Human Papillomavirus and Related Diseases Report SPAIN · 2019-06-17 · Human Papillomavirus and Related Diseases Report SPAIN Version posted at 17 June 2019

Human PapillomavirusandRelated Diseases Report

SPAINVersion posted at www.hpvcentre.net on 17 June 2019

http://www.hpvcentre.net

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©ICO/IARC Information Centre on HPV and Cancer (HPV Information Centre) 2019

All rights reserved. HPV Information Centre publications can be obtained from the HPV Informa-tion Centre Secretariat, Institut Català d’Oncologia, Avda. Gran Via de l’Hospitalet, 199-203 08908L’Hospitalet del Llobregat (Barcelona) Spain. E-mail: [email protected]. Requests for per-mission to reproduce or translate HPV Information Centre publications - whether for sale or for non-commercial distribution- should be addressed to the HPV Information Centre Secretariat, at the aboveaddress.

The designations employed and the presentation of the material in this publication do not imply theexpression of any opinion whatsoever on the part the HPV Information Centre concerning the legalstatus of any country, territory, city or area or of its authorities, or concerning the delimitation of itsfrontiers or boundaries. Dotted lines on maps represent approximate border lines for which there maynot yet be full agreement. The mention of specific companies or of certain manufacturers products doesnot imply that they are endorsed or recommended the HPV Information Centre in preference to othersof a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietaryproducts are distinguished by initial capital letters. All reasonable precautions have been taken by theHPV Information Centre to verify the information contained in this publication. However, the publishedmaterial is being distributed without warranty of any kind, either expressed or implied. The respon-sibility for the interpretation and use of the material lies with the reader. In no event shall the HPVInformation Centre be liable for damages arising from its use.

The development of this report has been supported by grants from the European Comission (7th Frame-work Programme grant HEALTH-F3-2010-242061, PREHDICT and HEALTH-F2-2011-282562, HPVAHEAD).

Recommended citation:

Bruni L, Albero G, Serrano B, Mena M, Gómez D, Muñoz J, Bosch FX, de Sanjosé S. ICO/IARCInformation Centre on HPV and Cancer (HPV Information Centre). Human Papillomavirus and RelatedDiseases in Spain. Summary Report 17 June 2019. [Date Accessed]

ICO/IARC HPV Information Centre

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Executive summary

Human papillomavirus (HPV) infection is now a well-established cause of cervical cancer and there isgrowing evidence of HPV being a relevant factor in other anogenital cancers (anus, vulva, vagina andpenis) as well as head and neck cancers. HPV types 16 and 18 are responsible for about 70% of all cer-vical cancer cases worldwide. HPV vaccines that prevent HPV 16 and 18 infections are now availableand have the potential to reduce the incidence of cervical and other anogenital cancers.This report provides key information for Spain on: cervical cancer; other anogenital cancers and headand neck cancers; HPV-related statistics; factors contributing to cervical cancer; cervical cancer screen-ing practices; HPV vaccine introduction; and other relevant immunisation indicators. The report isintended to strengthen the guidance for health policy implementation of primary and secondary cervi-cal cancer prevention strategies in the country.

Table 1: Key StatisticsPopulationWomen at risk for cervical cancer (Female population aged >=15 years) 20.2 millionBurden of cervical cancer and other HPV-related cancersAnnual number of cervical cancer cases 1,942Annual number of cervical cancer deaths 825Crude incidence rates per 100,000 and year: Male Female

Cervical cancer - 8.2Anal cancer ‡ 0.4-1.7 0.1-1.5

Vulvar cancer ‡ - 1.9-4.0Vaginal cancer ‡ - 0.2-1.1

Penile cancer ‡ 0.9-3.2 -Oropharyngeal cancer 4.3 0.8

Burden of cervical HPV infectionPrevalence (%) of HPV 16 and/or HPV 18 among women with:

Normal cytology 2.7Low-grade cervical lesions (LSIL/CIN-1) 23.7

High-grade cervical lesions (HSIL/CIN-2/CIN-3/CIS) 46.3Cervical cancer 63.1

Other factors contributing to cervical cancerSmoking prevalence (%), women 27.8 [21.9-33.8]Total fertility rate (live births per women) 1.3Oral contraceptive use (%) among women 17.2HIV prevalence (%), adults (15-49 years) 0.4 [0.3 - 0.4]Sexual behaviourPercentage of 15-year-old who have had sexual intercourse (men/women) 24 / 19Range of median age at first sexual intercourse (men/women) 17.0-18.0 /

16.5-22.7Cervical screening practices and recommendationsCervical cancer screening cov-erage, % (age and screening in-terval, reference)

72.7% (All women aged 25-64 screened every 3y, EESE 2014 Spain)

Screening ages (years) 25-65 (cytology), 30-65 (HPV test)Screening interval (years) orfrequency of screens

3 years (cytology), 5 years (HPV test)

HPV vaccineHPV vaccine introduction

HPV vaccination programme National programDate of HPV vaccination routine immunization programme start 2007

‡Please see the specific sections for more information.


CONTENTS - iv -

Contents

Executive summary iii

1 Introduction 2

2 Demographic and socioeconomic factors 4

3 Burden of HPV related cancers 63.1 Cervical cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

3.1.1 Cervical cancer incidence in Spain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63.1.2 Cervical cancer incidence by histology in Spain . . . . . . . . . . . . . . . . . . . . . . 113.1.3 Cervical cancer incidence in Spain across Southern Europe . . . . . . . . . . . . . . . 133.1.4 Cervical cancer mortality in Spain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 153.1.5 Cervical cancer mortality in Spain across Southern Europe . . . . . . . . . . . . . . . 193.1.6 Cervical cancer incidence and mortality comparison, Premature deaths and dis-

ability in Spain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 213.2 Anogenital cancers other than the cervix . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

3.2.1 Anal cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 233.2.2 Vulvar cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 253.2.3 Vaginal cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 263.2.4 Penile cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27

3.3 Head and neck cancers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 293.3.1 Oropharyngeal cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29

4 HPV related statistics 334.1 HPV burden in women with normal cervical cytology, cervical precancerous lesions or

invasive cervical cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 334.1.1 HPV prevalence in women with normal cervical cytology . . . . . . . . . . . . . . . . 344.1.2 HPV type distribution among women with normal cervical cytology, precancerous

cervical lesions and cervical cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 354.1.3 HPV type distribution among HIV+ women with normal cervical cytology . . . . . . 444.1.4 Terminology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45

4.2 HPV burden in anogenital cancers other than cervix . . . . . . . . . . . . . . . . . . . . . . . 464.2.1 Anal cancer and precancerous anal lesions . . . . . . . . . . . . . . . . . . . . . . . . . 464.2.2 Vulvar cancer and precancerous vulvar lesions . . . . . . . . . . . . . . . . . . . . . . . 494.2.3 Vaginal cancer and precancerous vaginal lesions . . . . . . . . . . . . . . . . . . . . . 524.2.4 Penile cancer and precancerous penile lesions . . . . . . . . . . . . . . . . . . . . . . . 54

4.3 HPV burden in men . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 564.4 HPV burden in the head and neck . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59

4.4.1 Burden of oral HPV infection in healthy population . . . . . . . . . . . . . . . . . . . . 594.4.2 HPV burden in head and neck cancers . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59

5 Factors contributing to cervical cancer 62

6 Sexual and reproductive health behaviour indicators 64

7 HPV preventive strategies 667.1 Cervical cancer screening practices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 667.2 HPV vaccination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75

8 Protective factors for cervical cancer 94


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9 Indicators related to immunisation practices other than HPV vaccines 959.1 Immunisation schedule . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 959.2 Immunisation coverage estimates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95

10 Glossary 97


LIST OF FIGURES - vi -

List of Figures1 Spain and Southern Europe . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22 Population pyramid of Spain for 2017 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43 Population trends in four selected age groups in Spain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44 HPV-related cancer incidence in Spain (estimates for 2012) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65 Comparison of cervical cancer incidence to other cancers in women of all ages in Spain (estimates for 2018) . . 86 Comparison of age-specific cervical cancer to age-specific incidence of other cancers among women 15-44 years

of age in Spain (estimates for 2018) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97 Annual number of cases and age-specific incidence rates of cervical cancer in Spain (estimates for 2018) . . . . . 108 Time trends in cervical cancer incidence in Spain (cancer registry data) . . . . . . . . . . . . . . . . . . . . . . . . . 129 Age-standardised incidence rates of cervical cancer of Spain (estimates for 2018) . . . . . . . . . . . . . . . . . . . 1310 Annual number of new cases of cervical cancer by age group in Spain (estimates for 2018) . . . . . . . . . . . . . 1411 Comparison of cervical cancer mortality to other cancers in women of all ages in Spain (estimates for 2018) . . 1612 Comparison of age-specific mortality rates of cervical cancer to other cancers among women 15-44 years of age

in Spain (estimates for 2018) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1713 Annual number of deaths and age-specific mortality rates of cervical cancer in Spain (estimates for 2018) . . . . 1814 Comparison of age-standardised cervical cancer mortality rates in Spain and countries within the region (esti-

mates for 2018) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1915 Annual deaths number of cervical cancer by age group in Spain (estimates for 2018) . . . . . . . . . . . . . . . . . 2016 Comparison of age-specific cervical cancer incidence and mortality rates in Spain (estimates for 2018) . . . . . . 2117 Comparison of annual premature deaths and disability from cervical cancer in Spain to other cancers among

women (estimates for 2008) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2218 Time trends in anal cancer incidence in Spain (cancer registry data) . . . . . . . . . . . . . . . . . . . . . . . . . . . 2419 Time trends in vulvar cancer incidence in Spain (cancer registry data) . . . . . . . . . . . . . . . . . . . . . . . . . 2520 Time trends in vaginal cancer incidence in Spain (cancer registry data) . . . . . . . . . . . . . . . . . . . . . . . . . 2621 Time trends in penile cancer incidence in Spain (cancer registry data) . . . . . . . . . . . . . . . . . . . . . . . . . . 2722 Comparison of incidence and mortality rates of the oropharynx by age group and sex in Spain (estimates for

2018). Includes ICD-10 codes: C09-10 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3023 Crude age-specific HPV prevalence (%) and 95% confidence interval in women with normal cervical cytology in

Spain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3424 HPV prevalence among women with normal cervical cytology in Spain, by study . . . . . . . . . . . . . . . . . . . 3425 HPV 16 prevalence among women with normal cervical cytology in Spain, by study . . . . . . . . . . . . . . . . . 3526 HPV 16 prevalence among women with low-grade cervical lesions in Spain, by study . . . . . . . . . . . . . . . . . 3627 HPV 16 prevalence among women with high-grade cervical lesions in Spain, by study . . . . . . . . . . . . . . . . 3628 HPV 16 prevalence among women with invasive cervical cancer in Spain, by study . . . . . . . . . . . . . . . . . . 3629 Comparison of the ten most frequent HPV oncogenic types in Spain among women with and without cervical

lesions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3730 Comparison of the ten most frequent HPV oncogenic types in Spain among women with invasive cervical cancer

by histology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3931 Comparison of the ten most frequent HPV types in anal cancer cases in Europe and the World . . . . . . . . . . . 4732 Comparison of the ten most frequent HPV types in AIN 2/3 cases in Europe and the World . . . . . . . . . . . . . 4833 Comparison of the ten most frequent HPV types in cases of vulvar cancer in Europe and the World . . . . . . . . 5134 Comparison of the ten most frequent HPV types in VIN 2/3 cases in Europe and the World . . . . . . . . . . . . . 5135 Comparison of the ten most frequent HPV types in cases of vaginal cancer in Europe and the World . . . . . . . 5336 Comparison of the ten most frequent HPV types in VaIN 2/3 cases in Europe and the World . . . . . . . . . . . . 5337 Comparison of the ten most frequent HPV types in cases of penile cancer in Europe and the World . . . . . . . . 5538 Comparison of the ten most frequent HPV types in PeIN 2/3 cases in Europe and the World . . . . . . . . . . . . 5539 Estimated coverage of cervical cancer screening in Spain, by age and study . . . . . . . . . . . . . . . . . . . . . . 6840 Reported HPV vaccination coverage in females by birth cohort in National HPV Immunization programme in

Andalucia (Spain) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7541 Reported HPV vaccination coverage in females by birth cohort in National HPV Immunization programme in

Aragon (Spain) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7642 Reported HPV vaccination coverage in females by birth cohort in National HPV Immunization programme in

Asturias (Spain) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7743 Reported HPV vaccination coverage in females by birth cohort in National HPV Immunization programme in

Baleares (Spain) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7844 Reported HPV vaccination coverage in females by birth cohort in National HPV Immunization programme in C.

Valenciana (Spain) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7945 Reported HPV vaccination coverage in females by birth cohort in National HPV Immunization programme in

Canarias (Spain) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8046 Reported HPV vaccination coverage in females by birth cohort in National HPV Immunization programme in

Cantabria (Spain) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8147 Reported HPV vaccination coverage in females by birth cohort in National HPV Immunization programme in

Castilla La Mancha (Spain) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82


LIST OF FIGURES - vii -

48 Reported HPV vaccination coverage in females by birth cohort in National HPV Immunization programme inCastilla Leon (Spain) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83

49 Reported HPV vaccination coverage in females by birth cohort in National HPV Immunization programme inCatalunya (Spain) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84

50 Reported HPV vaccination coverage in females by birth cohort in National HPV Immunization programme inCeuta (Spain) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85

51 Reported HPV vaccination coverage in females by birth cohort in National HPV Immunization programme inExtremadura (Spain) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86

52 Reported HPV vaccination coverage in females by birth cohort in National HPV Immunization programme inGalicia (Spain) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87

53 Reported HPV vaccination coverage in females by birth cohort in National HPV Immunization programme inLa Rioja (Spain) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88

54 Reported HPV vaccination coverage in females by birth cohort in National HPV Immunization programme inMadrid (Spain) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89

55 Reported HPV vaccination coverage in females by birth cohort in National HPV Immunization programme inMelilla (Spain) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90

56 Reported HPV vaccination coverage in females by birth cohort in National HPV Immunization programme inMurcia (Spain) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91

57 Reported HPV vaccination coverage in females by birth cohort in National HPV Immunization programme inNavarra (Spain) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92

58 Reported HPV vaccination coverage in females by birth cohort in National HPV Immunization programme inPais Vasco (Spain) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93


LIST OF TABLES - viii -

List of Tables1 Key Statistics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . iii2 Sociodemographic indicators in Spain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53 Cervical cancer incidence in Spain (estimates for 2018) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74 Cervical cancer incidence in Spain by cancer registry . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75 Age-standardised incidence rates of cervical cancer in Spain by histological type and cancer registry . . . . . . . 116 Cervical cancer mortality in Spain (estimates for 2018) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 157 Premature deaths and disability from cervical cancer in Spain, Southern Europe and the rest of the world

(estimates for 2008) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 218 Anal cancer incidence in Spain by cancer registry and sex . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 239 Vulvar cancer incidence in Spain by cancer registry . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2510 Vaginal cancer incidence in Spain by cancer registry . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2611 Penile cancer incidence in Spain by cancer registry . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2712 Incidence and mortality of cancer of the oropharynx in Spain, Southern Europe and the rest of the world by sex

(estimates for 2018). Includes ICD-10 codes: C09-10 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2913 Incidence of oropharyngeal cancer in Spain by cancer registry and sex . . . . . . . . . . . . . . . . . . . . . . . . . 3114 Prevalence of HPV16 and HPV18 by cytology in Spain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3515 Type-specific HPV prevalence in women with normal cervical cytology, precancerous cervical lesions and invasive

cervical cancer in Spain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4016 Type-specific HPV prevalence among invasive cervical cancer cases in Spain by histology . . . . . . . . . . . . . . 4217 Studies on HPV prevalence among HIV women with normal cytology in Spain . . . . . . . . . . . . . . . . . . . . . 4418 Studies on HPV prevalence among anal cancer cases in Spain (male and female) . . . . . . . . . . . . . . . . . . . 4619 Studies on HPV prevalence among cases of AIN2/3 in Spain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4620 Studies on HPV prevalence among vulvar cancer cases in Spain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4921 Studies on HPV prevalence among VIN 2/3 cases in Spain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4922 Studies on HPV prevalence among vaginal cancer cases in Spain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5223 Studies on HPV prevalence among VaIN 2/3 cases in Spain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5224 Studies on HPV prevalence among penile cancer cases in Spain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5425 Studies on HPV prevalence among PeIN 2/3 cases in Spain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5426 Studies on HPV prevalence among men in Spain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5627 Studies on HPV prevalence among men from special subgroups in Spain . . . . . . . . . . . . . . . . . . . . . . . . 5628 Studies on oral HPV prevalence among healthy in Spain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5929 Studies on HPV prevalence among cases of oral cavity cancer in Spain . . . . . . . . . . . . . . . . . . . . . . . . . 5930 Studies on HPV prevalence among cases of oropharyngeal cancer in Spain . . . . . . . . . . . . . . . . . . . . . . . 6031 Studies on HPV prevalence among cases of hypopharyngeal or laryngeal cancer in Spain . . . . . . . . . . . . . . 6132 Factors contributing to cervical carcinogenesis (cofactors) in Spain . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6233 Percentage of 15-year-olds who have had sexual intercourse in Spain . . . . . . . . . . . . . . . . . . . . . . . . . . 6434 Median age at first sex in Spain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6435 Marriage patterns in Spain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6436 Average number of sexual partners in Spain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6537 Lifetime prevalence of anal intercourse among women in Spain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6538 Main characteristics of cervical cancer screening in Spain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6639 Estimated coverage of cervical cancer screening in Spain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6740 Estimated coverage of cervical cancer screening in Spain , by region . . . . . . . . . . . . . . . . . . . . . . . . . . . 6841 National HPV Immunization programme in Andalucia (Spain) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7542 National HPV Immunization programme in Aragon (Spain) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7643 National HPV Immunization programme in Asturias (Spain) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7744 National HPV Immunization programme in Baleares (Spain) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7845 National HPV Immunization programme in C. Valenciana (Spain) . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7946 National HPV Immunization programme in Canarias (Spain) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8047 National HPV Immunization programme in Cantabria (Spain) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8148 National HPV Immunization programme in Castilla La Mancha (Spain) . . . . . . . . . . . . . . . . . . . . . . . . 8249 National HPV Immunization programme in Castilla Leon (Spain) . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8350 National HPV Immunization programme in Catalunya (Spain) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8451 National HPV Immunization programme in Ceuta (Spain) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8552 National HPV Immunization programme in Extremadura (Spain) . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8653 National HPV Immunization programme in Galicia (Spain) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8754 National HPV Immunization programme in La Rioja (Spain) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8855 National HPV Immunization programme in Madrid (Spain) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8956 National HPV Immunization programme in Melilla (Spain) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9057 National HPV Immunization programme in Murcia (Spain) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9158 National HPV Immunization programme in Navarra (Spain) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9259 National HPV Immunization programme in Pais Vasco (Spain) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9360 Prevalence of male circumcision in Spain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94


LIST OF TABLES - 1 -

61 Prevalence of condom use in Spain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9462 General immunization schedule in Spain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9563 Immunization coverage estimates in Spain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9664 Glossary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97


1 INTRODUCTION - 2 -

1 Introduction

Figure 1: Spain and Southern Europe

The HPV Information Centre aims to compile and centralise updated data and statistics on humanpapillomavirus (HPV) and related cancers. This report aims to summarise the data available to fullyevaluate the burden of disease in Spain and to facilitate stakeholders and relevant bodies of decisionmakers to formulate recommendations on cervical cancer prevention. Data include relevant cancerstatistic estimates, epidemiological determinants of cervical cancer such as demographics, socioeco-nomic factors, risk factors, burden of HPV infection, screening and immunisation. This report is partof the PREHDICT project (health-economic modelling of Prevention strategies for Hpv-related Diseasesin European CounTries) granted by the EU Seven Franmework Programme. PREHDICT has been pro-jected to provide objective data and supported criteria for future cancer prevention across Europeancountries. Its overall goals are to determine prerequisites and strategies for vaccination in Europeancountries and to predict the impact of vaccination on screening programmes. The report is structuredinto the following sections: The ICO Information Centre on HPV and Cancer (HPV Information Centre)participates in the PREHDICT project compiling and centralising updated data and statistics on humanpapillomavirus (HPV) and HPV-related cancers of European countries. The aim is to disseminate theinformation to all European countries concerned to facilitate stakeholders and relevant bodies of deci-sion makers to formulate recommendations on the prevention of cervical cancer and other HPV-relatedcancers. This is a ESP report based on data from the European epidemiological database specificallycreated for this project. Data include relevant cancer statistic estimates, epidemiological determinantsof cervical cancer such as demographics, socioeconomic factors, risk factors, burden of HPV infection,screening and immunisation. The report is structured into the following sections:

Section 2, Demographic and socioeconomic factors. This section summarises the sociodemo-graphic profile of Spain, 43 European countries are covered in the PREHDICT project: EU-27 (Austria,Belgium, Bulgaria, Cyprus, Czech Republic, Denmark, Estonia, Finland, France, Germany, Greece,Hungary, Ireland, Italy, Latvia, Lithuania, Luxembourg, Malta, Netherlands, Poland, Portugal, Roma-nia, Slovakia, Slovenia, Spain, Sweden and United Kingdom), 12 Associated Countries (Albania, Bosnia


1 INTRODUCTION - 3 -

and Herzegovina, Croatia, FYR Macedonia, Iceland, Israel, Liechtenstein, Montenegro, Norway, Serbia(including Kosovo), Switzerland and Turkey) and 4 countries from Eastern Europe (Russia Federation,Belarus, Republic of Moldova and Ukraine) (Figure 1).

Section 3, Burden of HPV related cancers. This section describes the current burden of inva-sive cervical cancer and other HPV-related cancers in Spain with estimates of prevalence, incidence,and mortality rates. Information in other HPV-related cancers includes other anogenital cancers (anus,vulva, vagina, and penis), head and neck cancers (oral cavity, oropharynx, and hypopharynx) genitalwarts and recurrent respiratory papillomatosis.

Section 4, HPV related statistics. This section reports on prevalence of HPV and HPV type-specificdistribution in Spain, in women with normal cytology, precancerous lesions and invasive cervical cancer.In addition, the burden of HPV in other anogenital cancers (anus, vulva, vagina, and penis), head andneck cancers (oral cavity, oropharynx, and hypopharynx) and men are presented.

Section 5, Factors contributing to cervical cancer. This section describes factors that can modifythe natural history of HPV and cervical carcinogenesis such as smoking, parity, oral contraceptive use,and co-infection with HIV.

Section 6, Sexual and reproductive health behaviour indicators. This section presents sexualand reproductive behaviour indicators that may be used as proxy measures of risk for HPV infectionand anogenital cancers, such as age at first sexual intercourse, average number of sexual partners, andreceptive anal intercourse among others.

Section 7, HPV preventive strategies. This section presents preventive strategies that include ba-sic characteristics and performance of cervical cancer screening status, status of HPV vaccine licensureintroduction, and recommendations in national immunisation programmes.

Section 8, Protective factors for cervical cancer. This section presents male circumcision andthe use of condoms.

Section 9, Indicators related to immunisation practices other than HPV vaccines. This sectionpresents data on immunisation coverage and practices for selected vaccines. This information will berelevant for assessing the country’s capacity to introduce and implement the new vaccines.


2 DEMOGRAPHIC AND SOCIOECONOMIC FACTORS - 4 -

2 Demographic and socioeconomic factors

Figure 2: Population pyramid of Spain for 2017

Under 55−9

10−1415−1920−2425−2930−3435−3940−4445−4950−5455−5960−6465−6970−7475−79

80+

1,030,375 969,6011,224,811 1,155,3011,220,904 1,153,585

1,101,718 1,043,8981,102,623 1,063,671

1,183,400 1,168,7231,387,756 1,382,945

1,808,947 1,778,7282,024,045 1,960,085

1,923,878 1,870,0791,796,671 1,790,886

1,618,139 1,663,1841,326,347 1,408,984

1,130,608 1,258,390953,827 1,122,261

714,091 921,7151,038,159 1,771,811

Males Females

Data accessed on 27 Mar 2017.Please refer to original source for methods of estimation.Including Canary Islands, Ceuta and Melilla.Year of estimate: 2017;Data sources:United Nations, Department of Economic and Social Affairs, Population Division (2015). World Population Prospects: The 2015 Revision, DVD Edition. Available at: https://esa.un.org/unpd/wpp/Download/Standard/Population/. [Accessed on March 21, 2017].

Figure 3: Population trends in four selected age groups in SpainProjections

1950

1960

1970

1980

1990

2000

2010

2020

2030

2040

2050

2060

2070

2080

2090

2100

1

2

3

Num

ber

of w

omen

(in

mill

ions

)

Girls 10−14 yrs

Women 15−24 yrs

Female population trends in SpainNumber of women by year and age group

Projections

1950

1960

1970

1980

1990

2000

2010

2020

2030

2040

2050

2060

2070

2080

2090

2100

5

10

15

20

25

Num

ber

of w

omen

(in

mill

ions

)

Women 25−64 yrs

All Women

Data accessed on 27 Mar 2017.Please refer to original source for methods of estimation.Including Canary Islands, Ceuta and Melilla.Year of estimate: 2017;Data sources:United Nations, Department of Economic and Social Affairs, Population Division (2015). World Population Prospects: The 2015 Revision, DVD Edition. Available at: https://esa.un.org/unpd/wpp/Download/Standard/Population/. [Accessed on March 21, 2017].


https://esa.un.org/unpd/wpp/Download/Standard/Population/.




2 DEMOGRAPHIC AND SOCIOECONOMIC FACTORS - 5 -

Table 2: Sociodemographic indicators in SpainIndicator Male Female TotalPopulation in thousands1,± 22,586.3 23,483.8 46,070.1

Population growth rate (%)1,a,∓ - - -0.2

Median age of the population (in years)1,a,∗ - - 43.2

Population living in urban areas (%)2,a,∗ - - 79.6

Crude birth rate (births per 1,000)1,a,∓ - - 9.3

Crude death rate (deaths per 1,000)1,a,∓ - - 8.8

Life expectancy at birth (in years)3,b,c,∗ 80.1 85.5 82.8

Adult mortality rate (probability of dying between 15 and 60 years old per1,000)4,∗

74 38 56

Maternal mortality ratio (per 100,000 live births)3,d,∗ - - 5

Under age five mortality rate (per 1,000 live births)3,e,∗ - - 4.1

Density of physicians (per 1,000 population)5, f ,? - - 3.819

Gross national income per capita (PPP current international $)6,g,∗ - - 34880

Adult literacy rate (%) (aged 15 and older)7,h,∗ 98.8 97.5 98.1

Youth literacy rate (%) (aged 15-24 years)7,h,∗ 99.8 99.7 99.8

Net primary school enrollment ratio7,∗ 99.3 99.6 99.4

Net secondary school enrollment ratio7,∗ 95.7 97.1 96.4Data accessed on 27 Mar 2017.Please refer to original source for methods of estimation.aIncluding Canary Islands, Ceuta and Melilla.bWorld Population Prospects, the 2015 revision (WPP2015). New York (NY): United Nations DESA, Population Division.cWHO annual life tables for 1985–2015 based on the WPP2015, on the data held in the WHO Mortality Database and on HIV mortality estimates prepared by UNAIDS. WHO MemberStates with a population of less than 90 000 in 2015 were not included in the analysis.dWHO, UNICEF, UNFPA, World Bank Group and the United Nations Population Division. Trends in maternal mortality: 1990 to 2015. Estimates by WHO, UNICEF, UNFPA,World Bank Group and the United Nations Population Division. Geneva: World Health Organization; 2015 (http://www.who.int/reproductivehealth/publications/monitoring/maternal-mortality-2015/en/, accessed 25 March 2016). WHO Member States with a population of less than 100 000 in 2015 were not included in the analysis.eLevels & Trends in Child Mortality. Report 2015. Estimates Developed by the UN Inter-agency Group for Child Mortality Estimation. New York (NY), Geneva and Washington (DC):United Nations Children’s Fund, World Health Organization, World Bank and United Nations; 2015 (http://www.unicef.org/publications/files/Child_Mortality_Report_2015_Web_9_Sept_15.pdf, accessed 26 March 2016).f Number of medical doctors (physicians), including generalist and specialist medical practitioners, per 1 000 population.gGNI per capita based on purchasing power parity (PPP). PPP GNI is gross national income (GNI) converted to international dollars using purchasing power parity rates. An internationaldollar has the same purchasing power over GNI as a U.S. dollar has in the United States. GNI is the sum of value added by all resident producers plus any product taxes (less subsidies)not included in the valuation of output plus net receipts of primary income (compensation of employees and property income) from abroad. Data are in current international dollars basedon the 2011 ICP round.hUIS EstimationYear of estimate: ±2017; ∓2010-2015; ∗2015; ?2014;Data sources:1United Nations, Department of Economic and Social Affairs, Population Division (2015). World Population Prospects: The 2015 Revision, DVD Edition. Available at: https://esa.un.org/unpd/wpp/Download/Standard/Population/. [Accessed on March 21, 2017].2United Nations, Department of Economic and Social Affairs, Population Division (2014). World Urbanization Prospects: The 2014 Revision, CD-ROM Edition. Available at: https://esa.un.org/unpd/wup/CD-ROM/. [Accessed on March 21, 2017].3World Health Statistics 2016. Geneva, World Health Organization, 2016. Available at: http://who.int/entity/gho/publications/world_health_statistics/2016/en/index.html. [Accessed on March 21, 2017].4World Health Organization. Global Health Observatory data repository. Available at: http://apps.who.int/gho/data/view.main.1360?lang=en. [Accessed on March 21, 2017].5The 2016 update, Global Health Workforce Statistics, World Health Organization, Geneva (http://www.who.int/hrh/statistics/hwfstats/). [Accessed on March 21, 2017].6World Bank, World Development Indicators Database. Washington, DC. International Comparison Program database. Available at: http://databank.worldbank.org/data/reports.aspx?source=world-development-indicators#. [Accessed on March 21, 2017].7UNESCO Institute for Statistics Data Centre [online database]. Montreal, UNESCO Institute for Statistics. Available at: http://stats.uis.unesco.org [Accessed on March 21, 2017].


http://www.who.int/reproductivehealth/publications/monitoring/maternal-mortality-2015/en/,

http://www.who.int/reproductivehealth/publications/monitoring/maternal-mortality-2015/en/,

http://www.unicef.org/publications/files/Child_Mortality_Report_2015_Web_9_Sept_15.pdf,

http://www.unicef.org/publications/files/Child_Mortality_Report_2015_Web_9_Sept_15.pdf,



https://esa.un.org/unpd/wup/CD-ROM/.

https://esa.un.org/unpd/wup/CD-ROM/.

http://who.int/entity/gho/publications/world_health_statistics/2016/en/index.html.

http://who.int/entity/gho/publications/world_health_statistics/2016/en/index.html.

http://apps.who.int/gho/data/view.main.1360?lang=en.

http://www.who.int/hrh/statistics/hwfstats/).

http://databank.worldbank.org/data/reports.aspx?source=world-development-indicators#.

http://databank.worldbank.org/data/reports.aspx?source=world-development-indicators#.

http://stats.uis.unesco.org

3 BURDEN OF HPV RELATED CANCERS - 6 -

3 Burden of HPV related cancers

HPV is the cause of almost all cervical cancer cases and is responsible for an important fraction of otheranogenital and head and neck cancer. Here, we present the most recent estimations on the burden ofHPV-associated cancer.

