HPV Vaccine – Does it Prevent Cervical Cancer?

1. HPV Vaccine – Does it Prevent Cervical Cancer?

2. What is HPV? • HPV related diseases • Prevention

3. What is Human Papillomavirus (HPV)? • Cervical Cancer is caused by certain types of virus known as Human Papillomavirus. • ~ Oncogenic • ~ Non-oncogenic

4. Human Papillomavirus (HPV)

5. Types of HPV >100 Types 30-40 types Anogenital area 15-20 types High risk 10-15 types Low risk HPV 6, 11 cause 90% of genital warts HPV 16, 18 cause 70% of cervical cancer HPV 16, 18 can cause: • 85% of anal cancers2 • 40% of penile cancers2 • 35% of throat cancers2 • 25% of mouth cancers2 HPV 6, 11, 16, 18 can cause Vaginal & Vulvar Lesions/Cancer 1. Centers for Disease Control and Prevention. Genital HPV infection fact sheet. 2. Centers for Disease Control and Prevention. HPV-Associated Cancers

6. How does HPV get transmitted? • Sexual contact • Sexual intercourse • Genital–genital, manual–genital, oral–genital • Genital HPV infection in virgins is rare, but may result from nonpenetrative sexual contact. • Condom use may help reduce the risk, but not fully protective. • Nonsexual routes • Mother to newborn (vertical transmission) • Fomites (e.g., undergarments, surgical gloves, biopsy forceps) • Hypothesized but not well documented; would be rare • Most infected individuals are unaware that they are infected and may unknowingly spread the virus.

7. How common is HPV? Most men and women who have had sex have been exposed to HPV Lifetime risk according to the US Centers for Disease Control for sexually active men and women is at least 50%.

8. Risk Factors of HPV Infection Women Young age (peak age group 20–24 years of age) Lifetime number of sex partners Early age of first sexual intercourse Male partner sexual behavior Smoking (↓immunity) Oral contraceptive use (sexual behavior) Uncircumcised male partners Men Young age (peak age group 25–29 years of age) Lifetime number of sex partners Being uncircumcised Sexual partner with CIN

9. GENITAL WARTS Cauliflower-like lesions Often found on the vulva, perineum, perianal area, vagina, cervix, penis and scrotum HPV 6, 11 cause 90% of genital warts Male perineum area

10. CERVICAL CANCER • Abnormal cell growth in the cervix • 2nd most common cause of cancer death among women • HPV 16, 18 cause 70% of cervical cancer Progression from CIN to Cancer Normal CIN 2 Invasive Cancer CIN 1 CIN 3/AIS

11. Disease Progression Time after HPV infection 3 to 6 months 4 to 5 Years 9 to 15 Years Persistent Infection InitialHPV Infection CIN 2/3 or AIS Cervical Cancer CIN 1 + co-factors (viral, host, environmental) “Cleared” HPV Infection CIN=Cervical Intraepithelial Neoplasia AIS=Adenocarcinoma in situ • The HPV detected today could have been acquired years ago • Many women diagnosed with cervical cancer were likely exposed to HPV during their teens and 20s

12. 71.6 Cervical cancer incidence rate peak at ages 60-69 years and declined thereafter Cervical cancer incidence rate increase with age after 30 Age specific cancer incidence per 100,000 population 0.0 0-9 10-19 20-29 30-39 40-49 50-59 60-69 70+ Age Group Cervical Cancer Incidence By Age,Peninsular Malaysia (Per 100,000) Figure 4: Cervix Uteri Age specific Cancer Incidence per 100,000 population, Peninsular Malaysia 2003 Source: 2nd Report of National Cancer Registry Malaysia 2003 (Fig 1.2.3(b))

13. Incidence of Cervical Cancer in Malaysia Cervical cancer is the 2nd most common cancer affecting Malaysian women of reproductive age below 49 years1 1. Malaysia Cancer Statistics - Data and Figure, Peninsular Malaysia, 2006 13

14. Cervical Cancer Incidence and Mortality Estimates by Region • 2002 estimated cervical cancer incidence and mortality by region1: 14,6705796 United States/Canada 61,13231,314 Eastern Asia 59,92929,814 Europe 157,75986,708 Southcentral Asia 17,1658124 Central America 42,53822,594 Southeast Asia 78,89661,670 Africa 48,32821,402 South America 1,063330 Australia/ New Zealand 1. Ferlay J, Bray F, Pisani P, Parkin DM. Lyon, France: IARC Press; 2004.

15. VAGINAL LESIONS (VaIN*) VaIN 3 and Vulvar Carcinoma Arising in VIN 3 VaIN 3 Photo courtesy of Dr. J. Monsonego Photo courtesy of Dr. R.W. Jones Commonly involves the upper third of the vagina and is often multifocal Average age of women: 35–50 years No symptoms and difficult to diagnose Spontaneously clear, but potential to progress to invasive vaginal cancer *VaIN=Vaginal Intraepithelial Neoplasia CIN=Cervical Intraepithelial Neoplasia VIN=Vulvar Intraepithelial Neoplasia

16. VULVAR LESION (VIN*) *VIN=Vulvar Intraepithelial Neoplasia HPV 16 appears to be the dominant HPV type associated with high-grade VIN Estimated 42%–65% of VIN 1 cases are associated with HPV types 6 and 11 Most common symptoms include pruritus, pain, soreness, swelling and persistant ulcers.

