HPV-Associated Disease and Prevention

Transcription

1 HPV-Associated Disease and Prevention Odessa Regional Medical Center May 28, 2015 Erich M. Sturgis, MD, MPH Professor Department of Head & Neck Surgery Department of Epidemiology Christopher & Susan Damico Chair in Viral Associated Malignancies No C.O.I., disclosures, or off-label

2 Outline Pathophysiology Epidemic Prevention Screening

3 2008 Nobel Prize in Physiology or Medicine Harold zur Hausen, M.D.

4 ~40 HPV Types Mucosal sites of infection ~ 80 HPV Types Cutaneous sites of infection High risk (oncogenic) HPV 16, 18 most common Anogenital & Oropharyngeal Cancers Cancer Precursors: Anogenital High Grade Dysplasias Low risk (nononcogenic) HPV 6, 11 most common Genital Warts Laryngeal Papillomas Low Grade Cervical Disease Common Cutaneous Warts

5 HPV Infection & Progression to Cancer Schematic

6 C.T. Allen, et al. Laryngoscope 2010

7 Estimated, % Cancers Attributed to HPV Anogenital Cancers 72% Anal Vulvar Vaginal Penile Cervical Oropharyngeal

8 H&N Squamous Cell Carcinomas Nose/Paranasal Sinuses Nasopharynx Oral Cavity Oropharynx soft palate tonsil base of tongue post pharyngeal wall Hypopharynx Larynx

9 Prevalence of HPV 6 & 11 Nasal Benign Diseases Attributed to HPV 100% 80% 60% Palate 40% 20% Larynx Trachea 0% CIN 1 VIN 1 Genital Warts RRP Each Year in the U.S.: 1.4 million new cases of CIN 1 1 million new cases of genital warts 330,000 new cases of CIN 2-3

10 Genital HPV Infection Most females & males will be infected with at least one HPV type at some point 80 million Americans currently infected 14 million new infections/year in the US the most common STD most are asymptomatic most common in teens & early 20s Jemal A et al. J Natl Cancer Inst 2013;105:

11 HPV Prevalence among Women by Age (with normal cytology) D. Forman et al. Vaccine 2012

12 Oral HPV prevalence by age

13 Outline Pathophysiology Epidemic Prevention Screening

14 Global Burden of Cervical 2015: 1 in Cancer 6 live in Africa 2050: 1 in : 2 in 5 (Gerland, P et al. Science 2014)

15 Burden of Cervical Cancer in Texas

16 J Natl Cancer Inst 2013

17 J Natl Cancer Inst 2013

18 J Natl Cancer Inst 2013 Jemal A, et al. J Natl Cancer Inst 2013

19 Epidemic of HPV Cancers in U.S. Men APC: +5% +5% +3% Penis < 1/100,000

20 HPV Cancers in U.S. Women Vulva Anus APC: +1% +3% Vagina

21 Number of Cases Newly Diagnosed-Untreated Cases Presenting to MD Anderson Each Year Oropharynx Cervix Anus Vulva Penis Vagina 50 0

22 Outline Pathophysiology Epidemic Prevention Screening

23 HPV Prophylactic Vaccines Recombinant L1 capsid proteins that form virus-like particles Non-infectious and non-oncogenic Produce higher levels of neutralizing antibody than natural infection HPV Virus-Like Particle

24 HPV Vaccines Currently Licensed in U.S. Bivalent 2vHPV (Cervarix) Quadrivalent 4vHPV (Gardasil) 9-Valent 9vHPV (Gardasil 9) Manufacturer GSK Merck Merck HPV Types Included Contraindications Dose Schedule 16, 18 6, 11, 16, 18 Hypersensitivity to latex* 3 dose series: 0, 1, 6 months Hypersensitivity to yeast 3 dose series: 0, 2, 6 months 6, 11, 16, 18, 31, 33, 45, 52, 58 Hypersensitivity to yeast 3 dose series: 0, 2, 6 months

25 HPV Vaccine Comparison Genital warts ~66% of ~15% of Cervical Cancer Cervical Cancers ~90% of HPV+ Anal & Oropharyngeal Cancers

26 HPV Vaccine Recommendation Girls and Boys can start HPV vaccination at age 9 Preteens should finish HPV vaccine series by 13 th birthday Catch-up Vaccination: girls years old who have not started or finished HPV vaccine series Catch-up Vaccination: boys years old who have not started or finished HPV vaccine series

27 HPV Vaccination Is Safe, Effective, and Provides Lasting Protection SAFE Benefits far outweigh any potential risks Similar to safety reviews of MCV4 and Tdap vaccination EFFECTIVE Population impact against early and mid outcomes are already being reported in multiple countries LASTING PROTECTION No evidence of waning protection Garland et al, Prev Med 2011; Ali et al, BMJ 2013; Markowitz JID 2013; Nsouli-Maktabi MSMR 2013

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29 2013

30 38% 14%

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32 21% <7% 57% 43% 39% 15% 13-17yo Girls in 2013: 38% 13-17yo Boys in 2013: 14% Jemal A, et al. J Natl Cancer Inst 2013

33 Outline Pathophysiology Epidemic Prevention Screening

34 George Papanikolaou ( )

35 annual burden of genital HPV-related disease (U.S. females) 4,100 cervical cancer deaths 12,900 new cases of cervical cancer 330,000 new cases of HSIL: CIN2/3 (high grade cervical dysplasia) 1 million new cases of genital warts 1.4 million new cases of LSIL: CIN1 (low grade cervical dysplasia) 3 million cases & $7 billion

36 Trends in Cancer Incidence & Number Oropharynx vs. Cervix Chaturvedi AK, et al. JCO 2011.

37 Cervix Oropharynx Median Age at Presentation: 45yo 55yo

38 Conclusions HPV cancer epidemic oropharyngeal, anal, & vulvar HPV vaccination is imperative: Further Delay = Exponential Costs & Suffering Without novel screening/treatment of premalignancy: 30 years of increasing incidence

39 Thank You George Harrison Oropharynx Cancer Hafner & Sturgis. J Texas Dent Assoc 2008