Figure 4: HPV-related cancer incidence in Spain (estimates for 2012)

0 5 10

Head and neck (b)

Other anogenital (a)

Cervix uteri

0.6

1.0

7.7

Age−standardised incidence rate per 100,0000 womenWorld Standard

Data accessed on 08 May 2017.aOther anogenital cancer cases (vulvar, vaginal, anal, and penile).bHead and neck cancer cases (oropharynx, oral cavity and larynx).ASR: Age-standardized rate, rates per 100,000 per year.Please refer to original source for methods.GLOBOCAN quality index for availability of incidence data: High quality regional (coverage between 10% and 50%).GLOBOCAN quality index of methods for calculating incidence: Methods to estimate the sex- and age-specific incidence rates of cancer for a specific country: Estimated from nationalmortality by modelling using incidence mortality ratios derived from recorded data in country-specific cancer registriesData sources:de Martel C, Plummer M, Vignat J, Franceschi S. Worldwide burden of cancer attributable to HPV by site, country and HPV type. Int J Cancer. 2017

3.1 Cervical cancer

Cancer of the cervix uteri is the 3rd most common cancer among women worldwide, with an estimated569,847 new cases and 311,365 deaths in 2018 (GLOBOCAN). The majority of cases are squamous cellcarcinoma followed by adenocarcinomas. (Vaccine 2006, Vol. 24, Suppl 3; Vaccine 2008, Vol. 26, Suppl10; Vaccine 2012, Vol. 30, Suppl 5; IARC Monographs 2007, Vol. 90)

This section describes the current burden of invasive cervical cancer in Spain and in comparison togeographic region, including estimates of the annual number of new cases, deaths, incidence, and mor-tality rates.

3.1.1 Cervical cancer incidence in Spain

About 1,942 new cervical cancer cases are diagnosed annually inSpain (estimates for 2018).

Cervical cancer ranks* as the 16th leading cause of female cancer inSpain.

Cervical cancer is the 4th most common female cancer in women aged15 to 44 years in Spain.

KEY STATS.



* Ranking of cervical cancer incidence to other cancers among all women according to highest incidence rates (ranking 1st) excluding non-melanoma skin cancer and considering separated

colon, rectum and anus. Ranking is based on crude incidence rates (actual number of cervical cancer cases). Ranking using age-standardized rate (ASR) may differ.

Table 3: Cervical cancer incidence in Spain (estimates for 2018)

Indicator Spain Southern Europe World

Annual number of new cancer cases 1,942 9,155 569,847

Crude incidence ratea 8.2 11.7 15.1

Age-standardized incidence ratea 5.2 7.8 13.1

Cumulative risk (%) at 75 years oldb 0.5 0.8 1.4Data accessed on 05 Oct 2018.For more detailed methods of estimation please refer to http://gco.iarc.fr/today/data-sources-methodsaRates per 100,000 women per year.bCumulative risk (incidence) is the probability or risk of individuals getting from the disease during ages 0-74 years. For cancer, it is expressed as the % of new born children who would beexpected to develop from a particular cancer before the age of 75 if they had the rates of cancer observed in the period in the absence of competing causes.Data sources:Ferlay J, Ervik M, Lam F, Colombet M, Mery L, Piñeros M, Znaor A, Soerjomataram I, Bray F (2018). Global Cancer Observatory: Cancer Today. Lyon, France: International Agency forResearch on Cancer. Available from: https://gco.iarc.fr/today, accessed [05 October 2018].

Table 4: Cervical cancer incidence in Spain by cancer registryCancer registry1 Period N casesa Crude rateb ASRb

Albacete 2008-2010 39 6.6 4.7

Asturias 2008-2010 162 9.8 5.8

Basque Country 2008-2012 447 8.0 4.8

Canary Islands 2008-2011 356 10.1 6.9

Castellón 2008-2012 117 7.8 5.3

Ciudad Real 2008-2011 74 7.0 5.1

Cuenca 2008-2011 31 7.3 5.5

Girona 2008-2012 115 6.3 4.4

Granada 2008-2012 193 8.4 5.9

La Rioja 2008-2012 61 7.7 5.1

Mallorca 2008-2011 186 10.9 7.2

Murcia 2008-2010 217 10.1 7.4

Navarra 2008-2010 63 6.7 4.3

Tarragona 2008-2012 192 9.7 6.8Data accessed on 05 Oct 2018.ASR: Age-standardized rate, Standardized rates have been estimated using the direct method and the World population as the reference;Please refer to original source (available at http://ci5.iarc.fr/CI5-XI/Default.aspx)aAccumulated number of cases during the period in the population covered by the corresponding registry.bRates per 100,000 women per year.Data sources:1Bray F, Colombet M, Mery L, Piñeros M, Znaor A, Zanetti R and Ferlay J, editors (2017). Cancer Incidence in Five Continents, Vol. XI (electronic version). Lyon: International Agency forResearch on Cancer. Available from: http://ci5.iarc.fr, accessed [05 October 2018].


http://gco.iarc.fr/today/data-sources-methods

https://gco.iarc.fr/today,

http://ci5.iarc.fr/CI5-XI/Default.aspx)

http://ci5.iarc.fr,


Figure 5: Comparison of cervical cancer incidence to other cancers in women of all ages in Spain(estimates for 2018)

0 20 40 60 80 100 120 140

Kaposi sarcomaHypopharynxNasopharynxMesothelioma

VaginaOropharynx

AnusSalivary glands

LarynxOesophagus

Hodgkin lymphomaVulva

GallbladderMultiple myeloma

Lip, oral cavityLiver

Cervix uteriBrain, nervous system

KidneyLeukaemia

StomachMelanoma of skin

OvaryBladder

Non−Hodgkin lymphomaThyroid

PancreasRectum

Corpus uteriLungColon

Breast

0.20.30.40.50.60.80.91.11.21.72.0

4.95.25.96.97.08.28.3 9.710.512.413.114.514.715.915.916.0

18.728.729.2

41.5138.8

Annual crude incidence rate per 100,000Spain: Female (All ages)

Data accessed on 07 Oct 2018.Non-melanoma skin cancer is not included.Rates per 100,000 women per year.Data sources:Ferlay J, Ervik M, Lam F, Colombet M, Mery L, Piñeros M, Znaor A, Soerjomataram I, Bray F (2018). Global Cancer Observatory: Cancer Today. Lyon, France: International Agency forResearch on Cancer. Available from: https://gco.iarc.fr/today, accessed [05 October 2018].




Figure 6: Comparison of age-specific cervical cancer to age-specific incidence of other cancers amongwomen 15-44 years of age in Spain (estimates for 2018)

0 10 20 30 40 50 60

OropharynxKaposi sarcoma

MesotheliomaVagina

OesophagusAnus

GallbladderSalivary glands

HypopharynxLarynx

LiverMultiple myeloma

NasopharynxPancreas

Lip, oral cavityBladder

StomachKidney

VulvaRectum

Corpus uteriColon

Brain, nervous systemLeukaemia

LungHodgkin lymphoma

Non−Hodgkin lymphomaOvary

Cervix uteriMelanoma of skin

ThyroidBreast

0.00.00.00.00.10.10.10.10.10.10.30.30.40.70.70.91.41.41.81.92.12.52.52.52.82.9

4.45.0

6.57.2

14.158.2

Annual crude incidence rate per 100,000Spain: Female (15−44 years)

Data accessed on 07 Oct 2018.Non-melanoma skin cancer is not included.Rates per 100,000 women per year.Data sources:Ferlay J, Ervik M, Lam F, Colombet M, Mery L, Piñeros M, Znaor A, Soerjomataram I, Bray F (2018). Global Cancer Observatory: Cancer Today. Lyon, France: International Agency forResearch on Cancer. Available from: https://gco.iarc.fr/today, accessed [05 October 2018].




Figure 7: Annual number of cases and age-specific incidence rates of cervical cancer in Spain (estimatesfor 2018)

Ann

ual n

umbe

r of

new

cas

es o

f cer

vica

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cer

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15−39 40−64 65+

0

250

500

750

1000

1250

1500

529

301*

1111

40−44 yrs: 235 cases





Age group (years)

*15-19 yrs: 0 cases. 20-24 yrs: 5 cases. 25-29 yrs: 42 cases. 30-34 yrs: 91 cases. 35-39 yrs: 163 cases.Data accessed on 05 Oct 2018.Rates per 100,000 women per year.Data sources:Ferlay J, Ervik M, Lam F, Colombet M, Mery L, Piñeros M, Znaor A, Soerjomataram I, Bray F (2018). Global Cancer Observatory: Cancer Today. Lyon, France: International Agency forResearch on Cancer. Available from: https://gco.iarc.fr/today, accessed [05 October 2018].




3.1.2 Cervical cancer incidence by histology in Spain

Table 5: Age-standardised incidence rates of cervical cancer in Spain by histological type and cancerregistry

CarcinomaCancer registry Period Squamous Adeno Other Unspec.

Albacete 2008-2010 2.9 0.9 0.1 0.6

Asturias 2008-2010 3.9 1.5 0.1 0.2

Basque Country 2008-2012 3.4 1.1 0.1 0.2

Canary Islands 2008-2011 4.9 1.4 0.2 0.2

Castellón 2008-2012 3.7 1.0 0.2 0.2

Ciudad Real 2008-2011 4.3 0.3 - 0.2

Cuenca 2008-2011 3.7 1.1 0.4 0.2

Girona 2008-2012 3.2 0.9 0.1 0.0

Granada 2008-2012 4.0 1.1 0.4 0.1

La Rioja 2008-2012 3.5 1.3 0.2 0.2

Mallorca 2008-2011 5.6 1.2 0.2 0.1

Murcia 2008-2010 4.8 1.4 0.0 1.0

Navarra 2008-2010 3.0 0.9 0.1 0.2

Tarragona 2008-2012 4.9 1.3 0.2 0.2Data accessed on 05 Oct 2018.Adeno: adenocarcinoma; Other: Other carcinoma; Squamous: Squamous cell carcinoma; Unspec: Unspecified carcinoma;Rates per 100,000 women per year.Standarized rates have been estimated using the direct method and the World population as the references.Data sources:1Bray F, Colombet M, Mery L, Piñeros M, Znaor A, Zanetti R and Ferlay J, editors (2017). Cancer Incidence in Five Continents, Vol. XI (electronic version). Lyon: International Agency forResearch on Cancer. Available from: http://ci5.iarc.fr, accessed [05 October 2018].


http://ci5.iarc.fr,


Figure 8: Time trends in cervical cancer incidence in Spain (cancer registry data)

●

●

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Cervix uteri

0

2

4

6

8

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12

14

16

18

20

Ann

ual c

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te

(per

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,000

)

1993

1994

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

Overall trend : −0.6 (−1.5 to 0.3) (1, a): −0.6 (−1.5 to 0.3) (1, a): −0.6 (−1.5 to 0.3) (1, a): −0.6 (−1.5 to 0.3) (1, a): −0.6 (−1.5 to 0.3) (1, a): −0.6 (−1.5 to 0.3) (1, a): −0.6 (−1.5 to 0.3) (1, a): −0.6 (−1.5 to 0.3) (1, a): −0.6 (−1.5 to 0.3) (1, a): −0.6 (−1.5 to 0.3) (1, a): −0.6 (−1.5 to 0.3) (1, a): −0.6 (−1.5 to 0.3) (1, a): −0.6 (−1.5 to 0.3) (1, a): −0.6 (−1.5 to 0.3) (1, a): −0.6 (−1.5 to 0.3) (1, a)Recent trend : −1.3 (−3.1 to 0.5) (1, b): −1.3 (−3.1 to 0.5) (1, b): −1.3 (−3.1 to 0.5) (1, b): −1.3 (−3.1 to 0.5) (1, b): −1.3 (−3.1 to 0.5) (1, b): −1.3 (−3.1 to 0.5) (1, b): −1.3 (−3.1 to 0.5) (1, b): −1.3 (−3.1 to 0.5) (1, b): −1.3 (−3.1 to 0.5) (1, b): −1.3 (−3.1 to 0.5) (1, b): −1.3 (−3.1 to 0.5) (1, b): −1.3 (−3.1 to 0.5) (1, b): −1.3 (−3.1 to 0.5) (1, b): −1.3 (−3.1 to 0.5) (1, b): −1.3 (−3.1 to 0.5) (1, b)

●●

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Cervix uteri: Squamous cell carcinoma

0

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2001

2002

2003

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2005

2006

2007

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Cervix uteri: Adenocarcinoma

Year

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4

6

8

10

12

14

16

18

20

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)

1993

1994

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

All ages (2, c)

15−44 yrs (2, c)

45−74 yrs (2, c)

All ages (2, c)

15−44 yrs (2, c)

45−74 yrs (2, c)

All ages (2, c)

15−44 yrs (2, c)

45−74 yrs (2, c)

Data accessed on 27 Apr 2015.aEstimated annual percentage change based on the trend variable from the net drift for the most recent two 5-year periods.bEstimated annual percentage change based on the trend variable from the net drift for 15 years, from 1991-2005.cThe following regional cancer registries provided data and contributed to their national estimate: Albacete, Cuenca, Girona, Granada, Murcia, Navarra, Tarragona.Data sources:1Vaccarella S, Lortet-Tieulent J, Plummer M, Franceschi S, Bray F. Worldwide trends in cervical cancer incidence: Impact of screening against changes in disease risk factors. eur J Cancer2013;49:3262-73.2Ferlay J, Bray F, Steliarova-Foucher E and Forman D. Cancer Incidence in Five Continents, CI5plus: IARC CancerBase No. 9 [Internet]. Lyon, France: International Agency for Researchon Cancer; 2014. Available from: http://ci5.iarc.fr


http://ci5.iarc.fr


3.1.3 Cervical cancer incidence in Spain across Southern Europe

Figure 9: Age-standardised incidence rates of cervical cancer of Spain (estimates for 2018)

0 5 10 15 20 25 30

Andorra *

San Marino *

Malta

Spain

Cyprus

Albania

Italy

Slovenia

Croatia

Greece

Portugal

Macedonia

Montenegro

Serbia

Bosnia & H.

3.5

5.2

5.7

6.5

7.1

7.1

7.9

8.1

8.9

10

12.5

20.3

23.9

Cervical cancer: Age−standardised incidence rate per 100,000 womenWorld Standard. Female (All ages)

* No rates are available.Data accessed on 05 Oct 2018.Rates per 100,000 women per year.Data sources:Ferlay J, Ervik M, Lam F, Colombet M, Mery L, Piñeros M, Znaor A, Soerjomataram I, Bray F (2018). Global Cancer Observatory: Cancer Today. Lyon, France: International Agency forResearch on Cancer. Available from: https://gco.iarc.fr/today, accessed [05 October 2018].




Figure 10: Annual number of new cases of cervical cancer by age group in Spain (estimates for2018)

Spain

15−19 20−24 25−29 30−34 35−39 40−44 45−49 50−54 55−59 60−64 65−69 70−74 >=750

250

500

750

1000

1250

1500

** 42

282

91

539

163

818

235

1083

257

1176

248

1095

212

961

159

785

129

678

114

535

286

1142

Age group (years)

Ann

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r of

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l can

cer

Southern Europe

*0 cases for Spain and 1 cases for Southern Europe in the 15-19 age group. 5 cases for Spain and 59 cases for Southern Europe in the 20-24 age group.Data accessed on 05 Oct 2018.Data sources:Ferlay J, Ervik M, Lam F, Colombet M, Mery L, Piñeros M, Znaor A, Soerjomataram I, Bray F (2018). Global Cancer Observatory: Cancer Today. Lyon, France: International Agency forResearch on Cancer. Available from: https://gco.iarc.fr/today, accessed [05 October 2018].




3.1.4 Cervical cancer mortality in Spain

About 825 cervical cancer deaths occur annually in Spain (estimatesfor 2018).

Cervical cancer ranks* as the 16th leading cause of female cancerdeaths in Spain.

Cervical cancer is the 4th leading cause of cancer deaths in womenaged 15 to 44 years in Spain.

KEY STATS.

* Ranking of cervical cancer incidence to other cancers among all women according to highest incidence rates (ranking 1st) excluding non-melanoma skin cancer and considering separated

colon, rectum and anus. Ranking is based on crude incidence rates (actual number of cervical cancer cases). Ranking using age-standardized rate (ASR) may differ.

Table 6: Cervical cancer mortality in Spain (estimates for 2018)

Indicator Spain Southern Europe World

Annual number of deaths 825 3,512 311,365

Crude mortality ratea 3.5 4.5 8.2

Age-standardized mortality ratea 1.7 2.2 6.9

Cumulative risk (%) at 75 years oldb 0.2 0.2 0.8Data accessed on 05 Oct 2018.For more detailed methods of estimation please refer to http://gco.iarc.fr/today/data-sources-methodsaRates per 100,000 women per year.bCumulative risk (mortality) is the probability or risk of individuals dying from the disease during ages 0-74 years. For cancer, it is expressed as the % of new born children who would beexpected to die from a particular cancer before the age of 75 if they had the rates of cancer observed in the period in the absence of competing causes.Data sources:Ferlay J, Ervik M, Lam F, Colombet M, Mery L, Piñeros M, Znaor A, Soerjomataram I, Bray F (2018). Global Cancer Observatory: Cancer Today. Lyon, France: International Agency forResearch on Cancer. Available from: https://gco.iarc.fr/today, accessed [05 October 2018].





Figure 11: Comparison of cervical cancer mortality to other cancers in women of all ages in Spain(estimates for 2018)

0 10 20 30 40

Kaposi sarcomaHypopharynx

AnusNasopharynx

VaginaSalivary glands

OropharynxHodgkin lymphoma

LarynxMesothelioma

ThyroidOesophagus

VulvaLip, oral cavity

Melanoma of skinGallbladderCervix uteri

KidneyMultiple myeloma

BladderNon−Hodgkin lymphoma

Brain, nervous systemRectum

Corpus uteriLeukaemia

LiverOvary

StomachPancreas

ColonLung

Breast

0.00.10.20.20.30.30.40.40.40.50.91.41.51.92.3

3.13.53.6

4.24.7

5.96.16.2

7.07.17.2

9.09.3

15.121.7

22.627.2

Annual crude mortality rate per 100,000Spain: Female (All ages)

Data accessed on 07 Oct 2018.Non-melanoma skin cancer is not included.aRates per 100,000 women per year.Data sources:Ferlay J, Ervik M, Lam F, Colombet M, Mery L, Piñeros M, Znaor A, Soerjomataram I, Bray F (2018). Global Cancer Observatory: Cancer Today. Lyon, France: International Agency forResearch on Cancer. Available from: https://gco.iarc.fr/today, accessed [05 October 2018].




Figure 12: Comparison of age-specific mortality rates of cervical cancer to other cancers among women15-44 years of age in Spain (estimates for 2018)

0 5 10

Kaposi sarcomaHypopharynx

LarynxOropharynx

Salivary glandsVagina

AnusMesotheliomaNasopharynx

OesophagusThyroid

GallbladderVulva

Multiple myelomaBladder

Lip, oral cavityHodgkin lymphoma

Corpus uteriKidney

LiverRectum

PancreasMelanoma of skin

Non−Hodgkin lymphomaStomach

ColonLeukaemia

OvaryCervix uteri

Brain, nervous systemLung

Breast

0.00.00.00.00.00.00.00.00.00.00.00.10.10.10.10.10.20.20.20.20.30.40.50.5

0.70.80.8

1.01.01.1

1.34.8

Annual crude mortality rate per 100,000Spain: Female (15−44 years)

Data accessed on 07 Oct 2018.Non-melanoma skin cancer is not included.aRates per 100,000 women per year.Data sources:Ferlay J, Ervik M, Lam F, Colombet M, Mery L, Piñeros M, Znaor A, Soerjomataram I, Bray F (2018). Global Cancer Observatory: Cancer Today. Lyon, France: International Agency forResearch on Cancer. Available from: https://gco.iarc.fr/today, accessed [05 October 2018].




Figure 13: Annual number of deaths and age-specific mortality rates of cervical cancer in Spain (esti-mates for 2018)

Ann

ual n

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r of

dea

ths

of c

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ance

r

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15−39 40−64 65+

0

60

120

180

240

300

360

420

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392

32*

401






Age group (years)

* 15-19 yrs: 0 cases. 20-24 yrs: 1 cases. 25-29 yrs: 4 cases. 30-34 yrs: 12 cases. 35-39 yrs: 15 cases.Data accessed on 05 Oct 2018.Rates per 100,000 women per year.Data sources:Ferlay J, Ervik M, Lam F, Colombet M, Mery L, Piñeros M, Znaor A, Soerjomataram I, Bray F (2018). Global Cancer Observatory: Cancer Today. Lyon, France: International Agency forResearch on Cancer. Available from: https://gco.iarc.fr/today, accessed [05 October 2018].




3.1.5 Cervical cancer mortality in Spain across Southern Europe

Figure 14: Comparison of age-standardised cervical cancer mortality rates in Spain and countrieswithin the region (estimates for 2018)

0 2 4 6 8 10

Andorra *

San Marino *

Malta

Cyprus

Italy

Spain

Greece

Albania

Portugal

Slovenia

Macedonia

Croatia

Montenegro

Bosnia & H.

Serbia

1.4

1.5

1.5

1.7

2.1

2.3

2.8

2.8

3.5

3.7

4.2

4.7

7

Cervical cancer: Age−standardised mortality rate per 100,000 womenWorld Standard. Female (All ages)

* No rates are available.Data accessed on 05 Oct 2018.Rates per 100,000 women per year.Data sources:Ferlay J, Ervik M, Lam F, Colombet M, Mery L, Piñeros M, Znaor A, Soerjomataram I, Bray F (2018). Global Cancer Observatory: Cancer Today. Lyon, France: International Agency forResearch on Cancer. Available from: https://gco.iarc.fr/today, accessed [05 October 2018].




Figure 15: Annual deaths number of cervical cancer by age group in Spain (estimates for 2018)

Spain

15−19 20−24 25−29 30−34 35−39 40−44 45−49 50−54 55−59 60−64 65−69 70−74 >=750

250

500

750

1000

1250

* ** 15

9751

202

78

293

95

366

98

389

79

359

62

342

63

322267

1079

Age group (years)

Ann

ual n

umbe

r of

new

cas

es o

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vica

l can

cer

Southern Europe

*0 cases for Spain and 0 cases for Southern Europe in the 15-19 age group. 1 cases for Spain and 3 cases for Southern Europe in the 20-24 age group. 4 cases for Spain and 15 cases forSouthern Europe in the 25-29 age group. 12 cases for Spain and 45 cases for Southern Europe in the 30-34 age group.Data accessed on 05 Oct 2018.Data sources:Ferlay J, Ervik M, Lam F, Colombet M, Mery L, Piñeros M, Znaor A, Soerjomataram I, Bray F (2018). Global Cancer Observatory: Cancer Today. Lyon, France: International Agency forResearch on Cancer. Available from: https://gco.iarc.fr/today, accessed [05 October 2018].




3.1.6 Cervical cancer incidence and mortality comparison, Premature deaths and disabilityin Spain

Figure 16: Comparison of age-specific cervical cancer incidence and mortality rates in Spain (estimatesfor 2018)

15−1

9

20−2

4

25−2

9

30−3

4

35−3

9

40−4

4

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9

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>=75

Age group (years)

0

5

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15

Age

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ance

r

IncidenceMortality

Data accessed on 05 Oct 2018.Rates per 100,000 women per year.Data sources:Ferlay J, Ervik M, Lam F, Colombet M, Mery L, Piñeros M, Znaor A, Soerjomataram I, Bray F (2018). Global Cancer Observatory: Cancer Today. Lyon, France: International Agency forResearch on Cancer. Available from: https://gco.iarc.fr/today, accessed [05 October 2018].

Table 7: Premature deaths and disability from cervical cancer in Spain, Southern Europe and the restof the world (estimates for 2008)

Spain Southern Europe WorldIndicator Number ASR (W) Number ASR (W) Number ASR (W)Estimated disability-adjusted lifeyears (DALYs)

22,340 78 98,923 96 8,738,004 293

Years of life lost (YLLs) 17,611 59 80,996 75 7,788,282 264

Years lived with disability (YLDs) 4,729 19 17,927 21 949,722 28Data accessed on 04 Nov 2013.Data sources:Soerjomataram I, Lortet-Tieulent J, Parkin DM, Ferlay J, Mathers C, Forman D, Bray F. Global burden of cancer in 2008: a systematic analysis of disability-adjusted life-years in 12 worldregions. Lancet. 2012 Nov 24;380(9856):1840-50.




Figure 17: Comparison of annual premature deaths and disability from cervical cancer in Spain to othercancers among women (estimates for 2008)

Kaposi sarcomaNasopharyngeal ca.

Laryngeal ca.Other pharynx ca.

Hodgkin lymphomaThyroid ca.

Oesophageal ca.Ca. of the lip and oral cavity

Melanoma of skinKidney ca.

GallbladderBladder ca.

Multiple myelomaLiver ca.

Cervix uteri ca.Non−Hodgkin lymphoma

LeukaemiaCorpus uteri ca.

Ca. of the brain and CNSPancreatic ca.

Stomach ca.Ovarian ca.

Lung ca.Colorectal ca.

Breast ca.

0 50000 100000 150000 200000

01,1122,0892,3172,9273,0594,433

7,3479,28510,41910,94211,29313,045

20,01222,34022,65224,83525,01525,926

33,90436,67837,155

55,031101,202

171,311

YLLsYLDs

Estimated disability−adjusted life years (DALYs).

Data accessed on 04 Nov 2013.CNS: Central Nervous System; YLDs: years lived with disability; YLLs: Years of life lost;Data sources:Soerjomataram I, Lortet-Tieulent J, Parkin DM, Ferlay J, Mathers C, Forman D, Bray F. Global burden of cancer in 2008: a systematic analysis of disability-adjusted life-years in 12 worldregions. Lancet. 2012 Nov 24;380(9856):1840-50.



3.2 Anogenital cancers other than the cervix

Data on HPV role in anogenital cancers other than cervix are limited, but there is an increasing bodyof evidence strongly linking HPV DNA with cancers of anus, vulva, vagina, and penis. Although thesecancers are much less frequent compared to cervical cancer, their association with HPV make thempotentially preventable and subject to similar preventative strategies as those for cervical cancer. (Vac-cine 2006, Vol. 24, Suppl 3; Vaccine 2008, Vol. 26, Suppl 10; Vaccine 2012, Vol. 30, Suppl 5; IARCMonographs 2007, Vol. 90).

