Human Papillomavirus and Related Diseases Report UNITED STATES OF AMERICA

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1 Human Papillomavirus and Related Diseases Report UNITED STATES OF AMERICA Version posted at on 27 July 2017

2 - ii - Copyright and Permissions ICO Information Centre on HPV and Cancer (HPV Information Centre) 2017 All rights reserved. HPV Information Centre publications can be obtained from the HPV Information Centre Secretariat, Institut Català d Oncologia, Avda. Gran Via de l Hospitalet, L Hospitalet del Llobregat (Barcelona) Spain. hpvcentre@iconcologia.net. Requests for permission to reproduce or translate HPV Information Centre publications - whether for sale or for noncommercial distribution- should be addressed to the HPV Information Centre Secretariat, at the above address. The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part the HPV Information Centre concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers products does not imply that they are endorsed or recommended the HPV Information Centre in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by the HPV Information Centre to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the HPV Information Centre be liable for damages arising from its use. The development of this report has been supported by grants from the European Comission (7th Framework Programme grant HEALTH-F , HEALTH-F , HPV AHEAD). Recommended citation: Bruni L, Barrionuevo-Rosas L, Albero G, Serrano B, Mena M, Gómez D, Muñoz J, Bosch FX, de Sanjosé S. ICO Information Centre on HPV and Cancer (HPV Information Centre). Human Papillomavirus and Related Diseases in USA. Summary Report 27 July [Date Accessed]

3 - iii - Executive summary Human papillomavirus (HPV) infection is now a well-established cause of cervical cancer and there is growing evidence of HPV being a relevant factor in other anogenital cancers (anus, vulva, vagina and penis) as well as head and neck cancers. HPV types 16 and 18 are responsible for about 70% of all cervical cancer cases worldwide. HPV vaccines that prevent HPV 16 and 18 infections are now available and have the potential to reduce the incidence of cervical and other anogenital cancers. This report provides key information for the USA on: cervical cancer; other anogenital cancers and head and neck cancers; HPV-related statistics; factors contributing to cervical cancer; cervical cancer screening practices; HPV vaccine introduction; and other relevant immunisation indicators. The report is intended to strengthen the guidance for health policy implementation of primary and secondary cervical cancer prevention strategies in the country. Table 1: Key Statistics Population Women at risk for cervical cancer (Female aged >=15 years) million Burden of cervical cancer and other HPV-related cancers Annual number of cervical cancer cases 12,966 Annual number of cervical cancer deaths 6,605 Crude incidence rates per 100,000 and year: Male Female Cervical cancer Anal cancer Vulvar cancer Vaginal cancer Penile cancer Pharynx cancer (excluding nasopharynx) Burden of cervical HPV infection Prevalence (%) of HPV 16 and/or HPV 18 among women with: Normal cytology 3.9 Low-grade cervical lesions (LSIL/CIN-1) 24.7 High-grade cervical lesions (HSIL/CIN-2/CIN-3/CIS) 57.9 Cervical cancer 71.2 Other factors contributing to cervical cancer Smoking prevalence (%), women 15.9 [ ] Total fertility rate (live births per women) 1.9 Oral contraceptive use (%) among women 13.3 HIV prevalence (%), adults (15-49 years) - Sexual behaviour Percentage of 15-year-old who have had sexual intercourse (men/women) 18 / 13 Range of median age at first sexual intercourse (men/women) 16.8 / 17.2 Cervical screening practices and recommendations Cervical cancer screening coverage, 80.5% (All women aged screened every 3y, NHIS 2013 USA) % (age and screening in- terval, reference) Screening ages (years) (cytology), over 30 (HPV test) Screening interval (years) or 3 years (cytology), 5 years (HPV test) frequency of screens HPV vaccine HPV vaccine introduction HPV vaccination programme National program Date of HPV vaccination routine immunization programme start 2006 National Program of Cancer Registries (NPCR)

