1. Jennifer S. Smith University of North Carolina JenniferS@unc.edu Cervical Cancer-Free America Initiative Overview Changing the Dialogue about Cervical Cancer Prevention

2. Carolina Framework for Action against Cervical Cancer There are four key challenges to eradication of cervical cancer that a comprehensive public health strategy can address: HPV infection Lack of screening Screening errors Not receiving follow-up care for abnormal Pap smear results Brewer and Smith

3. HPV virus-like particles (VLPs): Basis of HPV vaccination For Prevention of Cervical Cancer: Persistent HPV 16/18 infections HPV 16/18 abnormal pap smear

4. HPV Types by Cervical Status: Potential Impact of 16/18 Vaccine ~70% ~50% ~14-25% HPV Type Specific Prevalence in All Cases ICC data: Smith et al. Int Journal of Cancer, 2007, 121 (3), 621-32. HSIL data: Smith et al. Int Journal of Cancer, 2007, 121 (3), 621-32. LSIL data: Clifford et al. Cancer Epidemiol Biomarkers. 2005;14:1157-1164

5. Optimal to Vaccinate Adolescent Girls before Sexual Debut 1- Hypothetical distribution of HPV prevalence in EU modeled after data available in the US and Canada 35 30 25 20 15 10 5 Age (years) % Estimated start of sexual life 051015202530354045505560657075 Frequency Papillomavirus Infection (all types)

6. Prophylactic HPV Vaccine Approved for Adolescent Girls VaccineHPV TypesFDA approvedAge range Bivalent16/18 200910-25* yrs Quadrivalent6/11/16/18 20069-26* yrs *Routine vaccination for 11-12 year old females

7. Females aged 13-17 years US 2009: 44.3% (42.4%-46.1%) for 1+ dose 26.7% (25.2%-28.3%) for 3 doses completed August 20, 2010 / 59(32);1018-1023 HPV Vaccine Coverage National Immunization Survey-Teen

8. Continued Need for Screening Following HPV Vaccination ~70% ~50% ~14-25% HPV Type Specific Prevalence in All Cases ICC data: Smith et al. Int Journal of Cancer, 2007, 121 (3), 621-32. HSIL data: Smith et al. Int Journal of Cancer, 2007, 121 (3), 621-32. LSIL data: Clifford et al. Cancer Epidemiol Biomarkers. 2005;14:1157-1164

9. Decrease in Cervical Cancer Mortality Following Introduction of Pap Test in the United States 1. OBGYN.net. Available at: http://www.obgyn.net/displayarticle.asp?page=/yw/articles/braun_PAP 2. American Cancer Society. Cancer Facts & Figures. Available at: http://www.cancer.org/

10. Sensitivity of Cervical Cancer Screening Methods Screening method Endpoint ≥CIN 2 Sensitivity % (95% CI) Pap smear only 71 (61-81) HPV DNA test only 95 (89-99) Pap smear with HPV DNA test 100 (96-100) Naucler P, et al. JNCI. 2009;101:88-99.

11. 30-64 Years 21-29 Years <21 Years No routine Pap smear No routine Pap smear Pap Smear Guidelines: 2009 American College of Obstetrics and Gynecology Pap smear every 3 years..if patient has had 3 or more normal Pap results in a row, no abnormal test results in 10 years, and lacks other risk factors. * Pap smear every 3 years..if patient has had 3 or more normal Pap results in a row, no abnormal test results in 10 years, and lacks other risk factors. * * History of cervical cancer or DES in utero, HIV positive, immunosuppression, or other risk factors for acquiring STDs. Bi-annual Pap smear ACOG Practice Bulletin No. 109. Obstet Gynecol. 2009;114:1409-20. ≥65 Years Consider discontinuing Pap smear at 65 or 70 years..if patient has had 3 or more normal Pap results in a row, no abnormal test results in 10 years, and lacks other risk factors. * Consider discontinuing Pap smear at 65 or 70 years..if patient has had 3 or more normal Pap results in a row, no abnormal test results in 10 years, and lacks other risk factors. *

12. We can Change the Dialogue We can End Cervical Cancer Policy Makers Vaccination Screening We can Effect Real Change at the State-Level

13. ALASKA HAWAII DC Age-adjusted Death Rates per 100,000 Quantile Interval 3.0 – 3.7 2.8 – 2.9 2.5 – 2.7 2.2 – 2.4 1.9 – 2.1 1.5 – 1.8 US Rate 2.5 Age-adjusted Mortality Rates per 100,000, 2001-2005 SEER Data SEER = Surveillance, Epidemiology, and End Results 1. Surveillance, Epidemiology and End Results (SEER) Cancer Stats NCI, 2001-2005. California Indiana Texas North Carolina Alabama Kentucky

14. Cervical Cancer Free America Common State Goals To increase HPV vaccination among young female adolescents ages 10-18 To increase cervical cancer screening among women ages 25-70 who have not been screened in the last four years.

15. Cervical Cancer Free California California Medical Association Foundation Sara Cook, Carol Lee, Elissa Maas

16. Cervical Cancer Free Alabama University of Alabama Mona Fouad, Warner Huh, Theresa Wynn

17. Cervical Cancer Free Kentucky University of Kentucky Baretta Casey, Rick Crosby, Robin Vanderpool

18. Cervical Cancer Free Indiana University of Indiana Gregory Zimet Kirk Forbes

19. Cervical Cancer Free North Carolina University of North Carolina Noel Brewer, Pamela Entzel, Jennifer Smith

20. How Can We Work Actively Together? January: Cervical Cancer Awareness Month Cervical Cancer Awareness Month is right around the corner. is right around the corner.