CANCER CERVIX BURDEN OF HPV

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hpv is a major cause of ca cx and other malignancies...............

hpv is a major cause of ca cx and other malignancies...............

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  • Key Point The worldwide burden of HPV-related cervical disease and genital warts is considerable. Background According to estimates from the World Health Organization (WHO), the worldwide annual incidence of HPV infection is 660 million, 1 with low- and high-grade dysplasia being 30 million and 10 million cases, respectively. 2 The WHO estimates that 30 million cases of genital warts occur every year. 3 The largest number of cases of cervical HPV infection have no detectable cytologic abnormalities, and many of these cases are self-limited. However, an important subset will subsequently become associated with disease. 2 Together, HPV 16 and 18 are responsible for at least 70% of cervical cancers and at least 50% of high-grade lesions. 4 Together, HPV types 6, 16, and 18 are responsible for approximately 30% of low-grade lesions of the cervix, 4 and HPV types 6 and 11 are strongly associated with anogenital warts. 5 In a study by Gissmann and colleagues (N=63), HPV 6 and 11 DNA was detected in >90% of anogenital warts. 5 1. World Health Organization. Report of the consultation on human papillomavirus vaccines. Geneva, Switzerland. 2005:1–38. 2. World Health Organization. The current status of development of prophylactic vaccines against human papillomavirus infection. Report of a technical meeting, 16-18 February 1999. Geneva, Switzerland. 1999:1–22. 3. World Health Organization. Office of Information. Sexually transmitted infections increasing – 250 million new infections annually. WHO Features. 1990;(152):1–6. 4. WHO/ICO Information Centre on HPV and Cervical Cancer. HPV and cervical cancer in the world 2007 report. Vaccine. 2007;25(suppl 3):C1–C230. 5. Gissmann L, Wolnik L, Ikenberg H, Koldovsky U, Schnürch HG, zur Hausen H. Human papillomavirus types 6 and 11 DNA sequences in genital and laryngeal papillomas and in some cervical cancers. Proc Natl Acad Sci U S A. 1983;80:560–563. 3/WHO 1990/ p.1/¶2 1/WHO 2005/p 5/¶1 2/WHO 1999/ p.6/¶2 2/WHO 1999/ p. 6/¶2 5/Gissmann/p. 561/Table 2. 4/WHO/ICO/p. C1/ Figure 3 3/WHO 1999/p.6/ para 2 1/WHO 2005/p.8/ para 1 1/WHO 2005/ p.8/para 1 4/WHO 1990/ p.1/para 2 5/Gissmann/p. 561/col 2/table 2 2/WHO/ICO/p. C1/ Figure 3
  • Region / Country N deaths Asia 159774 Eastern Asia 5814 Hong Kong NA Macao NA DPR Korea 518 Japan 3350 Mongolia 106 Republic of Korea 1043 Southern Asia 93818 Afghanistan 319 Bangladesh 10364 Bhutan 27 India 72825 Iran 286 Maldives NA Nepal 1872 Pakistan 7311 Sri Lanka 814
  • India’s population is approximately 1/6 th of the world burden but the disease burden in India is more than 25%( 1/4 th )
  • Oncogenic HPV DNA sequences are found in more than 99% of cervical cancers globally. HPV infection is associated with cancers other than cervix. Oncogenic HPV DNA sequences are found in a proportion of anal, vulval, vaginal, penile and head and neck cancers and the precursor intra epithelial lesions. HPV 16 is again the dominant oncogenic type and overall the malignant burden attributable to HPV infection is calculated to be 5% of all cancers
  • 1/WHO/p. 1/col 2/para 2; p. 7/col 1/para 1

Transcript

  • 1. NARENDRA MALHOTRA M.D., F.I.C.O.G., F.I.C.M.C.H
    • President FOGSI (2008-2009)
    • Dean I.C.M.U. (2008)
    • Director Ian Donald School of Ultrasound
    • National Tech. Advisor for FOGSI-G.O.I.—Mc Arthur Foundation EOC Course
    • Practicing Obstetrician Gynecologist at Agra. Special Interest in High Risk Obs., Ultrasound, Laparoscopy and Infertility, ART & Genetics
    • Member and Fellow of many Indian and international organisations
    • Senior V. P. of FOGSI (2003)
    • Vice Dean Indian College of Medical Ultrasound (2006)
    • FOGSI Imaging Science Chairman (1996-2000)
    • Awarded best paper and best poster at FOGSI : 5 times, Ethicon fellowship, AOFOG young gyn. award, Corion award, Man of the year award, Best Citizens of India award
    • Over 30 published and 100 presented papers
    • Over 50 guest lectures given in India & Abroad
    • Organised many workshops, training programmes, travel seminars and conferences
    • Editor 8 books, many chapters, on editorial board of many journals
    • Editor of series of STEP by STEP books
    • Revising editor for Jeatcoate’s Textbook of Gynaecology (2007)
    • Editor FOGSI Textbook 3 rd Edition
    • Very active Sports man, Rotarian and Social worker
    MALHOTRA NURSING & MATERNITY HOME PVT. LTD . 84, M.G. Road, Agra-282 010 Phone : (O) 0562-2260275/2260276/2260277, (R) 0562-2260279, (M) 98370-33335; Fax : 0562-2265194 E-mail : [email_address] Website : www.malhotrahospitals.com Apollo Pankaj Hospitals, Agra CO-ORDINATOR DEPTT. OBS & GYN
  • 2. HPV DISEASES Is it Relevant to Us? Narendra Malhotra Jaideep Malhotra Neharika Malhotra www.malhotrahospitals.com
  • 3. “ The woman is an axle around whom not only the family or society but the whole universe revolves”. Her health is of utmost importance in all stages of her life….. A Woman is the pivot of the Universe!