4 CONTENTS - iv - Contents Executive summary iii 1 Introduction 2 2 Demographic and socioeconomic factors 4 3 Burden of HPV related cancers Cervical cancer Cervical cancer incidence in the USA Cervical cancer incidence by histology in the USA Cervical cancer incidence in the USA across Northern America Cervical cancer mortality in the USA Cervical cancer mortality in the USA across Northern America Cervical cancer incidence and mortality comparison, Premature deaths and disability in the USA Anogenital cancers other than the cervix Anal cancer Vulvar cancer Vaginal cancer Penile cancer Head and neck cancers Pharyngeal cancer (excluding nasopharynx) HPV related statistics HPV burden in women with normal cervical cytology, cervical precancerous lesions or invasive cervical cancer HPV prevalence in women with normal cervical cytology HPV type distribution among women with normal cervical cytology, precancerous cervical lesions and cervical cancer HPV type distribution among HIV+ women with normal cervical cytology Terminology HPV burden in anogenital cancers other than cervix Anal cancer and precancerous anal lesions Vulvar cancer and precancerous vulvar lesions Vaginal cancer and precancerous vaginal lesions Penile cancer and precancerous penile lesions HPV burden in men HPV burden in the head and neck Burden of oral HPV infection in healthy HPV burden in head and neck cancers Factors contributing to cervical cancer Sexual and reproductive health behaviour indicators HPV preventive strategies Cervical cancer screening practices HPV vaccination Protective factors for cervical cancer 124

5 LIST OF CONTENTS - v - 9 Indicators related to immunisation practices other than HPV vaccines Immunisation schedule Immunisation coverage estimates Glossary 128

6 LIST OF FIGURES - vi - List of Figures 1 The USA and Northern America Population pyramid of the USA for Population trends in four selected age groups in the USA HPV-related cancer incidence in the USA (estimates for 2012) Comparison of cervical cancer incidence to other cancers in women of all ages in the USA (estimates for 2012) Comparison of age-specific cervical cancer to age-specific incidence of other cancers among women years of age in the USA (estimates for 2012) Annual number of cases and age-specific incidence rates of cervical cancer in the USA (estimates for 2012) Time trends in cervical cancer incidence in the USA (cancer registry data) Age-standardised incidence rates of cervical cancer of the USA (estimates for 2012) Comparison of age-specific cervical cancer incidence rates in the USA, within the region, and the rest of world Annual number of new cases of cervical cancer by age group in the USA (estimates for 2012) Comparison of cervical cancer mortality to other cancers in women of all ages in the USA (estimates for 2012) Comparison of age-specific mortality rates of cervical cancer to other cancers among women years of age in the USA (estimates for 2012) Annual number of deaths and age-specific mortality rates of cervical cancer in the USA (estimates for 2012) Comparison of age-standardised cervical cancer mortality rates in the USA and countries within the region (estimates for 2012) Comparison of age-specific cervical cancer mortality rates in the USA, within its region and the rest of the world Annual deaths number of cervical cancer by age group in the USA (estimates for 2012) Comparison of age-specific cervical cancer incidence and mortality rates in the USA (estimates for 2012) Comparison of annual premature deaths and disability from cervical cancer in the USA to other cancers among women (estimates for 2008) Anal cancer incidence rates by age group in the USA (cancer registry data) Time trends in anal cancer incidence in the USA (cancer registry data) Vulvar cancer incidence rates by age group in the USA Time trends in vulvar cancer incidence in the USA (cancer registry data) Incidence rates of vaginal cancer by age group in the USA Time trends in vaginal cancer incidence in the USA (cancer registry data) Incidence rates of penile cancer by age group in the USA Time trends in penile cancer incidence in the USA (cancer registry data) Comparison of incidence and mortality rates of the pharynx (excluding nasopharynx) by age group and sex in the USA (estimates for 2012). Includes ICD-10 codes: C09-10,C Crude age-specific HPV prevalence (%) and 95% confidence interval in women with normal cervical cytology in the USA HPV prevalence among women with normal cervical cytology in the USA, by study HPV 16 prevalence among women with normal cervical cytology in the USA, by study HPV 16 prevalence among women with low-grade cervical lesions in the USA, by study HPV 16 prevalence among women with high-grade cervical lesions in the USA, by study HPV 16 prevalence among women with invasive cervical cancer in the USA, by study Comparison of the ten most frequent HPV oncogenic types in the USA among women with and without cervical lesions Comparison of the ten most frequent HPV oncogenic types in the USA among women with invasive cervical cancer by histology Comparison of the ten most frequent HPV types in anal cancer cases in the Americas and the World Comparison of the ten most frequent HPV types in AIN 2/3 cases in the Americas and the World Comparison of the ten most frequent HPV types in cases of vulvar cancer in the Americas and the World Comparison of the ten most frequent HPV types in VIN 2/3 cases in the Americas and the World Comparison of the ten most frequent HPV types in cases of vaginal cancer in the Americas and the World Comparison of the ten most frequent HPV types in VaIN 2/3 cases in the Americas and the World Comparison of the ten most frequent HPV types in cases of penile cancer in the Americas and the World Comparison of the ten most frequent HPV types in PeIN 2/3 cases in the Americas and the World Estimated coverage of cervical cancer screening in the USA, by age and study Reported HPV vaccination coverage in females by birth cohort in National HPV Immunization programme in USA123

