Pathology seminar series: Brief review of HPV, screening guidelines, and FDA approved HPV DNA Felipe Solano, MD.

Size: px

Start display at page:

Download "Pathology seminar series: Brief review of HPV, screening guidelines, and FDA approved HPV DNA Felipe Solano, MD."

Mariah Miranda Dixon
5 years ago
Views:

1 Pathology seminar series: Brief review of HPV, screening guidelines, and FDA approved HPV DNA Felipe Solano, MD Pathology UTHSCSA July 25 th 2011

2 Define the epidemiology and pathogenesis of HPV and cervical cancer. Learn about new guidelines suggested for HPV screening. Review FDA approved high risk HPV tests commercially available.

3 Important points in hisrtory of HPV screening 1941 Pap smear technique described 1975 HPV linked to cervical precancer 1980 First ACS guidelines 1988 Bethesda system Bethesda system First liquid method approved. HC2 FDA approved for HPV DNA tes@ng 2001 Bethesda system revised ACS guidelines 2006 FDA approved first HPV vaccine. Revised ASCCP guidelines 2009 FDA HPV genotyping tes@ng approved. ACOG/ASCCP review of guidelines FDA Cobas HPV tes@ng approved

4 Epidemiology

5 FACT Mortality rates in developed countries due to cervical cancer declined steadily from 1950 to 2003 (70% decline) due to and early as a result of screening with the Pap test (decrease incidence 50%).

6 Global incidence and mortality of cervical cancer 83% of all cases of cervical cancer worldwide occur in developing countries, and is the second most common cause of cancer- related morbi- mortality among women In 2002, in developing countries, 493,243 new cases were observed and 273,606 deaths, (55% mortality rate) This discrepancy is largely due to non- existent or poor cervical cancer programs in many developing countries. Including: inadequate screening, never screened, and high false rate for with invasive cancer (11 to 33% in Northern European and US studies)

8 US

9 1 % of cancer deaths in women

10 Incidence of cervical cancer: Incidence and mortality associated with cervical cancer are higher among minorities Hispanics (14.2/100,000) is almost double that for non-hispanic whites (7.3/100,000), and 3% of cancer deaths African Americans (11.5 /100,000) 30% higher than in whites, with about twice the mortality (5.0 versus 2.4 / 100,000), representing 2% of cancer deaths

12 US Abnormal Pap test How common is it? 12,200 cancers 300,000 HSIL 50% of cervical cancers in US are diagnosed in women never screened. Another 10% in women who have not been screened for 5 years 1.25 million LSIL 2-3 million ASC million women screened

13 Types of cervical cancer

14 Types of cervical cancer in US Poorly screened populations: majority squamous Populations with good screening: the proportion of adenocarcinomas is increased This is thought to be due to the diminished efficiency of Pap screening for glandular precursor lesions

15 P16

16 The role of HPV

17 HPV Family Papillomaviridae.Double stranded DNA Non- enveloped DNA virus (not covered by a lipid membrane). More resistant to the environment Early proteins (E1, E2, E3, E4, E5, E6, E7, E8) and 2 late proteins (capside: L1 > L2). Papillomaviruses are highly host- tropic, and are rarely transmided between species

18 Role of HPV HPV infec;on is common (most common STD) and most infec;ons are transient Natural history: 8 to 14 months It can coexist with other subtypes (specially in younger than 30 years old) The diseases included by HPV are warts, anogenital warts, juvenile- onset recurrent respiratory papillomatosis, cancer of the cervix, vulva, vagina, anus, penis, and head and neck When HPV persists (approximately 10-20% of the high risk HPV cases) from infec@on to development of CIN 3 and finally invasive cancer takes an average of 10 to 15 years HPV is detected in 99% of squamous and approximately 85% of adenocarcinomas of the cervix 15 of 40 genital mucosal HPV types iden@fied to date are known to be oncogenic. The two most common oncogenic types are HPV 16 and 18 (~70% of cervical and 50% of vulvar cancers and 31: 80%)

