Hazel Lewis Public Health Physician Wellington Cartwright Forum 7 August 2015 NCSP R centralised 1965 1990 2000 1988 Cartwright Report NCSP established In 14 AHB 1996 NSU Gisborne Inquiry CSI ID: 449490
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Slide1
The Future Control of Cervical Cancer
Hazel Lewis
Public Health Physician
Wellington
Cartwright Forum, 7 August 2015Slide2
NCSP
-
Rcentralised
1965
1990
2000
1988
Cartwright Report
NCSP
established
In 14 AHB
1996
NSU
Gisborne Inquiry (CSI)
McGoogan review
2001
2004
CCA
Legislation amended
NCSP
-
R outsourced
1999 Guidelines
2008
Guidelines incorporating HPV testing, LBC conversion
2008
History of cervical screening in New Zealand
2011
1
st
Parliam
Review
Screening
Trials
In Thames,
Wanganui,
Otago,
Waikato
2
nd
Parliam Review
2015
P
olicies,
stds reviews
NCSP research: HPV prevalence, modelling primary HPV, Compass study
Lab automatio
n
Monitoring indicators reviewed and implemented
146 recs implemented
A
udits
Cancer case auditsSlide3
Global Cervical Cancer Incidence, 2012Slide4
Global Cervical Cancer Mortality, 2012Slide5
Cervical cancer incidence trends (ASR (W) per 100,000)
Globocan, 2012Slide6
The next 10 years: Dual Prevention
We now have two
powerful technologies to dramatically reduce cervical cancer incidence:- Screening for HPV infectionImmunisation against HPVSuccess will depend on using both technologies together to achieve effective coverage in all groupsThis will require better technologies, better guidelines, better information systems and better partnerships with all communities- Slide7
Dual prevention has its pitfalls
In principle, dual prevention should increase effective coverage and reduce gaps
Two concerns:Perception of protectionImpact on cytology screening laboratoriesResponse:EducationChange screening test from cytology to HPVSlide8
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 programmeIncrease HPV vaccination coverage (2 doses?)Reduce inequalities between socio-economic and ethnic groupsMinimise cost barriers – ‘free’ in primary careImprove co-ordination between screening and immunisation programmesMedia involvement (change behaviours, minimise risks)Programmes must be: easily affordable, effective, equitable Slide9
Screening for HPV infectionCervical 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 cancerCancer slowly develops over a period of years from precursor lesions – CIN, making screening possiblehrHPV testing has been shown to provide a much better protection against CIN3 and cervical cancer than cytologySlide10
Natural history of HPV infection
Schiffman M, Castle P. N Engl J Med 2005, 353:2101-2104Slide11
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 yearsHowever, 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 adenocarcinomaPoor PPV – unnecessary colposcopyRequires at least 3 yearly repeatsEffects of new HPV vaccinesKey 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)Slide12
Primary HPV screening continued
Impact
on inequalities, as can self test with HPVExtending the screening interval from 3 to 5 yearsEducationEffects on laboratoriesTransition phase, for safety reasons, given NZ cervical screening, should be considered Slide13
HPV testsTwo types:
- those that report pooled hrHPV types
- those that report the presence of HPV 16 and 18HPV can be detected via DNA testing, RNA testing and testing of cellular markers of HPVSpecimens can be obtained using a swab, broom, brush or tampon which is then placed in a transport mediumOver 100 tests available worldwide but not comparable A test can be falsely negative – important to standardise the quality of test usedSlide14
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?Slide15
Immunisation against HPV
Introduced on 1 September 2008
Provided for year 8 (11-12 year old girls)Programme targeted and tailored implementation to achieve equityMixed school based and primary care deliveryVaccine 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)Slide16
HPV vaccine – current issues
Full HPV vaccine coverage (3 doses) well below target
Coverage falls after 1st doseGirls only, offered free vaccineImpact on current cytology based screening (high grade lesions)Absence of data linkage - Immunisation Register with NCSP Register, therefore unable to monitor effectivelyHPV immunised women may not be screened, and will be at risk for cervical cancerKey health education messages (HPV vaccine and screening) should be part of ongoing communication strategySlide17
Future developments in HPV immunisation
Nonavalent vaccines (CE
studies) FDA approved Gardasil 9, Dec 2014 with HPV types 6/11/16/18/31/33/45/52/58Two dose regimens should be exploredBetter integration of HPV vaccine with screening - Information systems (data linkage) - Education - WorkforceGreater involvement / empowerment of communities Slide18
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 PartnershipsTimely analysis and publication