Download The Role of Medical Research in Zimbabwe

Cervical Cancer and HPV
Z Mike Chirenje MD FRCOG
University of Zimbabwe, Department of
Obstetrics and Gynecology, Harare,
Zimbabwe
• Summary from (Chirenje ZM, HIV and Cancer
of the cervix, in: Best Practice & Research,
Clinical Obstetrics and Gynaecology. Vol. 19,
No. 2, pp. 269 – 276: April 2005, London UK).
Cancer Burden Worldwide
• In 1985 it was estimated that there were
approximately 7.6 million new cases of cancer
diagnosed throughout the world (Parkin DM
et al., Int. J. Cancer, 1993) .
Cancer Burden in Women
• Half of the cases occurred in women
• Distribution of cancer is highest in breast
followed by cervix
• In Africa cervical cancer carries the highest
burden occurring in 20-30% cancers among
women (compared to 4-6% in high income
countries)
Cancer Burden in Women
• 471,000 new cases diagnosed in 2000 of
which 80% were in the developing world
• Close to 300,000 women die from cervical
cancer worldwide every year
• Peak incidence for cervical cancer worldwide
is late 40s to early 50s
Cervical Cancer Burden
by Country Income
Country Grouping
Estimated Cases, 2002
Percent Share
Low income countries
of which: India
264,931
(132,082)
54%
(27%)
Lower middle income
112,232
23%
Upper middle income
60,223
12%
High Income
54,402
11%
Total
491,788
100%
 Majority of cervical cancer cases are in low income countries
 Possible target populations: Developing countries: 52.5 million girls
High-income countries: 6.5 million girls
Source: 2002 Globocan data and PATH staff estimates
Estimates of the Number of Cases
and Incidence of Cervical Cancer,
2002
Magnitude of Cervical Cancer Problem
in Zimbabwean women:
Female cancers registered in 2002 by site:
• Cervix uteri (771)
25.9%
• Kaposi sarcoma (478)
16.1%
• Breast (304)
10.2%
• Ovary (74)
2.5%
• Cervix corpus (40)
1.3%
Zimbabwe cancer Registry (2006).
• Therefore 1 in every 4 women diagnosed to have
cancer had cervical cancer.
Epidemiology and Treatment of Cervical
Cancer :
• Cervical cancer is often slow growing, with
progressive generalised wasting for several months
that creates difficult home care in low resources.
• Family members complain about the unbearable
smell that is socially embarrassing and impossible to
eradicate (unresponsive to antibiotics).
Epidemiology and Treatment of Cervical
Cancer :
• Survival of cervical cancer patients after treatment in
a study by Zimbabwe cancer registry demonstrated
that only 26.8% were alive after 3 years
(Chokunonga et. al. Int. J. Cancer, 2003).
• The peak age for ICC is 46 years resulting in major
catastrophic loss for immediate family, community
and national economic loss.
Epidemiology and Treatment of Cervical
Cancer :
• Majority (63.3%) are from rural communities
•
•
(Chirenje et. al 2000) where a typical 46 year old
woman has 3 to 4 children (oldest 16 years youngest
8 years of age) left behind as young orphans.
Majority (80%) present at FIGO > stage 2b
Psychological effect on nurses/doctors results in
withdrawal/depression symptoms.
Cervical Cancer Overview
• One of the earliest observations in cancer
epidemiology was that cancer of the uterine
cervix rarely occurred among celibate nuns
(Rigoni-Stern, 1842). Rigoni-Stern D.A, Fatti
statistici relativi alle mallattie cancrose.
Giovnali per servire ai progressi della
Patologia e della Terapeutica (1842); 2: 507 –
517.
Role of Screening in advent of HPV
Vaccines
• The role of oncogenic HPV has been
establishes as necessary cause of ICC and its
precursor (CIN)
• Over 100 different genotypes identified of
which 40 detected in anogenital area
•HPV and Cervical Specific
Lessions
HPV infections are among the most common
sexually transmitted infections among adults.
HR DNA is age dependant (peak age late 20’s)
with rates of 15 – 20% and drops significantly to
2-6% by mid thirties when the age specific
incidence rates (ASIR) of ICC are peaking up.
HPV Epidemiology
• Evidence from several African studies
demonstrate prevalence of multiple HPV
types among women with normal cytology,
abnormal cytology, CIN 2/3 (up to 50% HPV
types 16, 18) and ICC ( up to 70 % HPV types
16, 18).
Persistence of HR HPV infection (16,18,26,31,
33,35,39,45,51,52,53,56,58,59,66,68,73 and 82)
is necessary for development, maintenance and
progression of CIN the known precursor for ICC.
Persistence of HPV DNA from types 16, 18, 45
and 31 are found in 99.7% of all ICC.
Studies over the past 15 years have
conclusively established that oncogenic
HPV types (16, 18, 31, 45) are
aetiologically linked to CIN III and
invasive cervical cancer. (Womach SD,
Chirenje ZM, et al, BJOG 107(1) 33-38,
Int.J. Cancer 2000. 85, 206 - 210
• Summary from (Chirenje ZM, HIV and Cancer
of the cervix, in: Best Practice & Research,
Clinical Obstetrics and Gynaecology. Vol. 19,
No. 2, pp. 269 – 276: April 2005, London UK).
Practice Points
• HIV-positive women have 2 to 12 fold higher risk of
CIN lesions compared with HIV-negative women.
• HIV positive women should be offered cervical
cytology screening, referral for colposcopy and
follow-up with 6-monthly cervical cytology
surveillance.
• Treatment of CIN lesions in HIV-positive
women has high recurrence rates,
irrespective of treatment modality
(Chirenje ZM et al, J. Lower Gen. Tract.
Disease 2003).