Cervical Cancer Prevention

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Are you at risk for cervical cancer? Did you know there are ways to help prevent it with early detection? Your chance of surviving cervical cancer is greatly increased with early diagnosis and treatment.  Please join Dr. Leslie Dignan-Moore, specialist in Obstetrics & Gynecology, at this FREE informational program as she discusses Cervical Cancer and how regular screening can be the first step toward prevention.

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  • Key Point Human papillomavirus prevalence in the United States is high. Background Human papillomavirus (HPV) is one of the most common infections in the United States. The Centers for Disease Control and Prevention has reported that the lifetime risk of acquiring HPV infection for sexually active men and women is at least 50%. 1 By 50 years of age, at least 80% of women will have acquired genital HPV infection. 1 It is estimated that 6.2 million people in the United States become infected with HPV each year, 1 and, currently, an estimated 20 million are infected with HPV, 2 including approximately 9.2 million sexually active adolescents and young adults 15–24 years of age. 3 The majority (74%) of new HPV infections occurs among those 15–24 years of age, 3 and in women <25 years of age, prevalence ranges between 28% and 46%. 4,5 In one US study of 608 college women, 43% became infected with genital HPV during the 3 - year study period; 20% were infected in the first year, with the incidence decreasing over time. 6 References 1. Centers for Disease Control and Prevention. Genital HPV Infection Fact Sheet. Rockville, Md: CDC National Prevention Information Network; 2004. 2. Cates W Jr, and the American Social Health Association Panel. Estimates of the incidence and prevalence of sexually transmitted diseases in the United States. Sex Transm Dis . 1999;26(suppl):S2–S7. 3. Weinstock H, Berman S, Cates W Jr. Sexually transmitted diseases among American youth: Incidence and prevalence estimates, 2000. Perspect Sex Reprod Health . 2004;36:6–10. 4. Burk RD, Ho GYF, Beardsley L, Lempa M, Peters M, Bierman R. Sexual behavior and partner characteristics are the predominant risk factors for genital human papillomavirus infection in young women. J Infect Dis . 1996;174:679–689. 5. Bauer HM, Ting Y, Greer CE, et al. Genital human papillomavirus infection in female university students as determined by a PCR - based method. JAMA . 1991;265:472–477. 6. Ho GYF, Bierman R, Beardsley L, Chang CJ, Burk RD. Natural history of cervicovaginal papillomavirus infection in young women. N Engl J Med . 1998;338:423–428.
  • Key Point HPV infection is usually transmitted by sexual contact, commonly through sexual intercourse, although transmission can occur through nonpenetrative sexual contact. Background The greatest behavioral risk for the acquisition of HPV infection is sexual contact, specifically the rate of new partners per month. 1,2 Sexual intercourse is important in the transmission of HPV. 2 Other types of genital contact (genital–genital, manual–genital, oral–genital), which may begin at an earlier age than penetrative intercourse, may also lead to HPV infection. 1,3,4 A recent study of college - aged (19 years of age, average age at enrollment) US women reported a 2 - year genital HPV incidence rate of 39% among sexually active women and 8% among virginal women. 1 Genital HPV infection in virgins is rare, but may result from nonpenetrative sexual contact. 1 Condom use may help reduce the risk of HPV acquisition, but it is not fully protective. 1 Other nonsexual routes of HPV infection include vertical transmission (from a mother to a newborn baby), although this is rare. 5 A potential consequence of vertical transmission of HPV is recurrent respiratory papillomatosis (RRP), benign epithelial growths in the respiratory tract. In the larynx, growths may cause hoarseness and airway obstruction, which is potentially fatal. This condition presents most often in children younger than 5 years of age. 6 Transmission of HPV infection may occur via contact with fomites, such as undergarments, surgical gloves, and biopsy forceps. This route of transmission has been hypothesized but is not well documented. 7,8 References 1. Winer RL, Lee S-K, Hughes JP, Adam DE, Kiviat NB, Koutsky LA. Genital human papillomavirus infection: Incidence and risk factors in a cohort of female university students. Am J Epidemiol . 2003;157:218–226. 2. Kjaer SK, Chackerian B, van den Brule AJC, et al. High - risk human papillomavirus is sexually transmitted: Evidence from a follow - up study of virgins starting sexual activity (intercourse). Cancer Epidemiol Biomarkers Prev . 2001;10:101–106. 3. Fairley CK, Gay NJ, Forbes A, Abramson M, Garland SM. Hand – genital transmission of genital warts? An analysis of prevalence data. Epidemiol Infect . 1995;115:169 – 176. 4. Herrero R, Castellsague X, Pawlita M, et al. Human papillomavirus and oral cancer: The International Agency for Research on Cancer multicenter study. J Natl Cancer Inst . 2003;95:1772 –1783. 5. Smith EM, Ritchie JM, Yankowitz J, et al. Human papillomavirus prevalence and types in newborns and parents: Concordance and modes of transmission. Sex Transm Dis . 2004;31:57 – 62. 6. Kashima HK, Mounts P, Shah K. Recurrent respiratory papillomatosis. Obstet Gynecol Clin North Am . 1996;23:699 – 706. 7. Ferenczy A, Bergeron C, Richart RM. Human papillomavirus DNA in fomites on objects used for the management of patients with genital human papillomavirus infections. Obstet Gynecol . 1989;74:950 – 954. 8. Roden RBS, Lowy DR, Schiller JT. Papillomavirus is resistant to desiccation. J Infect Dis . 1997;176:1076 – 1079.
