Trends in HPV-Associated Cancers United States,

Transcription

1 National Center for Chronic Disease Prevention and Health Promotion Trends in HPV-Associated Cancers United States, Elizabeth A. Van Dyne, MD, MPH Division of Cancer Prevention and Control Epidemiology and Applied Research Branch NCI Cancer Center HPV Vaccination Meeting at Huntsman Cancer Institute, June 7, 2018

2 Acknowledgements National Center for Chronic Disease Prevention and Health Promotion Division of Cancer Prevention and Control Mona Saraiya Jane Henley Cheryll Thomas Vicki Benard National Center for Immunization and Respiratory Diseases Division of Viral Diseases Lauri Markowitz Elissa Meites 2

3 Background Human papillomavirus (HPV) is a known cause of cervical cancer, some oropharyngeal, vulvar, vaginal, penile, and anal cancers Cervical cancer is the only HPV-associated cancer with screening guidelines 3

4 Cervical Cancer Screening Guidelines American Cancer Society (ACS), American College of Obstetrics & Gynecology (ACOG) 2012 U.S. Preventive Services Task Force (USPSTF) 2012 Age to start Age 21 Age 21 Women ages Cytology every 3 years Cytology every 3 years Women ages Cotesting every 5 years (preferred) OR Cotesting every 5 years OR Every 3 years with Pap alone Women ages >65 Post- Hysterectomy Every 3 years with Pap alone Discontinue after age 65 years with adequate negative screening Discontinue if for benign reason Discontinue after age 65 years with adequate negative screening Discontinue if for benign reason 4

5 Cervical Cancer Screening Updates ACS has new guidelines in process USPSTF has new guidelines in process Either screening every 3 years with cervical cytology alone or every 5 years with high-risk human papillomavirus (hrhpv) testing alone in women ages 30 to 65 years 5

6 Management of Abnormal Cervical Cancer Screening Results 2012 ASCCP guidelines Multiple algorithms based on cytology results and HPV testing Link: 6

7 Management of Abnormal Cervical Cancer Screening Updates ASCCP 2019 guidelines for managing abnormal cervical cancer screening tests and cancer precursors Clinical actions based on individual risk Colposcopy is the next component for standardization 7

8 Objective Provide an update on the epidemiology and burden of HPV-associated cancers Examine trends of HPV-associated cancer types in the U.S. population from Age Sex Race Ethnicity 8

9 Case Definition for HPV-Associated Cancer Cancer registries do not routinely collect HPV genotyping information Cell types in which HPV DNA is frequently found Carcinomas of the cervix: Squamous cell carcinomas (SCCs) Adenocarcinomas Other carcinomas SCCs of the: Oropharynx, vulva, vagina, penis, anus* Malignant/invasive Histologically confirmed *includes rectal SCC Cases were classified by anatomic site (topographical) and morphology using the International Classification of Diseases for Oncology, 3rd Edition 9

10 Definition HPV-associated vs HPV-attributable HPV-associated cancer: a specific cellular type of cancer that is diagnosed in a part of the body where HPV is often found. HPV-attributable cancer: a cancer probably caused by HPV, and is estimated by multiplying the number of HPV-associated cancers by the percentage attributable to HPV. Based on a CDC study that used population-based data to genotype HPV types from cancer tissue 90% of cervical and anal cancers 70% of oropharyngeal, vaginal, and vulvar cancers 60% of penile cancers 10

11 Data Source All 50 states, the District of Columbia, and Puerto Rico For , registry data that met specific quality standards covered approximately 97% of the U.S. population 11

12 Methods and Data Analysis Average annual percent change (AAPC): weighted average of percent change per year of cancer incidence rates Statistically significant AAPCs were different from zero at the alpha 0.05 level Rates and trends were estimated by sex, age group, race, and ethnicity Age-adjusted to the 2000 U.S. standard population Data were suppressed for rates if cases were <16 per period 12