7 LIST OF TABLES List of Tables 1 Key Statistics iii 2 Sociodemographic indicators in the USA Cervical cancer incidence in the USA (estimates for 2012) Cervical cancer incidence in the USA by cancer registry Age-standardised incidence rates of cervical cancer in the USA by histological type and cancer registry Cervical cancer mortality in the USA (estimates for 2012) Premature deaths and disability from cervical cancer in USA, Northern America and the rest of the world (estimates for 2008) Anal cancer incidence in the USA by cancer registry and sex Vulvar cancer incidence in the USA by cancer registry Vaginal cancer incidence in the USA by cancer registry Penile cancer incidence in the USA by cancer registry Incidence and mortality of cancer of the pharynx (excluding nasopharynx) in the USA, Northern America and the rest of the world by sex (estimates for 2012). Includes ICD-10 codes: C09-10,C Incidence of oropharyngeal cancer in the USA by cancer registry and sex Prevalence of HPV16 and HPV18 by cytology in the USA Type-specific HPV prevalence in women with normal cervical cytology, precancerous cervical lesions and invasive cervical cancer in the USA Type-specific HPV prevalence among invasive cervical cancer cases in the USA by histology Studies on HPV prevalence among HIV women with normal cytology in the USA Studies on HPV prevalence among anal cancer cases in the USA (male and female) Studies on HPV prevalence among cases of AIN2/3 in the USA Studies on HPV prevalence among vulvar cancer cases in the USA Studies on HPV prevalence among VIN 2/3 cases in the USA Studies on HPV prevalence among vaginal cancer cases in the USA Studies on HPV prevalence among VaIN 2/3 cases in the USA Studies on HPV prevalence among penile cancer cases in the USA Studies on HPV prevalence among PeIN 2/3 cases in the USA Studies on HPV prevalence among men in the USA Studies on HPV prevalence among men from special subgroups in the USA Studies on oral HPV prevalence among healthy in the USA Studies on HPV prevalence among cases of oral cavity cancer in the USA Studies on HPV prevalence among cases of oropharyngeal cancer in the USA Studies on HPV prevalence among cases of hypopharyngeal or laryngeal cancer in the USA Factors contributing to cervical carcinogenesis (cofactors) in the USA Percentage of 15-year-olds who have had sexual intercourse in the USA Median age at first sex in the USA Marriage patterns in the USA Main characteristics of cervical cancer screening in the USA Estimated coverage of cervical cancer screening in the USA Estimated coverage of cervical cancer screening in the USA, by region National HPV Immunization programme in United States of America Prevalence of male circumcision in the USA Prevalence of condom use in the USA General immunization schedule in the USA Immunization coverage estimates in the USA Glossary

8 1 INTRODUCTION Introduction Figure 1: The USA and Northern America The HPV Information Centre aims to compile and centralise updated data and statistics on human papillomavirus (HPV) and related cancers. This report aims to summarise the data available to fully evaluate the burden of disease in the USA and to facilitate stakeholders and relevant bodies of decision makers to formulate recommendations on cervical cancer prevention. Data include relevant cancer statistic estimates, epidemiological determinants of cervical cancer such as demographics, socioeconomic factors, risk factors, burden of HPV infection, screening and immunisation. The report is structured into the following sections: Section 2, Demographic and socioeconomic factors. This section summarises the socio-demographic profile of country. For analytical purposes, the USA is classified in the geographical region of Northern America (Figure 1, lighter blue), which is composed of the following countries: Bermuda,

9 1 INTRODUCTION Canada, Greenland, St Pierre and Miquelon, USA. Throughout the report, the USA estimates will be complemented with corresponding regional estimates. Section 3, Burden of HPV related cancers. This section describes the current burden of invasive cervical cancer and other HPV-related cancers in the USA and the Northern America region with estimates of prevalence, incidence, and mortality rates. Section 4, HPV related statistics. This section reports on prevalence of HPV and HPV type-specific distribution in the USA, in women with normal cytology, precancerous lesions and invasive cervical cancer. In addition, the burden of HPV in other anogenital cancers (anus, vulva, vagina, and penis) and men are presented. Section 5, Factors contributing to cervical cancer. This section describes factors that can modify the natural history of HPV and cervical carcinogenesis such as smoking, parity, oral contraceptive use, and co-infection with HIV. Section 6, Sexual and reproductive health behaviour indicators. This section presents sexual and reproductive behaviour indicators that may be used as proxy measures of risk for HPV infection and anogenital cancers. Section 7, HPV preventive strategies. This section presents preventive strategies that include basic characteristics and performance of cervical cancer screening status, status of HPV vaccine licensure introduction, and recommendations in national immunisation programmes. Section 8, Protective factors for cervical cancer. This section presents the prevalence of male circumcision and condom use. Section 9, Indicators related to immunisation practices other than HPV vaccines. This section presents data on immunisation coverage and practices for selected vaccines. This information will be relevant for assessing the country s capacity to introduce and implement the new vaccines. The data are periodically updated and posted on the WHO immunisation surveillance, assessment and monitoring website at