  • Key Point The predominant risk factor for HPV infection can be linked to sexual behavior, particularly sexual intercourse at an early age. Background A number of factors directly or indirectly related to sexual behavior have been associated with increased risk for HPV infection in both men and women. Those consistently relating to infection in women are young age, intercourse at an early age, and sexual behavior, particularly with a higher number of partners. 1 ,2 The sexual behavior of male partners, 2 smoking, 3 oral contraceptive use, 3 and lack of circumcision of male partners 4 also appear to increase risk. Risk factors for HPV infection among men are similar to those in women and include young age, number of sex partners, and being uncircumcised. 5 References 1. Burk RD, Ho GYF, Beardsley L, Lempa M, Peters M, Bierman R. Sexual behavior and partner characteristics are the predominant risk factors for genital human papillomavirus infection in young women. J Infect Dis . 1996;174:679 – 689. 2. Murthy NS, Mathew A. Risk factors for pre - cancerous lesions of the cervix. Eur J Cancer Prev . 2000;9:5 – 14. 3. Winer RL, Lee S-K, Hughes JP, Adam DE, Kiviat NB, Koutsky LA. Genital human papillomavirus infection: Incidence and risk factors in a cohort of female university students. Am J Epidemiol . 2003;157:218–226. 4. Schiffman M, Castle PE. Human papillomavirus: Epidemiology and public health. Arch Pathol Lab Med . 2003;127:930 – 934. 5. Svare EI, Kjaer SK, Worm AM, Osterlind A, Meijer CJLM, van den Brule AJ. Risk factors for genital HPV DNA in men resemble those found in women: A study of male attendees at a Danish STD clinic. Sex Transm Infect . 2002;78:215 – 218.
  • Key Point Although most HPV infections are transient and asymptomatic, certain HPV types (eg, 16 and 18) are more likely to persist than other types. Background HPV infections are mostly transient. 1 The gradual development of an effective cell - mediated immune response is presumed to be the likely mechanism for HPV DNA clearance. 2 In a study of 608 college women, the median duration of new HPV infections was 8 months. 3 By 12 months after the incident infection, in about 70% of the women, HPV infection was no longer detected; and by 24 months, approximately 91% appeared to be cleared of HPV. 3 The incidence of high - risk HPV types was similar to the incidence of other types. 3 Virus types more likely to persist included HPV AE7, 16, 18, 61, and 73. 3 This study found that oncogenic HPV types are more likely to persist than nononcogenic types, but even these infections generally clear within 2 years. 3 References 1. Meijer CJLM, Helmerhorst TJM, Rozendaal L, van der Linden JC, Voorhorst FJ, Walboomers JMM. HPV typing and testing in gynaecological pathology: Has the time come? Histopathology . 1998;33:83 – 86. 2. Schiffman M, Kjaer SK. Chapter 2: Natural history of anogenital human papillomavirus infection and neoplasia. J Natl Cancer Inst Monogr . 2003;31:14 – 19. 3. Ho GYF, Bierman R, Beardsley L, Chang CJ, Burk RD. Natural history of cervicovaginal papillomavirus infection in young women. N Engl J Med . 1998;338:423–428.
