Recommandations SSGO dépistage cancer du col utérin. Pr Patrick Petignat University Hospitals of Geneva

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1 Recommandations SSGO dépistage cancer du col utérin Pr Patrick Petignat University Hospitals of Geneva GRSSGO 2018

2 Pap test for cervical cancer screening: A success story

3 Introduce essentially by gynecologists in last 60 (annual control) Cervical cancer screening Switzerland Opportunist Cytology-based (conventional LBC) HPV for ASCUS triage

4 Incidence CH : 5,3 / NICER Cancer Incidence Switzerland

5 Swiss CC coverage rate Participation rate Switzerland 70-80% Belgium 61% Norway 86.6% England % Richard et al., Cancer Epidem 2015 Arbyn et al. PlosOne 2015 Bang et al. J Public Health 2012 Jeangros et al. Eur J Public Health 2016

6 Incidence rates of invasive cervical cancer by region Switzerland, Std rates per SA SL CH year

Incidence rates of invasive cervical cancer by region Switzerland, 1983-2007 12 10 Std

7 Incidence rates of invasive cervical cancer by region Switzerland, Std rates per SA SL CH year

8 Incidence rates of invasive cervical cancer by region Switzerland, Std rates per SA SL CH year

9 Cervical cancer is a public health problem 60% cervical cancer incidence reduction False-positive cytology is public health proble European countries adopt HPV primary screening Cytology Screening HPV RCT Vaccination HPV dépistage NL

10 Cervical cancer screening in Switzerland Area to be considered: Screening women 20+ (optimal screening intervals) Screening women 30+ (potential for primary HPV testing (no Pap)) Possible harm from screening Anxiety over a positive test Pain/bleeding from procedures Treatment-related pregnancy complications Number of colposcopies is a marker for harms

11 SCREENING INTERVAL We can imagine that Improvement Nab of intervention

12 SCREENING INTERVAL But Nb of intervention Courtesy M Boulvain

13 SCREENING INTERVAL Transient infection (HPV and LSIL) About 75-80% of population have HPV exposure. and >95% will clear the infection About 70-80% (?) will have CIN1 and most will regress without treatment they have little neoplastic potential and maybe only 1% may develop into a cancer

14 SCREENING INTERVAL Transient infection (HPV and LSIL) HPV+ CIN1 CIN2 CIN3

15 >2 yrs 5 yrs 10 yrs SCREENING INTERVAL Transient infection (HPV and LSIL) HPV+ CIN1 CIN2 CIN3 1% 5% 20% CA

16 SCREENING INTERVAL >2 yrs 5 yrs 10 yrs HEALTHY 98% 60% 50% 30% HPV+ CIN1 CIN2 CIN3 1% 5% 20% CA Allow regression of transient lesions

17 SCREENING INTERVAL Cytology-based screening: false positive rate Ca 300 Cervical cancer is not a main public health concern in Switzerland HSIL LSIL Abnormal Pap are major public health concerns ASC-US Based on 1,2 million tests/y Courtesy P Vassilakos

18 SCREENING INTERVAL Optimize the screening? Benefits Prevent Cancer Reduce Morbidity/Mortality Harms Over-diagnosis Over-treatment Anxiety Determine the level of risk that is acceptable and the harms of screening

19 HPV TESTING <30 HPV and Cervical Cancer Over 99% of cervical cancers have HPV DNA detected within the tumor 70% of cervical cancer is caused by one of two types of HPV, 16 or 18

20 HPV TESTING <30 Murphy et al. 2012, JOGC

21 HPV TESTING <30 Cumulative Incidence of CIN3+ Dillner et al. BMJ 2008

22 HPV TESTING <30 Benefice of HPV testing Increased detection of prevalent CIN3 Decreased CIN3 in subsequent screening rounds Enhances detection of adenocarcinoma/ais Minimizes the increased number of colposcopies, thus it reduces harms.