13 Results 34,864 cases of HPVassociated cancer were diagnosed annually from Incidence rate 11.4 per 100,000 person per year: Males 13,266 Cases 38% 62% Females 21,598 Cases Males 9.1/100,000 Females 13.7/100,000 13

14 HPV-Associated Cancers by Site and Sex ,760 cases ,394 cases Oropharynx (M) 23% Anus (M) 4% Penis 3% Oropharynx (F) 8% Anus (F) 7% Vulva 9% Vagina 2% Cervix 44% Oropharynx (M) 35% Anus (M) 5% Penis 3% HPV-associated cancers among males: 1999: 34% 2014: 44% Oropharynx (F) 8% Anus (F) 11% Cervix 27% Vagina 2% Vulva 9% M = male; F = female 14

15 HPV-Associated Cancers Trends United States, Rate (cases per 100,000) Vagina Vulva Penis Anus-Female Anus-Male Oropharynx-Female Cervix Oropharynx-Male Year of diagnosis AAPC = 2.8* AAPC = -1.9* AAPC = 3.0* AAPC = 1.4* AAPC = 0.8* AAPC = 2.3* AAPC -0.1 AAPC = -0.5 Rates were considered to increase if annual average percentage change (AAPC) >0 (p<0.05) and to decrease if AAPC <0 (p<0.05); otherwise rates were considered stable. * = p<

16 Cervical Cancer Trends United States, ,996 cases AAPC = -1.9* ,457 cases Years of diagnosis Analyses limited to cervical carcinomas. Rates were considered to increase if annual average percentage change (AAPC) >0 (p<0.05) and to decrease if AAPC <0 (p<0.05); otherwise rates were considered stable. * = p<0.05. Rate (cases per 100,000) 16

17 Cervical Cancer Trends by Age United States, Age (Years) AAPC (95% CI) ** ** ** * * * * * * * * * * Analyses limited to cervical carcinomas. Rates were considered to increase if annual average percentage change (AAPC) >0 (p<0.05) and to decrease if AAPC <0 (p<0.05); otherwise rates were considered stable. * = p<0.05. ** Data suppressed. 17

18 Rate (cases per 100,000) Cervical Cancer Trends by Race/Ethnicity United States, Non-Hispanic White American Indian/Alaska Native Hispanic Year of diagnosis Non-Hispanic Black Asian/Pacific Islander AAPC = -3.9* AAPC = -3.4* AAPC = -1.9 AAPC = -1.4* AAPC = -3.1* Analyses limited to cervical carcinomas. Rates were considered to increase if annual average percentage change (AAPC) >0 (p<0.05) and to decrease if AAPC <0 (p<0.05); otherwise rates were considered stable. * = p<

19 Cervical Cancer Trends by Histology United States, Rate (cases per 100,000) Squamous Cell Carcinoma AAPC = -2.6* Adenocarcinoma AAPC = 0.0 Other Carcinoma AAPC = -3.7* Year of diagnosis Analyses limited to cervical carcinomas. Rates were considered to increase if annual average percentage change (AAPC) >0 (p<0.05) and to decrease if AAPC <0 (p<0.05); otherwise rates were considered stable. * = p<

20 Vulvar Cancer Trends United States, Rate (cases per 100,000) 2 1 2,595 cases AAPC = 1.4* 3,939 cases Year of diagnosis Analyses limited to vulvar squamous cell carcinomas. Rates were considered to increase if annual average percentage change (AAPC) >0 (p<0.05) and to decrease if AAPC <0 (p<0.05); otherwise rates were considered stable. * = p<

21 Anal Cancer Trends United States, Rate (cases per 100,000) 2 1 2,107 cases 1,150 cases Female Male AAPC = 3.0* 4,415 cases AAPC = 2.3* 2,203 cases Year of diagnosis Limited to anal squamous cell carcinomas. Rates were considered to increase if annual average percentage change (AAPC) >0 (p<0.05) and to decrease if AAPC <0 (p<0.05); otherwise rates were considered stable. * = p<

22 Anatomy of the Oropharynx The parts of the oropharynx are: Soft palate Side and back walls of the throat Tonsils Back one-third of tongue (base of tongue) 22