  • 4.  
  • 5. HPV 16 HPV 18 HPV 6 HPV 11 Cancer causing Types 1,2,4 Non-cancer causing types 1,2
    • >75% of Cervical Cancer 5,6
    • >50% of Vaginal & Vulvar Cancer 5
    90% of Anogenital warts 5 HPV is a necessary cause of cervical cancer – 99.7% 4 HPV 1.Schiffman M, Castle PE. Arch Pathol Lab Med . 2003;127:930–934. 2. Wiley DJ, Douglas J, Beutner K, et al. Clin Infect Dis . 2002;35(suppl 2):S210–S224. 3. Muñoz N, Bosch FX, Castellsagué X, et al. Int J Cancer . 2004;111:278–285. Reprinted from J Virol. 1994;68:4503–4505 with permission from the American Society for Microbiology Journals Department. 4. Walboomers JM, Jacobs MV, Manos MM, et al. J Pathol. 1999;189:12–19. 5. X. Castellsagué, S. de Sanjose, T. Aguado, K. S. Louie, L. Bruni, J.Muñoz, M. Diaz, K. Irwin, M. Gacic, O. Beauvais, G. Albero, E. Ferrer, S. Byrne,F. X. Bosch. HPV and Cervical Cancer in the World. 2007 Report. WHO/ICO Information Centre on HPV and Cervical Cancer (HPV Information Centre). Available at: www.who.int/hpvcentre6 . Bhatla N et al.Vaccine (2008;26; 2811-17 Human Papillomavirus (HPV)
  • 6. Estimated Annual Incidence of HPV-Related Diagnoses Cervical cancer: 0.5 million cases/year 1 ~70% attributable to HPV types 16 and 18 2 High-grade precancerous lesions: 10 million 3 ~50% attributable to HPV types 16 and 18 2 Low-grade cervical lesions: 30 million 3 ~30% attributable to HPV types 6, 16, and 18 2 Genital warts: 30 million 4 ~90% attributable to HPV types 6 and 11 5 HPV infection: 660 million 1 1. World Health Organization, Geneva, Switzerland. 2005:1–38. 2. WHO/ICO Information Centre on HPV and Cervical Cancer. Vaccine. 2007;25(suppl 3):C1–C230. 3. World Health Organization, Geneva, Switzerland. 1999:1–22. 4. World Health Organization. WHO Features. 1990;152:1–6. 5. Gissmann L et al. Proc Natl Acad Sci U S A. 1983;80:560–563. Attributable to oncogenic HPV types Attributable to nononcogenic HPV types
  • 7. Ranking Of Cervical Cancer To Others Cancers According To Incidence Rates 61% Data source : IARC, Globocan 2008 Available at: HPV Information Centre. Human Papillomavirus and Related Cancers in World. Summary Report 2010. [Accessed: July 2010]. Available at www. who. int/ hpvcentre of countries cervical cancer ranks among the 3 most frequent cancers among women from all ages WOMEN ALL AGES
  • 8. Cervical Cancer – Disease Burden Asia ~ 43% of new Cervical Cancer cases in world Asia ~ 44% of deaths due to Cervical Cancer in world New Cervical Cancer Cases Deaths due to Cervical Cancer 43% Global 2 529,409 SE Asia 1 * 122,132 44% Rest of The World Global 2 274,883 Rest of The World Global Population 17 % Rest of The World SE Asia 1 * 229,589 1. WHO/ICO Information Centre on HPV and Cervical Cancer (HPV Information Centre). Human Papillomavirus and Related Cancers in Asia. Summary Report 2010.. 2. WHO/ICO Information Centre on HPV and Cervical Cancer (HPV Information Centre). Human Papillomavirus and Related Cancers in World. Summary Report 2010. [Accessed on 11th Jul 2011. 3. http://www.prb.org/Publications/Datasheets/2010/2010wpds.aspx 2010 population Bureau [Accessed on 11th Jul 2011 SE Asia 3 * 1238.45 *Excluding China