3.2.1 Anal cancer

Anal cancer is rare in the general population with an average worldwide incidence of 1 per 100,000,but is reported to be increasing in more developed regions. Globally, there are an estimated 27,000 newcases every year (de Martel C et al. Lancet Oncol 2012;13(6):607-15). Women have higher incidences ofanal cancer than men. Incidence is particularly high among populations of men who have sex with men(MSM), women with history of cervical or vulvar cancer, and immunosuppressed populations, includingthose who are HIV-infected and patients with a history of organ transplantation. These cancers arepredominantly squamous cell carcinoma, adenocarcinomas, or basaloid and cloacogenic carcinomas.

Table 8: Anal cancer incidence in Spain by cancer registry and sexMALE FEMALE

Cancer registry1 Period N casesa Crude rateb ASRb N casesa Crude ratec ASRc

Albacete 2008-2010 4 0.7 0.4 5 0.8 0.5

Asturias 2008-2010 19 1.3 0.7 23 1.4 0.6

Basque Country 2008-2012 52 1.0 0.5 53 1.0 0.4

Canary Islands 2008-2011 51 1.5 0.9 31 0.9 0.5

Castellón 2008-2012 10 0.7 0.5 13 0.9 0.5

Ciudad Real 2008-2011 5 0.5 0.2 7 0.7 0.3

Cuenca 2008-2011 5 1.1 0.5 3 0.7 0.2

Girona 2008-2012 15 0.8 0.5 12 0.7 0.4

Granada 2008-2012 15 0.7 0.4 9 0.4 0.1

La Rioja 2008-2012 3 0.4 0.3 1 0.1 0.0

Mallorca 2008-2011 24 1.4 1.0 18 1.1 0.6

Murcia 2008-2010 8 0.4 0.2 6 0.3 0.1

Navarra 2008-2010 6 0.6 0.3 7 0.7 0.4

Tarragona 2008-2012 35 1.7 1.0 30 1.5 0.8Data accessed on 05 Oct 2018.ASR: Age-standardized rate, Standardized rates have been estimated using the direct method and the World population as the reference;Please refer to original source (available at http://ci5.iarc.fr/CI5-XI/Default.aspx)aAccumulated number of cases during the period in the population covered by the corresponding registry.bRates per 100,000 men per year.cRates per 100,000 women per year.Data sources:1Bray F, Colombet M, Mery L, Piñeros M, Znaor A, Zanetti R and Ferlay J, editors (2017). Cancer Incidence in Five Continents, Vol. XI (electronic version). Lyon: International Agency forResearch on Cancer. Available from: http://ci5.iarc.fr, accessed [05 October 2018].



http://ci5.iarc.fr,


Figure 18: Time trends in anal cancer incidence in Spain (cancer registry data)

● ●

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●

●

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●

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●

Anal cancer in men

0

1

2

3

4

5

Ann

ual c

rude

inci

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te

(per

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,000

)

1993

1994

1995

1996

*

1997

1998

1999

2000

2001

2002

*

2003

2004

2005

2006

2007

●

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●

●

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● ● ●

●●

●

●

●

Anal cancer in women

Year

0

1

2

3

4

5

Ann

ual c

rude

inci

denc

e ra

te

(per

100

,000

)

1993

*

1994

*

1995

*

1996

*

1997

1998

*

1999

2000

2001

*

2002

2003

*

2004

2005

2006

*

2007

All ages

15−44 yrs

45−74 yrs

All ages

15−44 yrs

45−74 yrs

*No cases were registered for this age group.Data accessed on 27 Apr 2015.The following regional cancer registries provided data and contributed to their national estimate: Albacete, Cuenca, Girona, Granada, Murcia, Navarra, Tarragona.Data sources:Ferlay J, Bray F, Steliarova-Foucher E and Forman D. Cancer Incidence in Five Continents, CI5plus: IARC CancerBase No. 9 [Internet]. Lyon, France: International Agency for Researchon Cancer; 2014. Available from: http://ci5.iarc.fr


http://ci5.iarc.fr


3.2.2 Vulvar cancer

Cancer of the vulva is rare among women worldwide, with an estimated 27,000 new cases in 2008, rep-resenting 4% of all gynaecologic cancers (de Martel C et al. Lancet Oncol 2012;13(6):607-15). Worldwide,about 60% of all vulvar cancer cases occur in more developed countries. Vulvar cancer has two distincthistological patterns with two different risk factor profiles: (1) basaloid/warty types (2) keratinisingtypes. Basaloid/warty lesions are more common in young women, are very often associated with HPVDNA detection (75-100%), and have a similar risk factor profile as cervical cancer. Keratinising vulvarcarcinomas represent the majority of the vulvar lesions (>60%), they occur more often in older womenand are more rarely associated with HPV (IARC Monograph Vol 100B).

Table 9: Vulvar cancer incidence in Spain by cancer registryCancer registry1 Period N casesa Crude rateb ASRb

Albacete 2008-2010 23 3.9 1.1

Asturias 2008-2010 66 4.0 1.3

Basque Country 2008-2012 211 3.8 1.4

Canary Islands 2008-2011 82 2.3 1.2

Castellón 2008-2012 46 3.1 1.3

Ciudad Real 2008-2011 37 3.5 1.2

Cuenca 2008-2011 17 4.0 1.3

Girona 2008-2012 52 2.8 1.1

Granada 2008-2012 68 2.9 1.2

La Rioja 2008-2012 20 2.5 0.8

Mallorca 2008-2011 53 3.1 1.5

Murcia 2008-2010 41 1.9 0.9

Navarra 2008-2010 34 3.6 1.4


Figure 19: Time trends in vulvar cancer incidence in Spain (cancer registry data)

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3.2.3 Vaginal cancer

Cancer of the vagina is a rare cancer, with an estimated 13,000 new cases in 2008, representing 2% ofall gynaecologic cancers (de Martel C et al. Lancet Oncol 2012;13(6):607-15). Similar to cervical cancer,the majority of vaginal cancer cases (68%) occur in less developed countries. Most vaginal cancers aresquamous cell carcinoma (90%) generally attributable to HPV, followed by clear cell adenocarcinomasand melanoma. Vaginal cancers are primarily reported in developed countries. Metastatic cervicalcancer can be misclassified as cancer of the vagina. Invasive vaginal cancer is diagnosed primarily inold women (≥ 65 years) and the diagnosis is rare in women under 45 years whereas the peak incidenceof carcinoma in situ is observed between ages 55 and 70 (Vaccine 2008, Vol. 26, Suppl 10).

Table 10: Vaginal cancer incidence in Spain by cancer registryCancer registry1 Period N casesa Crude rateb ASRb

Albacete 2008-2010 1 0.2 0.0

Asturias 2008-2010 18 1.1 0.4

Basque Country 2008-2012 34 0.6 0.3

Canary Islands 2008-2011 13 0.4 0.2

Castellón 2008-2012 10 0.7 0.4

Ciudad Real 2008-2011 7 0.7 0.2

Cuenca 2008-2011 2 0.5 0.0

Girona 2008-2012 5 0.3 0.1

Granada 2008-2012 9 0.4 0.2

La Rioja 2008-2012 3 0.4 0.2

Mallorca 2008-2011 12 0.7 0.4

Murcia 2008-2010 7 0.3 0.2

Navarra 2008-2010 5 0.5 0.3


Figure 20: Time trends in vaginal cancer incidence in Spain (cancer registry data)

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3.2.4 Penile cancer

The annual burden of penile cancer has been estimated to be 22,000 cases worldwide with incidencerates strongly correlating with those of cervical cancer (de Martel C et al. Lancet Oncol 2012;13(6):607-15). Penile cancer is rare and most commonly affects men aged 50-70 years. Incidence rates are higherin less developed countries than in more developed countries, accounting for up to 10% of male cancersin some parts of Africa, South America and Asia. Precursor cancerous penile lesions (PeIN) are rare.

Cancers of the penis are primarily of squamous cell carcinomas (SCC) (95%) and the most commonpenile SCC histologic sub-types are keratinising (49%), mixed warty-basaloid (17%), verrucous (8%)warty (6%), and basaloid (4%). HPV is most commonly detected in basaloid and warty tumours but isless common in keratinising and verrucous tumours. Approximately 60-100% of PeIN lesions are HPVDNA positive.

Table 11: Penile cancer incidence in Spain by cancer registryCancer registry Period N casesa Crude rateb ASRb

Albacete 2008-2010 11 1.8 1.1

Asturias 2008-2010 35 2.3 1.0

Basque Country 2008-2012 97 1.8 0.8

Canary Islands 2008-2011 53 1.5 1.0

Castellón 2008-2012 49 3.2 1.6

Ciudad Real 2008-2011 16 1.5 0.5

Cuenca 2008-2011 4 0.9 0.3

Girona 2008-2012 37 2.0 1.1

Granada 2008-2012 48 2.1 1.2

La Rioja 2008-2012 10 1.2 0.5

Mallorca 2008-2011 29 1.7 1.0

Murcia 2008-2010 31 1.4 0.9

Navarra 2008-2010 17 1.8 1.0

Tarragona 2008-2012 37 1.8 1.0Data accessed on 05 Oct 2018.ASR: Age-standardized rate, Standardized rates have been estimated using the direct method and the World population as the reference;Please refer to original source (available at http://ci5.iarc.fr/CI5-XI/Default.aspx)aAccumulated number of cases during the period in the population covered by the corresponding registry.bRates per 100,000 men per year.Data sources:1Bray F, Colombet M, Mery L, Piñeros M, Znaor A, Zanetti R and Ferlay J, editors (2017). Cancer Incidence in Five Continents, Vol. XI (electronic version). Lyon: International Agency forResearch on Cancer. Available from: http://ci5.iarc.fr, accessed [05 October 2018].

Figure 21: Time trends in penile cancer incidence in Spain (cancer registry data)

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(Continued on next page)



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( Figure 21 – continued from previous page)Data accessed on 27 Apr 2015.The following regional cancer registries provided data and contributed to their national estimate: Albacete, Cuenca, Girona, Granada, Murcia, Navarra, Tarragona.Data sources:Ferlay J, Bray F, Steliarova-Foucher E and Forman D. Cancer Incidence in Five Continents, CI5plus: IARC CancerBase No. 9 [Internet]. Lyon, France: International Agency for Researchon Cancer; 2014. Available from: http://ci5.iarc.fr


http://ci5.iarc.fr


3.3 Head and neck cancers

The majority of head and neck cancers are associated with high tobacco and alcohol consumption. How-ever, increasing trends in the incidence at specific sites suggest that other aetiological factors are in-volved, and infection by certain high-risk types of HPV (i.e. HPV16) have been reported to be associatedwith head and neck cancers, in particular with oropharyngeal cancer. Current evidence suggests thatHPV16 is associated with tonsil cancer (including Waldeyer ring cancer), base of tongue cancer andother oropharyngeal cancer sites. Associations with other head and neck cancer sites such as oral can-cer are neither strong nor consistent when compared to molecular-epidemiological data on HPV andoropharyngeal cancer. Association with laryngeal cancer is still unclear (IARC Monograph Vol 100B).

3.3.1 Oropharyngeal cancer

Table 12: Incidence and mortality of cancer of the oropharynx in Spain, Southern Europe and the restof the world by sex (estimates for 2018). Includes ICD-10 codes: C09-10

MALE FEMALEIndicator Spain Southern

EuropeWorld Spain Southern

EuropeWorld

INCIDENCEAnnual number of new cancer cases 972 2,943 74,472 193 668 18,415

Crude incidence ratea 4.3 3.9 1.9 0.8 0.9 0.5

Age-standardized incidence ratea 2.4 2.2 1.8 0.4 0.4 0.4

Cumulative risk (%) at 75 years oldb 0.3 0.3 0.2 0.1 0 0

MORTALITYAnnual number of deaths 514 1,557 42,116 87 317 8,889

Crude mortality ratea 2.3 2.1 1.1 0.4 0.4 0.2

Age-standardized mortality ratea 1.2 1.1 1.0 0.2 0.2 0.2

Cumulative risk (%) at 75 years oldc 0.2 0.1 0.1 0 0 0

Data accessed on 05 Oct 2018.For more detailed methods of estimation please refer to http://gco.iarc.fr/today/data-sources-methodsaMale: Rates per 100,000 men per year. Female: Rates per 100,000 women per year.bCumulative risk (incidence) is the probability or risk of individuals getting from the disease during ages 0-74 years. For cancer, it is expressed as the % of new born children who would beexpected to develop from a particular cancer before the age of 75 if they had the rates of cancer observed in the period in the absence of competing causes.cCumulative risk (mortality) is the probability or risk of individuals dying from the disease during ages 0-74 years. For cancer, it is expressed as the % of new born children who would beexpected to die from a particular cancer before the age of 75 if they had the rates of cancer observed in the period in the absence of competing causes.Data sources:Ferlay J, Ervik M, Lam F, Colombet M, Mery L, Piñeros M, Znaor A, Soerjomataram I, Bray F (2018). Global Cancer Observatory: Cancer Today. Lyon, France: International Agency forResearch on Cancer. Available from: https://gco.iarc.fr/today, accessed [05 October 2018].





Figure 22: Comparison of incidence and mortality rates of the oropharynx by age group and sex inSpain (estimates for 2018). Includes ICD-10 codes: C09-10

MALE

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Data accessed on 05 Oct 2018.Male: Rates per 100,000 men per year. Female: Rates per 100,000 women per year.Data sources:Ferlay J, Ervik M, Lam F, Colombet M, Mery L, Piñeros M, Znaor A, Soerjomataram I, Bray F (2018). Global Cancer Observatory: Cancer Today. Lyon, France: International Agency forResearch on Cancer. Available from: https://gco.iarc.fr/today, accessed [05 October 2018].




Table 13: Incidence of oropharyngeal cancer in Spain by cancer registry and sexMALE FEMALE

Cancer registry1,α Periodα N casesa Crude rateb ASRα N casesa Crude rateb ASRb

Tongue (ICD-10 code: C01-02)Albacete 2008-2010 23 3.8 2.8 8 1.3 0.7

Asturias 2008-2010 89 5.9 3.1 42 2.5 1.0

Basque Country 2008-2012 304 5.7 3.2 129 2.3 1.0

Canary Islands 2008-2011 173 5.0 3.4 60 1.7 1.0

Castellón 2008-2012 62 4.1 2.8 21 1.4 0.7

Ciudad Real 2008-2011 28 2.7 1.8 25 2.4 0.8

Cuenca 2008-2011 12 2.7 1.8 10 2.3 1.0

Girona 2008-2012 73 3.9 2.5 32 1.7 0.8

Granada 2008-2012 85 3.7 2.5 40 1.7 0.8

La Rioja 2008-2012 13 1.6 0.7 9 1.1 0.5

Mallorca 2008-2011 74 4.3 3.0 25 1.5 0.8

Murcia 2008-2010 72 3.3 2.5 40 1.9 1.1

Navarra 2008-2010 26 2.8 1.6 15 1.6 0.7

Tarragona 2008-2012 89 4.4 2.9 38 1.9 1.2

Tonsillar cancer (ICD-10 code: C09)Albacete 2008-2010 7 1.2 0.7 1 0.2 0.1

Asturias 2008-2010 36 2.4 1.2 4 0.2 0.1

Basque Country 2008-2012 125 2.4 1.4 29 0.5 0.3

Canary Islands 2008-2011 61 1.8 1.2 10 0.3 0.2

Castellón 2008-2012 14 0.9 0.6 6 0.4 0.3

Ciudad Real 2008-2011 10 1.0 0.7 2 0.2 0.1

Cuenca 2008-2011 7 1.6 1.1 0 0.0 0.0

Girona 2008-2012 35 1.9 1.2 6 0.3 0.2

Granada 2008-2012 37 1.6 1.1 5 0.2 0.2

La Rioja 2008-2012 8 1.0 0.6 0 0.0 0.0

Mallorca 2008-2011 22 1.3 1.0 6 0.4 0.2

Murcia 2008-2010 12 0.5 0.4 4 0.2 0.1

Navarra 2008-2010 12 1.3 0.8 1 0.1 0.1

Tarragona 2008-2012 51 2.5 1.7 6 0.3 0.2

Cancer of the oropharynx (excludes tonsil) (ICD-10 code: C10)Albacete 2008-2010 7 1.2 0.8 0 0.0 0.0

Asturias 2008-2010 45 3.0 1.6 8 0.5 0.2

Basque Country 2008-2012 104 2.0 1.2 24 0.4 0.3

Canary Islands 2008-2011 53 1.5 1.1 3 0.1 0.1

Castellón 2008-2012 17 1.1 0.8 2 0.1 0.1

Ciudad Real 2008-2011 7 0.7 0.4 2 0.2 0.2

Cuenca 2008-2011 1 0.2 0.0 0 0.0 0.0

Girona 2008-2012 26 1.4 0.9 8 0.4 0.3

Granada 2008-2012 13 0.6 0.4 2 0.1 0.0

La Rioja 2008-2012 16 2.0 1.3 1 0.1 0.0

Mallorca 2008-2011 19 1.1 0.8 4 0.2 0.1

Murcia 2008-2010 12 0.5 0.4 2 0.1 0.1

Navarra 2008-2010 8 0.8 0.6 3 0.3 0.2

Tarragona 2008-2012 31 1.5 1.1 6 0.3 0.2Data accessed on 15 Oct 2018.ASR: Age-standardised rate. Standardised rates have been estimated using the direct method and the World population as the reference.aAccumulated number of cases during the period in the population covered by the corresponding registry.




( Table 13 – continued from previous page)bMale: Rates per 100,000 men per year. Female: Rates per 100,000 women per year.αPlease refer to original source (available at http://ci5.iarc.fr/CI5-XI/Default.aspx)Data sources:1Bray F, Colombet M, Mery L, Piñeros M, Znaor A, Zanetti R and Ferlay J, editors (2017). Cancer Incidence in Five Continents, Vol. XI (electronic version). Lyon: International Agency forResearch on Cancer. Available from: http://ci5.iarc.fr, accessed [05 October 2018].



http://ci5.iarc.fr,

4 HPV RELATED STATISTICS - 33 -

4 HPV related statistics

HPV infection is commonly found in the anogenital tract of men and women with and without clinicallesions. The aetiological role of HPV infection among women with cervical cancer is well-established,and there is growing evidence of its central role in other anogenital sites. HPV is also responsible forother diseases such as recurrent juvenile respiratory papillomatosis and genital warts, both mainlycaused by HPV types 6 and 11 (Lacey CJ, Vaccine 2006; 24(S3):35). For this section, the methodologiesused to compile the information on HPV burden are derived from systematic reviews and meta-analysesof the literature. Due to the limitations of HPV DNA detection methods and study designs used, thesedata should be interpreted with caution and used only as a guide to assess the burden of HPV infectionwithin the population. (Vaccine 2006, Vol. 24, Suppl 3; Vaccine 2008, Vol. 26, Suppl 10; Vaccine2012,Vol. 30, Suppl 5; IARC Monographs 2007, Vol. 90).

4.1 HPV burden in women with normal cervical cytology, cervical precancerouslesions or invasive cervical cancer

The statistics shown in this section focus on HPV infection in the cervix uteri. HPV cervical infection re-sults in cervical morphological lesions ranging from normalcy (cytologically normal women) to differentstages of precancerous lesions (CIN-1, CIN-2, CIN-3/CIS) and invasive cervical cancer. HPV infectionis measured by HPV DNA detection in cervical cells (fresh tissue, paraffin embedded or exfoliated cells).

The prevalence of HPV increases with lesion severity. HPV causes virtually 100% of cervical cancercases, and an underestimation of HPV prevalence in cervical cancer is most likely due to the limitationsof study methodologies. Worldwide, HPV16 and 18 (the two vaccine-preventable types) contribute toover 70% of all cervical cancer cases, between 41% and 67% of high-grade cervical lesions and 16-32%of low-grade cervical lesions. After HPV16/18, the six most common HPV types are the same in allworld regions, namely 31, 33, 35, 45, 52 and 58; these account for an additional 20% of cervical cancersworldwide (Clifford G, Vaccine 2006;24(S3):26).

Methods: Prevalence and type distribution of human papillomavirus in cervical carcinoma,low-grade cervical lesions, high-grade cervical lesions and normal cytology: systematic re-view and meta-analysis

A systematic review of the literature was conducted regarding the worldwide HPV-prevalence and typedistribution for cervical carcinoma, low-grade cervical lesions, high-grade cervical lesions and normalcytology from 1990 to ’data as of ’ indicated in each section. The search terms for the review were ’HPV’AND cerv* using Pubmed. There were no limits in publication language. References cited in selectedarticles were also investigated. Inclusion criteria were: HPV DNA detection by means of PCR or HC2,a minimum of 20 cases for cervical carcinoma, 20 cases for low-grade cervical lesions, 20 cases for high-grade cervical lesions and 100 cases for normal cytology and a detailed description of HPV DNA detec-tion and genotyping techniques used. The number of cases tested and HPV positive extracted for eachstudy were pooled to estimate the prevalence of HPV DNA and the HPV type distribution globally andby geographical region. Binomial 95% confidence intervals were calculated for each HPV prevalence.For more details refer to the methods document.



4.1.1 HPV prevalence in women with normal cervical cytology

Figure 23: Crude age-specific HPV prevalence (%) and 95% confidence interval in women with normalcervical cytology in Spain

0

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Data updated on 12 Jun 2019 (data as of 30 Jun 2015).Data sources:Based on systematic reviews and meta-analysis performed by ICO. The ICO HPV Information Centre has updated data until June 2014. Reference publications: 1) Bruni L, J Infect Dis2010; 202: 1789. 2) De Sanjosé S, Lancet Infect Dis 2007; 7: 453Castellsagué X, J Med Virol 2012; 84: 947 | de Sanjose S, Sex Transm Dis 2003; 30: 788 | Dillner J, BMJ 2008; 337: a1754 | González C, Sex Transm Infect 2006; 82: 260 | Muñoz N, SexTransm Dis 1996; 23: 504

Figure 24: HPV prevalence among women with normal cervical cytology in Spain, by study

Study

Castellsagué 2012

Martorell 2010 (Valencia)a

Bernal 2008 (Zaragoza)

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de Sanjose 2003 (Barcelona)

Ortiz 2006 (Madrid and Alicante)a

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13.0 (11.9−14.2)

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17.5 (15.5−19.8)

7.3 (5.8−9.2)

1.3 (0.7−2.3)

10.8 (8.8−13.1)

7.8 (6.1−10.0)

5.2 (3.3−8.1)

0% 10% 20%

Data updated on 12 Jun 2019 (data as of 30 Jun 2015).95% CI: 95% Confidence Interval; N: number of women tested;The samples for HPV testing come from cervical specimens (fresh/fixed biopsies or exfoliated cells).aWomen from the general population, including some with cytological cervical abnormalitiesbAlava, Girona, Guipuzcoa, Murcia, Navarra, Salamanca, Sevilla, Vizcaya, ZaragozaData sources:Based on systematic reviews and meta-analysis performed by ICO. The ICO HPV Information Centre has updated data until June 2014. Reference publications: 1) Bruni L, J Infect Dis2010; 202: 1789. 2) De Sanjosé S, Lancet Infect Dis 2007; 7: 453Bernal M, Infect Agents Cancer 2008; 3: 8 | Castellsagué X, J Med Virol 2012; 84: 947 | de Sanjose S, Sex Transm Dis 2003; 30: 788 | Dillner J, BMJ 2008; 337: a1754 | González C, SexTransm Infect 2006; 82: 260 | Martorell M, Scand J Infect Dis 2010; 42: 549 | Muñoz N, Sex Transm Dis 1996; 23: 504 | Ortiz M, J Clin Microbiol 2006; 44: 1428



4.1.2 HPV type distribution among women with normal cervical cytology, precancerous cer-vical lesions and cervical cancer

Table 14: Prevalence of HPV16 and HPV18 by cytology in Spain

HPV 16/18 Prevalence

No. tested % (95% CI)

Normal cytology1,2 5,403 2.7 (2.3-3.2)

Low-grade lesions3,4 2,183 23.7 (21.9-25.5)

High-grade lesions5,6 868 46.3 (43.0-49.6)

Cervical cancer7,8 1,488 63.1 (60.6-65.5)

Data updated on 12 Jun 2019 (data as of 30 Jun 2015 / 30 Jun 2015).95% CI: 95% Confidence Interval; High-grade lesions: CIN-2, CIN-3, CIS or HSIL; Low-grade lesions: LSIL or CIN-1;The samples for HPV testing come from cervical specimens (fresh / fixed biopsies or exfoliated cells)Data sources:1Based on systematic reviews and meta-analysis performed by ICO. The ICO HPV Information Centre has updated data until June 2014. Reference publications: 1) Bruni L, J Infect Dis2010; 202: 1789. 2) De Sanjosé S, Lancet Infect Dis 2007; 7: 4532Castellsagué X, J Med Virol 2012; 84: 947 | de Sanjose S, Sex Transm Dis 2003; 30: 788 | Dillner J, BMJ 2008; 337: a1754 | González C, Sex Transm Infect 2006; 82: 260 | Muñoz N, SexTransm Dis 1996; 23: 5043Based on meta-analysis performed by IARC’s Infections and Cancer Epidemiology Group up to November 2011, the ICO HPV Information Centre has updated data until June 2015.Reference publications: 1) Guan P, Int J Cancer 2012;131:2349 2) Clifford GM, Cancer Epidemiol Biomarkers Prev 2005;14:11574Contributing studies: Conesa-Zamora P, BMC Infect Dis 2009; 9: 124 | de Méndez MT, Acta Cytol 2009; 53: 540 | de Oña M, J Med Virol 2010; 82: 597 | Doménech-Peris A, GynecolObstet Invest 2010; 70: 113 | García-Sierra N, J Clin Microbiol 2009; 47: 2165 | Herraez-Hernandez E, J Virol Methods 2013; 193: 9 | Martín P, BMC Infect Dis 2011; 11: 3165Based on meta-analysis performed by IARC’s Infections and Cancer Epidemiology Group up to November 2011, the ICO HPV Information Centre has updated data until June 2015.Reference publications: 1) Guan P, Int J Cancer 2012;131:2349 2) Smith JS, Int J Cancer 2007;121:621 3) Clifford GM, Br J Cancer 2003;89:101.6Contributing studies: Bosch FX, Cancer Epidemiol Biomarkers Prev 1993; 2: 415 | Conesa-Zamora P, BMC Infect Dis 2009; 9: 124 | Darwich L, Int J Gynecol Cancer 2011; 21: 1486 | deMéndez MT, Acta Cytol 2009; 53: 540 | de Oña M, J Med Virol 2010; 82: 597 | García-Sierra N, J Clin Microbiol 2009; 47: 2165 | Herraez-Hernandez E, J Virol Methods 2013; 193: 9 |Martín P, BMC Infect Dis 2011; 11: 316 | Muñoz N, Int J Cancer 1992; 52: 7437Based on meta-analysis performed by IARC’s Infections and Cancer Epidemiology Group up to November 2011, the ICO HPV Information Centre has updated data until June 2014.Reference publications: 1) Guan P, Int J Cancer 2012;131:2349 2) Li N, Int J Cancer 2011;128:927 3) Smith JS, Int J Cancer 2007;121:621 4) Clifford GM, Br J Cancer 2003;88:63 5) CliffordGM, Br J Cancer 2003;89:101.8Contributing studies: Alemany L, Gynecol Oncol 2012; 124: 512 | Bosch FX, J Natl Cancer Inst 1995; 87: 796 | Darwich L, Int J Gynecol Cancer 2011; 21: 1486 | González-Bosquet E,Gynecol Oncol 2008; 111: 9 | Herraez-Hernandez E, J Virol Methods 2013; 193: 9 | Martró E, Enferm Infecc Microbiol Clin 2012; 30: 225 | Mazarico E, Gynecol Oncol 2012; 125: 181 |Muñoz N, Int J Cancer 1992; 52: 743 | Rodriguez JA, Diagn Mol Pathol 1998; 7: 276

Figure 25: HPV 16 prevalence among women with normal cervical cytology in Spain, by study

StudyCastellsagué 2012

de Sanjose 2003

Dillner 2008

González 2006

Muñoz 1996

N3,059

847

721

447

329

% (95% CI)2.5 (2.0−3.1)

0.4 (0.1−1.0)

3.1 (2.0−4.6)

1.3 (0.6−2.9)

1.8 (0.8−3.9)

0% 10%

Data updated on 12 Jun 2019 (data as of 30 Jun 2015).95% CI: 95% Confidence Interval; N: number of women tested;The samples for HPV testing come from cervical specimens (fresh/fixed biopsies or exfoliated cells).Data sources:Based on systematic reviews and meta-analysis performed by ICO. The ICO HPV Information Centre has updated data until June 2014. Reference publications: 1) Bruni L, J Infect Dis2010; 202: 1789. 2) De Sanjosé S, Lancet Infect Dis 2007; 7: 453Castellsagué X, J Med Virol 2012; 84: 947 | de Sanjose S, Sex Transm Dis 2003; 30: 788 | Dillner J, BMJ 2008; 337: a1754 | González C, Sex Transm Infect 2006; 82: 260 | Muñoz N, SexTransm Dis 1996; 23: 504



Figure 26: HPV 16 prevalence among women with low-grade cervical lesions in Spain, by study

Studyde Oña 2010

Martín 2011

Herraez−Hernandez 2013

García−Sierra 2009

Conesa−Zamora 2009

Doménech−Peris 2010

N1,356

387

236

108

75

21

% (95% CI)12.2 (10.6−14.1)

24.8 (20.8−29.3)

39.8 (33.8−46.2)

17.6 (11.6−25.8)

29.3 (20.2−40.4)

23.8 (10.6−45.1)

10% 20% 30% 40% 50%

Data updated on 12 Jun 2019 (data as of 30 Jun 2015).95% CI: 95% Confidence Interval; Low-grade lesions: LSIL or CIN-1; N: number of women tested;The samples for HPV testing come from cervical specimens (fresh/fixed biopsies or exfoliated cells).Data sources:Based on meta-analysis performed by IARC’s Infections and Cancer Epidemiology Group up to November 2011, the ICO HPV Information Centre has updated data until June 2015.Reference publications: 1) Guan P, Int J Cancer 2012;131:2349 2) Clifford GM, Cancer Epidemiol Biomarkers Prev 2005;14:1157Conesa-Zamora P, BMC Infect Dis 2009; 9: 124 | de Méndez MT, Acta Cytol 2009; 53: 540 | de Oña M, J Med Virol 2010; 82: 597 | Doménech-Peris A, Gynecol Obstet Invest 2010; 70: 113| García-Sierra N, J Clin Microbiol 2009; 47: 2165 | Herraez-Hernandez E, J Virol Methods 2013; 193: 9 | Martín P, BMC Infect Dis 2011; 11: 316

Figure 27: HPV 16 prevalence among women with high-grade cervical lesions in Spain, by study

Studyde Oña 2010

Bosch 1993

Muñoz 1992

Martín 2011


Conesa−Zamora 2009

Darwich 2011

García−Sierra 2009

N306

157

157

82

68

39

34

25

% (95% CI)28.8 (24.0−34.1)

49.0 (41.3−56.8)

51.0 (43.2−58.7)

48.8 (38.3−59.4)

69.1 (57.4−78.8)

33.3 (20.6−49.0)

61.8 (45.0−76.1)

36.0 (20.2−55.5)

20% 30% 40% 50% 60% 70% 80%

Data updated on 12 Jun 2019 (data as of 30 Jun 2015).95% CI: 95% Confidence Interval; High-grade lesions: CIN-2, CIN-3, CIS or HSIL; N: number of women tested;The samples for HPV testing come from cervical specimens (fresh/fixed biopsies or exfoliated cells).Data sources:Based on meta-analysis performed by IARC’s Infections and Cancer Epidemiology Group up to November 2011, the ICO HPV Information Centre has updated data until June 2015.Reference publications: 1) Guan P, Int J Cancer 2012;131:2349 2) Smith JS, Int J Cancer 2007;121:621 3) Clifford GM, Br J Cancer 2003;89:101.Bosch FX, Cancer Epidemiol Biomarkers Prev 1993; 2: 415 | Conesa-Zamora P, BMC Infect Dis 2009; 9: 124 | Darwich L, Int J Gynecol Cancer 2011; 21: 1486 | de Méndez MT, Acta Cytol2009; 53: 540 | de Oña M, J Med Virol 2010; 82: 597 | García-Sierra N, J Clin Microbiol 2009; 47: 2165 | Herraez-Hernandez E, J Virol Methods 2013; 193: 9 | Martín P, BMC Infect Dis2011; 11: 316 | Muñoz N, Int J Cancer 1992; 52: 743

Figure 28: HPV 16 prevalence among women with invasive cervical cancer in Spain, by study

StudyAlemany 2012

Muñoz 1992

Martró 2012

Darwich 2011

Rodriguez 1998

Bosch 1995

Mazarico 2012

González−Bosquet 2008


N1,012

159

73

72

54

46

37

21

14

% (95% CI)58.2 (55.1−61.2)

54.1 (46.3−61.6)

47.9 (36.9−59.2)

79.2 (68.4−86.9)

61.1 (47.8−73.0)

54.3 (40.2−67.8)

43.2 (28.7−59.1)

52.4 (32.4−71.7)

78.6 (52.4−92.4)

20% 30% 40% 50% 60% 70% 80% 90% 100%

Data updated on 12 Jun 2019 (data as of 30 Jun 2015).




