1. Cervical Cancer

2. Cervical Cancer Statistics
United States
An estimated 13,240 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)
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 12th 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
Primary prevention
Secondary prevention
HPV
Cervical
Cancer
Normal
Cervix
Precancer
Infection
Progression
Invasion
HPV- Infected Cervix
Clearance
Regression
The natural history of cervical carcinogenesis (the development of cancer) is a multistep process that involves changes of the surface of the cervix—the epithelium [Ep’-i-theel-i-um].
Once HPV is present, in order to cause changes, it must persist, resisting clearance by the immune system.
The virus then inserts into the genes of the normal cervical cells, triggering genetic changes that cause transformation of normal cells into precancerous cells.
If not treated, some precancerous cells will be changed back by the body into normal cells (regression) and some will acquire other genetic changes that allow invasion into the deeper layers of the cervix. This invasion is the definition of a cancerous cell.
Mild Cytologic and/or
Histologic Abnormalities
HPV=human papillomavirus.
Schiffman M, Kjaer SK. J Natl Cancer Inst Monogr. 2003;(31):14-19.

10. The Cervical Transformation Zone
~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 Cervix has an active area of continous remodeling. Across a woman’s lifetime, the junction between the squamous [squay’-muss] cells of the outer surface of the cervix and the glandular (or columnar) cells of the inner canal progressively moves in towards the canal opening. This active, normal transformation make the cells particularly vulnerable to HPV infection.
Approximately 99% of HPV-related genital cancers occur in this “transformation zone.”
The Pap test is used to obtain cells from the cervix (primarily the transformation zone) for cervical cytology screening. A speculum is inserted to keep the vagina open and to clearly see the cervix. A sample of cells and mucus is lightly lifted from the ectocervix (part next to the vagina) using a small soft-tipped brush. A second brush may be used to take a sample from the endocervix (part closest to the body of the uterus).
1. Castle PE. J Low Genit Tract Dis. 2004;8: American Cancer Society. Prevention and early detection. Pap test. July 2006; Available at;

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.
Preventing cancer through the detection of precancerous changes is called secondary prevention.
Of 50 to 60 million Pap tests each year, nearly 4 million will show low grade changes,
Over 700,000 cases of moderate and severe dysplasia (precancer) are detected each year.
These women will undergo procedures to not only diagnose the problem but treat the precancer.
CDC. MMWK. 2000;49:

14. Cervical Cancer: Screening Window
Single Pap false negative rate is 20%.
Time from pre-cancer to cancer of the cervix varies.
50% of women with cervical cancer have never had a Pap smear.
What does single pap false negative rate mean?
This is the meaning of the false negative rate: A negative Pap test report may also note certain benign (non-neoplastic) findings, such as common infections orinflammation. Pap test results also indicate whether the specimen was satisfactory or unsatisfactory for examination.

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. 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 breastfeeding

19. HPV Vaccine Cont. Recommended for girls 11-12 years
Available for females 9 to 26 years
HPV Prevalence in Women 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
The Center for Disease Control, and the American College of Obstetrics & Gynecology

20. 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

21. HPV Vaccine– Utah $190/ dose ($570 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:

22. 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

23. 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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Consult your personal physician
with any questions or concerns.
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