vagina using a glass pipelleCanadian J Ernest Ayre developed technique of taking a scraping of the cervix, with “Ayre’s spatula”Paps were gradually adopted across Canada, started as a pilot project in BC in 1949, program was developed in Ontario in 1957Gradually incidence and mortality of cervical cancer decreasedLimitations: inadequate screening, false negatives, poor cervical sampling, and inappropriate follow up of abnormal smears
Slide22When Pap Testing Fails to Prevent Cervix Cancer
Study recruited women <50 with locally advanced cervical cancer (LACC) One-third of women presenting with LACC had appropriate Pap screening prior to diagnosis (13 out of 38) – invited for interviewPatients believe delays in their diagnosis resulted in detrimental quality of lifeThere is a need to educate physicians and the public about the symptoms of cervix cancer and to consider this diagnosis even when Pap screening has occurred
Slide23HPV testing in Screening Programs
For HPV to be considered for organized screening programs, it should haveGreater sensitivity than cytology for detecting existing high-grade cervical lesionsReduced rates of high-grade lesions in subsequent screening rounds, because of detection and treatment of lesions that would have persisted in the absence of HPV testingDemonstrated safety of extended screening intervals for HPV-negative patients
Murphy, et al. HPV Testing in Primary
Cervial
Screening: A Systematic Review and Meta-Analysis. J
Obstet
Gynaecol
Can 2012;34(5):443–452
Slide24HPV testing in screening programs
A systematic review and meta-analysis concluded that there is evidence from good quality RCTs supporting cervical cancer screening with HPV testing starting at age 30 or 35HPV testing provides a means of detecting clinically significant lesions earlierCIN3+ rates are lower in the second screening round2 studies showed that the intervention groups (HPV testing) had lower rates of cervical cancer incidence and mortality over timeLengthening of the screening interval in HPV negative women may be safe and feasible
Murphy, et al. HPV Testing in Primary Cervial Screening: A Systematic Review and Meta-Analysis. J Obstet Gynaecol Can 2012;34(5):443–452
Slide25HPV FOCAL trial
A publicly funded clinical trial conducted in BCComparing primary HPV testing with liquid-based cytology for cervical cancer screeningFrom 2008-2012, 19 009 women were randomized to the intervention (n = 9552) and control (n = 9457) groups Intervention group: HPV testing; if results negative returned at 48 monthsControl group: liquid-based cytology (LBC) testing; if negative returned at 24 months for LBC, if still negative then returned at 48 months At 48-month exit, both groups received HPV and LBC co-testing
Ogilvie, GS et al. Effect of Screening With Primary Cervical HPV Testing vs Cytology Testing on High-grade Cervical Intraepithelial Neoplasia at 48 Months: The HPV FOCAL Randomized Clinical Trial. JAMA. 2018 Jul 3;320(1):43-52. doi: 10.1001/jama.2018.7464.
Slide26HPV Focal Trial
The primary outcome was the cumulative incidence of CIN3+ 48 months following randomization; cumulative incidence of CIN2+ was a secondary outcomeThe CIN3+ incidence rate was 2.3/1000 (95% CI, 1.5-3.5) in the intervention group and 5.5/1000 (95% CI, 4.2-7.2) in the control group. The CIN3+ risk ratio was 0.42 (95% CI, 0.25-0.69). Baseline HPV-negative women had a significantly lower cumulative incidence of CIN3+ at 48 months than cytology-negative women (CIN3+ incidence rate, 1.4/1000 [95% CI, 0.8-2.4]; CIN3+ risk ratio, 0.25 [95% CI, 0.13-0.48]).Among women undergoing cervical cancer screening, the use of primary HPV testing compared with cytology testing resulted in a significantly lower likelihood of CIN3+ at 48 months
Ogilvie, GS et al. Effect of Screening With Primary Cervical HPV Testing vs Cytology Testing on High-grade Cervical Intraepithelial Neoplasia at 48 Months: The HPV FOCAL Randomized Clinical Trial. JAMA. 2018 Jul 3;320(1):43-52. doi: 10.1001/jama.2018.7464.