19 Risk Factors Sexual at a young age High number of sexual partners Cigarede smoking Long- term use of oral contracep@ves Other sexually transmided infec@ons (e.g., HIV and chlamydia) Fomites

20 Difference between oncogenic and non- oncogenic HPV types Low- risk types of HPV (6, 11, 42, 43, 44, 54) the genome is maintained in a nonintegrated form. HPV 6 and 11 account for about 90% of external genital warts High- risk HPV (16, 18, 31, 33,35, 39, 45, 51, 52, 56, 58, 59, 68) has the ability to integrate into the host genome, ul@mately leading to the overexpression of E6 and E7 viral genes. These genes may act to transform and immortalize cells via protein binding and inac;va;on of p53 and prb tumor suppressor genes E6 in associa@on with host E6- associated protein, which has ubiqui@n ligase ac@vity, acts to ubiqui@nate p53, leading to its proteosomal degrada@on E7 competes for re@noblastoma protein (prb) binding, freeing the transcrip@on factor E2F to transac@vate its targets, thus pushing the cell cycle forward Kumar V, Abbas AK, Fausto N, eds. Robbins and Cotrans Pathologic Basis of Disease. 5 th ed. Philadelphia, PA: Elsevier Saunders; 2005:chap 5.

21 Dr Valente

22 Four major steps in cervical cancer development: Oncogenic HPV of the epithelium at the zone Persistence of the HPV Progression of a clone of epithelial cells from persistent viral infec@on to precancer Development of carcinoma and invasion through the basement membrane

24 Guidelines

25 ? STANDARD OF CARE Thin Prep Pap Test BY 2004 If negative à repeat 1 year If SIL à colposcopy If ASCUS à HPV negative-repeat 4 to 6 months HPV positive-colposcopy Dr Valente

27 HPV Genotyping Clinical Update Na;onal Cancer Ins;tute studies have shown that women with HPV types 16 and 18 have about a 20% risk of progressing to CIN3 over 10 years despite nega@ve Pap tests. Suggest that colposcopy may be useful for these women However, most HPV 16/18 infec@ons regress, especially in women under age 30, who also have almost a 20% rate of high risk HPV infec@on The 2006 Consensus Guidelines included a statement that in cytology nega@ve women ages 30 years and older who are high- risk HPV DNA posi;ve it would be reasonable to obtain genotyping assays for HPV 16 and 18. Women who were posi;ve should be referred for immediate colposcopy, while those who are HPV 16/18 nega;ve but posi;ve for other high- risk types should be followed with repeat cytology and high- risk HPV tes;ng in 12 months Because a FDA- approved HPV genotyping assay was not available in 2006, this recommenda@on was made con@ngent on approval of such an assay. The first HPV genotyping assay was approved in March 2009 and based on this approval ASCCP released the Management Algorithm for Using HPV Genotyping to Manage HPV High- risk Posi;ve / Cytology Nega;ve Women 30 Years and Older. Note that it is also reasonable to manage women who are Pap nega@ve but high- risk HPV posi@ve by repea@ng both tests in 12 months. Genotyping assays are not suitable for women who are younger than 30 years old. Genotyping is inappropriate for women with abnormal Pap results, as results do not alter management.

28 ACOG Revised Cervical Cancer Screening Guidelines 2009 Specific ACOG in the updated guidelines, based on good and consistent evidence (level A), are as follows: Cervical cancer screening should begin at age 21 years and should be avoided at younger ages, when it may result in unnecessary and harmful workup and treatment in women who are at very low risk for cancer. For women aged 21 to 29 years, cervical cytology screening is recommended every 2 years. The interval between cervical cytology examina@ons may be extended to every 3 years for women at least aged 30 years who have had 3 consecu;ve nega;ve cervical cytology screening test results and who have no history of CIN 2 or CIN 3, HIV infec@on, immunocompromised state, or DES exposure in utero. Acceptable screening techniques are liquid- based and conven@onal cervical cytology methods. Rou@ne cytology tes@ng should be discon@nued in women who have had a total hysterectomy for benign condi@ons and who have no history of high- grade CIN. For women older than 30 years, an appropriate screening test is cytology combined with HPV DNA tes;ng. When both these test results are nega@ve in a low- risk woman 30 years or older, rescreening should be performed no sooner than 3 years later.