  • 9. Cervical Cancer – Disease Burden India ~134,000 World ~ 529,000 India ~25% of new Cervical Cancer cases in world India ~ 73,000 World ~ 274,000 India ~25% Rest of World - 75% India ~ 27% of deaths due to Cervical Cancer in world Rest of World - 73% India - 27% Incidence Mortality India ~27% Rest of World - 73% HPV and Cervical Cancer in the World. 2010 Report. WHO/ICO Information Centre on HPV and Cervical Cancer (HPV Information Centre). Available at: www.who.int/hpvcentre
  • 10. Key Statistics on India WHO/ICO Information Centre on HPV and Cervical Cancer (HPV Information Centre). Human Papillomavirus and Related Cancers in India. Summary Report 2010. [Accessed on 5 th July,2010]. Available at www. who. int/ hpvcentre
  • 11. Burden of Disease in India 72,825 Deaths Annually Approx. 200 women die every day Every 7 minutes a women dies Approx. 8 women die every hour WHO/ICO Information Centre on HPV and Cervical Cancer (HPV Information Centre). Human Papillomavirus and Related Cancers in India. Summary Report 2010. [Accessed on 5 th July,2010]. Available at www. who. int/ hpvcentre
  • 12. Age Adjusted Incidence Rates (AARs) for Ca Cervix: Population based cancer registry Three year report of PBCR 2006-08 chapter 6.
  • 13. Incidence of Cervical Cancer WHO/ICO Information Centre on HPV and Cervical Cancer (HPV Information Centre). Human Papillomavirus and Related Cancers in India. Summary Report 2010. [Accessed on 5 th July,2010]. Available at www. who. int/ hpvcentre
  • 14. Age-standardized incidence rates WHO/ICO Information Centre on HPV and Cervical Cancer (HPV Information Centre). Human Papillomavirus and Related Cancers in India. Summary Report 2010. [Accessed on 5 th July,2010]. Available at www. who. int/ hpvcentre Rates per 100,000 women per year. ** No rates are available
  • 15. Mortality Rate WHO/ICO Information Centre on HPV and Cervical Cancer (HPV Information Centre). Human Papillomavirus and Related Cancers in India. Summary Report 2010. [Accessed on 5 th July,2010]. Available at www. who. int/ hpvcentre
  • 16. Years of Life Lost to Cervical Cancer* *In women in the United States (2003) 1. Ries LAG, Harkins D, Krapcho M, et al. (eds). SEER Cancer Statistics Review, 1975–2003 , National Cancer Institute. Bethesda, MD; 2006. 26 19 18 26 Average years of life lost in women with Cervical Cancer
  • 17. Cervical cancer HPV 1983/1984 Zur Hausen group detects HPV DNA in cervical cancers new HPVs – HPV 16 and HPV 18
  • 18. Nobelprize for Medicine 2008 Harald zur Hausen
  • 19. Estimated HPV Contribution To Cancer Source : WHO/ICO Information Centre on HPV and Cervical Cancer, second edition 2009 ( www.who.int/hpvcentre ). Estimates are based on 4 reviews: Bosch et al, 2002; Kreimer et al, 2005; De Vuyst et al, 2008; Miralles-Guri et al, 2009. > 99% 84.3% 69.9% 47.0% 40.4% 35.6% 23,5% HPV DNA detection : 95% CI for the proportion 5% of all cancers are HPV associated UK15053 05/11
  • 20. What is HPV?
