Dr Nathalie Broutet Reproductive Health and Research, WHO UICC World Cancer Congress Paris, 2016
WHO and recommendations WHO Mandate to Develop Norms and Standards WHO Member States rely on WHO for expertise and guidance through the development of international norms and guidelines and promoting their implementation Recommendations are judgements Quality of evidence Trade off between benefits and harms Costs Values and preferences 2
Comprehensive approach: Programmatic interventions over the life course to prevent HPV infection and cervical cancer PRIMARY PREVENTION SECONDARY PREVENTION TERTIARY PREVENTION Girls 9-13 years HPV vaccination 3 From 10 years old and onward Health education and services, for example: Sexual health education tailored to the age group Providing contraceptive counseling and services including condoms Prevent tobacco use and support cessation* Women > 30 years of age Screening and treatment screen and treat with low cost technology VIA followed by cryotherapy HPV testing for high risk HPV types (e.g. types 16, 18 and others) All women as needed Treatment of invasive cancer at any age Palliative care Ablative surgery Radiotherapy Chemotherapy
So, 2014: the new C4-GEP Chapter 1: Epi, Nat Hist, AnaPath Chapter 2: Programmatic issues Chapter 3: Heath Education Chapter 4: HPV Vaccination Chapter 5: Screen and Treat strat. of pre-cancer Chapter6: Diagnosis and Tx of inv cancer Chapter 7 : Palliative care 4
Screening and treatment arsenal Tests HPV VIA Cytology Treatments for CIN Cryotherapy LEEP Cold knife conisation Sequence of tests followed by treatment 5
What are the downstream consequences of screening? Mortality Sensitivity TP FP Treated Cervical cancer CIN recurrence Bleeding Specificity TN FN Not treated Infection Premature delivery Over treatment 6
WHO recommended screen and treat algorithms 7 http://www.who.int/reproductivehealth/topics/cancers/ en/
Age at screening Screening should start at :30 years Although the magnitude of the net benefit will differ between age groups and may extend to younger and older women depending on their baseline risk. Priority should be given to screening women 30 to 49. Women HIV + should be screened immediately when they know their status if they are sexually active 8
Management HPV-positive women in LMIC Prevalence of 20% high-risk HPV infection among women >30 years old is not uncommon in e.g. sub-saharan Africa Screen-and-treat High treatment burden, considerable overtreatment (comparable to VIA) Ablative treatment (cryotherapy) limited availability Ablation of the transformation zone may be prophylactic for future HPV infections and neoplasia (Herfs et al., 2012) HPV + Triage Main issue: important to retain overall sensitivity of combination of tests 9
Research gaps Few randomized trials that evaluated screen-and-treat strategies and patient-important outcomes. very few studies that assessed the strategies that the guideline development group ranked as clinically relevant (e.g. HPV test followed by VIA). 10
Future triaging methods using biomarkers for cell transformation under investigation HPV E6 oncoprotein HPV E6/E7 messenger RNA Cellular p16inka/ki-67 (immunostaining on cytology) Methylation markers 11 11
Ablative treatment: cryotherapy Recommended treatment method by WHO for LMIC ~ 90% effective in eliminating CIN2/3 in HIV-negative women Need to explore alternative ablative treatment methods: Thermal coagulation Cryo-pen Challenges: accessibility and cost of cryo gases 12 12
Cervical cancer, research needs Feasibility and impact of HPV screen and treat approach Triage methods for HPV positive women Development of point of care HPV tests Investigation of new treatment alternatives (ablative, pharmacologic, immune) Price reduction strategy for HPV tests 13
Comprehensive Approach to Cervical Cancer Prevention and Control 14 http://www.who.int/reproductivehealth/t opics/cancers/en/index.html