Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Download Dr Hewitts lecture on HPV and colposcopy Oct 2014
Document related concepts
no text concepts found
Transcript
HPV and cervical screening Test of cure Dr Matt Hewitt Cervical cancer in Ireland – key statistics 9th most frequently diagnosed cancer in women (278) 12th most common cause of cancer death in women (103) Average age diagnosis - 46 years Average age death - 56 years Survival in Ireland is slightly lower than the European average. The trends in mortality since 1978 show an increase of 1.5% per year. • Ref: National Cancer Registry Ireland • Cervical cytology • CervicalCheck screening programme Early Diagnosis • Vaccination Secondary prevention Primary prevention Key points – prevention of deaths from cervical cancer • Down staging of cancers at diagnosis • Agreed assessment and referral for women with symptoms CERVIX SQ COL SQ COL SQ – squamous epithelium COL – Columnar epithelium Acidic vagina Metaplasia External os Glandular epithelium (Ectropion) New Sq Col Jun Transformation zone Area of metaplasia Native Sq Col Jun HPV Acidic vagina Metaplasia Acidic vagina Dysplasia Natural history of HPV infection •Transmission by sex •Lifetime risk 80% most within 18 months Exposure Infection •Transient •Most resolve within 18 months •Less than 20% persist •No antibodies detectable Persistence Malignant Transformation •Virus integrates into host DNA •Loss of tumour suppressor gene E2 •Uncontrolled cells division CIN Natural history of CIN Observe Treat (LLETZ) Metaplasia CIN I CIN II CIN III Cancer Use of HPV in screening •In the management of women with low grade sears •In the follow up of women who have had treatment •Future use of HPV in screening Low grade smears •Very common •Fill the colposcopy clinic with patients •Majority of low grade CIN will resolve spontaneously •Low grade CIN natural response to HPV infection •Patient anxiety •Cost •How to overcome these problems? • Use of HPV in low grade disease in colposcopy • Use of HPV in primary care Future screening protocols •Incorporate HPV in primary care screening •If Low grade smear and negative HPV avoid colp referral •Advantages • Cost saving • Reduced anxiety in colposcopy referral • Avoid unnecessary treatment •Disadvantage • Counselling women about HPV infection Options for follow-up after treatment Cumulative incidence of CIN3+ Sensitivity of cytology is low with high false negatives Traditional schedules Compensate by repeated smears – annual for ten years HPV test with cytology has negative predictive value of> 90% Dillner, J. et al. BMJ 2008 Follow-up after treatment Traditional strategy New strategy 6 month smear at Colposcopy 12 month smear 24 month smear 36 month smear 48 month smear 60 month smear 72 month smear 84 month smear 96 month smear 120 month smear Routine Recall 6 Months HPV and Smear 18 months HPV and Smear Discharge to routine screening if double negative HPV 16 and 18 Advantages of introducing the vaccine •Reduced incidence of cervical cancer (adeno and squamous) •Reduced incidence of genital warts •Reduce the incidence of genital cancer •Reduced incidence of some head and neck cancers •Potential to stop the cervical cancer screening programme •Greater impact in developing countries where there is no cervical screening Disadvantages of introducing the vaccine •Cost •Only covers 70 – 75% of cervical cancers •?Increased promiscuity •Ethical issues of vaccination of teenage girls •Delivery to young girls – counselling issues •Decreased uptake of smears in screening programme •Future role of colposcopy services •Long term efficacy •Side effects •Bad publicity MORTALITY FROM CERVICAL CANCER DEATHS (PER 100,000 PER YEAR) 5 IMPACT OF VACCINE AND DURATION OF PROTECTION 4 10 year protection & no screening 3 Screening & no vaccination 10 year protection & screening Lifelong & no screening Lifelong protection & screening 2 1 0 0 10 20 30 40 50 TIME SINCE START OF VACCINATION PROGRAM Thank You
