1. What you need to know about cervical cancer

2. Cervical Cancer Statistics  United States  An estimated 12,000 new cases each year  An estimated 4,000 deaths each year  700,000 cases of severe pre-cancer  International  Approximately 500,000 cases expected worldwide each year!  Number one cancer killer of reproductive age women Reference American Cancer Society

3. Cervical Cancer- Risk Factors  Early age of intercourse  Multiple sexual partners  Tobacco use  Diet  Oral Contraceptives  High-risk male partner  Other sexually transmitted infections  Human Papillomavirus (HPV)  Diethylstilbestrol (DES)  Family History of Cervical Cancer

4. Cervical Cancer- Human Papillomavirus  HPV DNA is present in virtually all cases of cervical cancer and pre-cancers.  Over 100 strains of HPV identified.  30 to 40 affect the genital area  15 to 20 cause cancer  HPV 16 & 18 cause > 70% of cervical cancer  HPV may be latent for years before inducing precancerous changes.

5. Cervical Cancer- Human Papillomavirus 50 to 80% sexually active adults (exposed) 50 to 80% sexually active adults (exposed)  6.2 million new infections /year in U.S.  74% of new infections occur in 15 to 24 y.o.  70% clear within 1 yr., 90% clear in 2 yrs.  Transmission: Intercourse (vaginal, anal, oral)  Transmission by genital contact also occurs

6. Human Papillomavirus & Cancers

7. Human Papillomavirus Sexual Behavior  2009 National Survey Family Growth  28% females sexually active by 15 years old  70% by 18 years  2009 Youth Behavioral Risk Survey  4.8% active by age 13  41% of 12 th grade females more then 3 partners  40% to 50% women under 25 years old infected with HPV

8. Reducing the Risk of HPV Transmission  Abstinence from genital contact  Lifetime mutual monogamy  If used correctly, condoms can help reduce the risk of HPV infection.  Incidence of genital HPV infection was less than half among women whose partners used condoms for all intercourse, as compared with women whose partners used condoms less than 5% of the time.

9. Natural History of Cervical Carcinogenesis Normal Cervix Mild Cytologic and/or Histologic Abnormalities Precancer CervicalCancer HPV=human papillomavirus. Schiffman M, Kjaer SK. J Natl Cancer Inst Monogr. 2003;(31):14-19. HPV Progression RegressionClearance InfectionInvasion HPV- Infected Cervix Primary prevention Secondary prevention

10. ~99% of HPV-related genital cancers arise within the transformation zone of the cervix The Pap test is used to obtain cells from the cervix (primarily transformation zone) for cervical cytology screening. The Cervical Transformation Zone 1. Castle PE. J Low Genit Tract Dis. 2004;8:224-230. 2. American Cancer Society. Prevention and early detection. Pap test. July 2006; Available at; http://www.cancer.org/docroot/PED/content/PED_2_3X_Pap_Test.asp?sitearea=PED

11. Signs and Symptoms  Bleeding after intercourse  Foul vaginal discharge  Abnormal bleeding (60 to 90%)  Pelvic pain  Leg swelling or pain  Pelvic mass  Visible cervical lesion  May be silent (20 to 30%) Pap Smears help with this

12. Cervical Cancer Pap Smear Screening  Beginning at age 21, or onset of sexual activity  Every 2 years until age 30 (Recently changed from Annually)  After 30, and 3 negative Pap's, may change to every 3 years, depending on the person  After hysterectomy for benign disease, and negative Pap's, may discontinue screening

13. Cervical Cancer Secondary Prevention in the US  50–60 million Pap tests per year  3.8 million cases of low grade squamous intraepithelial lesion detected per year  700,000 cases of moderate/ severe precancer detected per year  6 billion dollars spent on prevention  Pap tests, colposcopy, Loop Electrosurgical Excision Procedure (LEEP) etc. CDC. MMWK. 2000;49:1001-1003.

14. Cervical Cancer: Screening Window  Single Pap false negative rate is 20%.  Time from precancer to cancer of the cervix is variable.  50% of women with cervical cancer have never had a Pap smear. ( Some women have gone over 5 years since their previous Pap smear)

15. Treatments  Surgery  Early disease  Remove part of cervix (cone biopsy)  Simple or radical hysterectomy  Lymph node biopsies  Radiation  All stages of cervical cancer  Chemotherapy at same time

16. Survival Rates  Early disease—Stage I  85 to 100% 5 year survival  Advanced disease—Stages II to IV  50 to 70% 5 year survival

17. Primary Prevention HPV Vaccine  Licensed vaccine available is GARDASIL (Merck)  Noninfectious VLPs (virus like particles) made of virus outer proteins  HPV Strains 6 & 11 (cause genital warts)  HPV Strains 16 & 18 (cause cervical cancer)  3 doses of vaccine at 0, 2, 6 months (usually in the arm)

18. Secondary HPV Vaccine  Cervarix  Guards against HPV Strains 16 & 18  Distributed by GlaxoSmithKline  For ages 9-25

19. HPV Vaccine  Nearly 100 % effective at preventing precancers developing  Over 50,000 patients studied ( ages 9-45)  Side effects:  Injection site pain 85% (75% placebo)  Serious adverse events <0.1%, no differences  Safe during breast feeding (patients that became pregnant reported no birth defects during study)

20. HPV Vaccine Cont.  Recommended for girls 11-12 years Available for females 9 to 26 years  HPV Prevalence in Women 25-45 years old- 25%  Full effect if given before onset of sexual activity  Still beneficial after onset of sexual activity and in women with history of precancers  Only 1% of women will have been exposed to all 4 strains of quad-vaccine  Crossover protection to other oncogenic strains 30 to 60% The Center for Disease Control, and the American College of Obstetrics & Gynecology

21. HPV- Males  60% men are HPV positive  90% protection from genital warts  Vaccine Age 9 to 26 (Gardasil)  Benefit of vaccinating men?  Decrease male HPV related cancers  Decrease transmission--benefit especially important if vaccine uptake is less then 50% by females

22. HPV Vaccine– Utah  $120/ dose ($360 for full set)  Many insurances will cover the vaccine, or a portion  Uninsured / underinsured  0 to 18 y.o. females: covered under Vaccines For Children program  19 to 26 y.o. females eligible for free vaccine through Department of Health (same distribution points as VFC)  Phone: 800-717-1811  www.utahcancer.org  Student Health Clinic on campus

23. Cervical Cancer: Summary  Most people will have an HPV infection  HPV causes cervical and other cancers in a predictable, stepwise fashion.  Pap smear screening is effective at detecting pre-cancerous changes  HPV vaccination is nearly 100% effective in preventing infection and pre-cancerous changes

24. Cervical Cancer: Summary Cont.  Pap smears remain vitally important  Vaccines cover strains that produce 70% of cancers  Needs decades of use before decrease in incidence will be seen  Prevention and early detection saves lives and preserves fertility.

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26. Please Remember to be SCREENED. Consult your personal physician with any questions or concerns. Thank YOU!!!