( Figure 28 – continued from previous page)95% CI: 95% Confidence Interval; N: number of women tested;The samples for HPV testing come from cervical specimens (fresh/fixed biopsies or exfoliated cells).Data sources:Based on meta-analysis performed by IARC’s Infections and Cancer Epidemiology Group up to November 2011, the ICO HPV Information Centre has updated data until June 2014.Reference publications: 1) Guan P, Int J Cancer 2012;131:2349 2) Li N, Int J Cancer 2011;128:927 3) Smith JS, Int J Cancer 2007;121:621 4) Clifford GM, Br J Cancer 2003;88:63 5) CliffordGM, Br J Cancer 2003;89:101.Alemany L, Gynecol Oncol 2012; 124: 512 | Bosch FX, J Natl Cancer Inst 1995; 87: 796 | Darwich L, Int J Gynecol Cancer 2011; 21: 1486 | González-Bosquet E, Gynecol Oncol 2008; 111:9 | Herraez-Hernandez E, J Virol Methods 2013; 193: 9 | Martró E, Enferm Infecc Microbiol Clin 2012; 30: 225 | Mazarico E, Gynecol Oncol 2012; 125: 181 | Muñoz N, Int J Cancer 1992;52: 743 | Rodriguez JA, Diagn Mol Pathol 1998; 7: 276

Figure 29: Comparison of the ten most frequent HPV oncogenic types in Spain among women withand without cervical lesions

Nor

mal

cyt

olog

y(a,

b)

Low

−gra

de le

sion

s(c,

d)

Hig

h−gr

ade

lesi

ons(

e, f)

Cer

vica

l Can

cer(

g, h

)

39585653183166515216

HP

V−t

ype

0.40.40.40.50.60.80.81.01.22.1

18583556315152665316

HP

V−t

ype

5.35.66.07.27.37.9

9.711.612.8

18.4

53563518585131523316

HP

V−t

ype

2.02.52.93.13.23.74.35.45.8

43.2

0 10 20 30 40 50 60

51395635524531183316

HP

V−t

ype

0.91.11.42.12.43.13.6

5.15.1

58.0

Prevalence (%)



Data updated on 12 Jun 2019 (data as of 30 Jun 2015 / 30 Jun 2015).High-grade lesions: CIN-2, CIN-3, CIS or HSIL; Low-grade lesions: LSIL or CIN-1;The samples for HPV testing come from cervical specimens (fresh / fixed biopsies or exfoliated cells).Data sources:aBased on systematic reviews and meta-analysis performed by ICO. The ICO HPV Information Centre has updated data until June 2014. Reference publications: 1) Bruni L, J Infect Dis2010; 202: 1789. 2) De Sanjosé S, Lancet Infect Dis 2007; 7: 453bCastellsagué X, J Med Virol 2012; 84: 947 | de Sanjose S, Sex Transm Dis 2003; 30: 788 | Dillner J, BMJ 2008; 337: a1754 | González C, Sex Transm Infect 2006; 82: 260 | Muñoz N, SexTransm Dis 1996; 23: 504cBased on meta-analysis performed by IARC’s Infections and Cancer Epidemiology Group up to November 2011, the ICO HPV Information Centre has updated data until June 2015.Reference publications: 1) Guan P, Int J Cancer 2012;131:2349 2) Clifford GM, Cancer Epidemiol Biomarkers Prev 2005;14:1157dContributing studies: Conesa-Zamora P, BMC Infect Dis 2009; 9: 124 | de Méndez MT, Acta Cytol 2009; 53: 540 | de Oña M, J Med Virol 2010; 82: 597 | Doménech-Peris A, GynecolObstet Invest 2010; 70: 113 | García-Sierra N, J Clin Microbiol 2009; 47: 2165 | Herraez-Hernandez E, J Virol Methods 2013; 193: 9 | Martín P, BMC Infect Dis 2011; 11: 316eBased on meta-analysis performed by IARC’s Infections and Cancer Epidemiology Group up to November 2011, the ICO HPV Information Centre has updated data until June 2015.Reference publications: 1) Guan P, Int J Cancer 2012;131:2349 2) Smith JS, Int J Cancer 2007;121:621 3) Clifford GM, Br J Cancer 2003;89:101.f Contributing studies: Bosch FX, Cancer Epidemiol Biomarkers Prev 1993; 2: 415 | Conesa-Zamora P, BMC Infect Dis 2009; 9: 124 | Darwich L, Int J Gynecol Cancer 2011; 21: 1486 |de Méndez MT, Acta Cytol 2009; 53: 540 | de Oña M, J Med Virol 2010; 82: 597 | García-Sierra N, J Clin Microbiol 2009; 47: 2165 | Herraez-Hernandez E, J Virol Methods 2013; 193: 9 |Martín P, BMC Infect Dis 2011; 11: 316 | Muñoz N, Int J Cancer 1992; 52: 743gBased on meta-analysis performed by IARC’s Infections and Cancer Epidemiology Group up to November 2011, the ICO HPV Information Centre has updated data until June 2014.Reference publications: 1) Guan P, Int J Cancer 2012;131:2349 2) Li N, Int J Cancer 2011;128:927 3) Smith JS, Int J Cancer 2007;121:621 4) Clifford GM, Br J Cancer 2003;88:63 5) CliffordGM, Br J Cancer 2003;89:101.hContributing studies: Alemany L, Gynecol Oncol 2012; 124: 512 | Bosch FX, J Natl Cancer Inst 1995; 87: 796 | Darwich L, Int J Gynecol Cancer 2011; 21: 1486 | González-Bosquet E,Gynecol Oncol 2008; 111: 9 | Herraez-Hernandez E, J Virol Methods 2013; 193: 9 | Martró E, Enferm Infecc Microbiol Clin 2012; 30: 225 | Mazarico E, Gynecol Oncol 2012; 125: 181 |Muñoz N, Int J Cancer 1992; 52: 743 | Rodriguez JA, Diagn Mol Pathol 1998; 7: 276



Figure 30: Comparison of the ten most frequent HPV oncogenic types in Spain among women withinvasive cervical cancer by histology

Cer

vica

l Can

cer

Squa

mou

s ce

ll ca

rcin

oma

Ade

noca

rcin

oma

Une

spec

ifie

d

51395635524531183316

HP

V−t

ype

0.91.11.42.12.43.13.6

5.15.1

58.0

51395635524531183316

HP

V−t

ype

1.01.21.52.12.42.83.64.1

5.658.5

10th*9th*8th*7th*6th*

5135451816

HP

V−t

ype

1.01.02.0

15.048.0

0 10 20 30 40 50 60 70

56685833355245311816

HP

V−t

ype

1.11.11.1

3.43.44.5

7.97.99.0

61.8

Prevalence (%)

*No data available. No more types than shown were tested or were positive.Data updated on 19 May 2017 (data as of 30 Jun 2015).The samples for HPV testing come from cervical specimens (fresh / fixed biopsies or exfoliated cells). The ranking of the ten most frequent HPV types may present less than ten types beauseonly a limited number of types were tested or were HPV-positive.Data sources:Based on meta-analysis performed by IARC’s Infections and Cancer Epidemiology Group up to November 2011, the ICO HPV Information Centre has updated data until June 2014.Reference publications: 1) Guan P, Int J Cancer 2012;131:2349 2) Li N, Int J Cancer 2011;128:927 3) Smith JS, Int J Cancer 2007;121:621 4) Clifford GM, Br J Cancer 2003;88:63 5) CliffordGM, Br J Cancer 2003;89:101.Contributing studies: Alemany L, Gynecol Oncol 2012; 124: 512 | Bosch FX, J Natl Cancer Inst 1995; 87: 796 | Darwich L, Int J Gynecol Cancer 2011; 21: 1486 | González-Bosquet E,Gynecol Oncol 2008; 111: 9 | Herraez-Hernandez E, J Virol Methods 2013; 193: 9 | Martró E, Enferm Infecc Microbiol Clin 2012; 30: 225 | Mazarico E, Gynecol Oncol 2012; 125: 181 |Muñoz N, Int J Cancer 1992; 52: 743 | Rodriguez JA, Diagn Mol Pathol 1998; 7: 276



Table 15: Type-specific HPV prevalence in women with normal cervical cytology, precancerous cervicallesions and invasive cervical cancer in Spain

Normal cytology1,2 Low-grade lesions3,4 High-grade lesions5,6 Cervical cancer7,8

HPV Type No. HPV Prev No. HPV Prev No. HPV Prev No. HPV Prevtested % (95% CI) tested % (95% CI) tested % (95% CI) tested % (95% CI)

ONCOGENIC HPV TYPESHigh-risk HPV types16 5,403 2.1 (1.7-2.5) 2,183 18.4 (16.8-20.1) 868 43.2 (39.9-46.5) 1,488 58.0 (55.5-60.5)18 5,403 0.6 (0.4-0.8) 2,183 5.3 (4.4-6.3) 868 3.1 (2.1-4.5) 1,488 5.1 (4.1-6.3)31 5,403 0.8 (0.6-1.0) 2,183 7.3 (6.3-8.5) 868 4.3 (3.1-5.8) 1,488 3.6 (2.8-4.7)33 5,403 0.4 (0.3-0.6) 2,183 4.1 (3.3-5.0) 868 5.8 (4.4-7.5) 1,488 5.1 (4.1-6.3)35 4,682 0.2 (0.1-0.4) 365 6.0 (4.0-9.0) 441 2.9 (1.7-5.0) 1,488 2.1 (1.5-2.9)39 4,956 0.4 (0.3-0.6) 827 4.7 (3.5-6.4) 405 1.2 (0.5-2.9) 1,488 1.1 (0.7-1.7)45 4,682 0.2 (0.1-0.4) 2,183 1.9 (1.4-2.5) 711 1.8 (1.1-3.1) 1,488 3.1 (2.3-4.1)51 4,682 1.0 (0.8-1.3) 827 7.9 (6.2-9.9) 405 3.7 (2.3-6.0) 1,488 0.9 (0.6-1.6)52 4,682 1.2 (0.9-1.5) 827 9.7 (7.8-11.9) 405 5.4 (3.6-8.1) 1,488 2.4 (1.7-3.3)56 4,682 0.4 (0.3-0.6) 752 7.2 (5.5-9.3) 366 2.5 (1.3-4.6) 1,488 1.4 (0.9-2.1)58 4,682 0.4 (0.3-0.6) 2,183 5.6 (4.7-6.6) 711 3.2 (2.2-4.8) 1,488 0.9 (0.6-1.6)59 4,682 0.1 (0.1-0.3) 365 4.4 (2.7-7.0) 284 1.1 (0.4-3.1) 1,488 0.7 (0.4-1.3)

Probable/possible carcinogen26 4,235 0.1 (0.0-0.2) 365 0.8 (0.3-2.4) 250 0.4 (0.1-2.2) 1,395 0.1 (0.0-0.5)30 - - - - - - 1,066 0.3 (0.1-0.8)34 1,176 0.0 (0.0-0.3) - - 157 0.0 (0.0-2.4) 1,262 0.0 (0.0-0.3)53 4,235 0.5 (0.3-0.8) 827 12.8 (10.7-15.3) 405 2.0 (1.0-3.8) 1,488 0.7 (0.4-1.3)66 4,235 0.8 (0.6-1.1) 827 11.6 (9.6-14.0) 405 1.7 (0.8-3.5) 1,488 0.5 (0.2-1.0)67 - - 236 8.1 (5.2-12.2) 68 4.4 (1.5-12.2) 1,080 0.1 (0.0-0.5)68 4,682 0.2 (0.1-0.4) 365 4.9 (3.1-7.7) 284 1.4 (0.5-3.6) 1,488 0.7 (0.4-1.2)69 - - 236 2.1 (0.9-4.9) 68 2.9 (0.8-10.1) 1,153 0.0 (0.0-0.3)70 4,235 0.1 (0.0-0.2) 365 2.5 (1.3-4.6) 250 0.4 (0.1-2.2) 1,395 0.1 (0.0-0.5)73 4,235 0.1 (0.0-0.2) 344 2.6 (1.4-4.9) 250 0.4 (0.1-2.2) 1,416 0.8 (0.4-1.4)82 4,235 0.1 (0.1-0.3) 344 2.9 (1.6-5.3) 250 0.4 (0.1-2.2) 1,416 0.1 (0.0-0.5)85 - - 108 0.0 (0.0-3.4) 25 0.0 (0.0-13.3) - -97 - - - - - - - -

NON-ONCOGENIC HPV TYPES6 4,956 0.2 (0.1-0.4) 2,183 5.6 (4.7-6.7) 868 2.6 (1.8-3.9) 1,467 0.6 (0.3-1.2)

11 4,956 0.2 (0.1-0.4) 2,108 2.2 (1.6-2.9) 829 0.8 (0.4-1.7) 1,467 0.1 (0.0-0.5)32 - - - - - - 54 0.0 (0.0-6.6)40 4,235 0.1 (0.0-0.2) 236 5.5 (3.2-9.2) 68 2.9 (0.8-10.1) 1,349 0.0 (0.0-0.3)42 1,176 0.0 (0.0-0.3) 236 14.8 (10.9-19.9) 68 7.4 (3.2-16.1) 1,276 0.4 (0.2-0.9)43 4,235 0.0 (0.0-0.1) 236 7.6 (4.9-11.7) 68 4.4 (1.5-12.2) 1,349 0.1 (0.0-0.4)44 4,235 0.1 (0.1-0.3) 236 11.9 (8.3-16.6) 68 5.9 (2.3-14.2) 1,295 0.2 (0.0-0.6)54 4,235 0.1 (0.1-0.3) 236 3.8 (2.0-7.1) 68 2.9 (0.8-10.1) 1,349 0.0 (0.0-0.3)55 - - - - - - - -57 1,176 0.0 (0.0-0.3) - - - - 213 0.0 (0.0-1.8)61 1,176 0.0 (0.0-0.3) 236 1.7 (0.7-4.3) 68 2.9 (0.8-10.1) 1,276 0.0 (0.0-0.3)62 - - 236 2.5 (1.2-5.4) 68 2.9 (0.8-10.1) 105 0.0 (0.0-3.5)64 - - - - - - - -71 847 0.0 (0.0-0.5) 236 2.5 (1.2-5.4) 68 0.0 (0.0-5.3) 178 0.0 (0.0-2.1)72 1,176 0.0 (0.0-0.3) 236 1.3 (0.4-3.7) 68 1.5 (0.3-7.9) 264 0.0 (0.0-1.4)74 3,059 0.2 (0.1-0.4) - - - - 1,176 0.0 (0.0-0.3)81 1,176 0.0 (0.0-0.3) 236 2.1 (0.9-4.9) 68 2.9 (0.8-10.1) 264 0.0 (0.0-1.4)83 1,176 0.0 (0.0-0.3) - - - - 250 0.0 (0.0-1.5)84 847 0.0 (0.0-0.5) 236 3.4 (1.7-6.5) 68 0.0 (0.0-5.3) 105 1.0 (0.2-5.2)86 - - - - - - - -87 - - - - - - - -89 1,176 0.0 (0.0-0.3) 236 4.2 (2.3-7.6) 68 4.4 (1.5-12.2) 264 0.0 (0.0-1.4)90 - - - - - - 54 0.0 (0.0-6.6)91 - - - - - - 1,066 0.0 (0.0-0.4)

Data updated on 12 Jun 2019 (data as of 30 Jun 2015 / 30 Jun 2015).95% CI: 95% Confidence Interval; High-grade lesions: CIN-2, CIN-3, CIS or HSIL; Low-grade lesions: LSIL or CIN-1;The samples for HPV testing come from cervical specimens (fresh / fixed biopsies or exfoliated cells).Data sources:1Based on systematic reviews and meta-analysis performed by ICO. The ICO HPV Information Centre has updated data until June 2014. Reference publications: 1) Bruni L, J Infect Dis2010; 202: 1789. 2) De Sanjosé S, Lancet Infect Dis 2007; 7: 4532Castellsagué X, J Med Virol 2012; 84: 947 | de Sanjose S, Sex Transm Dis 2003; 30: 788 | Dillner J, BMJ 2008; 337: a1754 | González C, Sex Transm Infect 2006; 82: 260 | Muñoz N, SexTransm Dis 1996; 23: 5043Based on meta-analysis performed by IARC’s Infections and Cancer Epidemiology Group up to November 2011, the ICO HPV Information Centre has updated data until June 2015.Reference publications: 1) Guan P, Int J Cancer 2012;131:2349 2) Clifford GM, Cancer Epidemiol Biomarkers Prev 2005;14:11574Contributing studies: Conesa-Zamora P, BMC Infect Dis 2009; 9: 124 | de Méndez MT, Acta Cytol 2009; 53: 540 | de Oña M, J Med Virol 2010; 82: 597 | Doménech-Peris A, GynecolObstet Invest 2010; 70: 113 | García-Sierra N, J Clin Microbiol 2009; 47: 2165 | Herraez-Hernandez E, J Virol Methods 2013; 193: 9 | Martín P, BMC Infect Dis 2011; 11: 316




( Table 15 – continued from previous page)5Based on meta-analysis performed by IARC’s Infections and Cancer Epidemiology Group up to November 2011, the ICO HPV Information Centre has updated data until June 2015.Reference publications: 1) Guan P, Int J Cancer 2012;131:2349 2) Smith JS, Int J Cancer 2007;121:621 3) Clifford GM, Br J Cancer 2003;89:101.6Contributing studies: Bosch FX, Cancer Epidemiol Biomarkers Prev 1993; 2: 415 | Conesa-Zamora P, BMC Infect Dis 2009; 9: 124 | Darwich L, Int J Gynecol Cancer 2011; 21: 1486 | deMéndez MT, Acta Cytol 2009; 53: 540 | de Oña M, J Med Virol 2010; 82: 597 | García-Sierra N, J Clin Microbiol 2009; 47: 2165 | Herraez-Hernandez E, J Virol Methods 2013; 193: 9 |Martín P, BMC Infect Dis 2011; 11: 316 | Muñoz N, Int J Cancer 1992; 52: 7437Based on meta-analysis performed by IARC’s Infections and Cancer Epidemiology Group up to November 2011, the ICO HPV Information Centre has updated data until June 2014.Reference publications: 1) Guan P, Int J Cancer 2012;131:2349 2) Li N, Int J Cancer 2011;128:927 3) Smith JS, Int J Cancer 2007;121:621 4) Clifford GM, Br J Cancer 2003;88:63 5) CliffordGM, Br J Cancer 2003;89:101.8Contributing studies: Alemany L, Gynecol Oncol 2012; 124: 512 | Bosch FX, J Natl Cancer Inst 1995; 87: 796 | Darwich L, Int J Gynecol Cancer 2011; 21: 1486 | González-Bosquet E,Gynecol Oncol 2008; 111: 9 | Herraez-Hernandez E, J Virol Methods 2013; 193: 9 | Martró E, Enferm Infecc Microbiol Clin 2012; 30: 225 | Mazarico E, Gynecol Oncol 2012; 125: 181 |Muñoz N, Int J Cancer 1992; 52: 743 | Rodriguez JA, Diagn Mol Pathol 1998; 7: 276



Table 16: Type-specific HPV prevalence among invasive cervical cancer cases in Spain by histology

Any Histology Squamous cell carcinoma Adenocarcinoma UnespecifiedHPV Type No. HPV Prev No. HPV Prev No. HPV Prev No. HPV Prev

tested % (95% CI) tested % (95% CI) tested % (95% CI) tested % (95% CI)ONCOGENIC HPV TYPES

High-risk HPV types16 1,488 58.0 (55.5-60.5) 1,299 58.5 (55.8-61.2) 100 48.0 (38.5-57.7) 89 61.8 (51.4-71.2)18 1,488 5.1 (4.1-6.3) 1,299 4.1 (3.1-5.3) 100 15.0 (9.3-23.3) 89 9.0 (4.6-16.7)31 1,488 3.6 (2.8-4.7) 1,299 3.6 (2.7-4.8) 100 0.0 (0.0-3.7) 89 7.9 (3.9-15.4)33 1,488 5.1 (4.1-6.3) 1,299 5.6 (4.5-7.0) 100 0.0 (0.0-3.7) 89 3.4 (1.2-9.4)35 1,488 2.1 (1.5-2.9) 1,299 2.1 (1.4-3.0) 100 1.0 (0.2-5.4) 89 3.4 (1.2-9.4)39 1,488 1.1 (0.7-1.7) 1,299 1.2 (0.7-1.9) 100 0.0 (0.0-3.7) 89 1.1 (0.2-6.1)45 1,488 3.1 (2.3-4.1) 1,299 2.8 (2.1-3.9) 100 2.0 (0.6-7.0) 89 7.9 (3.9-15.4)51 1,488 0.9 (0.6-1.6) 1,299 1.0 (0.6-1.7) 100 1.0 (0.2-5.4) 89 0.0 (0.0-4.1)52 1,488 2.4 (1.7-3.3) 1,299 2.4 (1.7-3.4) 100 0.0 (0.0-3.7) 89 4.5 (1.8-11.0)56 1,488 1.4 (0.9-2.1) 1,299 1.5 (1.0-2.4) 100 0.0 (0.0-3.7) 89 1.1 (0.2-6.1)58 1,488 0.9 (0.6-1.6) 1,299 1.0 (0.6-1.7) 100 0.0 (0.0-3.7) 89 1.1 (0.2-6.1)59 1,488 0.7 (0.4-1.3) 1,299 0.8 (0.5-1.5) 100 0.0 (0.0-3.7) 89 0.0 (0.0-4.1)

Probable/possible carcinogen26 1,395 0.1 (0.0-0.5) - - - - - -30 1,066 0.3 (0.1-0.8) 912 0.3 (0.1-1.0) 100 0.0 (0.0-3.7) 54 0.0 (0.0-6.6)34 1,262 0.0 (0.0-0.3) 1,108 0.0 (0.0-0.3) 100 0.0 (0.0-3.7) 54 0.0 (0.0-6.6)53 1,488 0.7 (0.4-1.3) - - - - - -66 1,488 0.5 (0.2-1.0) 1,299 0.5 (0.3-1.1) 100 0.0 (0.0-3.7) 89 0.0 (0.0-4.1)67 1,080 0.1 (0.0-0.5) 912 0.0 (0.0-0.4) 100 0.0 (0.0-3.7) 68 1.5 (0.3-7.9)68 1,488 0.7 (0.4-1.2) 1,299 0.7 (0.4-1.3) 100 0.0 (0.0-3.7) 89 1.1 (0.2-6.1)69 1,153 0.0 (0.0-0.3) - - - - - -70 1,395 0.1 (0.0-0.5) - - - - - -73 1,416 0.8 (0.4-1.4) - - - - - -82 1,416 0.1 (0.0-0.5) 1,227 0.2 (0.0-0.6) 100 0.0 (0.0-3.7) 89 0.0 (0.0-4.1)85 - - - - - - - -97 - - - - - - - -

NON-ONCOGENIC HPV TYPES6 1,467 0.6 (0.3-1.2) - - - - - -

11 1,467 0.1 (0.0-0.5) - - - - - -27 - - - - - - - -32 54 0.0 (0.0-6.6) - - - - - -40 1,349 0.0 (0.0-0.3) - - - - - -42 1,276 0.4 (0.2-0.9) 1,108 0.1 (0.0-0.5) 100 0.0 (0.0-3.7) 68 5.9 (2.3-14.2)43 1,349 0.1 (0.0-0.4) - - - - - -44 1,295 0.2 (0.0-0.6) 1,181 0.0 (0.0-0.3) 100 0.0 (0.0-3.7) 14 14.3 (4.0-39.9)54 1,349 0.0 (0.0-0.3) - - - - - -55 - - - - - - - -57 213 0.0 (0.0-1.8) - - - - - -60 - - - - - - - -61 1,276 0.0 (0.0-0.3) - - - - - -62 105 0.0 (0.0-3.5) - - - - - -64 - - - - - - - -71 178 0.0 (0.0-2.1) - - - - - -72 264 0.0 (0.0-1.4) - - - - - -74 1,176 0.0 (0.0-0.3) - - - - - -76 - - - - - - - -81 264 0.0 (0.0-1.4) - - - - - -83 250 0.0 (0.0-1.5) - - - - - -84 105 1.0 (0.2-5.2) - - - - - -86 - - - - - - - -87 - - - - - - - -89 264 0.0 (0.0-1.4) - - - - - -90 54 0.0 (0.0-6.6) - - - - - -91 1,066 0.0 (0.0-0.4) - - - - - -

No Data Available - - - - - - - - - - - -

Data updated on 19 May 2017 (data as of 30 Jun 2015).95% CI: 95% Confidence Interval;The samples for HPV testing come from cervical specimens (fresh / fixed biopsies or exfoliated cells).Data sources:Based on meta-analysis performed by IARC’s Infections and Cancer Epidemiology Group up to November 2011, the ICO HPV Information Centre has updated data until June 2014.Reference publications: 1) Guan P, Int J Cancer 2012;131:2349 2) Li N, Int J Cancer 2011;128:927 3) Smith JS, Int J Cancer 2007;121:621 4) Clifford GM, Br J Cancer 2003;88:63 5) CliffordGM, Br J Cancer 2003;89:101.