Slide27HPV testing in Ontario
Currently in Ontario, HPV testing should only be considered as a triage following an atypical squamous cells of undetermined significance (ASCUS) result for women who are age 30 years and older
HPV testing is not funded by OHIP
Cancer Care Ontario’s screening guidelines recommend that Ontario transition to primary HPV screening
Cancer Care Ontario is working with the MOHLTC to implement the HPV test as a primary tool for cervical cancer screening
Slide28HPV testing in Ontario
Cervical Screening: Guideline Recommendations were released by Cancer Care Ontario in 2005, revised in 2011 – currently under reviewSuggested changing to primary HPV screening in 2013 with interim guidelines which included recommendations for use of cytologyEvidence supports the use of HPV DNA testing of cervical cells as primary screening in women age 30 and over, with cytology only if HPV test is positive
J. Murphy, E. Kennedy, S. Dunn, M. Fung
Kee
Fung, D.
Gzik
, C.M.
McLachlin
, M. Shier, and L.
Paszat
. Cervical Screening: Guideline Recommendations. A Quality Initiative of the
Program in Evidence-Based Care (PEBC), Cancer Care Ontario (CCO). Original Report Date: May 20, 2005 Current Report Date: October 5, 2011
Slide29Summary of Screening recommendations from 2005-2013
Year (Section)Evidence baseImplementation timeframePrimary screening testAge of screening initiationScreening intervalAge of screening cessation2011(Part 1)Evidence and consensus-based (up to 2011)2013 (anticipated implantation of HPV testing in Ontario)Women 30+: HPV testing; women <30: TBDTBDEvery 5 years with a negative HPV test result652011(Interim)(Part 2)Evidence and consensus-based2011-2012Cytology testing21 Q 3 years702005Evidence-based (up to 2005)2005-2010CytologyWithin 3 years of sexual activityAnnually until 3 neg tests, then q 2-3 years70
Slide30J. Murphy, E. Kennedy, S. Dunn, M. Fung Kee Fung, D. Gzik, C.M. McLachlin, M. Shier, and L. Paszat. Cervical Screening: Guideline Recommendations. A Quality Initiative of the
Program in Evidence-Based Care (PEBC), Cancer Care Ontario (CCO). Original Report Date: May 20, 2005 Current Report Date: October 5, 2011
Slide31HPV testing in primary screening
There is insufficient evidence to make a recommendation for the age at which HPV testing should be used as the primary screen HPV testing performs better for women age 30 and overThe recommendation for HPV testing is applicable only in the context of an organized screening program with an adequate database infrastructure that allows for an invitation to screening at recommended intervals, and a follow-up of women with abnormal test results
J. Murphy, E. Kennedy, S. Dunn, M. Fung Kee Fung, D. Gzik, C.M. McLachlin, M. Shier, and L. Paszat. Cervical Screening: Guideline Recommendations. A Quality Initiative of the
Program in Evidence-Based Care (PEBC), Cancer Care Ontario (CCO). Original Report Date: May 20, 2005 Current Report Date: October 5, 2011
Slide32How to order HPV testing
HPV DNA testing of cervical cells, collected in same way as a pap smear
Detects the presence of 14 high risk HPV types, and specifically identifies HPV16 and HPV18
Options to order HPV with pap, reflex HPV testing if pap result is ASCUS, HPV without pap
Not recommended in women less than 30
Cost is $90
Slide33Slide34Atypical squamous cells of undetermined significance
ASCUS – if age <30, repeat in 6 m. if negative x 2, then back to routine screening. If repeat abnormal, refer to colposcopyASCUS – if 30 or older, offer HPV testing (private pay). If not testing for HPV, then same as aboveASCUS in women age 30 and older is the only time CCO recommends HPV testing – why?5-10% of women with ASCUS on their pap will have a high grade lesion31% to 60% of women with ASCUS are infected with high-risk HPV, DNA testing for these types has about 99% NPV
Provencher D, Murphy K. The Role of HPV Testing. JOCG. 2007. www.jogc.com/article/S1701-2163(16)32576-2/fulltext
Slide35When to refer to Colposcopy
ASCUS with positive HPV in women age 30 or olderIf repeat pap after ASCUS or LSIL shows any abnormalityASC-H, AGC, Atypical Endocervical Cells, Atypical Endometrial Cells, HSIL, Squamous Carcinoma, Adenocarcinoma, Other Malignant Neoplasms
CCO. Cervical Prevention and Screening Map.