10 2 DEMOGRAPHIC AND SOCIOECONOMIC FACTORS Demographic and socioeconomic factors Figure 2: Population pyramid of the USA for 2017 Males Females Under 5 4,879,025 7,605,747 3,859,443 4,724,981 5,893,664 6,845,107 8,031,475 8,843,285 9,661,169 10,292,596 11,126,144 11,475,188 10,949,912 11,002,444 10,290,946 10,199,443 10,173,648 10,145,420 10,373,156 10,208,148 11,310,857 11,002,941 11,723,192 11,099,754 11,691,868 11,030,199 10,585,846 10,104,103 10,703,526 10,289,668 10,511,837 10,080,904 10,102,325 9,656,052 Data accessed on 27 Mar Please refer to original source for methods of estimation. Year of estimate: 2017; United Nations, Department of Economic and Social Affairs, Population Division (2015). World Population Prospects: The 2015 Revision, DVD Edition. Available at: unpd/wpp/download/standard/population/. [Accessed on March 21, 2017]. Number of women (in millions) Figure 3: Population trends in four selected age groups in the USA Projections Women yrs Girls yrs Number of women (in millions) Projections All Women Women yrs Female trends in the USA Number of women by year and age group Data accessed on 27 Mar Please refer to original source for methods of estimation. Year of estimate: 2017; United Nations, Department of Economic and Social Affairs, Population Division (2015). World Population Prospects: The 2015 Revision, DVD Edition. Available at: unpd/wpp/download/standard/population/. [Accessed on March 21, 2017].

11 2 DEMOGRAPHIC AND SOCIOECONOMIC FACTORS Table 2: Sociodemographic indicators in the USA Indicator Male Female Total Population in thousands 1,± 161, , ,474.0 Population growth rate (%) 1, Median age of the (in years) 1, Population living in urban areas (%) 2, Crude birth rate (births per 1,000) 1, Crude death rate (deaths per 1,000) 1, Life expectancy at birth (in years) 3,a,b, Adult mortality rate (probability of dying between 15 and 60 years old per 1,000) 4, Maternal mortality ratio (per 100,000 live births) 3,c, Under age five mortality rate (per 1,000 live births) 3,d, Density of physicians (per 1,000 ) 5,e, Gross national income per capita (PPP current international $) 6,f, Adult literacy rate (%) (aged 15 and older) Youth literacy rate (%) (aged years) Net primary school enrollment ratio 7, Net secondary school enrollment ratio 7, Data accessed on 27 Mar Please refer to original source for methods of estimation. a World Population Prospects, the 2015 revision (WPP2015). New York (NY): United Nations DESA, Population Division. b WHO annual life tables for based on the WPP2015, on the data held in the WHO Mortality Database and on HIV mortality estimates prepared by UNAIDS. WHO Member States with a of less than in 2015 were not included in the analysis. c WHO, UNICEF, UNFPA, World Bank Group and the United Nations Population Division. Trends in maternal mortality: 1990 to Estimates by WHO, UNICEF, UNFPA, World Bank Group and the United Nations Population Division. Geneva: World Health Organization; 2015 ( maternal-mortality-2015/en/, accessed 25 March 2016). WHO Member States with a of less than in 2015 were not included in the analysis. d Levels & Trends in Child Mortality. Report Estimates Developed by the UN Inter-agency Group for Child Mortality Estimation. New York (NY), Geneva and Washington (DC): United Nations Children s Fund, World Health Organization, World Bank and United Nations; 2015 ( Web_9_Sept_15.pdf, accessed 26 March 2016). e Number of medical doctors (physicians), including generalist and specialist medical practitioners, per f GNI per capita based on purchasing power parity (PPP). PPP GNI is gross national income (GNI) converted to international dollars using purchasing power parity rates. An international dollar has the same purchasing power over GNI as a U.S. dollar has in the United States. GNI is the sum of value added by all resident producers plus any product taxes (less subsidies) not included in the valuation of output plus net receipts of primary income (compensation of employees and property income) from abroad. Data are in current international dollars based on the 2011 ICP round. Year of estimate: ± 2017; ; 2015; 2013; 2014; 1 United Nations, Department of Economic and Social Affairs, Population Division (2015). World Population Prospects: The 2015 Revision, DVD Edition. Available at: org/unpd/wpp/download/standard/population/. [Accessed on March 21, 2017]. 2 United Nations, Department of Economic and Social Affairs, Population Division (2014). World Urbanization Prospects: The 2014 Revision, CD-ROM Edition. Available at: https: //esa.un.org/unpd/wup/cd-rom/. [Accessed on March 21, 2017]. 3 World Health Statistics Geneva, World Health Organization, Available at: html. [Accessed on March 21, 2017]. 4 World Health Organization. Global Health Observatory data repository. Available at: [Accessed on March 21, 2017]. 5 The 2016 update, Global Health Workforce Statistics, World Health Organization, Geneva ( [Accessed on March 21, 2017]. 6 World Bank, World Development Indicators Database. Washington, DC. International Comparison Program database. Available at: aspx?source=world-development-indicators#. [Accessed on March 21, 2017]. 7 UNESCO Institute for Statistics Data Centre [online database]. Montreal, UNESCO Institute for Statistics. Available at: [Accessed on March 21, 2017].