( Table 16 – continued from previous page)Contributing studies: Alemany L, Gynecol Oncol 2012; 124: 512 | Bosch FX, J Natl Cancer Inst 1995; 87: 796 | Darwich L, Int J Gynecol Cancer 2011; 21: 1486 | González-Bosquet E,Gynecol Oncol 2008; 111: 9 | Herraez-Hernandez E, J Virol Methods 2013; 193: 9 | Martró E, Enferm Infecc Microbiol Clin 2012; 30: 225 | Mazarico E, Gynecol Oncol 2012; 125: 181 |Muñoz N, Int J Cancer 1992; 52: 743 | Rodriguez JA, Diagn Mol Pathol 1998; 7: 276



4.1.3 HPV type distribution among HIV+ women with normal cervical cytology

Table 17: Studies on HPV prevalence among HIV women with normal cytology in SpainHPV detection Prevalence of 5 most

method and targeted HPV prevalence frequent HPVsStudy HPV types No. Tested % (95% CI) HPV type (%)

Cañadas 20101 PCR (E6/E7), TS, (HPV 6, 11, 16,18, 31, 33, 35, 39, 45, 51, 52, 56,58, 59, 68)

168 38.7 (31.3-46.5) HPV 16 (18.5%)HPV 33 (7.7%)HPV 39 (6.6%)HPV 52 (6.0%)HPV 58 (5.4%)

De Sanjose 20002 PCR (MY09/11),EIA, DBH,(HPV6, 11, 16, 18, 31, 33, 35, 39,40, 41, 45, 51, 52, 53, 54, 56, 58,59, 66, 73, 81)


Gonzalez 20083 PCR (E6/E7), HC2, TS, (HPV 6,11, 16, 18, 31, 33, 35, 39, 45, 51,52, 56, 58, 59, 68)


Data updated on 31 Jul 2013 (data as of 31 Dec 2011). Only for European countries.95% CI: 95% Confidence Interval;DBH: Dot Blot Hybridization; EIA: Enzyme ImmunoAssay; HC2: Hybrid Capture 2; PCR: Polymerase Chain Reaction; TS: Type Specific;Data sources:Systematic review and meta-analysis were performed by the ICO HPV Information Centre up to December 2011. Selected studies had to include at least 20 HIV positive women who hadboth normal cervical cytology and HPV test results (PCR or HC2).1Cañadas MP, J Clin Virol 2010;48:1982de Sanjosé S, Med Clin (Barc) 2000;115:813González C, Epidemiol Infect 2008;136:215



4.1.4 Terminology

Cytologically normal womenNo abnormal cells are observed on the surface of their cervix upon cytology.

Cervical Intraepithelial Neoplasia (CIN) / Squamous Intraepithelial Lesions (SIL)SIL and CIN are two commonly used terms to describe precancerous lesions or the abnormalgrowth of squamous cells observed in the cervix. SIL is an abnormal result derived from cervicalcytological screening or Pap smear testing. CIN is a histological diagnosis made upon analysis ofcervical tissue obtained by biopsy or surgical excision. The condition is graded as CIN 1, 2 or 3,according to the thickness of the abnormal epithelium (1/3, 2/3 or the entire thickness).

Low-grade cervical lesions (LSIL/CIN-1)Low-grade cervical lesions are defined by early changes in size, shape, and number of ab-normal cells formed on the surface of the cervix and may be referred to as mild dysplasia,LSIL, or CIN-1.

High-grade cervical lesions (HSIL/ CIN-2 / CIN-3 / CIS)High-grade cervical lesions are defined by a large number of precancerous cells on the sur-face of the cervix that are distinctly different from normal cells. They have the potentialto become cancerous cells and invade deeper tissues of the cervix. These lesions may bereferred to as moderate or severe dysplasia, HSIL, CIN-2, CIN-3 or cervical carcinoma insitu (CIS).

Carcinoma in situ (CIS)Preinvasive malignancy limited to the epithelium without invasion of the basement membrane.CIN 3 encompasses the squamous carcinoma in situ.

Invasive cervical cancer (ICC) / Cervical cancerIf the high-grade precancerous cells invade the basement membrane is called ICC. ICC stagesrange from stage I (cancer is in the cervix or uterus only) to stage IV (the cancer has spread todistant organs, such as the liver).

Invasive squamous cell carcinomaInvasive carcinoma composed of cells resembling those of squamous epithelium.

AdenocarcinomaInvasive tumour with glandular and squamous elements intermingled.



4.2 HPV burden in anogenital cancers other than cervix

Methods: Prevalence and type distribution of human papillomavirus in carcinoma of thevulva, vagina, anus and penis: systematic review and meta-analysis

A systematic review of the literature was conducted on the worldwide HPV-prevalence and type dis-tribution for anogenital carcinomas other than cervix from January 1986 to ’data as of ’ indicated ineach section. The search terms for the review were ’HPV’ AND (anus OR anal) OR (penile) OR vagin*OR vulv* using Pubmed. There were no limits in publication language. References cited in selectedarticles were also investigated. Inclusion criteria were: HPV DNA detection by means of PCR, a mini-mum of 10 cases by lesion and a detailed description of HPV DNA detection and genotyping techniquesused. The number of cases tested and HPV positive cases were extracted for each study to estimatethe prevalence of HPV DNA and the HPV type distribution. Binomial 95% confidence intervals werecalculated for each HPV prevalence.

4.2.1 Anal cancer and precancerous anal lesions

Anal cancer is similar to cervical cancer with respect to overall HPV DNA positivity, with approximately88% of cases associated with HPV infection worldwide (de Martel C et al. Lancet Oncol 2012;13(6):607-15). HPV16 is the most common type detected, representing 73% of all HPV-positive tumours. HPV18is the second most common type detected and is found in approximately 5% of cases. HPV DNA is alsodetected in the majority of precancerous anal lesions (AIN) (91.5% in AIN1 and 93.9% in AIN2/3) (DeVuyst H et al. Int J Cancer 2009; 124: 1626-36). In this section, the burden of HPV among cases of analcancers and precancerous anal lesions in Spain are presented.

Table 18: Studies on HPV prevalence among anal cancer cases in Spain (male and female)HPV detection Prevalence of 5 most

method and targeted HPV prevalence frequent HPVsStudya HPV types No. Tested % (95% CI) HPV type (%)

Alemany 2015 PCR-SPF10, EIA, (HPV 6, 11,16, 18, 26, 30, 31, 33, 34, 35, 39,40, 42, 43, 44, 45, 51, 52, 53, 54,56, 58, 59, 61, 66, 67, 68, 69, 70,73, 74, 82, 83, 87, 89, 91)


Data updated on 12 Jun 2019 (data as of 30 Jun 2015).95% CI: 95% Confidence Interval;EIA: Enzyme ImmunoAssay; PCR: Polymerase Chain Reaction; SPF: Short Primer Fragment;aIncludes cases from Bosnia-Herzegovina, Czech Republic, France, Germany, Poland, Portugal, Slovenia, Spain and United KingdomData sources:Based on systematic reviews (up to 2008) performed by ICO for the IARC Monograph on the Evaluation of Carcinogenic Risks to Humans volume 100B and IARC’s Infections and CancerEpidemiology Group. The ICO HPV Information Centre has updated data until June 2015. Reference publications: 1) Bouvard V, Lancet Oncol 2009;10:321 2) De Vuyst H, Int J Cancer2009;124:1626Alemany L, Int J Cancer 2015; 136: 98

Table 19: Studies on HPV prevalence among cases of AIN2/3 in SpainHPV detection Prevalence of 5 most


Alemany 2015a PCR-SPF10, EIA, (HPV 6, 11,16, 18, 26, 30, 31, 33, 34, 35, 39,40, 42, 43, 44, 45, 51, 52, 53, 54,56, 58, 59, 61, 66, 67, 68, 69, 70,73, 74, 82, 83, 87, 89, 91)





( Table 19 – continued from previous page)HPV detection Prevalence of 5 most


García-Espinosa2013b

PCR-GP5/6, PCR L1-Consensusprimer, DBH (HPV 6, 11, 16, 18,26, 31, 33, 35, 39, 40, 42, 43, 44,45, 51, 52, 53, 54, 56, 57, 58, 59,61, 66, 68, 70, 71, 72, 73, 81, 82,84)


Sirera 2013b PCR- MULTIPLEX (HPV 6, 11,16, 18, 31, 33, 35, 39, 45, 51, 52,56, 58, 59, 68)


Torres 2013b LBA (HPV 6, 11, 16, 18, 26, 31,33, 34, 35, 39, 40, 42, 44, 45, 51,52, 53, 54, 56, 58, 59, 61, 62, 66,67, 68, 69, 70, 71, 72, 73, 81, 82,83, 84)


Data updated on 12 Jun 2019 (data as of 30 Jun 2015).95% CI: 95% Confidence Interval; AIN 2/3: Anal intraepithelial neoplasia of grade 2/3;DBH: Dot Blot Hybridization; EIA: Enzyme ImmunoAssay; LBA: Line-Blot Assay; PCR: Polymerase Chain Reaction; SPF: Short Primer Fragment;aIncludes cases from Bosnia-Herzegovina, Czech Republic, France, Germany, Poland, Portugal, Slovenia, Spain and United KingdombHIV positive casesData sources:Based on systematic reviews (up to 2008) performed by ICO for the IARC Monograph on the Evaluation of Carcinogenic Risks to Humans volume 100B and IARC’s Infections and CancerEpidemiology Group. The ICO HPV Information Centre has updated data until June 2015. Reference publications: 1) Bouvard V, Lancet Oncol 2009;10:321 2) De Vuyst H, Int J Cancer2009;124:1626Alemany L, Int J Cancer 2015; 136: 98 | García-Espinosa B, Diagn Pathol 2013; 8: 204 | Sirera G, AIDS 2013; 27: 951 | Torres M, J Clin Microbiol 2013; 51: 3512

Figure 31: Comparison of the ten most frequent HPV types in anal cancer cases in Europe and theWorld

Europe (a)

52

30

31

74

35

33

11

18

6

16

0 10 20 30 40 50 60 70 80

0.6

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1.2

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2.4

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73.4

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World (b)

52

39

11

58

35

31

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18

16

0 10 20 30 40 50 60 70 80

1.2

1.2

1.4

1.6

1.6

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2.4

3.0

4.2

71.4

Data updated on 09 Feb 2017 (data as of 30 Jun 2014).aIncludes cases from Bosnia-Herzegovina, Czech Republic, France, Germany, Poland, Portugal, Slovenia, Spain and United Kingdom.bIncludes cases from Europe (Bosnia-Herzegovina, Czech Republic, France, Germany, Poland, Portugal, Slovenia, Spain and United Kingdom); America (Chile, Colombia, Ecuador,Guatemala, Honduras, Mexico, Paraguay and United States); Africa (Mali, Nigeria and Senegal); Asia (Bangladesh,India and South Korea)Data sources:Data from Alemany L, Int J Cancer 2015; 136: 98. This study has gathered the largest international series of anal cancer cases and precancerous lesions worldwide using a standard protocolwith a highly sensitive HPV DNA detection assay.



Figure 32: Comparison of the ten most frequent HPV types in AIN 2/3 cases in Europe and the World

Europe (a)

45

44

35

31

11

74

6

51

18

16

0 10 20 30 40 50 60 70 80

4.3

4.3

4.3

4.3

4.3

8.7

8.7

8.7

8.7

65.2

Type−specific HPV prevalence (%) of AIN 2/3 cases

World (b)

45

44

35

74

51

31

18

11

6

16

0 10 20 30 40 50 60 70 80

2.3

2.3

2.3

4.7

4.7

4.7

4.7

7.0

9.3

72.1

Data updated on 09 Feb 2017 (data as of 30 Jun 2014).AIN 2/3: Anal intraepithelial neoplasia of grade 2/3;aIncludes cases from Bosnia-Herzegovina, Czech Republic, France, Germany, Poland, Portugal, Slovenia, Spain and United KingdombIncludes cases from Europe (Bosnia-Herzegovina, Czech Republic, France, Germany, Poland, Portugal, Slovenia, Spain and United Kingdom); America (Chile, Colombia, Ecuador,Guatemala, Honduras, Mexico, Paraguay)Data sources:Data from Alemany L, Int J Cancer 2015; 136: 98. This study has gathered the largest international series of anal cancer cases and precancerous lesions worldwide using a standard protocolwith a highly sensitive HPV DNA detection assay.



4.2.2 Vulvar cancer and precancerous vulvar lesions

HPV attribution for vulvar cancer is 43% worldwide (de Martel C et al. Lancet Oncol 2012;13(6):607-15). Vulvar cancer has two distinct histological patterns with two different risk factor profiles: (1) basa-loid/warty types (2) keratinising types. Basaloid/warty lesions are more common in young women, arefrequently found adjacent to VIN, are very often associated with HPV DNA detection (86%), and havea similar risk factor profile as cervical cancer. Keratinising vulvar carcinomas represent the majorityof the vulvar lesions (>60%). These lesions develop from non HPV-related chronic vulvar dermatoses,especially lichen sclerosus and/or squamous hyperplasia, their immediate cancer precursor lesion is dif-ferentiated VIN, they occur more often in older women, and are rarely associated with HPV (6%) or withany of the other risk factors typical of cervical cancer. HPV prevalence is frequently detected amongcases of high-grade VIN (VIN2/3) (85.3%). HPV 16 is the most common type detected followed by HPV33 (De Vuyst H et al. Int J Cancer 2009; 124: 1626-36).In this section, the HPV burden among cases ofvulvar cancer cases and precancerous vulvar lesions in Spain are presented.

Table 20: Studies on HPV prevalence among vulvar cancer cases in SpainHPV detection Prevalence of 5 most


Alonso 2011 PCR-SPF10, (HPV 6, 11, 16, 18,31, 33, 35, 42, 45, 51, 52, 53, 54,56, 58, 66)


de Sanjosé 2013a PCR-SPF10, EIA, (HPV 6, 11,16, 18, 26, 30, 31, 33, 34, 35, 39,40, 42, 43, 44, 45, 51, 52, 53, 54,56, 58, 59, 61, 66, 67, 68, 69, 70,73, 74, 82, 83, 87, 89, 91)


Guerrero 2011 PCR L1-Consensus primer,(HPV 6, 11, 16, 18, 26, 31, 33, 34,35, 39, 40, 42, 43, 44, 45, 51, 52,53, 54, 56, 57, 58, 59, 61, 66, 68,70, 71, 72, 73, 81, 82, 83, 84)

30 16.7 (7.3-33.6) HPV 59 (10.0%)HPV 6 (3.3%)HPV 16 (3.3%)HPV 18 (3.3%)

Lerma 1999 PCR L1-Consensus primer, TS(HPV 16, 18)

57 12.3 (6.1-23.2) HPV 16 (12.3%)

Data updated on 12 Jun 2019 (data as of 30 Jun 2015).95% CI: 95% Confidence Interval;EIA: Enzyme ImmunoAssay; PCR: Polymerase Chain Reaction; SPF: Short Primer Fragment; TS: Type Specific;aIncludes cases from Austria, Belarus, Bosnia-Herzegovina, Czech Republic, France, Germany, Greece, Italy, Poland, Portugal, Spain and United KingdomData sources:Based on systematic reviews (up to 2008) performed by ICO for the IARC Monograph on the Evaluation of Carcinogenic Risks to Humans volume 100B and IARC’s Infections and CancerEpidemiology Group. The ICO HPV Information Centre has updated data until June 2015. Reference publications: 1) Bouvard V, Lancet Oncol 2009;10:321 2) De Vuyst H, Int J Cancer2009;124:1626Alonso I, Gynecol Oncol 2011; 122: 509 | de Sanjosé S, Eur J Cancer 2013; 49: 3450 | Guerrero D, Int J Cancer 2011; 128: 2853 | Lerma E, Int J Gynecol Pathol 1999; 18: 191

Table 21: Studies on HPV prevalence among VIN 2/3 cases in SpainHPV detection Prevalence of 5 most


de Sanjosé 2013a PCR-SPF10, EIA, (HPV 6, 11,16, 18, 26, 30, 31, 33, 34, 35, 39,40, 42, 43, 44, 45, 51, 52, 53, 54,56, 58, 59, 61, 66, 67, 68, 69, 70,73, 74, 82, 83, 87, 89, 91)


Lerma 1999 PCR L1-Consensus primer, TS(HPV 16, 18)

18 27.8 (12.5-50.9) HPV 16 (27.8%)

Data updated on 12 Jun 2019 (data as of 30 Jun 2015).95% CI: 95% Confidence Interval; VIN 2/3: Vulvar intraepithelial neoplasia of grade 2/3;EIA: Enzyme ImmunoAssay; PCR: Polymerase Chain Reaction; SPF: Short Primer Fragment; TS: Type Specific;aIncludes cases from Austria, Belarus, Bosnia-Herzegovina, Czech Republic, France, Germany, Greece, Italy, Poland, Portugal, Spain and United Kingdom




( Table 21 – continued from previous page)Data sources:Based on systematic reviews (up to 2008) performed by ICO for the IARC Monograph on the Evaluation of Carcinogenic Risks to Humans volume 100B and IARC’s Infections and CancerEpidemiology Group. The ICO HPV Information Centre has updated data until June 2015. Reference publications: 1) Bouvard V, Lancet Oncol 2009;10:321 2) De Vuyst H, Int J Cancer2009;124:1626de Sanjosé S, Eur J Cancer 2013; 49: 3450 | Lerma E, Int J Gynecol Pathol 1999; 18: 191



Figure 33: Comparison of the ten most frequent HPV types in cases of vulvar cancer in Europe and theWorld

Europe (a)

35

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53

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16

0 10 20

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Type−specific HPV prevalence (%) of vulvar cancer cases

World (b)

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Data updated on 09 Feb 2017 (data as of 30 Jun 2014).aIncludes cases from Austria, Belarus, Bosnia-Herzegovina, Czech Republic, France, Germany, Greece, Italy, Poland, Portugal, Spain and United Kingdom.bIncludes cases from America (Argentina, Brazil, Chile, Colombia, Ecuador, Guatemala, Honduras, Mexico, Paraguay, Uruguay, United States of America and Venezuela); Africa (Mali,Mozambique, Nigeria, and Senegal); Oceania (Australia and New Zealand); Europe (Austria, Belarus, Bosnia-Herzegovina, Czech Republic, France, Germany, Greece, Italy, Poland, Portugal,Spain and United Kingdom); and in Asia (Bangladesh, India, Israel, South Korea, Kuwait, Lebanon, Philippines, Taiwan and Turkey)Data sources:Data from de Sanjosé S, Eur J Cancer 2013; 49: 3450. This study has gathered the largest international series of vulva cancer cases and precancerous lesions worldwide using a standardprotocol with a highly sensitive HPV DNA detection assay.

Figure 34: Comparison of the ten most frequent HPV types in VIN 2/3 cases in Europe and the World

Europe (a)

31

74

66

44

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0.6

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Type−specific HPV prevalence (%) of VIN 2/3 cases

World (b)

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56

51

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16

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2.4

10.2

67.1

Data updated on 09 Feb 2017 (data as of 30 Jun 2014).aIncludes cases from Austria, Belarus, Bosnia-Herzegovina, Czech Republic, France, Germany, Greece, Italy, Poland, Portugal, Spain and United Kingdom.bIncludes cases from America (Argentina, Brazil, Chile, Colombia, Ecuador, Guatemala, Honduras, Mexico, Paraguay, Uruguay and Venezuela); Oceania (Australia and New Zealand);Europe (Austria, Belarus, Bosnia-Herzegovina, Czech Republic, France, Germany, Greece, Italy, Poland, Portugal, Spain and United Kingdom); and in Asia (Bangladesh, India, Israel, SouthKorea, Kuwait, Lebanon, Philippines, Taiwan and Turkey)Data sources:Data from de Sanjosé S, Eur J Cancer 2013; 49: 3450. This study has gathered the largest international series of vulva cancer cases and precancerous lesions worldwide using a standardprotocol with a highly sensitive HPV DNA detection assay.



4.2.3 Vaginal cancer and precancerous vaginal lesions

Vaginal and cervical cancers share similar risk factors and it is generally accepted that both carcinomasshare the same aetiology of HPV infection although there is limited evidence available. Women withvaginal cancer are more likely to have a history of other ano-genital cancers, particularly of the cervix,and these two carcinomas are frequently diagnosed simultaneously. HPV DNA is detected among 70%of invasive vaginal carcinomas and 91% of high-grade vaginal neoplasias (VaIN2/3). HPV16 is themost common type in high-grade vaginal neoplasias and it is detected in at least 70% of HPV-positivecarcinomas (de Martel C et al. Lancet Oncol 2012;13(6):607-15; De Vuyst H et al. Int J Cancer 2009;124:1626-36). In this section, the HPV burden among cases of vaginal cancer cases and precancerousvaginal lesions in Spain are presented.

Table 22: Studies on HPV prevalence among vaginal cancer cases in SpainHPV detection Prevalence of 5 most


Alemany 2014a PCR-SPF10, EIA, (HPV 6, 11,16, 18, 26, 30, 31, 33, 35, 39, 42,45, 51, 52, 53, 56, 58, 59, 66, 67,68, 69, 73, 82)


Fuste 2010 PCR-SPF10, (HPV 6, 11, 16, 18,31, 33, 35, 39, 40, 42, 45, 51, 52,56, 58, 59, 68)


Data updated on 12 Jun 2019 (data as of 30 Jun 2015).95% CI: 95% Confidence Interval;EIA: Enzyme ImmunoAssay; PCR: Polymerase Chain Reaction; SPF: Short Primer Fragment;aIncludes cases from Austria, Belarus, Czech Republic, France, Germany, Greece, Poland, Spain and United KingdomData sources:Based on systematic reviews (up to 2008) performed by ICO for the IARC Monograph on the Evaluation of Carcinogenic Risks to Humans volume 100B and IARC’s Infections and CancerEpidemiology Group. The ICO HPV Information Centre has updated data until June 2015. Reference publications: 1) Bouvard V, Lancet Oncol 2009;10:321 2) De Vuyst H, Int J Cancer2009;124:1626Alemany L, Eur J Cancer 2014; 50: 2846 | Fuste V, Histopathology 2010; 57: 907

Table 23: Studies on HPV prevalence among VaIN 2/3 cases in SpainHPV detection Prevalence of 5 most


Alemany 2014 PCR-SPF10, EIA, (HPV 6, 11,16, 18, 26, 30, 31, 33, 35, 39, 42,45, 51, 52, 53, 56, 58, 59, 66, 67,68, 69, 73, 82)


Data updated on 12 Jun 2019 (data as of 30 Jun 2015).95% CI: 95% Confidence Interval; VAIN 2/3: Vaginal intraepithelial neoplasia of grade 2/3;EIA: Enzyme ImmunoAssay; PCR: Polymerase Chain Reaction; SPF: Short Primer Fragment;Based on systematic reviews (up to 2008) performed by ICO for the IARC Monograph on the Evaluation of Carcinogenic Risks to Humans volume 100B and IARC’s Infections and CancerEpidemiology Group. The ICO HPV Information Centre has updated data until June 2015. Reference publications: 1) Bouvard V, Lancet Oncol 2009;10:321 2) De Vuyst H, Int J Cancer2009;124:1626Alemany L, Eur J Cancer 2014; 50: 2846Data sources:Based on systematic reviews (up to 2008) performed by ICO for the IARC Monograph on the Evaluation of Carcinogenic Risks to Humans volume 100B and IARC’s Infections and CancerEpidemiology Group. The ICO HPV Information Centre has updated data until June 2015. Reference publications: 1) Bouvard V, Lancet Oncol 2009;10:321 2) De Vuyst H, Int J Cancer2009;124:1626Alemany L, Eur J Cancer 2014; 50: 2846



Figure 35: Comparison of the ten most frequent HPV types in cases of vaginal cancer in Europe and theWorld

Europe (a)

52

45

35

31

58

56

33

73

18

16

0 10 20 30 40 50

1.3

1.3

1.3

2.0

2.6

2.6

2.6

3.3

3.3

47.4

Type−specific HPV prevalence (%) of vaginal cancer cases

World (b)

39

73

51

52

58

45

33

18

31

16

0 10 20 30 40 50

1.5

1.7

1.7

2.2

2.7

2.7

3.7

3.7

3.9

43.6

Data updated on 09 Feb 2017 (data as of 30 Jun 2014).aIncludes cases from Austria, Belarus, Czech Republic, France, Germany, Greece, Poland, Spain and United Kingdom.bIncludes cases from Europe (Austria, Belarus, Czech Republic, France, Germany, Greece, Poland, Spain and United Kingdom); America (Argentina, Brazil, Chile, Colombia, Ecuador,Guatemala, Mexico, Paraguay, Uruguay, United states of America and Venezuela); Africa (Mozambique, Nigeria); Asia (Bangladesh, India, Israel, South Korea, Kuwait, Philippines, Taiwanand Turkey); and Oceania (Australia)Data sources:Data from Alemany L, Eur J Cancer 2014; 50: 2846. This study has gathered the largest international series of vaginal cancer cases and precancerous lesions worldwide using a standardprotocol with a highly sensitive HPV DNA detection assay.

Figure 36: Comparison of the ten most frequent HPV types in VaIN 2/3 cases in Europe and the World

Europe (a)

30

59

56

53

35

73

52

18

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16

0 10 20 30 40 50 60 70

1.0

2.1

2.1

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65.6

Type−specific HPV prevalence (%) of VaIN 2/3 cases

World (b)

35

6

51

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33

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52

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1.6

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5.3

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56.1

Data updated on 09 Feb 2017 (data as of 30 Jun 2014).VAIN 2/3: Vaginal intraepithelial neoplasia of grade 2/3;aIncludes cases from Austria, Belarus, Czech Republic, France, Germany, Greece, Poland, Spain and United Kingdom.bIncludes cases from Europe (Austria, Belarus, Czech Republic, France, Germany, Greece, Poland, Spain and United Kingdom); America (Argentina, Brazil, Chile, Colombia, Ecuador,Guatemala, Mexico, Paraguay, Uruguay, United states of America and Venezuela); Asia (Bangladesh, India, Israel, South Korea, Kuwait, Philippines, Taiwan and Turkey); and Oceania(Australia)Data sources:Data from Alemany L, Eur J Cancer 2014; 50: 2846. This study has gathered the largest international series of vaginal cancer cases and precancerous lesions worldwide using a standardprotocol with a highly sensitive HPV DNA detection assay.



4.2.4 Penile cancer and precancerous penile lesions

HPV DNA is detectable in approximately 50% of all penile cancers (de Martel C et al. Lancet Oncol2012;13(6):607-15). Among HPV-related penile tumours, HPV16 is the most common type detected,followed by HPV18 and HPV types 6/11 (Miralles C et al. J Clin Pathol 2009;62:870-8). Over 95% ofinvasive penile cancers are SCC and the most common penile SCC histologic sub-types are keratinising(49%), mixed warty-basaloid (17%), verrucous (8%), warty (6%), and basaloid (4%). HPV is commonlydetected in basaloid and warty tumours but is less common in keratinising and verrucous tumours. Inthis section, the HPV burden among cases of penile cancer cases and precancerous penile lesions inSpain are presented.

Table 24: Studies on HPV prevalence among penile cancer cases in SpainHPV detection Prevalence of 5 most


Ferrándiz-Pulido2013

PCR-SPF10, EIA, (HPV 6, 11,16, 18, 31, 33, 34, 35, 39, 40, 42,43, 44, 45, 51, 52, 53, 54, 56, 58,59, 66, 68, 70, 73, 74)


Guerrero 2008 (HPV 6, 11, 16, 18, 26, 31, 33, 34,35, 39, 40, 42, 43, 44, 45, 51, 52,53, 54, 56, 57, 58, 59, 61, 66, 68,70, 71, 72, 73, 81, 82, 83, 84)

24 45.8 (27.9-64.9) HPV 16 (45.8%)HPV 39 (4.2%)

Pascual 2007 PCR-MY09/11, PCRL1-Consensus primer,Sequencing (HPV 6, 11, 16, 18)

49 77.6 (64.1-87.0) HPV 16 (65.3%)HPV 18 (8.2%)

Data updated on 12 Jun 2019 (data as of 30 Jun 2015).95% CI: 95% Confidence Interval;EIA: Enzyme ImmunoAssay; PCR: Polymerase Chain Reaction; SPF: Short Primer Fragment;Data sources:The ICO HPV Information Centre has updated data until June 2015. Reference publications (up to 2008): 1) Bouvard V, Lancet Oncol 2009;10:321 2) Miralles-Guri C,J Clin Pathol2009;62:870Ferrándiz-Pulido C, J Am Acad Dermatol 2013; 68: 73 | Guerrero D, BJU Int 2008; 102: 747 | Pascual A, Histol Histopathol 2007; 22: 177

Table 25: Studies on HPV prevalence among PeIN 2/3 cases in SpainHPV detection Prevalence of 5 most

method and targeted HPV prevalence frequent HPVsStudy Method No. Tested % (95% CI) HPV type (%)

No Data Available - - - - -

Data updated on 12 Jun 2019 (data as of 30 Jun 2015).95% CI: 95% Confidence Interval; PeIN 2/3: Penile intraepithelial neoplasia of grade 2/3;Data sources:The ICO HPV Information Centre has updated data until June 2014. Reference publication (up to 2008): Bouvard V, Lancet Oncol 2009;10:321



Figure 37: Comparison of the ten most frequent HPV types in cases of penile cancer in Europe and theWorld

Europe (a)

44

35

31

18

58

45

33

6

52

16

0 10 20 30

0.5

0.5

0.5

0.5

0.7

0.7

1.0

1.0

1.2

23.4

Type−specific HPV prevalence (%) of penile cancer cases

World (b)

74

59

18

11

52

45

35

33

6

16

0 10 20 30

0.6

0.7

0.7

0.7

0.9

1.0

1.0

1.2

1.6

22.8

Data updated on 09 Feb 2017 (data as of 30 Jun 2015).aIncludes cases from Czech Republic, France, Greece, Poland, Portugal, Spain and United KingdombIncludes cases from Australia, Bangladesh, India, South Korea, Lebanon, Philippines, Chile, Colombia, Ecuador, Guatemala, Honduras, Mexico, Paraguay, Venezuela and United States,Mozambique, Nigeria, Senegal, Czech Republic, France, Greece, Poland, Portugal, Spain and United Kingdom.