https://www.cancercareontario.ca/sites/ccocancercare/files/assets/DPMCervicalPreventionandScreening.pdf
Slide36Follow up after Colposcopy
Different pathways depending if HPV testing has been done or not
HPV reflex testing is only recommended for women 30 or older who have LSIL, ASCUS, or normal cytology
HPV exit test should only be done for women 30 or older
It is not recommended to continue to test for HPV test after 2 positive repeat tests
Slide37Follow up after colposcopy – with HPV testing
Women 25 and older managed conservatively (no treatment)Cytology normal, ASCUS or LSIL with -ve HPV – low risk, screen trienniallyCytology normal or ASCUS with +ve HPV at exit from colpo – elevated risk, screen annually in primary careWomen treated for cervical dysplasia regardless of ageCytology normal, ASCUS or LSIL with –ve HPV – low risk, screen trieniallyCytology normal, ASCUS or LSIL with +ve HPV – elevated risk, screen annually in primary care
Slide38Follow up after colposcopy – with HPV testing
Younger women ages 21-24
Cytology is LSIL, ASCUS or normal – elevated risk, discharge to
screen annually
in the primary care setting
Atypical Glandular Cells (AGC),
Adenocarcincoma
In Situ (AIS) regardless of age
Post treatment, they should be followed in the colposcopy clinic for at least 5 years
If all results are negative, they can then be discharged back to primary care for
annual screening
or have long term annual colposcopy follow up
The role of HPV testing in AIS is unclear as
hrHPV
is a necessary condition for AIS
Slide39Follow up after Colposcopy – without HPV testing
Women 25 and older managed conservatively (no treatment)
If 3 consecutive negative
colpo
and
cyto
(
initialy
colpo
visit and 2 follow up visits) – low risk, routine screening triennially
If 3 consecutive
colpo
negative and
cyto
is ASCUS or LSIL – elevated risk,
screen annually
in primary care
Women treated for cervical dysplasia regardless of age
If 3 consecutive and
colpo
negative – low risk, routine screening triennially
If 3 consecutive
colpo
negative and
cyto
LSIL or ASCUS – elevated risk,
screen annually
in primary care
Slide40HPV and ANAL Cancer
Slide41HPV and Anal Cancer
Anal cancer is rare – 508 cases in Canada in 201080-90% are caused by HPV (strains 16 and 18)80% are squamous cell carcinoma of the anusMost arise in the squamo-collumnar junctionIncidence in Canada is 1.7 per 100,000 person yearsIn people with HIV, 49-144 per 100,000 person years
Medford, R.
Salit
, I.
Anal cancer and intraepithelial neoplasia: epidemiology, screening and prevention of a sexually transmitted disease .
CMAJ
2015. DOI:10.1503 /cmaj.140476
Slide42HPV and ANAL cancer
More common in women (66.4%), but increasing in people with HIV infection, especially men who have sex with men (MSM)Men and women with HIV, women with genital dysplasia or cancer, and recipients of solid-organ transplants are also at increased riskSan Francisco Men's Health Study (SFMHS) Anal HPV DNA was detected in 93% of HIV-positive (regardless of CD4 count) and 61% of HIV-negative MSMRates of anal cancer among HIV-positive men are approximately 70 per 100 000 person years - higher than cervical cancer rates among women, even in areas of the world with the highest rates of cervical cancer
Palefsky JM, Holly EA, Ralston ML, et al. Prevalence and risk factors for human papillomavirus infection of the anal canal in human immunodeficiency virus (HIV)-positive and HIV-negative homosexual men. J Infect Dis. 1998 02;177(2):361-7.
Slide43HPV and ANAL Cancer
Premalignant changes are called anal intraepithelial lesions (AIN), which can be classified as LSIL or HSILStudies have suggested the rate of transformation from HSIL to anal cancer is about 5%Screening for anal cancer and AIN is recommended for some patients, but there are no consensus guidelines in Canada
Long, C, et al. Screening, Surveillance, and Treatment of Anal Intraepithelial Neoplasia. Clin Colon Rectal Surg. 2016 Mar; 29(1): 57–64.