23 Oropharyngeal Cancer Trends United States, AAPC = 2.8* Rate (cases per 100,000) 8 7 Male 14,931 cases 6 5 6,850 cases Female AAPC = 0.8* 1 2,388 cases 3,300 cases Year of Diagnosis Analyses limited to oropharyngeal squamous cell carcinomas. Rates were considered to increase if annual average percentage change (AAPC) >0 (p<0.05) and to decrease if AAPC <0 (p<0.05); otherwise rates were considered stable. * = p<

24 Oropharyngeal Cancer Trends among Men by Race/Ethnicity United States, Rate (cases per 100,000) Non-Hispanic White American Indian/Alaska Native Hispanic Non-Hispanic Black Asian/Pacific Islander AAPC = 3.8* AAPC = 2.5 AAPC = -1.5* AAPC = 0.1 AAPC = 1.5* Year of Diagnosis Analyses limited to oropharyngeal squamous cell carcinomas. Rates were considered to increase if annual average percentage change (AAPC) >0 (p<0.05) and to decrease if AAPC <0 (p<0.05); otherwise rates were considered stable. * = p<

25 Oropharyngeal Cancer among Men by Primary Site United States, AAPC = 3.7* 3.5 AAPC = 3.5* Rate (cases per 100,000) Base of Tongue Tonsils Other sites AAPC = Year of Diagnosis Analyses limited to oropharyngeal squamous cell carcinomas. Rates were considered to increase if annual average percentage change (AAPC) >0 (p<0.05) and to decrease if AAPC <0 (p<0.05); otherwise rates were considered stable. * = p<

26 Oropharyngeal Cancer Trends among Women by Race/Ethnicity United States, Rate (cases per 100,000) Non-Hispanic White Asian/Pacific Islander Non-Hispanic Black Hispanic AAPC = 1.5* AAPC = -1.6* AAPC = -0.3 AAPC = Year of Diagnosis Analyses limited to oropharyngeal squamous cell carcinomas. Trends were measured with AAPC in annual rates (per 100,000, age-adjusted to the 2000 U.S. standard population). Rates were considered to increase if AAPC >0 (p<0.05) and to decrease if AAPC <0 (p<0.05); otherwise rates were considered stable. *Data suppressed for American Indian/Alaska due to counts. * = p<

27 Oropharyngeal Cancer among Men and Cervical Cancer by Age United States, Age-adjusted rate (cases per 100,000) < Age at diagnosis (years) Oropharyngeal cancer among men Median age = 59 years Cervical cancer Median age = 49 years HPV-Associated Cancer Diagnosis by Age, 27

28 Limitations Registries do not routinely collect information on HPV DNA status in cancer tissue 28

29 Summary HPV-associated cancer rates are changing from Increased: Oropharyngeal cancer among men and women Anal cancer among men and women Vulvar cancer Decreased: Cervical cancer Stable: Penile cancer Vaginal cancer 29

30 Conclusion Oropharyngeal cancer is now the most common HPV-associated cancer and increasing, particularly among males In the future, the HPV vaccine should decrease the burden of HPVassociated cancers, but it may take decades to see population-level impact due to the length of time between the initial HPV infection and the development of cancer 30

31 US Cancer Statistics Data Briefs ( ) Cancers associated with human papillomavirus, United States December pdf Annual rate and number of HPV-associated cancer cases by sex, cancer type, and state,

32 Quarterly Updates on HPV-Associated and Attributable cancers Brief 2-page report with state-specific data on number of HPV vaccine doses ordered and HPV-associated cancers 32

33 You Are the Key to HPV Cancer Prevention 2018 Web-on-demand video Continuing education is available until April 11,

34 Thank you! For more information, contact CDC CDC-INFO ( ) TTY: The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.