12 3 BURDEN OF HPV RELATED CANCERS Burden of HPV related cancers HPV is the cause of almost all cervical cancer cases and is responsible for an important fraction of other anogenital and head and neck cancer. Here, we present the most recent estimations on the burden of HPV-associated cancer. Figure 4: HPV-related cancer incidence in the USA (estimates for 2012) Cervix uteri 6.6 Other anogenital (a) 1.7 Head and neck (b) Age standardised incidence rate per 100,0000 women World Standard Data accessed on 08 May a Other anogenital cancer cases (vulvar, vaginal, anal, and penile). b Head and neck cancer cases (oropharynx, oral cavity and larynx). ASR: Age-standardized rate, rates per 100,000 per year. Please refer to original source for methods. GLOBOCAN quality index for availability of incidence data: High quality national data or high quality regional (coverage greater than 50%). GLOBOCAN quality index of methods for calculating incidence: Methods to estimate the sex- and age-specific incidence rates of cancer for a specific country: Rates projected to 2012 de Martel C, Plummer M, Vignat J, Franceschi S. Worldwide burden of cancer attributable to HPV by site, country and HPV type. Int J Cancer Cervical cancer Cancer of the cervix uteri is the 4th most common cancer among women worldwide, with an estimated 527,624 new cases and 265,672 deaths in 2012 (GLOBOCAN). The majority of cases are squamous cell carcinoma followed by adenocarcinomas. (Vaccine 2006, Vol. 24, Suppl 3; Vaccine 2008, Vol. 26, Suppl 10; Vaccine 2012, Vol. 30, Suppl 5; IARC Monographs 2007, Vol. 90) This section describes the current burden of invasive cervical cancer in the USA and in comparison to geographic region, including estimates of the annual number of new cases, deaths, incidence, and mortality rates Cervical cancer incidence in the USA KEY STATS. About 12,966 new cervical cancer cases are diagnosed annually in the USA (estimations for 2012). Cervical cancer ranks* as the 13 th leading cause of female cancer in the USA. Cervical cancer is the 4 th most common female cancer in women aged 15 to 44 years in the USA.

13 3 BURDEN OF HPV RELATED CANCERS * Ranking of cervical cancer incidence to other cancers among all women according to highest incidence rates (ranking 1st). Ranking is based on crude incidence rates (actual number of cervical cancer cases). Ranking using age-standardized rate (ASR) may differ. Table 3: Cervical cancer incidence in the USA (estimates for 2012) Indicator USA Northern America World Annual number of new cancer cases 12,966 14, ,624 Crude incidence rate a Age-standardized incidence rate a Cumulative risk (%) at 75 years old b Data accessed on 15 Nov Incidence data is available from high quality national data or high quality regional (coverage greater than 50%) sources. Data is included in Cancer incidence in Five Continents (CI5) volume IX and/or X. Incidence rates were estimated projecting rates to For more detailed methods of estimation please refer to asp?country=840 a Rates per 100,000 women per year. b Cumulative risk (incidence) is the probability or risk of individuals getting from the disease during ages 0-74 years. For cancer, it is expressed as the % of new born children who would be expected to develop from a particular cancer before the age of 75 if they had the rates of cancer observed in the period in the absence of competing causes. Ferlay J, Soerjomataram I, Ervik M, Dikshit R, Eser S, Mathers C, Rebelo M, Parkin DM, Forman D, Bray F. GLOBOCAN 2012 v1.2, Cancer Incidence and Mortality Worldwide: IARC CancerBase No. 11 [Internet]. Lyon, France: International Agency for Research on Cancer; Available from: Table 4: Cervical cancer incidence in the USA by cancer registry Cancer registry Period N cases a Crude rate b ASR b Alabama , Alabama (Black) Alabama (White) Alaska Alaska (American Indian) Arizona , Arizona (American Indian) Arizona (Asian and Pacific Islander) Arizona (Black) Arizona (White) Arkansas Arkansas (Black) Arkansas (White) California , California (American Indian) California (Asian and Pacific Islander) California (Black) California (Hispanic White) , California (Non-Hispanic White) , California (White) , California, Los Angeles County , California, Los Angeles County (Asian and Pacific Islander) 1 California, Los Angeles County (Black) (Continued on next page)