Slide44Screening for AIN and Anal Cancer
Digital anorectal exams
Anal pap smears
HPV testing
High resolution
anoscopy
Slide45Anal Cancer Screening Modalities
DAREAnal Pap testHPV testingHigh resolution anoscopySensitivityNot studied69-93%Alone: 100%Cotesting with pap: 72-96%Current diagnostic standardSpecificityNot studied32-59%Alone: 16%Current diagnostic standardResource availabilityN/AUbiquitousUbiquitousHighly selective centresProvider availability UniversalSpecialty clinicsSpecialty clinicsHighly selective centresLearning curvePart of usual trainingPart of usual trainingPart of usual training>200 casesCurrent consensusAnnually, in all HIV positive patientsAnnually in highest riskNo recommendationSecond-line screen following positive pap test
Leeds, I. Fang, S. Anal cancer and intraepithelial neoplasia screening: A review. World J
Gastrointest
Surg. 2016 Jan 27; 8(1): 41–51.
Slide46Screening for AIN and Anal Cancer
There is a lack of evidence that screening reduces rates of anal cancer or mortality, so there are no guidelines in this areaAnal cytology has not been shown to have any correlation with histologyThere is lack of consensus on how abnormal results should be managedThe University of California San Francisco screening algorithm is the most widely disseminatedAll high risk patients are screened annually with an anal pap smearAll atypical cytology results are referred for HRA
Leeds, I. Fang, S. Anal cancer and intraepithelial neoplasia screening: A review. World J Gastrointest Surg. 2016 Jan 27; 8(1): 41–51.
Slide47Recommendations – Cancer Care Ontario
CCO does not provide guidelines for screening for anal cancer in Ontario. “Experts suggest that anal pap testing should be conducted only in areas where there is access to cytopathology expertise for interpretation of results and appropriate follow-up of abnormal results (i.e. high-resolution anoscopy).”
E-mail correspondance from Cancer Care Ontario, Jan 30, 2019
Slide48recommendations – Canadian Cancer Society
“Some health professionals now recommend routine anal cancer screening for HIV-positive and HIV-negative MSM, using an anal Pap test, similar to the Pap test done to detect cervical cell changes in women and trans men. Others refer MSM clients for High Resolution Anoscopy.Studies show that annual screening of HIV-positive MSM and screening every 2-3 years for HIV-negative MSM provides benefits in both life expectancy and cost effectiveness.”
Colon cancer screening guidelines for gay and bisexual men
. Canadian Cancer Society http://
convio.cancer.ca
/site/
PageServer?pagename
=SSL_ON_HCP_HCPG_Colon#_
Anal_Pap_test
Slide49How to perform an Anal Pap
Avoid anal sex, douching, and the use of enemas for 24 hours prior to this procedureUse a water-moistened Dacron swab to collect cells (prior to anoscopy or anal examination)With the patient in left lateral position, gently insert the swab until it cannot be advanced further – it will be proximal to the anorectal transformation zone (squamocolumnar junction)Withdraw the swab with lateral pressure using a spiral motionSample may be processed using the ThinPrep liquid cytology technique
Colon cancer screening guidelines for gay and bisexual men
Canadian Cancer Society http://
convio.cancer.ca
/site/
PageServer?pagename
=SSL_ON_HCP_HCPG_Colon#_
Anal_Pap_test
Slide50What should we do?
HIV positive MSM are recommended to have anal pap smears
HRA is not currently offered in London
Refer to the Immunodeficiency Clinic at Toronto General Hospital
For HSIL, symptoms, abnormal DRE or
anoscopy
in office – refer to colorectal surgeon
Slide51Treatment for AIN
Vaccinate - there is evidence that vaccination decreases AIN incidenceSmoking cessationExpectant surveillanceTopical imiquimod or 5-FUWide local excisionTopical cryotherapy, electocautery, or infrared coagulationRecurrence rates are high
Long, C, et al. Screening, Surveillance, and Treatment of Anal Intraepithelial Neoplasia. Clin Colon Rectal Surg. 2016 Mar; 29(1): 57–64.