  • Key Point Screening rates for cervical cancer exceed those of other common cancers. Background Screening for cervical cancer is key to reducing mortality because it increases detection of precancerous abnormalities. Screening rates for this disease are higher than those for either breast or colorectal cancer, with 81% of women having had a Pap test within the past 3 years. 1 The high screening rate for cervical cancer almost certainly contributes to detection of the disease before it becomes advanced. Incidence of new cases of cervical cancer that are detected at an advanced stage (0.6 cases per 100,000) is lower than that for breast, colon, and rectal cancers. 1 Reference 1. National Healthcare Quality Report. Rockville, Md: US Dept of Health and Human Services; 2003:iii - v, 1 – 38.
  • Key Point Pap smears have been used extensively and have been shown to reduce cervical cancer incidence, but they have limitations. Background The Pap smear has contributed greatly to early detection of cervical cancer and has been credited with reducing cancer - associated mortality by more than two thirds 1 ; however, there are some limitations. For example, in a US study of 455 women diagnosed with invasive cervical carcinoma, 28% had at least 1 Pap smear, each of which provided a normal result during the 6 to 36 months prior to diagnosis. 2 Potential sources of error with Pap smears include lack of sampling of lesions below the surface (they do not exfoliate), imperfect collection methods (some lesions are missed), inaccessibility of certain areas of the cervix, and errors of interpretation. 3 –5 Limitations of conventional Pap smears have led to the development of new technologies, most notably thin - layer and liquid - based screening. 4 These methods are aimed at reducing the false - positive rate of conventional Pap smears and improving the quality of the sample, as immediate fixation is provided by placing the specimen directly into a liquid fixative. 4,6,7 Sensitivity of the thin - layer Pap test was assessed in a study of 4,075 women and found to be 61% for detection of ≥ ASCUS after referral for colposcopy. 8 In a review of 472,743 Pap smears, malignant cytology was identified in 36 smears obtained via liquid - based methods and in 32 by conventional techniques. False - positive results were obtained in 8.4% of liquid - based specimens and 12.5% of conventional specimens. 7 The impact of thin - layer and liquid - based screening on morbidity and mortality rates for cervical cancer remains undetermined. 4 References 1. Crum CP, Rivera MN. Vaccines for cervical cancer. Cancer J . 2003;9:368 – 376. 2. Sung HY, Kearney KA, Miller M, Kinney W, Sawaya GF, et al. Papanicolaou smear history and diagnosis of invasive cervical carcinoma among members of a large prepaid health plan. Cancer . 2000;88:2283 – 2289. 3. Schink JC. Strategies for detecting cervical dysplasia: Visual inspection, spectroscopy, and speculoscopy. OBG Management . 2003;(suppl):5 – 8. 4. Selvaggi SM. Implications of low diagnostic reproducibility of cervical cytologic and histologic diagnoses. JAMA . 2001;285:1506 –1508. 5. Chacho MS, Mattie ME, Schwartz PE. Cytohistologic correlation rates between conventional Papanicolaou smears and ThinPrep cervical cytology: A comparison. Cancer. 2003;99:135 – 140. 6. Saslow D, Runowicz CD, Solomon D, et al. American Cancer Society Guideline for the early detection of cervical neoplasia and cancer. CA Cancer J Clin . 2002;52:342 – 362. 7. Uyar DS, Eltabbakh GH, Mount SL. Positive predictive value of liquid - based and conventional cervical Papanicolaou smears reported as malignant. Gynecol Oncol. 2003;89:227–232. 8. Kulasingam SL, Hughes JP, Kiviat NB, et al. Evaluation of human papillomavirus testing in primary screening for cervical abnormalities: Comparison of sensitivity, specificity, and frequency of referral. JAMA . 2002;288:1749 – 1757.
  • Key Point Although most HPV infections are transient and asymptomatic, certain HPV types (eg, 16 and 18) are more likely to persist than other types. Background HPV infections are mostly transient. 1 The gradual development of an effective cell - mediated immune response is presumed to be the likely mechanism for HPV DNA clearance. 2 In a study of 608 college women, the median duration of new HPV infections was 8 months. 3 By 12 months after the incident infection, in about 70% of the women, HPV infection was no longer detected; and by 24 months, approximately 91% appeared to be cleared of HPV. 3 The incidence of high - risk HPV types was similar to the incidence of other types. 3 Virus types more likely to persist included HPV AE7, 16, 18, 61, and 73. 3 This study found that oncogenic HPV types are more likely to persist than nononcogenic types, but even these infections generally clear within 2 years. 3 References 1. Meijer CJLM, Helmerhorst TJM, Rozendaal L, van der Linden JC, Voorhorst FJ, Walboomers JMM. HPV typing and testing in gynaecological pathology: Has the time come? Histopathology . 1998;33:83 – 86. 2. Schiffman M, Kjaer SK. Chapter 2: Natural history of anogenital human papillomavirus infection and neoplasia. J Natl Cancer Inst Monogr . 2003;31:14 – 19. 3. Ho GYF, Bierman R, Beardsley L, Chang CJ, Burk RD. Natural history of cervicovaginal papillomavirus infection in young women. N Engl J Med . 1998;338:423–428.