14 3 BURDEN OF HPV RELATED CANCERS ( Table 4 continued from previous page) Cancer registry Period N cases a Crude rate b ASR b California, Los Angeles County (Chinese) California, Los Angeles County (Filipino) , California, Los Angeles County (Hispanic White) 1 California, Los Angeles County (Japanese) California, Los Angeles County (Korean) California, Los Angeles County (Non-Hispanic White) 1 California, Los Angeles County (White) , California: Alameda County (Black) California: Alameda County (White) California: Los Angeles (Black) California: Los Angeles (Chinese) California: Los Angeles (Filipino) California: Los Angeles (Hispanic) California: Los Angeles (Hispanic White) , California: Los Angeles (Japanese) California: Los Angeles (Korean) California: Los Angeles (Non-Hispanic White) California: Los Angeles (Other White) , California: San Francisco , California: San Francisco (Black) California: San Francisco (Chinese) California: San Francisco (Filipino) California: San Francisco (Hispanic White) California: San Francisco (Japanese) California: San Francisco (Non-Hispanic White) 2 California: San Francisco (Black) California: San Francisco (Chinese) California: San Francisco (Filipino) California: San Francisco (Hispanic White) California: San Francisco (Japanese) California: San Francisco (Non-Hispanic White) 4 California: San Francisco (White) California: San Francisco California: San Francisco (Asian and Pacific Islander) 1 California: San Francisco (Black) California: San Francisco (Hispanic White) California: San Francisco (Non-Hispanic White) 1 California: San Francisco (White) Central California (Hispanic) (Continued on next page)

15 3 BURDEN OF HPV RELATED CANCERS ( Table 4 continued from previous page) Cancer registry Period N cases a Crude rate b ASR b Central California (Non-Hispanic White) Central Louisiana (Black) Central Louisiana (White) Colorado Colorado (Asian and Pacific Islander) Colorado (Black) Colorado (White) Connecticut Connecticut (Black) Connecticut (White) Delaware Delaware (Black) Delaware (White) District of Columbia District of Columbia (Black) District of Columbia (White) Florida , Florida (Asian and Pacific Islander) Florida (Black) Florida (White) , Georgia , Georgia (Asian and Pacific Islander) Georgia (Black) Georgia (White) , Georgia, Atlanta Georgia, Atlanta (Black) Georgia, Atlanta (White) Hawaii Hawaii (Chinese) Hawaii (Filipino) Hawaii (Hawaiian) Hawaii (Japanese) Hawaii (White) Idaho Illinois , Illinois (Asian and Pacific Islander) Illinois (Black) Illinois (White) , Indiana , Indiana (Black) Indiana (White) , Iowa (Continued on next page)

16 3 BURDEN OF HPV RELATED CANCERS ( Table 4 continued from previous page) Cancer registry Period N cases a Crude rate b ASR b Kentucky , Louisiana , Louisiana (Black) , Louisiana (White) , Louisiana, New Orleans , Louisiana, New Orleans (Black) , Louisiana, New Orleans (White) , Maine Massachusetts , Massachusetts (Asian and Pacific Islander) Massachusetts (Black) Massachusetts (White) Michigan , Michigan (Asian and Pacific Islander) Michigan (Black) Michigan (White) , Michigan, Detroit Michigan, Detroit (Black) Michigan, Detroit (White) Mississippi Missouri , Missouri (Black) Missouri (White) , Montana Montana (American Indian) Nebraska Nebraska (Black) Nebraska (White) Nevada New Hampshire New Jersey , New Jersey (Black) New Jersey (White) , New Mexico New Mexico (American Indian) New Mexico (Hispanic) New Mexico (Hispanic White) New Mexico (Non-Hispanic White) New Mexico (Other White) New Mexico (White) New York City , New York State , (Continued on next page)