Data sources:Alemany L, Eur Urol 2016; 69: 953

Figure 38: Comparison of the ten most frequent HPV types in PeIN 2/3 cases in Europe and the World

Europe (a)

43

58

52

51

45

31

18

6

33

16

0 10 20 30 40 50 60 70 80

1.6

3.1

3.1

3.1

3.1

3.1

3.1

3.1

6.3

73.4

Type−specific HPV prevalence (%) of PeIN 2/3 cases

World (b)

53

45

18

6

52

51

31

58

33

16

0 10 20 30 40 50 60 70 80

2.4

2.4

2.4

2.4

3.5

3.5

3.5

4.7

5.9

69.4

Data updated on 09 Feb 2017 (data as of 30 Jun 2015).aIncludes cases from Czech Republic, France, Greece, Poland, Portugal, Spain and United KingdombIncludes cases from Australia, Bangladesh, India, South Korea, Lebanon, Philippines, Chile, Colombia, Ecuador, Guatemala, Honduras, Mexico, Paraguay, Venezuela, Mozambique,Nigeria, Senegal, Czech Republic, France, Greece, Poland, Portugal, Spain and United Kingdom.

Data sources:Alemany L, Eur Urol 2016; 69: 953



4.3 HPV burden in men

The information to date regarding anogenital HPV infection is primarily derived from cross-sectionalstudies of selected populations such as general population, university students, military recruits, andstudies that examined husbands of control women, as well as from prospective studies. Special sub-groups include mainly studies that examined STD (sexually transmitted diseases) clinic attendees,MSM (men who have sex with men), HIV positive men, and partners of women with HPV lesions, CIN(cervical intraepithelial neoplasia), cervical cancer or cervical carcinoma in situ. Globally, prevalence ofexternal genital HPV infection in men is higher than cervical HPV infection in women, but persistenceis less likely. As with genital HPV prevalence, high numbers of sexual partners increase the acquisitionof oncogenic HPV infections (Vaccine 2012, Vol. 30, Suppl 5). In this section, the HPV burden amongmen in Spain is presented.

Methods

HPV burden in men was based on published systematic reviews and meta-analyses (Dunne EF, J InfectDis 2006; 194: 1044, Smith JS, J Adolesc Health 2011; 48: 540, Olesen TB, Sex Transm Infect 2014;90: 455, and Hebnes JB, J Sex Med 2014; 11: 2630) up to October 31, 2015. The search terms for thereview were human papillomavirus, men, polymerase chain reaction (PCR), hybrid capture (HC), andviral DNA. References cited in selected articles were also investigated. Inclusion criteria were: HPVDNA detection by means of PCR or HC (ISH if data are not available for the country), and a detaileddescription of HPV DNA detection and genotyping techniques used. The number of cases tested andHPV positive cases were extracted for each study to estimate the anogenital prevalence of HPV DNA.Binomial 95% confidence intervals were calculated for each anogenital HPV prevalence.

Table 26: Studies on HPV prevalence among men in SpainAnatomic sites HPV detection Age HPV prevalence

Study samples method Population (years) No % (95% CI)Franceschi 2002 Glans, corona,

urethraPCR-GP5+/6+ Husbands of control

women24-78 168 3.6 (1.3-7.6)

Vardas 2011a Penis RT-PCR-Multiplex orBiplex

Heterosexual menenrolled in a HPVvaccine trial

Median20

(15-24)

3132 21.2 (19.8-22.7)

Data updated on 12 Jun 2019 (data as of 31 Oct 2015).95% CI: 95% Confidence Interval;PCR: Polymerase Chain Reaction; RT-PCR: Real Time Polymerase Chain Reaction;aIncludes cases from Australia, Brazil, Canada, Croatia, Germany, Mexico, Spain, and USA.Data sources:Based on published systematic reviews, the ICO HPV Information Centre has updated data until October 2015. Reference publications: 1) Dunne EF, J Infect Dis 2006; 194: 1044 2) SmithJS, J Adolesc Health 2011; 48: 540 3) Olesen TB, Sex Transm Infect 2014; 90: 455 4) Hebnes JB, J Sex Med 2014; 11: 2630.Franceschi S, Br J Cancer 2002; 86: 705 | Vardas E, J Infect Dis 2011; 203: 58

Table 27: Studies on HPV prevalence among men from special subgroups in SpainAnatomic sites HPV detection Age HPV prevalence

Study samples method Population (years) No % (95% CI)Álvarez-Argüelles2013

Anus PCR-Generalprimers in L1(MY09/11, GP5 +/6+), PCR with TSprimers in E6/E7for typing

STD clinic attendees 17-87 123 49.6 (40.5-58.8)

( Table 27 – continued from previous page)



( Table 27 – continued from previous page)Anatomic sites HPV detection Age HPV prevalence

Study samples method Population (years) No % (95% CI)Álvarez-Argüelles2013

Balanopreputial PCR-Generalprimers in L1(MY09/11, GP5 +/6+), PCR with TSprimers in E6/E7for typing

STD clinic attendees 17-87 1318 36.9 (34.3-39.5)

Franceschi2002

Glans, corona,urethra

PCR-GP5+/6+ Husbands of womenwith invasive cervicalcancer

25-74 84 11.9 (5.9-20.8)

Franceschi2002

Glans, corona,urethra

PCR-GP5+/6+ Husbands of womenwith cervicalcarcinoma in situ

22-76 102 21.6 (14.0-30.8)

Goldstone2011

Penis RT-PCR-Multiplex orBiplex

HIV- MSM Median22

(16-27)

602 18.4 (15.4-21.8)

Goldstone2011

Anus RT-PCR-Multiplex orBiplex

HIV- MSM Median22

(16-27)

602 42.4 (38.4-46.4)

Hidalgo-Tenorio 2015

Anus PCR-GeneAmpHR-HPV

HIV+ MSM Mean37.4

(SD=9.5)

197 80.2 (73.9-85.5)

Sendagorta2014

Anus PCR-Genomicamplification

HIV+ MSM/bisexualmen

>=18 298 93 (89.4-95.6)

Sendagorta2015

Anus PCR-HR ClartHPV2

HIV+ MSM Median42

(IQR=33-50)

101 82.2 (73.3-89.1)

Torres 2013 Anus PCR-RocheLinear ArrayHPV Genotypingtest

HIV+ MSM IQR=28.2-40.1

1439 95.8 (94.6-96.7)

Videla 2013 Anus PCR-TS primersin E6/E7F-HPVTM typing(Molgentix SL,Spain)

HIV+ MSM attendingan outpatient HIVclinic

36-47 538 84.2 (80.8-87.2)

Videla 2013 Coronal sulcus,glans, urethra,shaft

PCR-TS primersin E6/E7F-HPVTM typing(Molgentix SL,Spain)

HIV+ MSM attendingan outpatient HIVclinic

36-47 457 24.9 (21.0-29.2)

Videla 2013 Coronal sulcus,glans, urethra,shaft

PCR-TS primersin E6/E7F-HPVTM typing(Molgentix SL,Spain)

HIV+ Heterosexualmen attending anoutpatient HIV clinic

40-48 191 27.2 (21.0-34.1)

Videla 2013 Anus PCR-TS primersin E6/E7F-HPVTM typing(Molgentix SL,Spain)

HIV+ Heterosexualmen attending anoutpatient HIV clinic

40-48 195 41.5 (34.5-48.8)

Data updated on 12 Jun 2019 (data as of 31 Oct 2015).95% CI: 95% Confidence Interval;PCR: Polymerase Chain Reaction; RT-PCR: Real Time Polymerase Chain Reaction; TS: Type Specific;Data sources:Based on published systematic reviews, the ICO HPV Information Centre has updated data until October 2015. Reference publications: 1) Dunne EF, J Infect Dis 2006; 194: 1044 2) SmithJS, J Adolesc Health 2011; 48: 540 3) Olesen TB, Sex Transm Infect 2014; 90: 455 4) Hebnes JB, J Sex Med 2014; 11: 2630.Álvarez-Argüelles ME, PLoS ONE 2013; 8: 129 | Franceschi S, Br J Cancer 2002; 86: 705 | Goldstone S, J Infect Dis 2011; 203: 66 | Hidalgo-Tenorio C, PLoS One 2015; 10: 120 |Sendagorta E, Dis Colon Rectum 2014; 57: 475 | Sendagorta E, J Med Virol 2015; 87: 1397 | Torres M, J Clin Microbiol 2013; 51: 3512 | Videla S, Sex Transm Dis 2013; 40: 03





4.4 HPV burden in the head and neck

The last evaluation of the International Agency for Research in Cancer (IARC) on the carcinogenicity ofHPV in humans concluded that (a) there is enough evidence for the carcinogenicity of HPV type 16 inthe oral cavity, oropharynx (including tonsil cancer, base of tongue cancer and other oropharyngeal can-cer sites), and (b) limited evidence for laryngeal cancer (IARC Monograph Vol 100B). There is increasingevidence that HPV-related oropharyngeal cancers constitute an epidemiological, molecular and clinicaldistinct form as compared to non HPV-related ones. Some studies indicate that the most likely expla-nation for the origin of this distinct form of head and neck cancers associated with HPV is a sexuallyacquired oral HPV infection that is not cleared, persists and evolves into a neoplastic lesion. The mostrecent figures estimate that 25.6% of all oropharyngeal cancers are attributable to HPV infection withHPV16 being the most frequent type (de Martel C. Lancet Oncol. 2012;13(6):607). In this section, theHPV burden in the head and neck in Spain is presented..

4.4.1 Burden of oral HPV infection in healthy population

Table 28: Studies on oral HPV prevalence among healthy in SpainMethod HPV detection Prev. of 5 most

specimen method frequentcollection and and targeted Age No. HPV prevalence HPVs

Study anatomic site HPV types Population (years) Tested % (95% CI) HPV type (%)MENNo DataAvailable

- - - - - - - -

WOMENCañadas 2004 Toothbrush on the

oral cavityPCR-MY09/MY11.Genotyping by DBHwith TS probes (6,11, 16, 18, 26, 31-33,35, 39, 40, 45, 51-56,58, 59, 61, 66-68, 70,71 (AE8), 72, 73, 81(AE7), 83 (PAP291),84 (PAP155), 85(AE5), AE2 (IS39),and AE6)

Female sex workerswho attended adermatology or STDclinic.

- 188 8.5 (4.9-13.5) HPV 6 (2.7%)HPV 16 (2.1%)HPV 11 (0.5%)

BOTH OR UNSPECIFIEDCañadas 2004 Toothbrush on the

oral cavityPCR-MY09/MY11.Genotyping by DBHwith TS probes (6,11, 16, 18, 26, 31-33,35, 39, 40, 45, 51-56,58, 59, 61, 66-68, 70,71 (AE8), 72, 73, 81(AE7), 83 (PAP291),84 (PAP155), 85(AE5), AE2 (IS39),and AE6)

Female sex workerswho attended adermatology or STDclinic.

- 188 8.5 (4.9-13.5) HPV 6 (2.7%)HPV 16 (2.1%)HPV 11 (0.5%)

Data as of 29 Feb 2012. Only for European countries.95% CI: 95% Confidence Interval;DBH: Dot Blot Hybridization; PCR: Polymerase Chain Reaction; TS: Type Specific;Data sources:Systematic review and meta-analysis was performed by ICO HPV Information Centre until July 2012. Pubmed was searched using the keywords oral and papillomavirus. Inclusion criteria:studies reporting oral HPV prevalence in healthy population in Europe; n > 50. Exclusion criteria: focused only in children or immunosuppressed population; not written in English;case-control studies; commentaries and systematic reviews and studies that did not use HPV DNA detection methods.1Cañadas MP, J Clin Microbiol 2004;42:1330

4.4.2 HPV burden in head and neck cancers

Table 29: Studies on HPV prevalence among cases of oral cavity cancer in SpainHPV detection Prevalence of 5 most


MEN






Herrero 2003 GP5+/GP6+ (L1) Hybridizationwith EIA oligonucleotide probes(2. 6. 11. 16. 18. 31. 33. 35. 39.40. 42. 43. 44. 45. 51. 52. 56. 58.59. 66. 68)

140 5.7 (2.9-10.9) HPV 16 (5.7%)

Llamas-Martínez2008

WD-66/67/72/76/154 (E6) RFLP(6.11.16.18.31.33.39.42.45.52)

19 47.4 (27.3-68.3) -

WOMENHerrero 2003 GP5+/GP6+ (L1) Hybridization

with EIA oligonucleotide probes(2. 6. 11. 16. 18. 31. 33. 35. 39.40. 42. 43. 44. 45. 51. 52. 56. 58.59. 66. 68)

32 6.3 (1.7-20.1) HPV 16 (6.3%)


WD-66/67/72/76/154 (E6) RFLP(6.11.16.18.31.33.39.42.45.52)

14 35.7 (16.3-61.2) -

BOTH OR UNSPECIFIEDGarcía-de Marcos2014

PCR L1-Consensus primer,PCR-SPF10, EIA, LiPA (HPV 6,11, 16, 18, 31, 33, 35, 39, 40, 42,43, 44, 45, 51, 52, 53, 54, 56, 58,59, 66, 68, 70, 73, 74)

61 26.2 (16.8-38.4) -


172 5.8 (3.2-10.4) HPV 16 (5.8%)


WD-66/67/72/76/154 (E6) RFLP(6.11.16.18.31.33.39.42.45.52)

33 42.4 (27.2-59.2) HPV 16 (33.3%)HPV 6 (30.3%)HPV 31 (9.1%)

Data as of 31 Dec 2015. Only for European countries.95% CI: 95% Confidence Interval;EIA: Enzyme ImmunoAssay; LiPA: Line Probe Assay; PCR: Polymerase Chain Reaction; RFLP: Restriction Fragment Length Polymorphism; SPF: Short Primer Fragment;Data sources:Based on systematic reviews and meta-analysis performed by ICO. Reference publications: 1) Ndiaye C, Lancet Oncol 2014; 15: 1319 2) Kreimer AR, Cancer Epidemiol Biomarkers Prev2005; 14: 467García-de Marcos JA, Int J Oral Maxillofac Surg 2014; 43: 274 | Herrero R, J Natl Cancer Inst 2003; 95: 1772 | Llamas-Martínez S, Anticancer Res 2008; 28: 3733

Table 30: Studies on HPV prevalence among cases of oropharyngeal cancer in SpainHPV detection Prevalence of 5 most


MENHerrero 2003 GP5+/GP6+ (L1) Hybridization


40 5.0 (1.4-16.5) HPV 16 (5.0%)

WOMENHerrero 2003 GP5+/GP6+ (L1) Hybridization


4 50.0 (15.0-85.0) HPV 16 (50.0%)

BOTH OR UNSPECIFIED







44 9.1 (3.6-21.2) HPV 16 (9.1%)

Data as of 31 Dec 2015. Only for European countries.95% CI: 95% Confidence Interval;EIA: Enzyme ImmunoAssay;Data sources:Based on systematic reviews and meta-analysis performed by ICO. Reference publications: 1) Ndiaye C, Lancet Oncol 2014; 15: 1319 2) Kreimer AR, Cancer Epidemiol Biomarkers Prev2005; 14: 467Herrero R, J Natl Cancer Inst 2003; 95: 1772

Table 31: Studies on HPV prevalence among cases of hypopharyngeal or laryngeal cancer in SpainHPV detection Prevalence of 5 most


MENNo Data Available - - - - -

WOMENNo Data Available - - - - -

BOTH OR UNSPECIFIEDAlvarez Alvarez1997

TS-PCR E6 and L1 for 6b/16/18Amplification with TS primers(6b. 16. 18)

35 25.7 (14.2-42.1) HPV 6 (22.9%)HPV 16 (5.7%)

Pérez-Ayala 1990 TS-PCR E6 for 6/11Hybridization with TS probes(11.16)

51 56.9 (43.3-69.5) HPV 16 (56.9%)

Data as of 31 Dec 2015. Only for European countries.95% CI: 95% Confidence Interval;PCR: Polymerase Chain Reaction; TS: Type Specific;Data sources:Based on systematic reviews and meta-analysis performed by ICO. Reference publications: 1) Ndiaye C, Lancet Oncol 2014; 15: 1319 2) Kreimer AR, Cancer Epidemiol Biomarkers Prev2005; 14: 467Alvarez Alvarez I, Am J Otolaryngol 1997; 18: 375 | Pérez-Ayala M, Int J Cancer 1990; 46: 8


5 FACTORS CONTRIBUTING TO CERVICAL CANCER - 62 -

5 Factors contributing to cervical cancer

HPV is a necessary cause of cervical cancer, but it is not a sufficient cause. Other cofactors are necessaryfor progression from cervical HPV infection to cancer. Tobacco smoking, high parity, long-term hormonalcontraceptive use, and co-infection with HIV have been identified as established cofactors. Co-infectionwith Chlamydia trachomatis and herpes simplex virus type-2, immunosuppression, and certain dietarydeficiencies are other probable cofactors. Genetic and immunological host factors and viral factors otherthan type, such as variants of type, viral load and viral integration, are likely to be important but havenot been clearly identified. (Muñoz N, Vaccine 2006; 24(S3): 1-10). In this section, the prevalence ofsmoking, parity (fertility), oral contraceptive use, and HIV in Spain are presented.

Table 32: Factors contributing to cervical carcinogenesis (cofactors) in SpainINDICATORa MALE FEMALE TOTALSmoking

Smoking of any tobacco adjustedprevalence (%) [95% CI]

Current1,b,c,± 33.0 [26.3-39.6] 27.8 [21.9-33.8] 30.3 [24.1-36.7]Daily1,b,d,± 28.2 [22.4-34.6] 23.2 [17.9-28.7] 25.7 [20.1-31.6]

Cigarette smoking adjustedprevalence (%) [95% CI]

Current1,b,c,± 29.1 [22.3-35.8] 24.3 [18.1-30.0] 26.7 [20.2-32.8]Daily1,b,d,± 25.0 [18.9-29.9] 21.1 [16.1-25.7] 23.0 [17.5-27.8]

ParityTotal fertility rate per woman2,∓ - 1.3 -

Age-specific fertility rate(per 1000 women)

15-19 years3,± - 8.4 -20-24 years3,± - 27.0 -25-29 years3,± - 55.8 -30-34 years3,± - 88.2 -35-39 years3,± - 60.9 -40-44 years3,± - 14.4 -45-49 years3,± - 0.9 -

Hormonal contraceptionOral contraceptive use (%) among women15-49yrswho are married or in union4,∗

- 17.2 -

Hormonal contraception use (%) (pill, injectable orimplant), among women15-49yrs who are marriedor in union4,e,∗

- 17.4 -

HIVEstimated percent of adults aged 15-49 whoare living with HIV [low estimate - highestimate]5, f ,∓

- - 0.4 [0.3 - 0.4]

Estimated percent of young adults aged 15-24who are living with HIV [low estimate - highestimate]5, f ,∓

0.1 [<0.1 - 0.2] <0.1 [<0.1 - <0.1] -

HIV prevalence (%) among female sex workers inthe capital city5,6,g,∓

- 0.4 -

HIV prevalence (%) among men who have sex withmen in the capital city5,7,∓

11.3 - -

Estimated number of adults (15+ years) livingwith HIV [low estimate - high estimate]5,h,∓

- 34 000 [28 000 - 41 000] 150 000 [130 000 - 180 000]

Estimated number of adults and children livingwith HIV [low estimate - high estimate]5,h,∓

- - 150 000 [130 000 - 180 000]

Estimated number of AIDS deaths in adults andchildren [low estimate - high estimate]5,i,∓

- - 1200 [1000 - 1400]

Data accessed on 22 Mar 2017.aPlease refer to original source for methods of estimation of the following indicators.bAdjusted and age-standardized prevalence estimates of tobacco use by country, for the year 2013. These rates are constructed solely for the purpose of comparing tobacco use prevalenceestimates across countries, and should not be used to estimate the number of smokers in the population.c"Current" means smoking at the time of the survey, including daily and non-daily smoking. "Tobacco smoking" means smoking any form of tobacco, including cigarettes, cigars, pipes,hookah, shisha, water-pipe, etc. and excluding smokeless tobacco.d "Daily" means smoking every day at the time of the survey. "Tobacco smoking" means smoking any form of tobacco, including cigarettes, cigars, pipes, hookah, shisha, water-pipe, etc. andexcluding smokeless tobacco.eProportion (%) of women using hormonal contraception (pill, injectable or implant), among those of reproductive age who are married or in union.f Estimates include all people with HIV infection, regardless of whether they have developed symptoms of AIDS.gData on key populations at higher risk from country progress reports typically derive from surveys in capital cities and are not representative of the entire country. In particular, surveysin capital cities are likely to overestimate national HIV prevalence and service coverage.hThe number of people with HIV infection, whether or not they have developed symptoms of AIDS, estimated to be alive at the end of a specific year.iThe estimated number of adults and children that have died due to HIV/AIDS in a specific year.Year of estimate: ±2013; ∓2015; ∗2006;Data sources:1WHO report on the global tobacco epidemic, 2015: The MPOWER package. Geneva, World Health Organization, 2015. Available at http://www.who.int/tobacco/global_report/2015/en/index.html



http://www.who.int/tobacco/global_report/2015/en/index.html

http://www.who.int/tobacco/global_report/2015/en/index.html

5 FACTORS CONTRIBUTING TO CERVICAL CANCER - 63 -

( Table 32 – continued from previous page)2Eurostat - Statistical office of the European Comission [web site]. Luxembourg: European Commission; 2015. Available at: http://ec.europa.eu/eurostat/tgm/table.do?tab=table&init=1&language=en&pcode=tsdde220&plugin=1. [Accessed on March 22, 2017].3United Nations, Department of Economic and Social Affairs, Population Division (2015). World Fertility Data 2015 (POP/DB/Fert/Rev2015). Available at: http://www.un.org/en/development/desa/population/publications/dataset/fertility/wfd2015.shtml. [Accessed on March 22, 2017].4United Nations, Department of Economic and Social Affairs, Population Division (2016). World Contraceptive Use 2016 (POP/DB/CP/Rev2016). http://www.un.org/en/development/desa/population/publications/dataset/contraception/wcu2016.shtml. Available at: [Accessed on March 22, 2017].5UNAIDS database [internet]. Available at: http://aidsinfo.unaids.org/ [Accessed on March 22, 2017]6 Estudio EPI-VIH 20137 Estudio EPI-VIH. Vigilancia centinela del VIH realizada en 15 centros de VIH/ITS repartidos por las principales ciudades españolas


http://ec.europa.eu/eurostat/tgm/table.do?tab=table&init=1&language=en&pcode=tsdde220&plugin=1.

http://ec.europa.eu/eurostat/tgm/table.do?tab=table&init=1&language=en&pcode=tsdde220&plugin=1.

http://www.un.org/en/development/desa/population/publications/dataset/fertility/wfd2015.shtml.

http://www.un.org/en/development/desa/population/publications/dataset/fertility/wfd2015.shtml.

http://www.un.org/en/development/desa/population/publications/dataset/contraception/wcu2016.shtml.


http://aidsinfo.unaids.org/

6 SEXUAL AND REPRODUCTIVE HEALTH BEHAVIOUR INDICATORS - 64 -

6 Sexual and reproductive health behaviour indicators

Sexual intercourse is the primary route of transmission of genital HPV infection. Information aboutsexual and reproductive health behaviours is essential to the design of effective preventive strategiesagainst anogenital cancers. In this section, we describe sexual and reproductive health indicators thatmay be used as proxy measures of risk for HPV infection and anogenital cancers. Several studieshave reported that earlier sexual debut is a risk factor for HPV infection, although the reason for thisrelationship is still unclear. In this section, information on sexual and reproductive health behaviour inSpain are presented.

Table 33: Percentage of 15-year-olds who have had sexual intercourse in SpainIndicator Male FemalePercentage of 15-year-old subjects who report sexual intercourse 24 19

Data accessed on 16 Mar 2017.Fifteen-year-olds teenagers only were asked whether they had ever had sexual intercourse.Indicates a significant gender difference (at p<0.05).Year of estimation: 2013-2014Please refer to original source for methods of estimationData sources:Growing up unequal: gender and socioeconomic differences in young people’s health and well-being. Health Behaviour in School-aged Children (HBSC) study: international report fromthe 2013/2014 survey. Inchley J, Currie D, Young T, et al. Copenhagen, WHO Regional Office for Europe, 2016 (Health Policy for Children and Adolescents, No. 7). Available at:http://www.euro.who.int/__data/assets/pdf_file/0003/303438/HSBC-No.7-Growing-up-unequal-Full-Report.pdf?ua=1

Table 34: Median age at first sex in SpainMALE FEMALE TOTALMedian age Median age Median age

Study Year/period Birth cohort N at first sex N at first sex N at first sexCastellsague 20121 2007-2008 1942-1952a,b - - 479 22.7 - -

1982-1990a,b - - 1,617 16.7 - -de Sanjose 20082 2005 1935-1987b - - 6,249 20.9 - -Gomez 20073 2001-2003 1981-1990c,b - - 384 16.5 - -Spain ESHS 20034 2003 1954-1963 - 18.0 - 19.0 - 19.0

1964-1973 - 18.0 - 18.0 - 18.01974-1985 - 17.0 - 18.0 - 18.0

Vaccarella 20065 1998-2000 1925-1984c,b - - 908 21.0 - -

Data accessed on 16 Mar 2017.N: number of subjects;aData pertain to women attending routine cervical cancer screening.bMean age at first sex.cData pertain to population attending family planning centers or screening centers.Data sources:1Castellsagué X, Iftner T, Roura E, Vidart JA, Kjaer SK, Bosch FX, et al. Prevalence and genotype distribution of human papillomavirus infection of the cervix in Spain: the CLEOPATREstudy. J Med Virol. 2012 Jun;84(6):947-56.2de Sanjose S, Cortés X, Méndez C, Puig-Tintore L, Torné A, Roura E, et al. Age at sexual initiation and number of sexual partners in the female Spanish population Results from theAFRODITA survey. Eur. J. Obstet. Gynecol. Reprod. Biol. 2008 Oct;140(2):234-240.3Gómez MA, Sola A, Cortés MJ, Mira JJ. Sexual behaviour and contraception in people under the age of 20 in Alicante, Spain. Eur J Contracept Reprod Health Care. 2007 Jun;12(2):125-30.4Suarez Cardona M. Encuesta de Salud y Habitos Sexuales 2003. Informe general. ISBN 10 84-260-3732-1. Madrid: Instituto Nacional de Estatística, Ministerio de Sanidad y Consumo,2006.5Vaccarella S, Franceschi S, Herrero R, Muñoz N, Snijders PJ, Clifford GM, et al; IARC HPV Prevalence Surveys Study Group. Sexual behavior, condom use, and human papillomavirus:pooled analysis of the IARC human papillomavirus prevalence surveys. Cancer Epidemiol Biomarkers Prev. 2006;15(2):326-33.

Table 35: Marriage patterns in SpainIndicator Male FemaleAverage age at first marriage1 30.3 27.7Age-specific % of ever married2 15-19 years 2.66 3.99

20-24 years 7.72 16.825-29 years 30.3 48.130-34 years 59.6 73.735-39 years 74.7 83.140-44 years 80.9 87.245-49 years 84.5 89.0

Data accessed on 16 Mar 2017.Year of estimate: 2011;Please refer to original source for methods of estimation.Data sources:1The world bank: health nutrition and population statistics. Updated 16-Dec-2016. Accessed on March 16 2017. Available at http://data.worldbank.org/data-catalog/health-nutrition-and-population-statistics



http://www.euro.who.int/__data/assets/pdf_file/0003/303438/HSBC-No.7-Growing-up-unequal-Full-Report.pdf?ua=1

http://data.worldbank.org/data-catalog/health-nutrition-and-population-statistics

http://data.worldbank.org/data-catalog/health-nutrition-and-population-statistics

6 SEXUAL AND REPRODUCTIVE HEALTH BEHAVIOUR INDICATORS - 65 -

( Table 35 – continued from previous page)2United Nations, Department of Economic and Social Affairs, Population Division (2015). World Marriage Data 2015 (POP/DB/Marr/Rev2015). Available at: http://www.un.org/en/development/desa/population/theme/marriage-unions/WMD2015.shtml Accessed on April 3, 2017.