Slide52Take home messages
Vaccinate against HPV
Currently, only order HPV testing if you have a women age 30 or older with ASCUS
Screening for cervical cancer may change to primary HPV testing
Think of AIN and anal cancer in patients with HIV, immunosuppression, or MSM
There are no guidelines for screening for AIN, but you could considering doing an anal pap
Slide53References
Update on HPV Vaccines. The Public Health Agency of Canada. January 2012 • Volume 38 • ACS-1 ISSN 1481-8531 https://
doi.org
/10.14745/ccdr.v38i00a01
Updated Recommendations on Human Papillomavirus (HPV) Vaccines: 9-valent HPV vaccine 2-dose immunization schedule and the use of HPV vaccines in immunocompromised populations. An Advisory Committee Statement (ACS) National Advisory Committee on Immunization (NACI)
Nine-valent Human Papillomavirus (HPV9) Vaccine for Ontario’s High-Risk HPV Immunization Program: Information for Patients. MOHLTC. http://
health.gov.on.ca
/
en
/pro/programs/immunization/docs/hpv9_patient_fact_sheet.pdf
Plotnick
, M; Craig, C. Should HPV Vaccination Be Offered to Mid-adult Women? J
Obstet
Gynaecol
Can 2017;39(5):361e365 https://
doi.org
/10.1016/j.jogc.2017.01.015
Shaw, P. The History of Cervical Screening I: The Pap. Test.
JSoc
Obstet
Gynaecol
Can 2000;22(2): I I0-14
Corkum
M T,
Shaddick
H,
Jewlal
E, et al. (January 24, 2019) When Pap Testing Fails to Prevent Cervix Cancer: A Qualitative Study of the Experience of Screened Women Under 50 with Advanced Cervix Cancer in Canada.
Cureus
11(1): e3950. DOI 10.7759/cureus.3950
Public Health Agency of Canada. Update on Human Papillomavirus Vaccines. Jan, 2012. Volume 38, ACS – 1. https://
www.canada.ca
/
en
/public-health/services/reports-publications/
canada
-communicable-disease-report-
ccdr
/monthly-issue/2012-38/
canada
-communicable-disease-
report.html
Slide54References
J. Murphy, E. Kennedy, S. Dunn, M. Fung
Kee
Fung, D.
Gzik
, C.M.
McLachlin
, M. Shier, and L.
Paszat
. Cervical Screening: Guideline Recommendations. A Quality Initiative of the
Program in Evidence-Based Care (PEBC), Cancer Care Ontario (CCO). Original Report Date: May 20, 2005 Current Report Date: October 5, 2011
Cancer Care Ontario. Clinical Guidance: Recommended Best Practices for Delivery of Colposcopy Services in Ontario. June 2016.
Colon cancer screening guidelines for gay and bisexual men.
Canadian Cancer Society
http://convio.cancer.ca/site/PageServer?pagename=SSL_ON_HCP_HCPG_Colon#_Anal_Pap_test
Steben
M, et al. A Review of the Impact and Effectiveness of the Quadrivalent Human Papillomavirus Vaccine: 10 Years of Clinical Experience in Canada
Obstet
Gynaecol
Can 2018;40(12):1635–1645
Leeds I, Fang S. Anal cancer and intraepithelial neoplasia screening: A review.
World J Gastrointest Surg
. 2016 Jan 27; 8(1): 41–51.
Medford R,
Salit
I. Anal cancer and intraepithelial neoplasia: epidemiology, screening and prevention of a sexually transmitted disease CMAJ, February 3, 2015, 187(2).
Slide55references
Provencher
D, Murphy K. The Role of HPV Testing. JOCG. 2007.
www.jogc.com/article/S1701-2163(16)32576-2/fulltext
Murphy, et al. HPV Testing in Primary Cervical Screening: A Systematic Review and Meta-Analysis.
J
Obstet
Gynaecol
Can 2012;34(5):443–452
Ogilvie, GS et al. Effect of Screening With Primary Cervical HPV Testing vs Cytology Testing on High-grade Cervical Intraepithelial Neoplasia at 48 Months: The HPV FOCAL Randomized Clinical Trial.
JAMA.
2018
Jul
3;320(1):43-52.
doi
: 10.1001/jama.2018.7464.
Palefsky
JM, Holly EA, Ralston ML, et al. Prevalence and risk factors for human papillomavirus infection of the anal canal in human immunodeficiency virus (HIV)-positive and HIV-negative homosexual men. J Infect Dis. 1998 02;177(2):361-7.
Long, C, et al.
Screening, Surveillance, and Treatment of Anal Intraepithelial Neoplasia.
Clin Colon Rectal Surg
. 2016 Mar; 29(1): 57–64.