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Cervical Cancer Prevention in Africa:
The Future
Nelly Yatich, DrPH
University of California San Francisco
July 19th, 2016
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DISCLOSURE
• I have no financial or other conflicts of
interest to declare
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Magnitude of cervical cancer
• Globally 528,000 cases diagnosed per year
• ~ 85% of global burden in the developing world
• Accounts for ~ 12% of all female cancers in the developing world
• High ASRs >30 per 100,000, include E. Africa (42.7), Melanesia
(33.3), Southern (31.5) and Middle (30.6) Africa
• Remains the most common cancer in women in Eastern and
Middle Africa
• Globally 266,000 deaths per year
• Accounts for 7.5% of all female cancer deaths
• Almost 87% cervical cancer deaths occur in developing countries
• Rates of > 20 per 100,000 in in Melanesia (20.6), Middle (22.2)
and Eastern (27.6) Africa
Globocan, 2012
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Cervical cancer burden in HIV/AIDS
HIV Prevalence 2014
(UNAIDS)
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Cervical cancer incidence
(Globocan, 2012)
Cervical cancer in women with HIV
• Increased longevity of patients on ART may:
– Increase risk of exposure to HPV
– Provide the time required for progression to cervical cancer
• HIV-positive women are more likely to have:
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Human Papilloma Virus (HPV) infection
Persistent infection with high risk HPV
An increased risk of developing precancerous lesions
A recurrence of precancerous lesions after treatment
Precancerous lesions that progress rapidly to cervical cancer
Higher risk of developing cervical cancer than HIV(-) women
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Model of HPV–related CIN and cervical
cancer with ART
Palefsky, Current Opinion in Oncology, 2003
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Screening for cervical cancer
• Cytological screening of women has resulted in a decline in
cervical cancer deaths in wealthier countries
• High mortality in the developing world due to shortage of highquality precancer screening and treatment programs
• Most developing countries lack infrastructure and trained
personnel for cytology
• VIA has been reported to have sensitivity values comparable to
Pap and provides opportunity to “see and treat”
• VIA Accuracy:
– Depends on provider experience
– May miss small or endocervical lesions
– Requires pelvic exam (space, supplies, fear by clients)
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The future – HPV screening
• Precision oncology: Interventions concentrated on those
who will benefit, sparing expense and side effects for those
who will not
• HPV testing is:
– Etiology-based
– Has been shown to be more sensitive, with higher positive and
negative predictive value than cytology
– Is more readily exportable to low resource settings
• 2013 WHO guidelines recommend:
– HPV over VIA, where possible
– Treatment based on screening results alone
– Cryotherapy as standard treatment, LEEP at referral
centers
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• Cluster RCT of 52 villages in India (131,746 women)
• Random assignment to
– HPV testing
– Cytology
– VIA
– Standard Care
• Outcome: Cervical cancer incidence or death
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India Trial, Results
• Test positivity rates:
– HPV: 10%, Cytology 7%, VIA 14%
• Detection rate for CIN1 was higher in the VIA
group
• Detection rate for CIN 2 and 3 similar across
all three groups
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The future – HPV Vaccination
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Gardasil® (Merck) and Cervarix ®(GSK)
Efficacy 96-98% in prevention of cervical pre-cancers
Both vaccines appear to offer cross-protection against other HPV types
Vaccine most effective if given before 1st sexual contact
Administered as a series of 3 injections over a 6-month period at 0, 1-2,
and 6 months
Challenges for developing countries:
• Health care infrastructure
• Capacity for initiating and sustaining an immunization program for
adolescents
• Affordability and cost-effectiveness of vaccination relative to
other programs competing for resources
• Cultural acceptability
• Political will
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Research Priorities
• Optimal screening strategies for cervical cancer precursors
in Africa
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Role of HPV testing
Role of self-collection
Testing at community settings
Point of care treatment
• Integration of HPV vaccine with screening in developing
countries
• Second generation of prophylactic HPV vaccines
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How can evidence-based strategies be
successfully implemented?
• Systematic assessment of the barriers and facilitators to
implementation of the interventions
• Partnership with the communities and stakeholders to
develop feasible and sustainable strategies
• Ensure that strategies as implemented remain faithful to
original intervention
• Cost effectiveness analysis
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Community-based HPV testing
• Outreach and education:
– Use a brief educational module validated in this setting for use
by CHWs
– Provide outreach, education and screening in most accessible
location
• Screening:
– Low-cost HPV screening available
– Self-collected specimens eliminate many barriers to
VIA/screening
• Notification of results:
– Text message, phone call results with follow-up information
• Treatment:
– Cryotherapy, with LEEP for larger lesions
– Linkage strategies to be developed with communities
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Conclusion
• Cervical cancer remains a huge burden of disease for
women in resource-limited settings
• HIV infection is associated with higher incidence of cervical
cancer and CIN/SIL
• Alternatives to cytology, such as HPV testing, are critical to
ensure adequate coverage and appropriate interventions
• Community partnership is key
• Although current vaccines are highly effective in women,
implementation of HPV vaccination in developing countries
remains a challenge
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