23 2012 Reminder Swiss policy 2012 Age Screening interval years 2 years years 3 years

24 2018 Swiss policy

25 2018 Swiss policy* yrs Every 3 years Age Screening interval yrs 3 years cytology yrs 3 years cytology or HPV with triage cytology *Doesn t include CIN2, CIN3, women infected with HIV or immunocompromised (solid organ transplants)

26 2018 Swiss policy 2018 (21-29 yrs old) 1. Women <21 yrs should not be screened regardless of age of sexual onset and other behavior-related risk factors 2. Women >21 yrs who no sexual intercourse may not need a Pap test (to be decided women and physician) 3. Women yrs cytology alone every 3 years 4. Recommend against three consecutive annual cytology before 5. Recommend against HPV testing (alone or in combination with cytology) in women aged <30 years 6. Vaccinated = unvaccinated

27 2018 Swiss policy 2018 (30-70 yrs old) 1. Women yrs every 3 years, HPV testing (alone) or cytology* 2. If HPV women should be informed about the HPV price (no reimbursement) 3. If HPV - screening should begin 3 years after the last negative cytology 4. Recommend against co-testing (concomitant HPV and cytology) 5. Recommend against testing HPV low-risk *Women and physician choice

28 2018 Swiss policy 2018 (stop) 1. Stop at age 71 for women with adequate negative prior screening (no CIN2+) 2. Stop after hysterectomy with removal of cervix (no history of CIN2+)

29 Swiss policy 2018 Age Screening interval % coverage rate Incidence Cancer cervical / Belgium ,3 Denmark ,6 England à ,3 Finland ,3 France ,8 Italy ,1 Netherland ,3 Spain à 5 49,6 7,6 Switzerland * 5,2 Sweden ,2 Cervical Cancer Screening Programs in 19 ICSN Countries, 2012: Organization, Policies, and Program Reach., JNCI 2017

30 Sweden HPV primary screening Finland - HPV primary screening in guidelines Norway - 4 counties HPV primary screening England - HPV as primary screening Netherlands - HPV primary screening (implemented) Italy - 3 counties HPV primary screening Adapted from Melchers

31 Disparity between guidelines and practice - Anecdotes Women were saved by a pap test in young age I discover a HSIL at 16 years old Women were saved, she was 72 years old

32 Perception of change From women perspective New recommendation may appear to decrease service for the purpose of saving money for insurer Many women are not interested in assuming more cancer risk even if the harm is significant Improve quality and lower costs of care for patients

33 Perception of change From Healthcare provider perspective - Consider Pap smears to be part of every woman s annual visit; - Women will not come for an annual check-up and may be less inclined to undergo screening Do not minimize harm from overuse practicing medicine according to guideline is a strong appeal to our professionalism

34 Conclusion Provider must understand guidelines and reasons behind (harm and benefit) Must explain to patients controversies (when to start, interval and stopping) Must help women to make their own decisions Biggest gain would screening among women never/rarely screened

35 Thank you for your attention

36 Case # Swiss policy A 45 y.o. new patient who says she has always had a Pap test and would like to have a cervical cancer screening

37 Case # Swiss policy You recommend: 1. HPV test 2. Pap test 3. Co-testing

38 Case # Swiss policy You recommend: 1. Annually 2. Every two years 3. Every three years

39 Case # Swiss policy Lifetime risk of colposcopy Pap test 3 yrs : 760 colpos/1000 women Pap test 2 yrs : 1080 colpos/1000 women Pap test 1 yr : 2000 colpos/1000 women Stout NK et al. Arch Intern Med 2008;168:181.

Update on Cervical Cancer Screening. Rahmouna Farez M.D. Assistant Professor, Medical College of Wisconsin 5/2/2014

Update on Cervical Cancer Screening Rahmouna Farez M.D. Assistant Professor, Medical College of Wisconsin 5/2/2014 Objectives Review the natural history of HPV as it relates to cervical cancer screening