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The Role of WHO in Control of Cervical Cancer

The Role of WHO in Control of Cervical Cancer. World Health Organization. Katharine Shapiro, PA, MPH Department of Reproductive Health Research Cervical Cancer Control Project Dr. Cecilia Sepulveda, Coordinator, Program on Cancer Control. The Role of WHO in Control of Cervical Cancer.

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The Role of WHO in Control of Cervical Cancer

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  1. The Role of WHO in Control of Cervical Cancer World Health Organization Katharine Shapiro, PA, MPH Department of Reproductive Health Research Cervical Cancer Control Project Dr. Cecilia Sepulveda, Coordinator, Program on Cancer Control

  2. The Role of WHO in Control of Cervical Cancer Acknowledgements: Dr. Nathalie Broutet Reproductive Health Research, Dr. Andreas Ullrich, Program on Cancer Control, Dr. Sonia Pagliusi, Initiative for Vaccine Research

  3. Topics to be covered • Magnitude of the problem • Causes and natural history • WHO - A comprehensive approach • Prevention - vaccines • Early detection - screening and treatment • Treatment and palliative care • Collaboration • The challenges ahead

  4. Magnitude of the problem • Cervical cancer is of the leading causes of cancer among women • 480,000 new cases per year • 234,000 deaths per year • 1.4 million prevalent cases (Globocan, 2000)

  5. Magnitude of the problem Incidence 452 000

  6. Regional disparities in incidence trends

  7. Magnitude of the problemMain reasons for regional differences • Lack of effective primary prevention • Lack of effective early detection and treatment programmes • Differences in prevalence of risk factors

  8. WHO activities to control cervical cancerProgram on cancer controlA comprehensive approach

  9. WHO activities to control cervical cancerProgram on cancer controlA comprehensive approach Healthy population Prevention Early detection and treatment Exposed to Risk T reatment Early Stages Advanced Stages Palliation Death

  10. Standardization of diagnostic procedures Phase I & II of bivalent VLPs Available candidate vaccines Phase II trials Preclinical development of novel HPV vaccine candidates Vaccine candidates to be developed PhaseII trials of novel candidates Phase I & II trials of selected candidates Exploring affordable vaccine production Parallel track approach to HPV vaccine development Epidemiological studies in Asia Epidemiological studies in Africa HPV vaccine introduction world-wide Phase III trials Qualitative research for vaccine introduction Cost-effectiveness analyses Advocacy Decision point YEAR 2003 2004 2005 2006 2007 2008

  11. Prophylactic vaccines against HPV HPV Type and Antigen Organization Status Merck Phase III US, L. America Nordic countries, Asia 16-18-6-11 L1 VLP NCI (US), GSK 16-18 L1VLP To start Phase III Costa Rica Ph II-III L.America US GSK 16-18 L1VLP

  12. Estimated incidence of cervical cancer cases* Ongoing clinical trials for prophylactic HPV vaccines 64.900 14.900 245.600 67.200 77.300 2.100 Asia accounts for about half of all cases *adapted from Globocan 2000

  13. WHO activities to control cervical cancerProgram on cancer controlA comprehensive approach Healthy population Prevention Early detection and treatment Exposed to Risk T reatment Early Stages Advanced Stages Palliation Death

  14. Efficacy of screening SiteReduction in mortality* • Breast (age 50-69) 30% • Cervix 90% • Colon 30% * Providing adequate compliance achieved at the population level

  15. Failures of cervical screening At level of the national program At the level of the community At the level of the woman At the level of the primary care provider At the level of the laboratory At the level of the gynecologist

  16. Cervical Cancer: Alternatives for early detection Early diagnosis Cost Effective Available Cytology Screening $$ +++ Yes VIA $ +++? Yes HPV Screening $$$ +++? Yes REF: 1) National Cancer Control Programmes, Policies and Managerial Guidelines, 2nd ed. 2) Report on a WHO Consultation Cervical Cancer Cancer in Developing Countries (in press)

  17. 2001 Consultation Cervical Cancer Screening - Conclusions • Central to the success of any screening programme is adequate organisation and functioning irrespective of which method of screening is used • Currently Cervical cytology is the only test known to reduce cervical cancer incidence and mortality in programmes, particularly in organized ones. (Though never proven by RCT)

  18. 2001 Consultation Cervical Cancer Screening - Conclusions • At present there is not sufficient evidence to recommend VIA based screening programmes. The results from on going RCT are being analysed; will be available after IARC April meeting • At his point in time there is insufficient evidence to recommend HPV tests for primary screening. Further research is required (Cost benefit analysis and RCT)

  19. WHO steps for screening in resource-limited settings • Screen every woman once at age 45 • Once resources permit, expand to screen every woman at ages 35, 45 and 55 • When that has been achieved, expand to screen every 5 years from age of 35 to 59 • Only when the coverage is adequate for women age 35-59, extend screening to age 25 or more

  20. WHO activities to control cervical cancerProgram on cancer controlA comprehensive approach Healthy population Prevention Early detection and treatment Exposed to Risk Treatment Early Stages Advanced Stages Palliation Death

  21. Elements of an organised program • The target population is identifiable • Measures are available to guarantee high coverage and attendance • There are adequate facilities for performing high quality screening tests • There is an effective referral system for diagnosis and treatment of abnormalities • There are adequate facilities for diagnosis and treatment

  22. Cervical Cancer Control : The Package Programme Manager Adaptation tools: Programmatic guides • Adaptation and Evidence-Based guides • Training tools • Service Programme Guidance • Review of Screening and Programmatic strategies Generic Guidelines Health care providers • Comprehensive Cervical Cancer Control: a Guide for Essential Practice (C4-GEP) • Specific, practical guides adapted to health care setting

  23. WHO Core Functions“Stimulating the development and testing of new technologies and guidelines for disease control”Collaboration * • Within WHO: • Reproductive Health Research (RHR) • Program on Cancer Control (PCC) • Initiative for Vaccine Research (IVR) • International Agency for Research on Cancer (IARC) • Regional Offices - PAHO • UN Agencies • International Atomic Energy Agency (IAEA) • UN Fund for Population Activities (UNFPA) • Other Organizations • ACCP, Academic institutions

  24. Challenges Ahead • Advocating for evidence based policies • Reinforcing cytology screening where feasible • Promoting low cost screening technologies for low resource settings • Stimulating early diagnosis (awareness of early signs & symptoms) • Accelerating the development & dissemination of HPV vaccines in developing countries

  25. Challenges Ahead • Promoting integrated intervention for prevention, early detection, treatment and palliation) • Assisting countries in implementing effective and efficient programmes using a systematic approach involving all levels of the health care system • WHO Cancer website: www.who.int/cancer • RHR website: http://www.who.int/reproductive-health/ • IVR website: www.who.int/entity/vaccine_research/en • IARC website: www.who.int/entity/vaccine_research/en

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