29 Specific ACOG in the updated guidelines, based on limited and inconsistent evidence (level B), are as follows: Sexually women younger than 21 years should be counselled and tested for sexually transmided and should be counselled regarding safe sex and Cervical cytology is not necessary, and speculum need not be performed in women. Cervical cancer screening can be discon;nued between the ages of 65 and 70 years in women who have 3 or more consecu;ve nega;ve cytology test results and no abnormal test results in the past 10 years because cervical cancer develops slowly, and risk factors decrease with age. Women previously treated for CIN 2, CIN 3, or cancer remain at risk for persistent or recurrent disease for at least 20 years ajer treatment and ajer ini@al posdreatment surveillance. This group should therefore con;nue to be screened annually for at least 20 years. Even afer the period of posgreatment surveillance, screening should con;nue for women status post hysterectomy with removal of the cervix who have a history of CIN 2 or CIN 3, or in whom a nega;ve history cannot be documented. In this pa@ent group, there are no good data to support or refute discon@nuing screening.

30 Revised ACOG based primarily on consensus and expert opinion (level C), are as follows: Physicians should inform their that annual gynecologic examina;ons may be appropriate regardless of the frequency of cervical cytology screening, even if cervical screening is not performed at each visit. Women who were vaccinated against HPV- 16 and HPV- 18 should follow the same screening guidelines as nonvaccinated women. A proposed performance measure recommended by ACOG is the percentage of women aged 21 to 29 years who have received a Pap test within the past 2 years.

31 Vaccines

32 HPV vaccines Merck (Gardasil), 4 HPV types (6,11,16,18) 6 and 11: protects 90% of genital warts Glaxcosmith Kline (Cervarix) bivalent 16/18 L1 Capsid HPV 16/18 (70%) Dr Valente

33 HPV Vaccine Safety Not a live virus no oncogenic poten@al Do not give in pregnancy. No birth defects in offspring Rare cases of Guillan- Barre COST in US: $360 for the 3 injec@ons- not including administra@on fees If all 12 old girls in USA were vaccinated: Prevent 200,000 HPV infec@ons Prevent 100,000 abnormal paps Prevent 3,300 cases of cervix cancer Vaccinate both men & women: probably more effec@ve Not cost effec@ve to prevent cervix cancer Large trial planned 33

34 The future of pap and screening tests

35 DECREASING PAP VOLUME Revised screening guidelines HPV Vaccination false sense Women > 18 years screening peaking in 2000 (80%) Lack of Health Education Aging female population Dr Valente

36 Molecular for HPV

37 Types of FDA approved high risk HPV Digene (Qiagen, HC2) Cervista (Hologic) Cobas HPV Test

specimens Uses 2 RNA probes 13 carcinogenic

38 Hybrid capture assay signal amplified hybridizaytion signal microplate assay using chemoluminescence. Detect 18 types of HPV DNA in cervical specimens Uses 2 RNA probes 13 carcinogenic high risk HPV types 16, 18, 31, 33,35, 39, 45, 51, 52, 56, 58, 59, 68 5 low risk 6, 11, 42, 43, 44

39 Cervista (Hologic) DNA of HPV types 16, 18, 31, 33,35, 39, 45, 51, 52, 56, 58, 59, 66, 68 Invader chemistry, a signal amplifica@on method for detec@on of specific nucleic acid sequences. This method uses two types of isothermal reac@ons: a primary reac@on that occurs on the targeted DNA sequence and a secondary reac@on that produces a fluorescent signal.

41 negative sample is < 1.5 (low gdna).

