1. HPV: How to prevent your patients from becoming my patients Katina Robison, MD Assistant Professor, Department of Obstetrics & Gynecology Director of Colposcopy Brown University / Women and Infants’ Hospital Program in Women’s Oncology

2. Oropharyngeal Cancer Cervical Cancer Anal Cancer

3. HPV Prevalence Koutsky LA, Am J med 1997 – estimated prevalence 1.4 million (1%) genital warts 5 million (4%) detected by colposcopy 14 million (10%) HPV positive – neg colpo 81 million (60%) HPV negative with detectable antibodies TOTAL INFECTED = 75% of population

4. There are at least 14 oncogenic HPV genotypes in the anogenital region

5. Most Prevalent HPV Types Squamous Cervical Cancer Munoz et al. N Engl J Med. 2003;348:518-527 58% 13% 5% 4% 3% All HPV-infected patients (%) 60 50 40 30 20 10 0 >70% of cases of cervical cancer are associated with HPV 16 or 18 HPV 16 HPV 18

6. Most Prevalent HPV Types Adenocarcinoma Castellsague X et al. J Natl Cancer Inst. 2006;98:303-315. Prevalence of HPV type in cases of adenocarcinonma (%) HPV DNA was detected in 93% of patients with cervical adenocarcinoma. HPV 16 HPV 18 HPV 45Multitype

7. HPV 16/18 One of highest oncogenic risks known! Male 40 pack-yr smoking hx vs nonsmoker RR of lung cancer: 9.6 Postmenopausal women on HRT vs no HRT RR of breast cancer: 1.3 HPV16+ vs negative RR of cervical cancer: 434

8. Prevention

9. HPV vaccines are 93% effective in preventing cervical cancers secondary to HPV 16 and 18

10. How is Rhode Island doing? GIRLS 39.9% IN KANSAS 76.6% IN RHODE ISLAND BOYS 11.0% IN KANSAS 69.3% IN RHODE ISLAND

11. HPV Vaccine $360 Cervical Cancer Treatment $40,000

12. Screening

13. Cervical PAPANICOLOU Smear Herrero R. Monogr Natl Cancer Inst 1996; 21:1-6 77% reduction in the incidence of invasive cervical cancer No RCTs have evaluated efficacy

14. April 2014: FDA approves cobas HPV test for primary cervical cancer screening in women over 25 years

15. Effectiveness For Screening HPV versus Cytology Detect CIN 2+SensitivitySpecificity HPV + 97.1%93.3% Cytology 76.6%95.8% Cuzick, J et al Lancet 2003;362:1871-76

16. ACOG: When to Start and Why? Age 21 Cancer rarely seen prior to  19 years Only 1.7% adolescents estimated to have HSIL 70-90% HPV regression rates within 3 years 1,2 80-90% LSIL regression in 13-21 yo (50-80% in adult women) 1 CIN 2 regresses 65% and 75% of the time after 18 months and 3 years 3 1 Moscicki AB. J Pediatr 1998; 132:277-2 2 Ho GY. NEJM 1998; 338:423-42 3 Moore K, et al. AJOG 2007; 197:141e1-141e6 4 Fuchs, et al. J Pedi Adol Gyn 2007;20:269-274.

17. Frequency of screening 21 to 29 years Cytology alone Every 3 years HPV testing should NOT be used to screen 30 to 65 years Cytology alone (acceptable) Every 3 years Cytology and HPV testing (preferred) Every 5 years

18. Can we screen for other HPV related cancers? Formal guidelines are lacking Consider in HIV positive, MSM, and studies underway in HIV negative women Anal Cytology

19. Thank You krobison@wihri.org 401-954-9811