35 Strengths Systematic population-based approach to monitor HPV-associated cancers in the United States High quality data from cancer registries Covers the entire U.S. population, so can be used to look at rare cancers 35

36 Number of HPV-Associated Cancer Cases Probably Caused by HPV per Year in the United States, Average number of cancers per year in sites where HPV is often found (HPV-associated cancers) Percentage probably caused by any HPV type Number probably caused by any HPV type Percentage probably caused by HPV types 16/18 Number probably caused by HPV types 16/18 Percentage probably caused by HPV types 31/33/45/52/58 Number probably caused by HPV types 31/33/45/52/58 Cancer site Cervix 11,670 91% 10,600 66% 7,700 15% 1,700 Vagina % % % 100 Vulva 3,802 69% 2,600 49% 1,800 14% 500 Penis 1,240 63% % 600 9% 100 Anus 6,220 5,700 5, Female 4,114 93% 3,800 80% 3,300 11% 400 Male 2,106 89% 1,900 79% 1,700 4% 100 Oropharynx 17,273 12,200 10, Female 3,297 63% 2,100 51% 1,700 10% 300 Male 13,976 72% 10,100 63% 8,900 4% 600 TOTAL 41,038 79% 32,500 64% 26,200 9% 3,800 Female 23,716 83% 19,700 63% 15,000 13% 3,000 Male 17,322 74% 12,800 65% 11,200 5% 800 Data are from population-based registries participating in the CDC National Program of Cancer Registries and/or NCI Surveillance, Epidemiology, and End Results Program, meeting criteria for high data quality for all years , and covering about 99% of the US population. 36

37 Estimated Number of Cancer Cases Attributable to HPV by Sex, Cancer Type, and HPV Type, United States, Cancer probably caused by HPV type HPV types 16/18 HPV types 31/33/45/52/58 other HPV types HPV-negative* can be prevented by bivalent and quadrivalent vaccines Sex / Cancer Site Cervix can be prevented by 9-valent vaccine Vagina Male Female Vulva Anus Oropharynx Penis Anus Oropharynx 0 1,000 2,000 3,000 4,000 5,000 6,000 7,000 8,000 9,000 10,000 11,000 12,000 13,000 14,000 Average number of cases per year *HPV DNA was not detected in a percentage of cancers (Saraiya M et al. US assessment of HPV types in cancers: implications for current and 37

38 HPV DNA by Primary Cancer Site United States, % 90.6% 91.1% 80% 60% 68.8% 75.0% 63.3% 70.1% 40% 20% 0% Cervix Vulva Vagina Penile Oropharynx Anal Saraiya, M., et al., US assessment of HPV types in cancers: implications for current and 9-valent HPV vaccines. J Natl Cancer Inst,

39 Cancers Caused by HPV per Year, U.S., Cancer site Percentage probably caused by any HPV type Number probably caused by any HPV type Female Male Both Sexes Cervix 91% 10, ,600 Vagina 75% Vulva 69% 2, ,600 Penis 63% Anus* 91% 3,800 1,900 5,700 Oropharynx 70% 2,100 10,100 12,200 TOTAL 79% 19,700 12,800 32,500 *Includes anal and rectal squamous cell carcinomas Sources: and Saraiya M et al. J Natl Cancer Inst. 2015;107:djv086 39

40 Natural History of HPV Infection to Cervical Cancer Schiffman et al. NEJM 2005

41 Major Events for Cervical Cancer Prevention in the U.S. Pap screening introduced Pap screening and adjunct HPV testing in females years HPV vaccine became available Screening no longer recommended for females under age 21 Lengthened screening intervals across all age groups

42 Berman and Schiller. Cancer

43 Oropharyngeal Cancer Trends among Men by Age United States, Rate (cases per 100,000) <40 years years years years > 70 years Year of Diagnosis AAPC = 4.0* AAPC = 2.9* AAPC = 2.8* AAPC = 1.0* AAPC = -0.8 Analyses limited to oropharyngeal squamous cell carcinomas. Rates were considered to increase if annual average percentage change (AAPC) >0 (p<0.05) and to decrease if AAPC <0 (p<0.05); otherwise rates were considered stable. * = p<