42 Limita;ons of Cervista This test does not detect DNA of HPV low- risk The test exhibits cross- with HPV type 67 and 70 A nega@ve result does not exclude the possibility of HPV infec@on because very low levels of infec@on or sampling error may cause a false- nega@ve result. Less than 2ml of solu@on for the test ajer the ThinPrep Pap Test slides are prepared are considered inadequate The test has been validated for use only with cervical cytology specimens collected in PreservCyt Solu@on using a Rovers Cervex Brush, Wallach Papede, or Endocervical Brush/ Spatula The performance was established using DNA extracted Ge with GenfindTM Kit, and using cervical cytology PreservCyt specimens processed on the ThinPrep 2000 processor The performance of the CervistaTM HPV HR test has not been adequately established for HPV vaccinated individuals Interference was observed in cervical specimens contaminated with high levels (2%) of contracep@ve jelly and/or an@- fungal creams

43 Cervista HPV 16/18 Uses the same technology as Cervista HPV HR, and the test may be run from the same 2 ml specimen Iden@fies the two most highly oncogenic and persistent high- risk HPV types known to cause high- grade cervical neoplasia Facilitates risk- stra@fica@on of pa@ents at greater risk for cervical disease in order to tailor care more appropriately

46 Cobas HPV Test FDA approved April 2011 The cobas HPV test is a qualitative in vitro test for the detection of Human Papillomavirus (HPV) The test utilizes amplification of target DNA by the Polymerase Chain and nucleic acid hybridization for the detection of 14 high-risk (HR) HPV types The test specifically identifies types HPV 16 and HPV 18 while concurrently detecting the rest of the high risk types (31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 66 and 68)

47 How good are both, pap and DNA for screening

48 HPV DNA BY HYBRID CAPTURE Correlation with HSIL Sensitivity Specificity Abn Cytol 87% 30% High Risk HPV 93% 30% Cyto + High Risk HPV 100% 20% Gynecol Oncol 62:153, 1996 Dr Valente

49 HPV molecular Significance of HPV Improves screening women infected with high risk HPV Its provides reassurance that they are unlikely to develop cancer in several years Reduce the need for costly and invasive follow up procedures of High risk HPV is high with low specificity specially in young. Useful: to with ASCUS or equivocal pap smears (Trying to catch the false from pap ASCUS) Normal pap and women >30 years of age

50 Some numbers at UH

51 Pap and HPV at UH

52 Cost Pap: Liquid base cytology cost 45 to 60 compared to for Pap smear Liquid base cytology offers higher than pap smear with comparable specificity Liquid base cytology is cost Molecular ARUP charge UH approximately 45/sample/Digen test +30 (handling): 75 Cervista in process: approximately 30 (reagents and equipment only)

53 Other References Kitchener HC, et al. HPV in with liquid- based cytology in primary cervical screening (ARTISTIC): a randomised controlled trial. Lancet Oncol Jul;10(7): Epub 2009 Jun 17. Khan MJ, et al. The elevated 10- year risk of cervical precancer and cancer in women with human papillomavirus (HPV) type 16 or 18 and the possible u@lity of type- specific HPV tes@ng in clinical prac@ce. J Natl Cancer Inst Jul 20;97(14): Kinney W, Stoler MH, Castle PE. Special commentary: pa@ent safety and the next genera@on of HPV DNA tests. Am J Clin Pathol Aug;134(2): Cox JT, Moriarty AT, Castle PE. Commentary on: Statement on HPV DNA test u@liza@on. Diagn Cytopathol Jul;37(7): Zhao C, Zhao S, Heider A, Aus@n RM. Significance of high- risk human papillomavirus DNA detec@on in women 50 years and older with squamous cell papanicolaou test abnormali@es. Arch Pathol Lab Med Aug;134(8): Jemal A, Murray T, et al. cancer sta@s@cs, CA cancer J Clin :10. US preventa@ve Task force Screening for Cervical cancer. Lancet 369: , hdp:// Guidelines for cervical cancer screening from: Na@onal cancer ins@tute American cancer society American society of colposcopy and cervical pathology ACOG WHO

54 Thanks

Human Papillomavirus

Human Papillomavirus Dawn Palaszewski, MD Assistant Professor of Obstetrics and Gynecology University of February 18, 2018 9:40 am Dawn Palaszewski, MD Assistant Professor Department of Obstetrics and