    • Non enveloped dsDNA virus, simple
    • capsid of 2 proteins L1 and L2
    • Common virus with >100 types identified
    • Infects cutaneous and mucosal epithelia
    • 30–40 infect the mucosal epithelia of women and men
    • 2 groups
      • low risk types causing warts
    • HPV 6,11
      • high risk types causing cancer
    • 15 oncogenic types
    • HPV 16,18 – most important
  • 21. Ten Most Frequent HPV Types of Cervical Cancer India Southern Asia WHO/ICO Information Centre on HPV and Cervical Cancer (HPV Information Centre). Human Papillomavirus and Related Cancers in India. Summary Report 2010. [Accessed on 5 th July,2010]. Available at www. who. int/ hpvcentre 16 + 18 = 82.5%
  • 22. Type-specific HPV prevalence in women in India 1.WHO/ICO Information Centre on HPV and Cervical Cancer (HPV Information Centre). Human Papillomavirus and Related Cancers in India. Summary Report 2010. [Accessed on 5th July,2010]. Available at www. who. int/ hpvcentre 2. WHO/ICO Information Centre on HPV and Cervical Cancer (HPV Information Centre). Human Papillomavirusand Related Cancers in Asia. Summary Report 2010. [Accessed on 5 th July 2010]. Available at www. who. int/ hpvcentre HPV Type HPV Prevalence (%) Low Grade Lesions High Grade Lesions Cervical Cancer India 1 Asia 2 India 1 Asia 2 India 1 Asia 2 6 8.1 1.6 -- 1.0 0.3 0.3 11 -- 1.5 -- 1.5 0.7 0.3 16 23.5 18.1 48.0 36.8 67.6 53.3 18 5.9 17.6 8.0 8.0 14.9 15.2
  • 23. Ten Most Frequent Hpv Types Among Cervical Cancer Cases Worldwide By Histology SQUAMOUS CELL CARCINOMA ADENOCARCINOMA Data source : IARC Infection and Cancer Epidemiology Group. Clifford et al Br J Cancer 2003, Clifford et al Int J Cancer 2007 Available at: HPV Information Centre. Human Papillomavirus and Related Cancers in World. Summary Report 2009. [Accessed: 27 May 2010]. Available at www. who. int/ hpvcentre
  • 24. CERVICAL HPV PREVALENCE IN WOMEN WITH NORMAL CYTOLOGY Meta-analysis of 1,016,719 women HPV prevalence (%) Bruni et al, JID 2010 Adjusted HPV prevalence standardized by the geographical structure HPV prevalence 11.7% (95%CI=11.6-11.7%) 1.7 4.7 7.1 8.8 9.0 9.2 10.0 10.7 13.0 14.0 15.3 17.4 19.6 21.4 33.6 35.4 0 10 20 30 40 Western Asia Northern America Southern Asia Southern Europe Western Europe Northern Africa Northern Europe Eastern Asia Central America South-Eastern Asia South America Southern Africa Western Africa Eastern Europe Eastern Africa Caribbean
  • 25. Cervical Cancer Screening Practices Estimated coverage of cervical cancer screening in India, by age & study WHO/ICO Information Centre on HPV and Cervical Cancer (HPV Information Centre). Human Papillomavirus and Related Cancers in India. Summary Report 2010. [Accessed on 5 th July,2010]. Available at www. who. int/ hpvcentre Overall 2.6%
  • 26. HPV causes more than cervical cancer Percentages represent cases atrributable to HPV infection Cervical Cancer 1,3 Vulvar Cancer 1 Vaginal Cancer 1 Anal Cancer 1-3 Genital Warts 1,3 Head & Neck Cancer 3 Penile Cancer 3 Braaten KP et al. Rev Obstet Gynecol. 2008;1:2–10. Hoots BE et al. Int J Cancer. 2009;124:2375–2383. IARC. IARC monographs on the evaluation of carcinogenic risks to humans. Human papillomaviruses. Vol 90. Lyon, France: IARC, 2007. 80+% ~40% ~100% 60-90% ~100% 12-70% 45%
  • 27. *Ray K et al, Indian J Med Res 2006; 124: 559-568 Genital Warts – Disease Burden: India* Increasing trend of Genital warts in India 18% 6% 11% 10.5% 0 2 4 6 8 10 12 14 16 18 20 1990-93 1994-97 1998-01 2002-04 Study Period Percentage
  • 28. HPV Vaccination: The Basis of Cancer Control World Health Organization, United Nations Population Fund. Preparing for the Introduction of HPV Vaccines: Policy and Programme Guidance for Countries . Geneva, Switzerland: World Health Organization; 2006. Palliative care Cancer treatment Secondary prevention: Screening and treatment of precancers Primary prevention: Vaccination
  • 29. Summary
    • India is one of the worst hit country in the world in terms of incidence and mortality for cervical cancer.
    • HPV is a necessary cause of cervical cancer
    • HPV is also responsible for other cancers as well as genital warts.
    • HPV 16 and 18 are the main culprits in the causation and progression of cervical cancer
    • Poor awareness, screening practices and under utilized HPV vaccines can be the primary reasons for high mortality and morbidity due to cervical cancer
    Its time to join hands and fight against cervical cancer
  • 30.
    • SAVE US FROM HPV
  • 31. Cervical Vaccine can be the best wedding gift a mother can give to her daughter
  • 32. Welcome to the 3 big international conferences