17. HPV-Related Disease in Males Genital warts Penile intraepithelial neoplasia (PIN) and carcinoma Anal intraepithelial neoplasia (AIN) and carcinoma Some oropharyngeal cancers (tongue, tonsillar, throat and soft palate) HPV = human papillomavirus.

18. HPV Disease Prevention Primary* *Applicable for males & females Secondary* *Applicable for females only Prevention of any factors that could lead to disease in healthy individuals Prevention by halting the progression of the infection/disease Modifying lifestyle risks ie. tobacco, keep healthy, sexual intercourse >20yrs, condoms Vaccination Pap Smear

19. HPV Prophylactic Vaccination: A shift from secondary to primary prevention

20. 2 Types of HPV Vaccines Quadrivalent HPV Vaccine which protects against HPV types 6, 11, 16, 18 Bivalent HPV Vaccine which protects against HPV 16, 18 only .

21. Quadrivalent HPV (HPV 6, 11, 16, 18) Vaccine Protects Against 90% of Genital warts caused by HPV 6 & 11 70% of Pre-cancers & cervical cancer caused by HPV 16 & 18 Vulvar & vaginal cancer caused by HPV 6, 11, 16 & 18

22. VACCINE GARDASIL Quadrivalent (HPV 6, 11, 16, 18) Bivalent (HPV 16, 18) Vulva & Vagina Cancer HPV 6, 11, 16, 18 Cervical Cancer HPV 16 & 18 Genital Warts HPV 6 & 11

23. 98% of cases of cervical cancer related to HPV Types 16 and 18 of cases of cervical precancerous lesions related to HPV Types 6, 11, 16 and 18 96% 99% of cases of genital warts related to HPV Types 6 and 11 of cases of vaginal and vulvar cancer related to HPV Types 16 and 18 100% The Right Vaccine for the Right Health Impact GARDASIL [(Quadrivalent Human Papillomavirus (Types 6, 11, 16, 18) Recombinant Vaccines] has been demonstrated to preventmore cancers and diseases :

24. Adult women (24-45 years old) 91% HPV 6-, 11-, 16-, or 18-related persistent infection, genital warts, vulvar and vaginal lesions, CIN of any grade, AIS and cervical cancer 83% HPV 16- or 18-related persistent infection, genital warts, vulvar and vaginal lesions, CIN of any grade, AIS and cervical cancer

25. Is Gardasil for boys/men? • Indicated in boys and men 9 to 26 years of age for the prevention of genital warts (condyloma acuminata) caused by HPV types 6 and 11. • Is efficacious in reducing the incidence of genital warts related to HPV types 6 and 11 in males relevant to the HPV type(s) 6, 11, 16 and 18

26. Males (18-26 years old) 90% efficacious against HPV type 6, 11, 16, 18-related external genital lesions (EGL) – 91% were genital warts 89% efficacious against HPV 6 and 11-related genital warts

27. Gardasil - Administration 0-, 2-, 6-month dosing regimen Intramuscular administration Each 0.5-mL injection volume For women from age 9 to 26 years of age For boys/men age 9 – 26 years old Ideally given before first sexual contact, but females who have had sexual activity should still be vaccinated Regular Pap smear screening still required after vaccination

28. HPV Vaccines – Global Funding Tender with Gardasil (2012) - MALAYSIA To date GARDASIL is available through public funding in 23 countries

29. AUSTRALIA: National Immunization Program April 2007: - target group  ongoing target group of 12 -18 year old girls - largely delivered in a school based program  women aged up to 26 years - delivered through general practice as a catch up for 2 years

31. HPV vaccination can help prevent certain HPV-related cancers and most genital warts Adding HPV vaccination to Pap exams comprises a comprehensiveapproach to cervical cancer prevention1 Pap exams are essential, but alone may not be enough In a retrospective study of 642 women diagnosed with cervical cancer in a large prepaid health plan between 1988 and 1994: ~28% of women diagnosed with cervical cancer had at least one normalPap exam 6 to 36 months prior to diagnosis. PATIENT EDUCATION HPV VACCINATION PAP EXAM AND AND 31

32. What have we learned so far? Human Papillomavirus (HPV) can: Affect males & females (at least 50% in a lifetime) Cause cervical cancer, genital warts, vaginal & vulvar cancer Be PREVENTED through: Regular Pap smear screening Vaccination HPV vaccine can prevent: genital warts in males & females cervical cancer, vaginal & vulvar cancersin females

33. Cervical cancer & HPV diseases can be prevented.Don’t Wait until it is too late. Protect Yourself.Protect Your Loved Ones.Now!

35. Thank You! Dr. Christine Lee Department of O&G SGH