17 3 BURDEN OF HPV RELATED CANCERS ( Table 4 continued from previous page) Cancer registry Period N cases a Crude rate b ASR b New York State (Asian and Pacific Islander) New York State (Black) , New York State (White) , New York State (Less City) , North Carolina , North Carolina (American Indian) North Carolina (Asian and Pacific Islander) North Carolina (Black) North Carolina (White) , North Dakota NPCR (42 States) , NPCR (42 States) (American Indian) NPCR (42 States) (Asian and Pacific Islander) , NPCR (42 States) (Black) , NPCR (42 States) (White) , Ohio , Ohio (Asian and Pacific Islander) Ohio (Black) Ohio (White) , Oklahoma Oklahoma (American Indian) Oklahoma (Black) Oklahoma (White) Oregon Oregon (Asian and Pacific Islander) Oregon (Black) Oregon (White) Pennsylvania , Pennsylvania (Asian and Pacific Islander) Pennsylvania (Black) Pennsylvania (White) , Puerto Rico , Rhode Island Rhode Island (Black) Rhode Island (White) SEER (Black) SEER (White) , SEER (14 Registries) , , SEER (14 Registries) (Asian and Pacific Islander) 2 SEER (14 Registries) (Black) , SEER (14 Registries) (Hispanic White) , SEER (14 Registries) (Non-Hispanic White) , (Continued on next page)

18 3 BURDEN OF HPV RELATED CANCERS ( Table 4 continued from previous page) Cancer registry Period N cases a Crude rate b ASR b SEER (18 Registries) , , SEER (18 Registries) (Asian and Pacific Islander) 1 SEER (18 Registries) (Black) , SEER (18 Registries) (Hispanic White) , SEER (18 Registries) (Non-Hispanic White) , SEER (18 Registries) (White) , SEER (9 Registries) , SEER (9 Registries) (Black) SEER (9 Registries) (White) , South Carolina South Carolina (Black) South Carolina (White) South Dakota Tennessee , Tennessee (Black) Tennessee (White) , Texas , Texas (Asian and Pacific Islander) Texas (Black) Texas (White) , Texas: El Paso County (Hispanic) Texas: El Paso County (Non-Hispanic) Utah Vermont Virginia , Virginia (Asian and Pacific Islander) Virginia (Black) Virginia (White) Washington State , Washington, Seattle West Virginia Wisconsin Wisconsin (Black) Wisconsin (White) Wyoming Data accessed on 05 May ASR: Age-standardized rate, Standardized rates have been estimated using the direct method and the World as the reference; Please refer to original source (available at a Accumulated number of cases during the period in the covered by the corresponding registry. b Rates per 100,000 women per year. 1 Forman D, Bray F, Brewster DH, Gombe Mbalawa C, Kohler B, Piñeros M, Steliarova-Foucher E, Swaminathan R and Ferlay J eds (2013). Cancer Incidence in Five Continents, Vol. X (electronic version) Lyon, IARC. 2 Curado. M. P., Edwards, B., Shin. H.R., Storm. H., Ferlay. J., Heanue. M. and Boyle. P., eds (2007). Cancer Incidence in Five Continents, Vol. IX. IARC Scientific Publications No. 160, Lyon, IARC. 3 Parkin, D.M.,Muir, C.S.,Whelan, S.L.,Gao, Y.-T.,Ferlay, J.,Powell, J., eds (1992). Cancer Incidence in Five Continents, Vol. VI. IARC Scientific Publications No. 120, Lyon, IARC. 4 Parkin, D.M., Whelan, S.L., Ferlay, J., Teppo, L., and Thomas, D.B., eds (2002). Cancer Incidence in Five Continents, Vol. VIII. IARC Scientific Publications No. 155, Lyon, IARC. 5 Muir, C.S.,Waterhouse, J.,Mack, T.,Powell, J.,Whelan, S.L., eds (1987). Cancer Incidence in Five Continents, Vol. V. IARC Scientific Publications No. 88, Lyon, IARC. 6 Parkin, D.M., Whelan, S.L., Ferlay, J., Raymond, L., and Young, J., eds (1997). Cancer Incidence in Five Continents, Vol. VII. IARC Scientific Publications No. 143, Lyon, IARC. 7 Doll, R.,Muir, C.S.,Waterhouse, J.A.H., eds (1970). Cancer Incidence in Five Continents, Vol. II. Union Internationale Contre le Cancer, Geneva. 8 Waterhouse, J.,Muir, C.S.,Correa, P.,Powell, J., eds (1976). Cancer Incidence in Five Continents, Vol. III. IARC Scientific Publications No. 15, Lyon, IARC.