Table 36: Average number of sexual partners in SpainMale Female Total

Study Period of estimate Year/Period Birth cohort Mean(N) Mean(N) Mean(N)

Castellsague 20121,a Lifetime 2007-2008 (1942-1952) -(-) 1.4(479) -(-)Lifetime 2007-2008 (1982-1990) -(-) 2.8(1,617) -(-)

Gomez 20072,b Lifetime 2001-2003 (1981-1990) -(-) 1.9(384) -(-)

HSBS 20033

Last year 2003 (1954-1963) 2.2(-) 1.0(-) 1.6(-)Last year 2003 (1954-1985) 2.6(-) 1.2(-) 1.9(-)Last year 2003 (1964-1973) 2.8(-) 1.1(-) 2.0(-)Last year 2003 (1974-1985) 2.8(-) 1.4(-) 2.1(-)

Vaccarella 20064,b Lifetime 1998-2000 (1923-1986) -(-) 1.5(908) -(-)

Data accessed on 08 Aug 2013.N: number of subjects sexually active;aData pertain to women attending routine cervical cancer screening.bData pertain to population attending family planning centers or screening centers.Data sources:1Castellsagué X, Iftner T, Roura E, Vidart JA, Kjaer SK, Bosch FX, et al. Prevalence and genotype distribution of human papillomavirus infection of the cervix in Spain: the CLEOPATREstudy. J Med Virol. 2012 Jun;84(6):947-56.2Gómez MA, Sola A, Cortés MJ, Mira JJ. Sexual behaviour and contraception in people under the age of 20 in Alicante, Spain. Eur J Contracept Reprod Health Care. 2007 Jun;12(2):125-30.3Suarez Cardona M. Encuesta de Salud y Habitos Sexuales 2003. Informe general. ISBN 10 84-260-3732-1. Madrid: Instituto Nacional de Estatística, Ministerio de Sanidad y Consumo,2006.4Vaccarella S, Franceschi S, Herrero R, Muñoz N, Snijders PJ, Clifford GM, et al; IARC HPV Prevalence Surveys Study Group. Sexual behavior, condom use, and human papillomavirus:pooled analysis of the IARC human papillomavirus prevalence surveys. Cancer Epidemiol Biomarkers Prev. 2006;15(2):326-33.

Table 37: Lifetime prevalence of anal intercourse among women in SpainFEMALE

Studya,b Year/Period Birth cohort N surveyed N sexual active % among sexually activeFaíldeGarrido2008

- - 1,086 719 6.0

Data accessed on 08 Aug 2013.N: number of subjects.aData pertain to adolescents and young adults.bProportion among women who ever practice receptive anal intercourse in the last 6 months.Data sources:Faílde Garrido JM, Lameiras Fernández M, Bimbela Pedrola JL. Prácticas sexuales de chicos y chicas españoles de 14-24 años de edad [Sexual behavior in a Spanish sample aged 14 to 24years old]. Gac Sanit. 2008 Nov-Dec;22(6):511-9; discussion 519. Spanish.


http://www.un.org/en/development/desa/population/theme/marriage-unions/WMD2015.shtml

http://www.un.org/en/development/desa/population/theme/marriage-unions/WMD2015.shtml

7 HPV PREVENTIVE STRATEGIES - 66 -

7 HPV preventive strategies

It is established that well-organised cervical screening programmes or widespread good quality cytologycan reduce cervical cancer incidence and mortality. The introduction of HPV vaccination could alsoeffectively reduce the burden of cervical cancer in the coming decades. This section presents indicatorson basic characteristics and performance of cervical cancer screening, status of HPV vaccine licensureand introduction in Spain.

7.1 Cervical cancer screening practices

Screening strategies differ between countries. Some countries have population-based programmes,where in each round of screening women in the target population are individually identified and in-vited to attend screening. This type of programme can be implemented nationwide or only in specificregions of the country. In opportunistic screening, invitations depend on the individual’s decision oron encounters with health-care providers. The most frequent method for cervical cancer screening iscytology, and there are alternative methods such as HPV DNA tests and visual inspection with aceticacid (VIA). VIA is an alternative to cytology-based screening in low-resource settings (the ’see and treat’approach). HPV DNA testing is being introduced into some countries as an adjunct to cytology screen-ing (’co-testing’) or as the primary screening test to be followed by a secondary, more specific test, suchas cytology.

Table 38: Main characteristics of cervical cancer screening in Spain

Availability of a cervical cancer screening programmeα Yes

Quality assurance structure and mandate to supervise and to monitor the screeningprocessβ

No. Varies by region

Active invitation to screeningγ No. Varies by region

Main screening test used for primary screening Cytology/HPV test

Undergoing demonstration projects

Screening ages (years) 25-65 (cytology), 30-65 (HPVtest)

Screening interval or frequency of screenings 3 years (cytology), 5 years (HPVtest)

Data accessed on 31 Dec 2016.αPublic national cervical cancer screening program in place (Cytology/VIA/HPV testing). Countries may have clinical guidelines or protocols, and cervical cancer screening services in aprivate sector but without a public national program. Publicly mandatβSelf-reported quality assurance: Organised programmes provide for a national or regional team responsible for implementation and require providers to follow guidelines, rules, or standardoperating procedures. They also define a quality assurance structurγSelf-reported active invitation or recruitment, as organised population-based programmes, identify and personally invite each eligible person in the target population to attend a givenround of screening.Data sources:Cervical cancer screening in Europe: Quality assurance and organisation of programmes. Elfström KM, Arnheim-Dahlström L, von Karsa L, Dillner J. Eur J Cancer. 2015 May;51(8):950-68.doi: 10.1016/j.ejca.2015.03.008. Epub 2015 Mar 25. PMID: 25817010Guidelines for the screening of cervical cancer in Spain, 2014. https://www.seap.es/c/document_library/get_file?uuid=2ee683d0-e7cd-46cb-8853-375482cf41a8&groupId=10157


https://www.seap.es/c/document_library/get_file?uuid=2ee683d0-e7cd-46cb-8853-375482cf41a8&groupId=10157

https://www.seap.es/c/document_library/get_file?uuid=2ee683d0-e7cd-46cb-8853-375482cf41a8&groupId=10157


Table 39: Estimated coverage of cervical cancer screening in SpainReference Year Population Urban vs

rural orboth (all)

N Women Age range Within thelast

year(s)

Coverage(%)b

EESE 2014 Spain1,a 2014 General femalepopulation

All 19,954,300 >=15 3y 57

13,121,100 25-64 3y 72 .75y 63 .35y 79 .4

Ever 74 .2Ever 86 .2

ENS 2006 Spain2,c 2006-2007 General femalepopulation

All - >15 1y 47 .4

2y 67 .43y 72 .6

Ever 79ENSE 2011-2012Spain3,d

2011-2012 General femalepopulation

All 19,827,000 >=15 3y 56 .6

- 25-64 3y 71 .15y 63 .75y 78 .8

Ever 72 .4Ever 94 .3

EUROSTATSpain4,e

2009 General femalepopulation

All - 20-69 3y 68 .5


All - 20-69 3y 67 .7

Luengo Matos20045,α, f


All 2,409 40-70 5y 46 .7

Puig-Tintore20086,β,g


All 5,789 18-65 3y 75 .6

5,799 18-65 Ever 86 .1WHS 2003 Spain7,h 2002-2003 General female

populationAll 3,231 18-69 3y 53 .8

2,195 25-64 3y 60 .3Rural 738 18-69 3y 44 .7Urban 2,493 18-69 3y 56 .3

Data accessed on 31 Dec 2016.aPopulation-based nationwide survey among almost 23,000 households.bProportion of women in the total sample of the mentioned age range in the country or region that reported having a Pap smear during a given time period (e.g., last year, last 2, 3, 5 yearsor ever).cPopulation-based nationwide household and individual survey. Frequency of pap smear or vaginal cytologies.dPopulation-based nationwide household and individual survey. Sample size of 26,502 surveys, 21,007 people aged 15 years or more, and 5,495 children aged 0 to 14 years.eSurvey data. European Health Interview Survey data.f Population-based survey. Three-stage cluster sampling.gPopulation-based postal survey.hWHO Household Surveys with multistage cluster sampling. Screening coverage among women aged 18-69. World Health Surveys. Geneva: World Health Organization (WHO); 2003.αPopulation-based survey. Three-stage cluster sampling. Luengo MS, Munoz vdE. [Use of pap smear for cervical cancer screening and factors related with its use in Spain.]. Aten Primaria2004 Mar 31;33(5):229-34.βPopulation-based postal survey. Puig-Tintore LM, Castellsague X, Torne A, de Sanjose S, Cortes J, Roura E, et al. Coverage and factors associated with cervical cancer screening: resultsfrom the AFRODITA study: a population-based survey in Spain. J Low GeData sources:1Ministerio de Sanidad, Servicios Sociales e Igualdad. Instituto Nacional de Estadistica (INE). Madrid. Spain. Encuesta europea de salud en España 2014 [European Health Survey, Spain2014]. Available at: http://www.ine.es/jaxi/menu.do?type=pcaxis&path=/t15/p420/p01&file=inebase&L=0 [Accessed by October 2015]2Instituto Nacional de Estadística (INE). Ministerio de Sanidad y Consumo; 2006. Madrid. España. Encuesta Nacional de Salud 2006 [National Health Survey, Spain 2006].3Ministerio de Sanidad, Servicios Sociales e Igualdad. Encuesta Nacional de Salud. España 2011/12. Detección precoz de cáncer. Serie Informes monográficos nº 5. Madrid: Ministerio deSanidad, Servicios Sociales e Igualdad, 2015.4European Commision (2015). EUROSTAT, the statistical office of the European Union (internet). Luxembourg. Available at: http://ec.europa.eu/eurostat/web/main/home [accessedby October 2015]5Luengo MS, Munoz vdE. Use of pap smear for cervical cancer screening and factors related with its use in Spain. Aten Primaria 2004 Mar 31;33(5):229-34.6Puig-Tintore LM, Castellsague X, Torne A, de Sanjose S, Cortes J, Roura E, et al. Coverage and factors associated with cervical cancer screening: results from the AFRODITA study: apopulation-based survey in Spain. J Low Genit Tract Dis 2008 Apr;12(2):82-97World Health Organization (WHO). Spain-World Health Survey 2003 (ESP_2003_WHS_v01_M). Available at: http://apps.who.int/healthinfo/systems/surveydata/index.php/catalog/130 [Accessed by October 2015]


http://www.ine.es/jaxi/menu.do?type=pcaxis&path=/t15/p420/p01&file=inebase&L=0

http://ec.europa.eu/eurostat/web/main/home

http://apps.who.int/healthinfo/systems/surveydata/index.php/catalog/130

http://apps.who.int/healthinfo/systems/surveydata/index.php/catalog/130


Figure 39: Estimated coverage of cervical cancer screening in Spain, by age and study

Est

imat

ed c

ervi

cal c

ance

r sc

reen

ing

cove

rage

(%)(

a)

− All women screened every 3yin 2014 − (1, b)

15−24

25−34

35−44

45−54

55−64

65−74

75−84

>=85

34.1

70.376.2 76.4

65.6

36.3

10.2 4.0

0

20

40

60

80

100

− All women screened every 5yin 2014 − (1, b)

15−24

25−34

35−44

45−54

55−64

65−74

75−84

>=85

35.3

76.382.6 83.2

73.4

46.2

16.1

6.2

0

20

40

60

80

100

− All women Ever screenedin 2014 − (1, b)

15−24

25−34

35−44

45−54

55−64

65−74

75−84

>=85

35.5

78.8

88.6 90.085.9

74.2

46.8

31.8

0

20

40

60

80

100

− All women screened every 3yin 2011−2012 − (2, c)

15−24

25−34

35−44

45−54

55−64

65−74

75−84

>=85

34.6

71.7 74.6 74.1

61.4

36.5

12.2 5.6

0

20

40

60

80

100

Age group (years)

Data accessed on 31 Dec 2016.aProportion of women in the total sample of the mentioned age range in the country or region that reported having a Pap smear during a given time period (e.g., last year, last 2, 3, 5 yearsor ever).bPopulation-based nationwide survey among almost 23,000 households.cPopulation-based nationwide household and individual survey. Sample size of 26,502 surveys, 21,007 people aged 15 years or more, and 5,495 children aged 0 to 14 years.Data sources:ICO Information Centre on HPV and Cancer. Country-specific references identified in each country-specific report as general recommendation from relevant scientific organizations and/orpublications.1Ministerio de Sanidad, Servicios Sociales e Igualdad. Instituto Nacional de Estadistica (INE). Madrid. Spain. Encuesta europea de salud en España 2014 [European Health Survey, Spain2014]. Available at: http://www.ine.es/jaxi/menu.do?type=pcaxis&path=/t15/p420/p01&file=inebase&L=0 [Accessed by October 2015]2Ministerio de Sanidad, Servicios Sociales e Igualdad. Encuesta Nacional de Salud. España 2011/12. Detección precoz de cáncer. Serie Informes monográficos nº 5. Madrid: Ministerio deSanidad, Servicios Sociales e Igualdad, 2015.

Table 40: Estimated coverage of cervical cancer screening in Spain , by regionRegion N Women Age range LYa Population Coverage

(%)bYear(s)studied

Reference

Andalucia

3,545,500 >=15 Ever General femalepopulation

67.5 2014 EESE 2014 Spain1

3,545,500 >=15 5y General femalepopulation

56.4 2014 EESE 2014 Spain1


49.0 2014 EESE 2014 Spain1

- >15 3y General femalepopulation

63.6 2006-2007

ENS 2006 Spain2


59.7 2011-2012

ENSE 2011-2012Spain3


46.7 2011-2012


- 25-64 5y General femalepopulation

66.6 2011-2012



53.2 2011-2012



62.8 2009 ENSE 2011-2012Spain3

848 18-65 3y General femalepopulation

66.3 2005 Puig-Tintore20084,α

Aragon

565,400 >=15 Ever General femalepopulation

70.7 2014 EESE 2014 Spain1

565,400 >=15 3y General femalepopulation

52.2 2014 EESE 2014 Spain1


57.6 2014 EESE 2014 Spain1






Region N Women Age range LYa Population Coverage(%)b

Year(s)studied

Reference


72.6 2006-2007

ENS 2006 Spain2


76.8 2011-2012



50.9 2011-2012



56.8 2011-2012



69.5 2011-2012



78.4 2009 ENSE 2011-2012Spain3



Asturias


53.5 2014 EESE 2014 Spain1


57.3 2014 EESE 2014 Spain1


73.1 2014 EESE 2014 Spain1


71.0 2006-2007

ENS 2006 Spain2


71.7 2011-2012



69.7 2011-2012



50.9 2011-2012



58.1 2011-2012



72.6 2009 ENSE 2011-2012Spain3



Baleares


68.8 2014 EESE 2014 Spain1


83.4 2014 EESE 2014 Spain1


72.6 2014 EESE 2014 Spain1


84.7 2006-2007

ENS 2006 Spain2


77.6 2011-2012



83.5 2011-2012



69.5 2011-2012



59.9 2011-2012



80.2 2009 ENSE 2011-2012Spain3



Canarias


84.0 2014 EESE 2014 Spain1


64.1 2014 EESE 2014 Spain1


69.0 2014 EESE 2014 Spain1






Year(s)studied

Reference


81.7 2006-2007

ENS 2006 Spain2


85.0 2011-2012



87.2 2011-2012



76.1 2011-2012



70.7 2011-2012



82.5 2009 ENSE 2011-2012Spain3



Cantabria


73.1 2014 EESE 2014 Spain1


61.0 2014 EESE 2014 Spain1


52.0 2014 EESE 2014 Spain1


66.6 2006-2007

ENS 2006 Spain2


48.5 2011-2012



59.0 2011-2012



67.7 2011-2012



54.6 2011-2012



75.6 2009 ENSE 2011-2012Spain3



Castilla- La Mancha


56.0 2014 EESE 2014 Spain1


66.3 2014 EESE 2014 Spain1


50.8 2014 EESE 2014 Spain1


67.8 2006-2007

ENS 2006 Spain2


58.3 2011-2012



75.7 2011-2012



67.5 2011-2012



47.7 2011-2012



72.6 2009 ENSE 2011-2012Spain3



Castilla-León


74.2 2014 EESE 2014 Spain1


46.6 2014 EESE 2014 Spain1


56.6 2014 EESE 2014 Spain1






Year(s)studied

Reference


69.5 2006-2007

ENS 2006 Spain2


72.7 2011-2012



83.8 2011-2012



54.7 2011-2012



62.2 2011-2012



72.7 2009 ENSE 2011-2012Spain3



Catalunya


70.2 2014 EESE 2014 Spain1


78.5 2014 EESE 2014 Spain1


64.3 2014 EESE 2014 Spain1


83.5 2006-2007

ENS 2006 Spain2


86.6 2011-2012



64.7 2011-2012



79.6 2011-2012



72.7 2011-2012



82.4 2009 ENSE 2011-2012Spain3



Ceuta


61.5 2014 EESE 2014 Spain1


57.3 2014 EESE 2014 Spain1


70.8 2014 EESE 2014 Spain1


62.5 2011-2012



68.8 2011-2012



70.1 2011-2012



55.7 2011-2012



54.0 2009 ENSE 2011-2012Spain3

Ceuta and Melilla - >15 3y General femalepopulation

60.3 2006-2007

ENS 2006 Spain2

Comunidad Valenciana


57.0 2014 EESE 2014 Spain1


70.5 2014 EESE 2014 Spain1


52.0 2014 EESE 2014 Spain1


71.4 2006-2007

ENS 2006 Spain2






Year(s)studied

Reference


79.2 2011-2012



83.4 2011-2012



59.5 2011-2012



66.8 2011-2012



77.8 2009 ENSE 2011-2012Spain3



Extremadura


43.5 2014 EESE 2014 Spain1


58.9 2014 EESE 2014 Spain1


50.2 2014 EESE 2014 Spain1


59.2 2006-2007

ENS 2006 Spain2


57.0 2011-2012



69.4 2011-2012



51.9 2011-2012



61.2 2011-2012



67.7 2009 ENSE 2011-2012Spain3



Galicia


57.7 2014 EESE 2014 Spain1


63.2 2014 EESE 2014 Spain1


71.3 2014 EESE 2014 Spain1


71.3 2006-2007

ENS 2006 Spain2


53.7 2011-2012



72.7 2011-2012



48.2 2011-2012



60.2 2011-2012



82.8 2009 ENSE 2011-2012Spain3



La Rioja


68.7 2014 EESE 2014 Spain1


64.0 2014 EESE 2014 Spain1


80.4 2014 EESE 2014 Spain1


66.0 2006-2007

ENS 2006 Spain2






Year(s)studied

Reference


68.8 2011-2012



77.3 2011-2012



83.4 2011-2012



63.9 2011-2012



83.0 2009 ENSE 2011-2012Spain3



Madrid


67.5 2014 EESE 2014 Spain1


82.5 2014 EESE 2014 Spain1


73.5 2014 EESE 2014 Spain1


70.5 2006-2007

ENS 2006 Spain2


79.2 2011-2012



62.3 2011-2012



69.6 2011-2012



83.4 2011-2012



82.6 2009 ENSE 2011-2012Spain3



Melilla


47.1 2014 EESE 2014 Spain1


33.4 2014 EESE 2014 Spain1


39.5 2014 EESE 2014 Spain1


48.9 2011-2012



42.2 2011-2012



32.9 2011-2012



36.4 2011-2012



57.2 2009 ENSE 2011-2012Spain3

Murcia


54.5 2014 EESE 2014 Spain1


68.3 2014 EESE 2014 Spain1


59.8 2014 EESE 2014 Spain1


67.9 2006-2007

ENS 2006 Spain2


74.8 2011-2012



66.8 2011-2012







Year(s)studied

Reference


61.8 2011-2012



58.9 2011-2012



74.8 2009 ENSE 2011-2012Spain3



Navarra


58.0 2014 EESE 2014 Spain1


66.2 2014 EESE 2014 Spain1


73.9 2014 EESE 2014 Spain1


75.7 2006-2007

ENS 2006 Spain2


79.3 2011-2012



75.4 2011-2012



57.4 2011-2012



66.6 2011-2012



79.8 2009 ENSE 2011-2012Spain3



País Vasco


61.3 2014 EESE 2014 Spain1


81.6 2014 EESE 2014 Spain1


68.8 2014 EESE 2014 Spain1


81.3 2006-2007

ENS 2006 Spain2


67.0 2011-2012



58.5 2011-2012



80.8 2011-2012



82.3 2011-2012



84.1 2009 ENSE 2011-2012Spain3



Data accessed on 31 Dec 2016.aLY: Within the last year(s).bProportion of women in the total sample of the mentioned age range in the country or region that reported having a Pap smear during a given time period (e.g., last year, last 2, 3, 5 yearsor ever).αPopulation-based postal survey. Puig-Tintore LM, Castellsague X, Torne A, de Sanjose S, Cortes J, Roura E, et al. Coverage and factors associated with cervical cancer screening: resultsfrom the AFRODITA study: a population-based survey in Spain. J Low GeData sources:1Ministerio de Sanidad, Servicios Sociales e Igualdad. Instituto Nacional de Estadistica (INE). Madrid. Spain. Encuesta europea de salud en España 2014 [European Health Survey, Spain2014]. Available at: http://www.ine.es/jaxi/menu.do?type=pcaxis&path=/t15/p420/p01&file=inebase&L=0 [Accessed by October 2015]2Instituto Nacional de Estadística (INE). Ministerio de Sanidad y Consumo; 2006. Madrid. España. Encuesta Nacional de Salud 2006 [National Health Survey, Spain 2006].3Ministerio de Sanidad, Servicios Sociales e Igualdad. Encuesta Nacional de Salud. España 2011/12. Detección precoz de cáncer. Serie Informes monográficos nº 5. Madrid: Ministerio deSanidad, Servicios Sociales e Igualdad, 2015.4Puig-Tintore LM, Castellsague X, Torne A, de Sanjose S, Cortes J, Roura E, et al. Coverage and factors associated with cervical cancer screening: results from the AFRODITA study: apopulation-based survey in Spain. J Low Genit Tract Dis 2008 Apr;12(2):82-9




7.2 HPV vaccination

Table 41: National HPV Immunization programme in Andalucia (Spain)Female Male

Year of introduction 2008 -

Primary target age (years) 14 -

Organized catch-up age (years) - -

Opportunistic catch-up age (years) - -

Strategy Health centers -

Schedulea,b 2-doses <14/15 (since mid-2014) 3-doses standard the rest -

Data updated on 11 Jul 2017 (data as of 31 Dec 2016)a 2 doses: 0-6m if not otherwise stated. Since 2014, based on clinical trials results several agencies responsible for the scientific evaluation of medicines, like the European Medicines Agency,aproved a two-dose schedule for girls aged less than 15 or 14 depending on the vaccine (Cervarix or Gardasil).b 3-doses standard: administration of three doses following the standard vaccination schedule as 0-2-6 months for the quadrivalent vaccine or 0-1-6 months for the bivalent vaccine.Data sources:1 Adapted from Bruni et al 2016 Lancet Global Health (data up to October 2014).Specifically, data from Spain was extracted from:

2 Ministerio de Sanidad, Política Social e Igualdad. Grupo de trabajo VPH 2012. Ponencia de Programa y Registro de Vacunaciones. Revisión del Programa de Vacunación frente a Virus delPapiloma Humano en España. Comisión de Salud Pública del Consejo Interterritorial del Sistema Nacional de Salud. [Internet]. 2013 Jan. Available from: http://www.msssi.gob.es/profesionales/saludPublica/prevPromocion/vacunaciones/docs/PapilomaVPH.pdf3 Ministerio de Sanidad, Servicios Sociales e Igualdad. Calendario Vacunación 2014 [Internet]. Available from: https://www.msssi.gob.es/ciudadanos/proteccionSalud/infancia/vacunaciones/programa/vacunaciones.htm

Figure 40: Reported HPV vaccination coverage in females by birth cohort in National HPVImmunization programme in Andalucia (Spain)

65.1

42.9 43.3 45.551.3

●

● ●

74.8

49.5 51.4

0

10

20

30

40

50

60

70

80

90

100

1994

1995

1996

1997

1998

1999

2000

Birth cohort

HP

V v

acci

natio

n co

vera

ge (

%)

●● 1−dose coverage Full−course coverage

Data updated on 11 Jul 2017 (data as of 31 Oct 2014)Data sources:1 Adapted from Bruni et al 2016 Lancet Global Health (data up to October 2014).2 Junta de Castilla y León. Campaña de Vacunación frente al Virus del Papiloma Humano. Coberturas de vacunación (Datos definitivos 2009-2013) [Internet]. Available from: http://www.saludcastillayleon.es/profesionales/es/vacunaciones/campana-vacunacion-frente-virus-papiloma-humano/coberturas-vacunacion-datos-definitivos-2009-20133 Ministerio de Sanidad, Servicios Sociales e Igualdad. Cobertura de vacunación frente a virus del papiloma humano -VPH- (3 dosis; niñas 11-14 años). Comunidades autónomas. Año 2012o curso escolar 2011-2012.4 Ministerio de Sanidad, Servicios Sociales e Igualdad. Cobertura de vacunación frente a virus del papiloma humano -VPH- (3 dosis; niñas 11-14 años). Comunidades autónomas. Año 2013o curso escolar 2012-2013. [Internet]. Available from: http://msc.es/profesionales/saludPublica/prevPromocion/vacunaciones/coberturas.htm#noveno5 Ministerio de Sanidad, Servicios Sociales e Igualdad. Grupo de trabajo VPH 2012. Ponencia de Programa y Registro de Vacunaciones. Revisión del Programa de Vacunación frente a Virusdel Papiloma Humano en España. Comisión de Salud Pública del Consejo Interterritorial del Sistema Nacional de Salud. [Internet]. 2013 Jan. Available from: http://www.msssi.gob.es/profesionales/saludPublica/prevPromocion/vacunaciones/docs/PapilomaVPH.pdf


http://www.msssi.gob.es/profesionales/saludPublica/prevPromocion/vacunaciones/docs/PapilomaVPH.pdf


https://www.msssi.gob.es/ciudadanos/proteccionSalud/infancia/vacunaciones/programa/vacunaciones.htm


http://www.saludcastillayleon.es/profesionales/es/vacunaciones/campana-vacunacion-frente-virus-papiloma-humano/coberturas-vacunacion-datos-definitivos-2009-2013


http://msc.es/profesionales/saludPublica/prevPromocion/vacunaciones/coberturas.htm#noveno




Table 42: National HPV Immunization programme in Aragon (Spain)Female Male







In 2011 switched from a "intensive" strategy where all targeted girls were vaccinated massively at once to a stepwise strategy,were girls are vaccinated when they reach 14 years of age

Data updated on 11 Jul 2017 (data as of 31 Dec 2016)a 2 doses: 0-6m if not otherwise stated. Since 2014, based on clinical trials results several agencies responsible for the scientific evaluation of medicines, like the European Medicines Agency,aproved a two-dose schedule for girls aged less than 15 or 14 depending on the vaccine (Cervarix or Gardasil).b 3-doses standard: administration of three doses following the standard vaccination schedule as 0-2-6 months for the quadrivalent vaccine or 0-1-6 months for the bivalent vaccine.Data sources:1 Adapted from Bruni et al 2016 Lancet Global Health (data up to October 2014).Specifically, data from Aragon was extracted from:

2 Ministerio de Sanidad, Política Social e Igualdad. Grupo de trabajo VPH 2012. Ponencia de Programa y Registro de Vacunaciones. Revisión del Programa de Vacunación frente a Virus delPapiloma Humano en España. Comisión de Salud Pública del Consejo Interterritorial del Sistema Nacional de Salud. [Internet]. 2013 Jan. Available from: http://www.msssi.gob.es/profesionales/saludPublica/prevPromocion/vacunaciones/docs/PapilomaVPH.pdf3 Ministerio de Sanidad, Servicios Sociales e Igualdad. Calendario Vacunación 2014 [Internet]. Available from: https://www.msssi.gob.es/ciudadanos/proteccionSalud/infancia/vacunaciones/programa/vacunaciones.htm4 Gobierno de Aragón, Departamento de Sanidad, Bienestar Social y Familia. Programas de salud - Vacunaciones - Vacuna virus del papiloma humano (VPH) [Internet]. Availablefrom: http://www.aragon.es/DepartamentosOrganismosPublicos/Departamentos/SanidadBienestarSocialFamilia/AreasTematicas/SanidadProfesionales/SaludPublica/ProgramasSalud/ci.mas_completo_01_Programa_de_Vacunaciones.detalleDepartamento?channelSelected=9c6a126a7cdcb210VgnVCM100000450a15acRCRD#section13

