HPV Update: Trends, Testing and Increasing Immunization Uptake

Laura White, MD, FRCSC

Huntsville and South Muskoka Grand Rounds

September 25, 2019

Disclosure of affiliations, financial support and mitigating bias Speaker Name: Dr. Laura White Session Information: HPV Update: Trends, Testing and Increasing Immunization Uptake, September 25, 2019

• MERCK has provided educational tools and support with promotion of HPV vaccine uptake

Program Planning Committee (PPC) Disclosure

• The following steps have been taken to mitigate bias:

• All PPC members and speakers have signed a COI form.

• All speakers have been emailed the certification/accreditation requirements for their presentation.

• Each presentation will be reviewed by the academic coordinator prior to its delivery. The coordinator will be looking for any signs of bias including use of brand names and logos of pharmaceutical companies.

• If bias is detected the PPC would review it and the speaker would be notified so that the bias can be corrected before the presentation is given. If the bias cannot be corrected or removed the session would be cancelled.

• If a bias is detected by a planning committee member during the presentation they would question the speaker about it.

• All biases would be reviewed at the next PPC meeting.

Scientific Planning Committee (SPC) Disclosure

• All SPC members and speakers have signed a COI form.

• All speakers have been emailed the certification/accreditation requirements for their presentation.

• Each presentation will be reviewed by the Academic Coordinator prior to its delivery. The coordinator will be looking for any signs of bias including use of brand names and logos of pharmaceutical companies.

• If bias is detected the SPC would review it and the speaker would be notified so that the bias can be corrected before the presentation is given. If the bias cannot be corrected or removed the session would be cancelled.

• If a bias is detected by a planning committee member during the presentation they would question the speaker about it.

• All biases would be reviewed at the next SPC meeting.

Human PapillomaVirus

• Double-stranded DNA viruses

• Highly species specific

• More than 200 types

• Low and high risk strains

• Methods of transmission

• 3760 cases were diagnosed in 2012 (64% in females ; 36% in males)

Figure 7.1: Proportion (%) of new cases for selected HPV-associated cancers,

Canada 2012*

*Quebec data are from 2010

Canadian Cancer Statistics 2016

Incidence of HPV-associated cancers

Analysis by: Health Statistics Division, Statistics Canada Data source: Canadian Cancer Registry database at Statistics Canada

Genital HPV Prevalence Is Higher in Men Than Women Across All Age Groups1,3

Age group (years)

BZ, Brazil; HIM, HPV Infection in Men; MX, Mexico; US, United States

1. Giuliano AR et al. Cancer Epidemiol Biomarkers Prev. 2008;17:2036-43; 2. Dunne EF et al. JAMA. 2007;297:813-19;

3. ICO/IARC HPV Information Centre on HPV and Cancer. http://www.hpvcentre.net/datastatistics.php. Accessed June 4, 2018.

HIM Study (Males)

US (women)

MX (women)

BZ (women)

One More Plug…

• IT’S A CANCER VACCINE

Ontario Guidelines for Follow-Up of Abnormal Cytology

URGENT referral to colposcopy:

• High-grade squamous intraepithelial lesion (HSIL)

• Atypical squamous cells, cannot exclude HSIL (ASC-H)

• Atypical glandular cells, atypical endocervical cells, atypical endometrial cells

Consider endometrial sampling

• Carcinoma, invasion

• Visible cervical abnormalities

Ref: CCO – Ontario Cervical Screening Guidelines Summary October 2016

Ref: CCO – Ontario Cervical Screening Guidelines Summary October 2016

HPV Status Recommended Interval

Negative 3 years

Positive 1 year

Unknown Recommendations from colposcopist

Re-referral to colposcopy should be based on repeat cytology, as per current guidelines

Benign or malignant?

Benign or malignant?

Benign or malignant?

Benign or malignant?

Benign or malignant?

Benign or malignant?

Benign or malignant?

HPV Testing

• 2 methods available: conventional Pap smear and liquid-based, thin layer preparation

• For both methods, cells are obtained from the external surface of the cervix (ectocervix) and the cervical canal (endocervix) to evaluate the transformation zone (squamocolumnar junction)

HPV Sample Collection

• Spatula + separate endocervical brush provide a specimen with more endocervical cells than when only a spatula is used

• Cotton tipped swabs should be avoided

• Advantage of liquid-based systems = single specimen for cytology AND HPV test

When HPV is particularly helpful

Persistent LSIL/ASCUS >30yo

LSIL/ASCUS post-menopausal patients

NEVER for high-grade lesions

Women having 2 +HPV tests 12 months apart should not have testing repeated

CASE STUDY

33 yo G3P3 with first pap showing LSIL

Heavy smoker

What next?

• Repeat pap smear in 6 months

• Smoking cessation discussion

• HPV vaccine discussion

CASE STUDY #1

Repeat pap in 6 months = ASCUS

What now?

• Consider HPV testing

• Can refer to colposcopy

• F/U re: vaccine