  • Key Point Additionally, the age at which a female is first exposed to HPV may have an impact on her risk for later cervical lesions and cancer. Background Data from a case-control study of 206 cases of cervical intraepithelial neoplasia (CIN), and 237 cases of invasive cervical cancer compared with 206 and 327 age-matched outpatient controls, respectively, demonstrated that women who had their first sexual intercourse encounter at age 17 years or younger had greater relative risks for CIN and invasive cervical cancer than did women whose first encounter occurred between 18 and 22 years of age. And the risks for these diseases in both age groups was greater than in the reference population of women who had had their first sexual intercourse encounter at either age 23 or older or never. 1 Reference 1 . La Vecchia C et al. Cancer . 1986;58:935–941.
  • Key Point GARDASIL® [Human Papillomavirus Quadrivalent (Types 6, 11, 16, and 18) Vaccine, Recombinant] was approved by the Food and Drug Administration (FDA) in June 2006 and received a recommendation from the Centers for Disease and Prevention’s (CDC’s) Advisory Committee on Immunization Practices (ACIP) in that same month.1 Background GARDASIL is indicated in females 9 through 26 years of age to help prevent genital warts caused by HPV Types 6 and 11, and cervical cancer caused by HPV Types 16 and 18, as well as the following precancerous or dysplastic lesions caused by HPV Types 6, 11, 16, and 18: Cervical adenocarcinoma in situ (AIS); cervical intraepithelial neoplasia (CIN) grades 1 through 3; vulvar intraepithelial neoplasia (VIN) grades 2 and 3; and vaginal intraepithelial neoplasia (VaIN) grades 2 and 3. The indication was expanded in September 2008 to include protection against vulvar and vaginal cancer caused by HPV Types 16 and 18. The ACIP, the American College of Obstetricians and Gynecologists, the American Academy of Family Physicians, the American College of Physicians, the American Academy of Pediatrics, and the Society for Adolescent Medicine have adopted recommendations for females aged 9 to 26 years.2 – 5 References 1. Markowitz LE et al. MMWR Recomm Rep. 2007;56(RR-2):1 – 24. 2. Centers for Disease Control and Prevention (CDC). http://www.cdc.gov/vaccines/recs/schedules/downloads/ adult/2009/adult-schedule.pdf. Accessed August 26, 2009. 3. Centers for Disease Control and Prevention (CDC). http://www.cdc.gov/vaccines/recs/schedules/downloads/child/ 2009/09_7-18yrs_schedule_pr.pdf. Accessed August 26, 2009. 4. American College of Obstetricians and Gynecologists (ACOG). Obstet Gynecol . 2006;108:699–705. 5. Middleman AB et al. J Adolesc Health . 2006;38(3):321–327.
  • Key Point Behavior reported in an independent study suggests minimal exposure to HPV at ≤ 1 years of age. 1 Background A national survey of adolescents and young adults (N=1,552) that focused on sexual health knowledge, attitudes, and experiences included 1,014 participants who reported having engaged in sexual intercourse. Of these, a very small number (2%) were 11 years of age or younger at their first intercourse encounter. These data suggest minimal risk of exposure to HPV among adolescents 11 years of age or younger, a small increase in risk among 12- to 13-year-olds, and another increase in risk among adolescents older than 16 years. 2 References 1. Markowitz LE et al. MMWR Recomm Rep. 2007;56(RR-2):1–24. 2. Hoff T et al. National Survey of Adolescents and Young Adults: Sexual Health Knowledge, Attitudes and Experiences. Henry J. Kaiser Family Foundation. Menlo Park, CA; 2003.
  • References 1. Centers for Disease Control and Prevention (CDC). http://www.cdc.gov/vaccines/recs/ACIP/default.htm. Accessed June 16, 2009. 2. Markowitz LE et al. MMWR Recomm Rep . 2007;56(RR-2):1–24.