Figure 41: Reported HPV vaccination coverage in females by birth cohort in National HPVImmunization programme in Aragon (Spain)

86.0

71.077.2 75.4

89.3●

● ●

92.0

81.0 85.0

0

10

20

30

40

50

60

70

80

90

100

1994

1995

1996

1997

1998

1999

2000

Birth cohort

HP

V v

acci

natio

n co

vera

ge (

%)








http://www.aragon.es/DepartamentosOrganismosPublicos/Departamentos/SanidadBienestarSocialFamilia/AreasTematicas/SanidadProfesionales/SaludPublica/ProgramasSalud/ci.mas_completo_01_Programa_de_Vacunaciones.detalleDepartamento?channelSelected=9c6a126a7cdcb210VgnVCM100000450a15acRCRD#section13

http://www.aragon.es/DepartamentosOrganismosPublicos/Departamentos/SanidadBienestarSocialFamilia/AreasTematicas/SanidadProfesionales/SaludPublica/ProgramasSalud/ci.mas_completo_01_Programa_de_Vacunaciones.detalleDepartamento?channelSelected=9c6a126a7cdcb210VgnVCM100000450a15acRCRD#section13







Table 43: National HPV Immunization programme in Asturias (Spain)Female Male









Figure 42: Reported HPV vaccination coverage in females by birth cohort in National HPVImmunization programme in Asturias (Spain)

No data available

0

10

20

30

40

50

60

70

80

90

100

HP

V v

acci

natio

n co

vera

ge (

%)













Table 44: National HPV Immunization programme in Baleares (Spain)Female Male





Strategy Sch. -




Figure 43: Reported HPV vaccination coverage in females by birth cohort in National HPVImmunization programme in Baleares (Spain)

80.5

49.9 53.0 53.0

70.9

●

● ●

92.9

60.1 63.6

0

10

20

30

40

50

60

70

80

90

100

1994

1995

1996

1997

1998

1999

2000

Birth cohort

HP

V v

acci

natio

n co

vera

ge (

%)














Table 45: National HPV Immunization programme in C. Valenciana (Spain)Female Male





Strategy Sch. -




Figure 44: Reported HPV vaccination coverage in females by birth cohort in National HPVImmunization programme in C. Valenciana (Spain)

75.1

62.367.1 69.3 71.2 73.5

●

●●

●

95.8

66.871.9

76.7

0

10

20

30

40

50

60

70

80

90

100

1994

1995

1996

1997

1998

1999

2000

Birth cohort

HP

V v

acci

natio

n co

vera

ge (

%)














Table 46: National HPV Immunization programme in Canarias (Spain)Female Male









Figure 45: Reported HPV vaccination coverage in females by birth cohort in National HPVImmunization programme in Canarias (Spain)

No data available

0

10

20

30

40

50

60

70

80

90

100

HP

V v

acci

natio

n co

vera

ge (

%)













Table 47: National HPV Immunization programme in Cantabria (Spain)Female Male







Age of the primary target will switch to 12 years old in 2015 with a complementary catch-up program for 13-14 years old.Data updated on 11 Jul 2017 (data as of 31 Dec 2016)a 2 doses: 0-6m if not otherwise stated. Since 2014, based on clinical trials results several agencies responsible for the scientific evaluation of medicines, like the European Medicines Agency,aproved a two-dose schedule for girls aged less than 15 or 14 depending on the vaccine (Cervarix or Gardasil).b 3-doses standard: administration of three doses following the standard vaccination schedule as 0-2-6 months for the quadrivalent vaccine or 0-1-6 months for the bivalent vaccine.Data sources:1 Adapted from Bruni et al 2016 Lancet Global Health (data up to October 2014).Specifically, data from Spain was extracted from:


Figure 46: Reported HPV vaccination coverage in females by birth cohort in National HPVImmunization programme in Cantabria (Spain)

51.5

72.4 72.181.3 77.1

85.0

●

● ●●

92.3

78.2 81.588.6

0

10

20

30

40

50

60

70

80

90

100

1994

1995

1996

1997

1998

1999

2000

Birth cohort

HP

V v

acci

natio

n co

vera

ge (

%)














Table 48: National HPV Immunization programme in Castilla La Mancha (Spain)Female Male









Figure 47: Reported HPV vaccination coverage in females by birth cohort in National HPVImmunization programme in Castilla La Mancha (Spain)

61.0 58.351.8 54.7 57.1

69.7

● ● ● ●

77.1 78.2 74.3 74.7

0

10

20

30

40

50

60

70

80

90

100

1994

1995

1996

1997

1998

1999

2000

Birth cohort

HP

V v

acci

natio

n co

vera

ge (

%)














Table 49: National HPV Immunization programme in Castilla Leon (Spain)Female Male







Data updated on 11 Jul 2017 (data as of 31 Dec 2016)a 2 doses: 0-6m if not otherwise stated. Since 2014, based on clinical trials results several agencies responsible for the scientific evaluation of medicines, like the European Medicines Agency,aproved a two-dose schedule for girls aged less than 15 or 14 depending on the vaccine (Cervarix or Gardasil).b 3-doses standard: administration of three doses following the standard vaccination schedule as 0-2-6 months for the quadrivalent vaccine or 0-1-6 months for the bivalent vaccine.Data sources:1 Adapted from Bruni et al 2016 Lancet Global Health (data up to October 2014).Specifically, data from Castilla Leon was extracted from:

2 Ministerio de Sanidad, Política Social e Igualdad. Grupo de trabajo VPH 2012. Ponencia de Programa y Registro de Vacunaciones. Revisión del Programa de Vacunación frente a Virus delPapiloma Humano en España. Comisión de Salud Pública del Consejo Interterritorial del Sistema Nacional de Salud. [Internet]. 2013 Jan. Available from: http://www.msssi.gob.es/profesionales/saludPublica/prevPromocion/vacunaciones/docs/PapilomaVPH.pdf3 Ministerio de Sanidad, Servicios Sociales e Igualdad. Calendario Vacunación 2014 [Internet]. Available from: https://www.msssi.gob.es/ciudadanos/proteccionSalud/infancia/vacunaciones/programa/vacunaciones.htm4 Junta de Castilla y León. Vacunación frente al Virus del Papiloma Humano (VPH) [Internet]. Available from: http://www.saludcastillayleon.es/profesionales/es/vacunaciones/vacunacion-frente-virus-papiloma-humano-vph

Figure 48: Reported HPV vaccination coverage in females by birth cohort in National HPVImmunization programme in Castilla Leon (Spain)

94.284.4 84.8 86.9 90.0 92.7 91.5

●● ● ● ● ● ●

96.688.9 88.7 92.5 93.6 95.2 93.9

0

10

20

30

40

50

60

70

80

90

100

1994

1995

1996

1997

1998

1999

2000

Birth cohort

HP

V v

acci

natio

n co

vera

ge (

%)








http://www.saludcastillayleon.es/profesionales/es/vacunaciones/vacunacion-frente-virus-papiloma-humano-vph

http://www.saludcastillayleon.es/profesionales/es/vacunaciones/vacunacion-frente-virus-papiloma-humano-vph







Table 50: National HPV Immunization programme in Catalunya (Spain)Female Male


Primary target age (years) 11-12 -



Strategy Sch. (grade 6) -




Figure 49: Reported HPV vaccination coverage in females by birth cohort in National HPVImmunization programme in Catalunya (Spain)

81.5 80.4 80.7 84.3 81.6

●● ●

89.181.2 84.8

0

10

20

30

40

50

60

70

80

90

100

1997

1998

1999

2000

2001

2002

2003

Birth cohort

HP

V v

acci

natio

n co

vera

ge (

%)














Table 51: National HPV Immunization programme in Ceuta (Spain)Female Male





Strategy Sch. -




Figure 50: Reported HPV vaccination coverage in females by birth cohort in National HPVImmunization programme in Ceuta (Spain)

88.879.3

63.4

78.588.1

●●

●

89.580.2

63.7

0

10

20

30

40

50

60

70

80

90

100

1995

1996

1997

1998

1999

2000

2001

Birth cohort

HP

V v

acci

natio

n co

vera

ge (

%)














Table 52: National HPV Immunization programme in Extremadura (Spain)Female Male





Strategy Sch. -




Figure 51: Reported HPV vaccination coverage in females by birth cohort in National HPVImmunization programme in Extremadura (Spain)

95.9

85.2

68.677.1 78.1 81.0

●● ●

98.088.6 84.7

0

10

20

30

40

50

60

70

80

90

100

1994

1995

1996

1997

1998

1999

2000

Birth cohort

HP

V v

acci

natio

n co

vera

ge (

%)














Table 53: National HPV Immunization programme in Galicia (Spain)Female Male









Figure 52: Reported HPV vaccination coverage in females by birth cohort in National HPVImmunization programme in Galicia (Spain)

66.5 64.369.1 70.2 72.1 73.8

● ●● ●78.7 75.4

81.5 85.2

0

10

20

30

40

50

60

70

80

90

100

1994

1995

1996

1997

1998

1999

2000

Birth cohort

HP

V v

acci

natio

n co

vera

ge (

%)














Table 54: National HPV Immunization programme in La Rioja (Spain)Female Male







Catch-up program for the 2nd year of secondary school during school years 2007/08 to 2009/10 (girls 13-14 years old)Data updated on 11 Jul 2017 (data as of 31 Dec 2016)a 2 doses: 0-6m if not otherwise stated. Since 2014, based on clinical trials results several agencies responsible for the scientific evaluation of medicines, like the European Medicines Agency,aproved a two-dose schedule for girls aged less than 15 or 14 depending on the vaccine (Cervarix or Gardasil).b 3-doses standard: administration of three doses following the standard vaccination schedule as 0-2-6 months for the quadrivalent vaccine or 0-1-6 months for the bivalent vaccine.Data sources:1 Adapted from Bruni et al 2016 Lancet Global Health (data up to October 2014).Specifically, data from Spain was extracted from:


Figure 53: Reported HPV vaccination coverage in females by birth cohort in National HPVImmunization programme in La Rioja (Spain)

97.6 94.7 91.197.4 96.9 93.5 95.0 94.8 93.4

● ●●

● ● ● ●

98.3 96.892.2

98.9 98.5 94.8 96.1

0

10

20

30

40

50

60

70

80

90

100

1993

1994

1995

1996

1997

1998

1999

2000

2001

2002

2003

Birth cohort

HP

V v

acci

natio

n co

vera

ge (

%)














Table 55: National HPV Immunization programme in Madrid (Spain)Female Male







Age of the primary target will switch to 12 years old in 2015. Catch-up at 14 years of age.Data updated on 11 Jul 2017 (data as of 31 Dec 2016)a 2 doses: 0-6m if not otherwise stated. Since 2014, based on clinical trials results several agencies responsible for the scientific evaluation of medicines, like the European Medicines Agency,aproved a two-dose schedule for girls aged less than 15 or 14 depending on the vaccine (Cervarix or Gardasil).b 3-doses standard: administration of three doses following the standard vaccination schedule as 0-2-6 months for the quadrivalent vaccine or 0-1-6 months for the bivalent vaccine.Data sources:1 Adapted from Bruni et al 2016 Lancet Global Health (data up to October 2014).Specifically, data from Spain was extracted from:


Figure 54: Reported HPV vaccination coverage in females by birth cohort in National HPVImmunization programme in Madrid (Spain)

82.174.4 72.3

65.972.6

79.6

●● ● ●

91.481.3 83.7 84.0

0

10

20

30

40

50

60

70

80

90

100

1994

1995

1996

1997

1998

1999

2000

Birth cohort

HP

V v

acci

natio

n co

vera

ge (

%)














Table 56: National HPV Immunization programme in Melilla (Spain)Female Male





Strategy Sch. -


In 2015 primary target will change to girls aged 13 and 14 years. In 2016 girls aged 12 and 13 years, and from 2017 onwards12 years old.



Figure 55: Reported HPV vaccination coverage in females by birth cohort in National HPVImmunization programme in Melilla (Spain)

85.6

71.779.0

73.9

89.0

74.2

●

●● ●

88.8

76.684.1 83.7

0

10

20

30

40

50

60

70

80

90

100

1994

1995

1996

1997

1998

1999

2000

Birth cohort

HP

V v

acci

natio

n co

vera

ge (

%)














Table 57: National HPV Immunization programme in Murcia (Spain)Female Male







In 2012 primary targeted cohort switched from 14 years (2nd year secondary school) to 12 years olds.Data updated on 11 Jul 2017 (data as of 31 Dec 2016)a 2 doses: 0-6m if not otherwise stated. Since 2014, based on clinical trials results several agencies responsible for the scientific evaluation of medicines, like the European Medicines Agency,aproved a two-dose schedule for girls aged less than 15 or 14 depending on the vaccine (Cervarix or Gardasil).b 3-doses standard: administration of three doses following the standard vaccination schedule as 0-2-6 months for the quadrivalent vaccine or 0-1-6 months for the bivalent vaccine.Data sources:1 Adapted from Bruni et al 2016 Lancet Global Health (data up to October 2014).Specifically, data from Spain was extracted from:


Figure 56: Reported HPV vaccination coverage in females by birth cohort in National HPVImmunization programme in Murcia (Spain)

61.0

90.1

74.279.2 75.0

83.4 83.7

●

●

●● ●

64.0

93.8

76.685.0 82.5

0

10

20

30

40

50

60

70

80

90

100

1994

1995

1996

1997

1998

1999

2000

2001

Birth cohort

HP

V v

acci

natio

n co

vera

ge (

%)














Table 58: National HPV Immunization programme in Navarra (Spain)Female Male





Strategy Sch. (1st year secondary sch.) -


Catch-up program for the 4th year of secondary school during 2007-9 (girls 15-16)Data updated on 11 Jul 2017 (data as of 31 Dec 2016)a 2 doses: 0-6m if not otherwise stated. Since 2014, based on clinical trials results several agencies responsible for the scientific evaluation of medicines, like the European Medicines Agency,aproved a two-dose schedule for girls aged less than 15 or 14 depending on the vaccine (Cervarix or Gardasil).b 3-doses standard: administration of three doses following the standard vaccination schedule as 0-2-6 months for the quadrivalent vaccine or 0-1-6 months for the bivalent vaccine.Data sources:1 Adapted from Bruni et al 2016 Lancet Global Health (data up to October 2014).Specifically, data from Spain was extracted from:


Figure 57: Reported HPV vaccination coverage in females by birth cohort in National HPVImmunization programme in Navarra (Spain)

91.497.4

81.2 82.072.6

85.3 84.2

● ●

● ● ●

96.1 99.7

86.7 89.1 91.8

0

10

20

30

40

50

60

70

80

90

100

1992

1993

1994

1995

1996

1997

1998

1999

2000

2001

Birth cohort

HP

V v

acci

natio

n co

vera

ge (

%)














Table 59: National HPV Immunization programme in Pais Vasco (Spain)Female Male





Strategy Sch. (1st year secondary sch.) -


In 2015 primary target will change to girls aged 11-12 (School grade 6).Data updated on 11 Jul 2017 (data as of 31 Dec 2016)a 2 doses: 0-6m if not otherwise stated. Since 2014, based on clinical trials results several agencies responsible for the scientific evaluation of medicines, like the European Medicines Agency,aproved a two-dose schedule for girls aged less than 15 or 14 depending on the vaccine (Cervarix or Gardasil).b 3-doses standard: administration of three doses following the standard vaccination schedule as 0-2-6 months for the quadrivalent vaccine or 0-1-6 months for the bivalent vaccine.Data sources:1 Adapted from Bruni et al 2016 Lancet Global Health (data up to October 2014).Specifically, data from Spain was extracted from:


Figure 58: Reported HPV vaccination coverage in females by birth cohort in National HPVImmunization programme in Pais Vasco (Spain)

No data available

0

10

20

30

40

50

60

70

80

90

100

HP

V v

acci

natio

n co

vera

ge (

%)












8 PROTECTIVE FACTORS FOR CERVICAL CANCER - 94 -

8 Protective factors for cervical cancer

Male circumcision and the use of condoms have shown a significant protective effect against HPV trans-mission.

Table 60: Prevalence of male circumcision in Spain

Reference Prevalence % (95% CI) Methods

Canadas 2013 17.9 (12.7-24.1) N=190: HIV-positive heterosexual men

Canadas 2013 25.8 (22.1-29.8) N=516: HIV-positive men who have sexwith men

Castellsague 2005 1.9 (0.0-10.1) N=53: Stable partners of control womenin an international multicenter case-control study on cervical cancer

WHO 2007 <20 Data from Demographic and HealthSurveys (DHS) and other publicationsto categorize the country-wide preva-lence of male circumcision as <20%, 20-80%, or >80%.

Data accessed on 31 Aug 2015.95% CI: 95% Confidence Interval;Please refer to country-specific reference(s) for full methodologies.Data sources:Based on systematic reviews and meta-analysis performed by ICO. The ICO HPV Information Centre has updated data until August 2015. Reference publication: Albero G, Sex TransmDis. 2012 Feb;39(2):104-13.Canadas MP, Clin Microbiol Infect 2013; 19: 611 | Castellsagué X, Am J Epidemiol 2005; 162: 907 | WHO 2007: Male circumcision: Global trends and determinants of prevalence, safetyand acceptability

Table 61: Prevalence of condom use in Spain

Indicator Year of estimate Prevalence %a

Condom use 2006 24.8Data accessed on 21 Mar 2017.Please refer to original source for methods of estimation.aCondom use: Proportion of male partners who are using condoms with their female partners of reproductive age (15-49 years) to whom they are married or in union by country.Data sources:United Nations, Department of Economic and Social Affairs, Population Division (2016). World Contraceptive Use 2016 (POP/DB/CP/Rev2016). http://www.un.org/en/development/desa/population/publications/dataset/contraception/wcu2016.shtml. Available at: [Accessed on March 22, 2017].Spain 2006 Fertility and Values Survey




9 INDICATORS RELATED TO IMMUNISATION PRACTICES OTHER THAN HPV VACCINES - 95 -

9 Indicators related to immunisation practices other than HPV vac-cines

This section presents data on immunisation coverage and practices for selected vaccines. This infor-mation will be relevant for assessing the country’s capacity to introduce and implement the new HPVvaccines. The data are periodically updated and posted on the WHO Immunisation surveillance, assess-ment and monitoring website at http://who.int/immunization_monitoring/en/.

9.1 Immunisation schedule

Table 62: General immunization schedule in SpainVaccine Schedule Coveragea CommentHexavalent diphtheria, tetanus toxoid withacellular pertussis, Hib, hepatitis B andIPV vaccine

2, 6 months; entire -

Diphtheria and tetanus toxoid with acellu-lar pertussis, Hib and IPV vaccine

4, 18 months; entire -

Hepatitis A vaccine - entire risk groupsHepatitis B adult dose vaccine - entire risk groupsHepatitis B pediatric dose vaccine birth; entire -Human Papillomavirus vaccine 12 years (x2); entire girlsInfluenza adult dose vaccine >= 65 years; entire and pregnant women,

health care workers,adults with chronicdiseases and other riskgroups

Influenza pediatric dose vaccine - entire children with chronic dis-eases

Meningococcal C conjugate vaccine 2,12 months;12years;

entire -

Measles mumps and rubella vaccine 12 months; 3-4years;

entire -

Pneumococcal conjugate vaccine - entire From 2016Pneumococcal polysaccharide vaccine > 64 years; entire and risk groupsTetanus and diphtheria toxoid for olderchildren / adults vaccube

14 years; entire -

Tetanus and diphtheria toxoids and acellu-lar pertussis vaccine

6 years; entire and pregnant women

Varicella vaccine 12 years (x2); entire susceptible adolescentsonly and universal atM15 and Y3-Y4 from2016

Yellow fever vaccine - - travelersData accessed on 27 Jan 2017.The shedules are the country official reported figuresaEntire:introduced in the entire country. Part:partially introduced.Data sources:Annual WHO/UNICEF Joint Reporting Form (Update of 2015/July/15). Geneva, Immunization, Vaccines and Biologicals (IVB), World Health Organization. Available at: http://www.who.int/immunization/monitoring_surveillance/en/

9.2 Immunisation coverage estimates


http://who.int/immunization_monitoring/en/

http://www.who.int/immunization/monitoring_surveillance/en/


9 INDICATORS RELATED TO IMMUNISATION PRACTICES OTHER THAN HPV VACCINES - 96 -

Table 63: Immunization coverage estimates in SpainIndicator Year of estimation Coverage (%)Third dose of diphtheria toxoid, tetanus toxoid and pertussis vaccine 2015 97Third dose of hepatitis B vaccine administered to infants 2015 97Third dose of Haemophilus influenzae type B vaccine 2015 97Measles-containing vaccine 2015 96Third dose of polio vaccine 2015 97

Data accessed on 27 Jan 2017.The coverage figures (%) are the country official reported figures. Immunization coverage levels are presented as a percentage of a target population that has been vaccinated.Data sources:Annual WHO/UNICEF Joint Reporting Form and WHO Regional offices reports (Update of 2015/July/16). Geneva, Immunization, Vaccines and Biologicals (IVB),World Health Organization.Available at: http://www.who.int/immunization/monitoring_surveillance/en/



10 GLOSSARY - 97 -

10 Glossary

Table 64: GlossaryTerm DefinitionIncidence Incidence is the number of new cases arising in a given period in a specified

population. This information is collected routinely by cancer registries. It can beexpressed as an absolute number of cases per year or as a rate per 100,000persons per year (see Crude rate and ASR below). The rate provides anapproximation of the average risk of developing a cancer.

Mortality Mortality is the number of deaths occurring in a given period in a specifiedpopulation. It can be expressed as an absolute number of deaths per year or as arate per 100,000 persons per year.

Prevalence The prevalence of a particular cancer can be defined as the number of persons ina defined population who have been diagnosed with that type of cancer, and whoare still alive at the end of a given year, the survivors. Complete prevalencerepresents the number of persons alive at certain point in time who previouslyhad a diagnosis of the disease, regardless of how long ago the diagnosis was, or ifthe patient is still under treatment or is considered cured. Partial prevalence ,which limits the number of patients to those diagnosed during a fixed time in thepast, is a particularly useful measure of cancer burden. Prevalence of cancersbased on cases diagnosed within one, three and five are presented as they arelikely to be of relevance to the different stages of cancer therapy, namely, initialtreatment (one year), clinical follow-up (three years) and cure (five years).Patients who are still alive five years after diagnosis are usually consideredcured since the death rates of such patients are similar to those in the generalpopulation. There are exceptions, particularly breast cancer. Prevalence ispresented for the adult population only (ages 15 and over), and is available bothas numbers and as proportions per 100,000 persons.

Crude rate Data on incidence or mortality are often presented as rates. For a specifictumour and population, a crude rate is calculated simply by dividing the numberof new cancers or cancer deaths observed during a given time period by thecorresponding number of person years in the population at risk. For cancer, theresult is usually expressed as an annual rate per 100,000 persons at risk.

ASR (age-standardisedrate)

An age-standardised rate (ASR) is a summary measure of the rate that apopulation would have if it had a standard age structure. Standardization isnecessary when comparing several populations that differ with respect to agebecause age has a powerful influence on the risk of cancer. The ASR is aweighted mean of the age-specific rates; the weights are taken from populationdistribution of the standard population. The most frequently used standardpopulation is the World Standard Population. The calculated incidence ormortality rate is then called age-standardised incidence or mortality rate(world). It is also expressed per 100,000. The world standard population used inGLOBOCAN is as proposed by Segi [1] and modified by Doll and al. [2]. Theage-standardised rate is calculated using 10 age-groups. The result may beslightly different from that computed using the same data categorised using thetraditional 5 year age bands.

Cumulative risk Cumulative incidence/mortality is the probability or risk of individualsgetting/dying from the disease during a specified period. For cancer, it isexpressed as the number of new born children (out of 100, or 1000) who would beexpected to develop/die from a particular cancer before the age of 75 if they hadthe rates of cancer observed in the period in the absence of competing causes.

Cytologically normalwomen

No abnormal cells are observed on the surface of their cervix upon cytology.

(Continued)


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Table 64 – ContinuedTerm DefinitionCervical IntraepithelialNeoplasia (CIN) /Squamous IntraepithelialLesions (SIL)

SIL and CIN are two commonly used terms to describe precancerous lesions orthe abnormal growth of squamous cells observed in the cervix. SIL is anabnormal result derived from cervical cytological screening or Pap smear testing.CIN is a histological diagnosis made upon analysis of cervical tissue obtained bybiopsy or surgical excision. The condition is graded as CIN 1, 2 or 3, according tothe thickness of the abnormal epithelium (1/3, 2/3 or the entire thickness).

Low-grade cervical lesions(LSIL/CIN-1)

Low-grade cervical lesions are defined by early changes in size, shape, andnumber of ab-normal cells formed on the surface of the cervix and may bereferred to as mild dysplasia, LSIL, or CIN-1.

High-grade cervicallesions (HSIL / CIN-2 /CIN-3 / CIS)

High-grade cervical lesions are defined by a large number of precancerous cellson the sur-face of the cervix that are distinctly different from normal cells. Theyhave the potential to become cancerous cells and invade deeper tissues of thecervix. These lesions may be referred to as moderate or severe dysplasia, HSIL,CIN-2, CIN-3 or cervical carcinoma in situ (CIS).

Carcinoma in situ (CIS) Preinvasive malignancy limited to the epithelium without invasion of thebasement membrane. CIN 3 encompasses the squamous carcinoma in situ.

Invasive cervical cancer(ICC) / Cervical cancer

If the high-grade precancerous cells invade the basement membrane is calledICC. ICC stages range from stage I (cancer is in the cervix or uterus only) tostage IV (the cancer has spread to distant organs, such as the liver).

Invasive squamous cellcarcinoma

Invasive carcinoma composed of cells resembling those of squamous epithelium

Adenocarcinoma Invasive tumour with glandular and squamous elements intermingled.Eastern Europe References included in Belarus, Bulgaria, Czech Republic, Hungary, Poland,

Republic of Moldova, Romania, Russian Federation, Slovakia, and Ukraine.Northern Europe References included in Denmark, Estonia, Finland, Iceland, Ireland, Latvia,

Lithuania, Norway, Sweden, and United Kingdom of Great Britain and NorthernIreland.

Southern Europe References included in Albania, Bosnia and Herzegovina, Croatia, Greece, Italy,Malta, Montenegro, Portugal, Serbia, Slovenia, Spain, The former YugoslavRepublic of Macedonia.

Western Europe References included in Austria, Belgium, France, Germany, Liechtenstein,Luxembourg, Netherlands, and Switzerland.

Europe PREHDICT References included in Albania, Austria, Belarus, Belgium, Bosnia andHerzegovina, Bulgaria, Croatia, Cyprus, Czech Republic, Denmark, Estonia,Finland, France, Germany, Greece, Hungary, Iceland, Ireland, Israel, Italy,Latvia, Liechtenstein, Lithuania, Luxembourg, Malta, Montenegro,Netherlands, Norway, Poland, Portugal, Republic of Moldova, Romania, RussianFederation, Serbia, Slovakia, Slovenia, Spain, Sweden, Switzerland, The formerYugoslav Republic of Macedonia, Turkey, Ukraine, and United Kingdom of GreatBritain and Northern Ireland.


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Acknowledgments

This report has been developed by the Unit of Infections and Cancer, Cancer Epidemiology ResearchProgram, at the Institut Català d’Oncologia (ICO, Catalan Institute of Oncology) within the PREHDICTproject (7th Framework Programme grant HEALTH-F3-2010-242061, PREHDICT). The HPV Informa-tion Centre is being developed by the Institut Català d’Oncologia (ICO). The Centre was originallylaunched by ICO with the collaboration of WHO’s Immunisation, Vaccines and Biologicals (IVB) depart-ment and support from the Bill and Melinda Gates Foundation.

Institut Català d’Oncologia (ICO), in alphabetic orderAlbero G, Barrionuevo-Rosas L, Bosch FX, Bruni L, de Sanjosé S, Gómez D, Mena M, Muñoz J, SerranoB.

7th Framework Programme grant PREHDICT project: health-economic modelling of PREventionstrategies for Hpv-related Diseases in European CounTries. Coordinated by Drs. Johannes Berkhofand Chris Meijer at VUMC, Vereniging Voor Christelijk Hoger Onderwijs Wetenschappelijk OnderzoekEn Patientenzorg, the Netherlands.(http://cordis.europa.eu/projects/rcn/94423_en.html)

7th Framework Programme grant HPV AHEAD project: Role of human papillomavirus infec-tion and other co-factors in the aetiology of head and neck cancer in India and Europe. Coordinated byDr. Massimo Tommasino at IARC, International Agency of Research on Cancer, Lyon, France.(http://cordis.europa.eu/project/rcn/100268_en.html)

International Agency for Research on Cancer (IARC)


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Human Papillomavirus and Related Diseases Report SPAIN · 2019-06-17 · Human Papillomavirus and Related Diseases Report SPAIN Version posted at 17 June 2019