1. Introduction to HPV Infection & Cervical Cancer Disease GardasilTM
Essential Training Package for HPV Vaccine Introduction
Module 1
Introduction to HPV Infection & Cervical Cancer Disease GardasilTM

2. Learning objectives
At the end of the module, you will have learned to:
Explain the incidence & mortality of cervical cancer globally and regionally
Explain the cause of most cases of cervical cancer
Explain HPV transmission and disease progression
Discuss symptoms, prevention and treatment of cervical cancer
Duration
45’

3. Key Issues
What is cervical cancer, its incidence & its mortality? 1
What causes cervical cancer? 2
How does HPV infection lead to cervical cancer? 3
What are the risk factors for cervical cancer? 4
Explain to the participants the key issues raised in this module:
1. What cervical cancer is and its mortality
2. The cause of most cases of cervical cancer
3. Explain HPV transmission and disease progression
4. The risk factors for pre-cancer lesions and cervical cancer
5. Symptoms, treatment and prevention of cervical cancer
What are the symptoms, treatment and prevention of cervical cancer? 5

4. Global Burden of Cervical Cancer
The second most common cancer in women
Every year:
530,000 new cases diagnosed
275,000 deaths
Over 85% in developing countries
By 2050:
one million cases
90% in developing countries
Let’s begin by sharing what you know or have heard about cervical cancer.
Let me explain what the magnitude of cervical cancer is:
Cervical cancer remains the second most common cancer in women in developing countries.
Cervical cancer affects an estimated 530,000 women each year and leads to 275,000 deaths, over 85% in developing countries.
By 2050, it is estimated that one million women worldwide will be diagnosed with cervical cancer (every year) and 90% of those who die from cervical cancer reside in developing countries.
The highest incidence and mortality rates are in sub-Saharan Africa; Latin America and the Caribbean; and South and Southeast Asia.
Source:
HPV vaccine introduction into national immunization programmes: Information for programme managers and health workers. WHO 2013
Comprehensive cervical cancer prevention and control: a healthier future for girls and women. Guidance Note. WHO 2013

5. Introduction
Let’s begin by looking at the estimated cervical cancer mortality rate worldwide. Data are available from IARC, the International Agency for Research on Cancer (IARC is part of WHO) - the most current available IARC data come from 2012.
Overall, the mortality rate or case fatality ratio is 50% - this means 50 of 100 women diagnosed with cervical cancer (every year) die from it.

6. What is cervical cancer?
The cervix is the lower part of uterus (womb)
Cervical cancer is the uncontrolled growth of abnormal cells in the cervix, which usually starts on the surface
Cervical cancer is invasive, which means it can grow deep into the cervix and uterus
It can spread to other parts of the body (metastasize) in some cases
Cervix is the lower part of uterus (womb)
Cervical cancer is the uncontrolled growth of abnormal cells in the cervix
Cervical cancer occurs when the cells in the cervix begin to grow and replicate in an abnormal and uncontrolled way. The uncontrolled growth usually starts in the surface cells at the outer part of the cervix
Invasive cancer means that the cancer affects the deeper tissues of the cervix
Cervical cancer can also spread to other parts of the body. This spread is called metastasis. Cervical cancer usually spreads by direct invasion of neighboring tissues to involve the bladder, the vagina, or the rectum and later involve the intestines, ureters, liver, and kidneys

7. What causes cervical cancer?
Human papillomavirus (HPV) is the main cause of cervical cancer
HPV is a common virus, which is
Easily spread by skin-to-skin contact during sexual activity with another infected person
HPV types 16 and 18 are associated with about 70% of all cervical cancer cases
Risk factors for HPV infection and cervical cancer:
Early sexual intercourse
Multiple sexual partners
Tobacco use
Certain Human papillomarvirus (HPV) types cause cancer including cervical, vulvar, vaginal, penile, anal, and oropharyngeal (base of the tongue, tonsils and back of throat) cancers
There are many different types of HPV, and many do not cause problems. However, infection with certain types of HPV can lead to Cervical cancer (HPV types 16 and 18 cause over 70 percent of cervical cancer cases) and other types can cause genital warts
Human Papillomavirus 7

8. Symptoms of advanced cervical cancer
HPV infection is often asymptomatic
Symptoms appear after cancer reaches an advanced stage
Main symptoms include:
Irregular vaginal bleeding or bleeding after sexual intercourse
Back, leg or pelvic pain
Fatigue, weight loss, loss of appetite
Vaginal discomfort or odorous discharge
Single swollen leg
More severe symptoms (usually more advanced):
Severe anaemia
Renal failure
Fistulae
Lymphoedema
HPV infection is often asymptomatic. Symptoms of cervical cancer tend to appear only after the cancer has reached an advanced stage and may include:
Irregular, intermenstrual or abnormal vaginal bleeding after sexual intercourse
Back, leg, or pelvic pain,
Fatigue, weight loss, loss of appetite
Vaginal discomfort or odorous discharge which may be pale, watery, pink, brown, or bloody
Single swollen leg
More severe symptoms may arise at more advanced stages including more severe anaemia, renal failure, fistulae, and lymphoedema
Human papillomavirus