19 3 BURDEN OF HPV RELATED CANCERS Figure 5: Comparison of cervical cancer incidence to other cancers in women of all ages in the USA (estimates for 2012) Breast Lung Colorectum (a) Corpus uteri Thyroid Melanoma of skin Non Hodgkin lymphoma (b) Kidney Pancreas Ovary Leukaemia Bladder Cervix uteri Brain, nervous system Multiple myeloma Lip, oral cavity Stomach Liver Gallbladder Hodgkin lymphoma Oesophagus Larynx Other pharynx Nasopharynx Kaposi sarcoma (c) Annual crude incidence rate per 100,000 USA: Female (All ages) Data accessed on 15 Nov a Includes anal cancer (C21). b Includes HIV disease resulting in malignant neoplasms (B21). c Includes B21.0 (HIV disease resulting in Kaposi sarcoma). Ferlay J, Soerjomataram I, Ervik M, Dikshit R, Eser S, Mathers C, Rebelo M, Parkin DM, Forman D, Bray F. GLOBOCAN 2012 v1.2, Cancer Incidence and Mortality Worldwide: IARC CancerBase No. 11 [Internet]. Lyon, France: International Agency for Research on Cancer; Available from:

20 3 BURDEN OF HPV RELATED CANCERS Figure 6: Comparison of age-specific cervical cancer to age-specific incidence of other cancers among women years of age in the USA (estimates for 2012) Breast Thyroid Melanoma of skin Cervix uteri Colorectum (a) Corpus uteri Ovary Non Hodgkin lymphoma (b) Hodgkin lymphoma Leukaemia Kidney Lung Brain, nervous system Lip, oral cavity Stomach Pancreas Bladder Liver Multiple myeloma Gallbladder Other pharynx Nasopharynx Larynx Oesophagus Kaposi sarcoma (c) Annual crude incidence rate per 100,000 USA: Female (15 44 years) Data accessed on 15 Nov a Includes anal cancer (C21). b Includes HIV disease resulting in malignant neoplasms (B21). c Includes B21.0 (HIV disease resulting in Kaposi sarcoma). Ferlay J, Soerjomataram I, Ervik M, Dikshit R, Eser S, Mathers C, Rebelo M, Parkin DM, Forman D, Bray F. GLOBOCAN 2012 v1.2, Cancer Incidence and Mortality Worldwide: IARC CancerBase No. 11 [Internet]. Lyon, France: International Agency for Research on Cancer; Available from:

21 3 BURDEN OF HPV RELATED CANCERS Figure 7: Annual number of cases and age-specific incidence rates of cervical cancer in the USA (estimates for 2012) Age specific rates of cervical cancer Annual number of new cases of cervical cancer * yrs: 1116 cases yrs: 1334 cases yrs: 1527 cases yrs: 1591 cases yrs: 1498 cases Age group (years) *15-19 yrs: 27 cases yrs: 325 cases yrs: 770 cases yrs: 1053 cases yrs: 1301 cases. Data accessed on 15 Nov Rates per 100,000 women per year. Ferlay J, Soerjomataram I, Ervik M, Dikshit R, Eser S, Mathers C, Rebelo M, Parkin DM, Forman D, Bray F. GLOBOCAN 2012 v1.2, Cancer Incidence and Mortality Worldwide: IARC CancerBase No. 11 [Internet]. Lyon, France: International Agency for Research on Cancer; Available from:

22 3 BURDEN OF HPV RELATED CANCERS Cervical cancer incidence by histology in the USA Table 5: Age-standardised incidence rates of cervical cancer in the USA by histological type and cancer registry Carcinoma Cancer registry Period Squamous Adeno Other Unspec. Alabama Alabama (Black) Alabama (White) Alaska Alaska (American Indian) a Arizona Arizona (American Indian) Arizona (Asian and Pacific Islander) Arizona (Black) Arizona (White) Arkansas Arkansas (Black) Arkansas (White) California California (American Indian) California (Asian and Pacific Islander) California (Black) California (White) California, Los Angeles County California, Los Angeles County (Asian and Pacific Islander) a California, Los Angeles County (Black) a California, Los Angeles County (Chinese) a California, Los Angeles County (Filipino) a California, Los Angeles County (Hispanic White) a California, Los Angeles County (Japanese) a California, Los Angeles County (Korean) a California, Los Angeles County (Non-Hispanic White) a California, Los Angeles County (White) a California: San Francisco California: San Francisco (Asian and Pacific Islander) a California: San Francisco (Black) a California: San Francisco (Hispanic White) a California: San Francisco (Non-Hispanic White) a California: San Francisco (White) a Colorado Colorado (Asian and Pacific Islander) (Continued on next page)

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