Epidemiologia dell HPV e cancro della cervice nel mondo. Silvia Franceschi
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1 Epidemiologia dell HPV e cancro della cervice nel mondo Silvia Franceschi Infezione da HPV: dalla diagnosi precoce alla prevenzione primaria. Roma, 27 Giugno 2012
2 Cancer incidence 2008 attributable to infection and HPV-associated (de Martel et al, Lancet Oncol 2012) More developed regions Less developed regions 5.6 million new cancer cases 2.1% attributable to HPV (i.e. 120,000 cancer cases) 5.3% attributable to other infections 7.1 million new cancer cases 6.9% attributable to HPV (i.e. 490,000 cancer cases) 16% attributable to other infections
3 Human papillomavirus HPV is a necessary cause of cervical cancer Prevalent in other anogenital cancers: Penis: 50% Anus: 88% Vulva: 43% Vagina: 70% Found in a sub-set of oropharyngeal cancers (oropharynx, including tonsils and base of tongue) Prevalence from 56% (N America) to 13% (Outside Europe, N America, Australia & New Zealand, Japan)
4 Cancers attributable to HPV Worldwide, cervical cancer dominates the HPV-associated cancers In N America, where cervical cancer is controlled by screening, HPV-associated cancers at other sites are equally important.
5
6 HPV prevalence (%) HPV Epidemics in many countries: Age-specific high risk HPV prevalence in Manchester, & Manchester, (MY0911 PCR) ARTISTIC, (Hybrid Capture II) Age
7 Incidence rate (per 100,000) English registrations of carcinoma-in-situ (CIN3) in 1988 (when the national screening programme was introduced) and in Age group
8 Phylogenetic tree of HPV genotypes
9 8 most common HPV types in 30,743 cases of invasive cervical cancer by region (Li et al, Int J Cancer, 2011) % % Africa (n=2,011) 60 West/Central Asia (n=2,051) % 40 82% 20 % HPV type Eastern Asia (n=11,651) 68% % HPV type 76% Europe (n=9,015) % HPV type 73% North America (n=2.485) % % HPV type South/Central America (n=3,010) HPV type HPV type
10 IARC Multi-centre HPV Prevalence Surveys Mexico Colombia Poland The Netherlands Ital Georgia Mongolia Spain y Iran China Korea Shanxi Algeria Nepal Shenyang Pakistan Shenzhen Nigeria India Hanoi Guinea Uganda Lampang Ho Chi Minh Songkla Kenya Vanuatu Chile Argentina published unpublished
11 Prevalence (%) of cervical HPV DNA in sexually active women, IARC Prevalence Surveys, Guinea Mongolia Vanuatu* Nigeria Poland China, Shenzhen Argentina India China, Shenyang China, Shanxi Chile Colombia Georgia Korea Mexico Vietnam, Ho Chi Minh Italy, Turin Thailand, Lampang Nepal Iran* Netherlands Algeria Thailand, Songkla Spain Pakistan Vietnam, Hanoi hpv 16 or 18 other high-risk type low-risk type only *Unpublished
12 Integration of HPV vaccination with screening in older women
13 High-risk HPV prevalence (%) Age-specific prevalence of high-risk HPV types in selected areas. IARC HPV prevalence Surveys (GP5+/GP6+) < Age (years) Guinea Nigeria China India Chile Vietnam, Hanoi
14 HPV-prevalence: CONCLUSIONS The very heavy burden of HPV infection in certain areas, i.e., Guinea, Nigeria, Mongolia, and Pacific Islands, calls for urgent effective interventions. Western age-specific curve of HPV prevalence should not be taken as the natural history of HPV infection. In inadequately screened populations, also women aged 45+ or 55+ years should be screened (VERO ANCHE IN ITALIA SOPRA A 65 ANNI).
15 20 years of studies on HPV DNA screening: What s the bottom line? Increased sensitivity for CIN2+ compared to conventional Pap smear Lower rate of CIN2+ in next screening round Total amount of CIN2+ detected is the same it is just detected earlier HPV testing is more reproducible and can, eventually, be cheaper than Pap smear Co-testing with Pap and HPV test not necessary
16 Incidence of CIN 3+ per 10,000 CIN3+ risk among HPV-negative women is lower after 6 years than the CIN3+ risk after 3 years for cytologynegative women: No need for double testing (Dillner et al, BMJ 2008) 90 cyt hpv- cyt-/hpv Time in months since intake testing
17 Why GAVI opened a funding window : Status of vaccine introduction worldwide Status as of April 2012 National HPV Programs GAVI eligible countries Source: Courtesy of Progress in Cervical Cancer Prevention: The CCA Report Card, August
18 Background Vaccine Investment Strategy June: Board agrees to use reduced overall disease burden as portfolio objective November: Board recognizes need for comprehensive vaccine investment strategy October: Board endorses the portfolio: HPV, Japanese encephalitis, rubella and typhoid November, GAVI Board opened funding window for HPV country proposals provided: Acceptable price for vaccine Countries have demonstrated ability to deliver vaccine Board also requested to develop HPV demonstration projects 18
19 HPV Demonstration Programme - Objectives 1. Learn by doing : Assess potential vaccine delivery strategies for coverage, feasibility, acceptability, and cost in order to generate evidence for decision-making on national introduction with GAVI s support. Adapt and/or develop tools to be used for future potential national introduction (e.g. record keeping, monitoring, IEC, social mobilization, training materials, etc.). 2. Integrated delivery of adolescent health interventions: Explore the feasibility of integrating selected adolescent health interventions with the delivery of HPV vaccine. 3. Comprehensive approach to cervical cancer prevention: Encourage integration of primary prevention through HPV vaccination into a national cervical cancer prevention and control strategy. 20
20 20 years of studies on HPV vaccine: What s the bottom line? HPV16/18 VLP vaccines are highly efficacious in in adolescent girls and can become cheaper More doable schedules need to be validated (<3 doses, vaccination of children) Several companies are developing polyvalent vaccines, but a major obstacle is the cost of large-scale randomised trials Development and fast-track evaluation of new HPV vaccines should be encouraged (publicly funded trials, well-validated virological endpoints instead of CIN2 or worse)
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