9. World Health Organization
How does HPV infection lead to cervical cancer?
28 November 2018
28 November, 2018
Graph A:
Cervical cancer begins with infection of cells on the surface of the cervix. Most HPV infections clear up spontaneously, but a small percentage of women infected with oncogenic (cancer-causing) HPV types develop persistent infections, and this can lead to precancerous changes or lesions. Some lesions resolve spontaneously, but others progress to invasive cervical cancer
Progress from infection to precancer and cancer is slow (15-20 years or more); so cervical cancer is most often found in women of middle age. Because of this long period of progression, there are good opportunities to identify and treat early stages of the disease—either HPV infections or precancerous lesions. If lesions are treated early, success rates are very high and invasive cancer typically does not develop
In women with immune suppression, such as women with untreated HIV infection, progression of HPV infection to precancer and cancer can be rapid, sometimes resulting in cervical cancer in women still in their 20’s
HPV infections (short-lived or persistent) do not show symptoms, so women must be screened periodically to determine if a persistent infection has occurred or if lesions have developed 9

10. Over what timespan does Cervical cancer develop?
Graph B: The prevalence curves are not drawn to scale. The graph shows age-related prevalence of HPV infections (pink), precancer (blue), and cervical cancer (green).
Most people become HPV infected shortly after they become sexually active
It takes 15 – 20 years to develop into cancer in women with normal immune systems. It can take only 5-10 years in women with abnormal immune systems, such as those with untreated HIV infection
Cervical cancer screening should start around 30 years of age (in women with normal immune systems) so that most precancerous lesions can be detected and treated, before cancer develops
This graph also shows us why we should vaccinate early – administering HPV vaccine in girls who are 9-13 years old allows them to be protected from HPV infection before they are exposed to the virus and before the high-risk period where HPV infection prevalence is highest

11. Prevention and Treatment
World Health Organization
28 November 2018
HPV vaccination prevents 95% of HPV infections with types 16 & 18
The WHO Comprehensive Approach to Cervical Cancer Prevention and Control includes primary prevention, secondary prevention and tertiary prevention. The most effective national strategies for prevention and control contain a combination of primary, secondary, and tertiary prevention which - due to its breadth of activities - calls for cross-disciplinary coordination
HPV vaccination offers the earliest opportunity to prevent cervical cancer before a girl is even infected. HPV vaccines prevent over 95% of HPV infections caused by HPV types 16 and 18, and may have some cross-protection against other less common HPV types which cause cervical cancer
Tobacco use is a risk factor for cervical cancer and people often start using tobacco during adolescence. This age group is therefore an important window of opportunity for prevention
Safe sexual practices, including delay in onset of sexual activity, reduce the risk of HPV infection. Therefore sexuality education is another component of cervical cancer prevention (such as through the promotion of condom use)

12. Key messages (1/2)
Cervical cancer is the 2nd most common cancer in women
Cervical cancer affects an estimated 528,000 women each year and leads to 266,000 deaths (2012) over 85% of affected women live in developing countries
Cervical cancer is caused by persistent infection with certain types of HPV virus – types 16 &18 cause most cervical cancers
HPV viruses are common and spread easily by skin-to- skin contact during sexual activity
Cervical cancer remains the second most common cancer in women
Cervical cancer affects an estimated 528,000 women each year and leads to 266,000 deaths (2012), over 85% in developing countries
Almost all cervical cancers are caused by the human papillomavirus (HPV). Persistent infection with specific types of HPV (most frequently, types 16 and 18) may lead to precancerous lesions
HPV is a common virus that is easily spread by skin-to-skin contact during sexual activity with another infected person 12

13. Key messages (2/2)
Risk factors for HPV infection and cervical cancer are:
early sexual intercourse,
multiple sexual partners
tobacco use
Progress from infection to pre-cancerous lesions and cancer is slow but can be rapid in women with immune suppression
Symptoms of cervical cancer tend to appear only after the cancer has reached an advanced stage
HPV vaccines prevent over 95% of infections from HPV types 16 & 18
Risk factors associated with HPV infection and cervical cancer are early sexual intercourse, multiple sexual partners, and tobacco use
Progress from infection to precancer and cancer is slow (15-20 years or more) but can be rapid in women with weak immune suppression
HPV infection is often asymptomatic. Symptoms of cervical cancer tend to appear only after the cancer has reached an advanced stage
HPV types 16 and 18 cause 70% of cervical cancer and HPV vaccines prevent over 95% of HPV infections caused by HPV types 16 and HPV vaccines may have some cross-protection against other less common HPV types that cause cervical cancer 13

14. End of module for your attention! Thank you
This is the end of the module, thank you for your attention!

15. References
Comprehensive cervical cancer prevention and control: a healthier future for girls and women. Guidance Note. WHO 2013
HPV vaccine introduction into national immunization programmes: Information for programme managers and health workers. WHO 2013