  • Key Point National guidelines recommend HPV vaccination in females regardless of previous HPV infection or abnormal Pap test results.1–4 According to the American College of Obstetricians and Gynecologists (ACOG), sexually active women and women with previous abnormal cervical cytology or genital warts can receive the quadrivalent HPV vaccine.2 Background GARDASIL® [Human Papillomavirus Quadrivalent (Types 6, 11, 16, and 18) Vaccine, Recombinant] is indicated in females 9 through 26 years of age to help prevent genital warts caused by HPV Types 6 and 11, and cervical cancer caused by HPV Types 16 and 18, as well as the following precancerous or dysplastic lesions caused by HPV Types 6, 11, 16, and 182: Cervical adenocarcinoma in situ (AIS); cervical intraepithelial neoplasia (CIN) grades 1 through 3; vulvar intraepithelial neoplasia (VIN) grades 2 and 3; and vaginal intraepithelial neoplasia (VaIN) grades 2 and 3. The indication was expanded in September 2008 to include protection against vulvar and vaginal cancer caused by HPV Types 16 and 18. The main US associations that provide vaccination recommendations for children, adolescents, and young adult women have all adopted similar recommendations for the use of GARDASIL. The Advisory Committee on Immunization Practices, ACOG, the American Academy of Family Physicians, the American College of Physicians, the American Academy of Pediatrics, and the Society for Adolescent Medicine agree in recommending routine vaccination in females aged 13 to 26 years.1–4 References 1. Centers for Disease Control and Prevention (CDC). http://www.cdc.gov/vaccines/recs/schedules/downloads/adult/2009/adult-schedule.pdf. Accessed August 26, 2009. 2. Centers for Disease Control and Prevention (CDC). http://www.cdc.gov/vaccines/recs/schedules/downloads/child/2009/09_7-18yrs_schedule_pr.pdf. Accessed August 26, 2009. 3. American College of Obstetricians and Gynecologists (ACOG). Obstet Gynecol . 2006;108:699–705. 4. Middleman AB et al. J Adolesc Health . 2006;38(3):321–327.
  • Cervical Cancer Prevention

    1. 1. Cervical Cancer Prevention Leslie Dignan-Moore, M.D. Springfield Clinic Department of Obstetrics and Gynecology
    2. 2. Cervical Cancer Myths <ul><li>Cervical cancer is not a big health concern. </li></ul><ul><li>Only older women get cervical cancer. </li></ul><ul><li>11,000 women diagnosed </li></ul><ul><li>4,000 women will die this year </li></ul><ul><li>About every 47 minutes another woman is diagnosed with cervical cancer. </li></ul><ul><li>Second most common cause of cancer-related death in women in their 20s-30s. </li></ul>
    3. 3. Cervical Cancer Myths <ul><li>Only women with a family history of cervical cancer are at risk. </li></ul><ul><li>I'll notice symptoms before I get true cancer. </li></ul><ul><li>Caused by a sexually transmitted viral infection. </li></ul><ul><li>NOT inherited. </li></ul><ul><li>Rarely are there signs of early stage cervical cancer. </li></ul>
    4. 4. Cervical Cancer Myths <ul><li>Nothing I do now will impact my risks of cervical cancer. </li></ul><ul><li>Smoking clearly has risk of lung cancer, but nothing to do with my cervix. </li></ul><ul><li>Vaccinations if correct age group. </li></ul><ul><li>Get your pap as recommended. </li></ul><ul><li>There has been a proven link between smoking and cervical cancer. </li></ul>
    5. 5. Start from the Beginning <ul><li>What is the cervix? </li></ul><ul><li>Facts on cervical cancer. </li></ul><ul><ul><li>What is the risk? </li></ul></ul><ul><ul><li>What causes cervical cancer? </li></ul></ul><ul><li>Screening techniques for cancer of the cervix. </li></ul><ul><ul><li>How often is appropriate for me? </li></ul></ul><ul><li>Vaccinations to prevent cancer </li></ul><ul><ul><li>HPV </li></ul></ul><ul><ul><ul><li>Who should get the vaccine? </li></ul></ul></ul>
    6. 6. Anatomy of My Body
    7. 7. Incidence of Cervical CA by State Surveillance, Epidemiology, and end results program, national cancer institute 1975-1991; 1992-2005. www.cdc.gov
    8. 8. Death Rates of Cervical CA by State Surveillance, epidemiology, and end results program, national cancer institute 1975-1991; 1992-2005. www.cdc.gov.
    9. 9. Cervical Cancer Facts United States Cancer Statisitics: 1999-2006 Incidence and Mortality Web-based report. DHHS, CDCP, and NCI;2010. www.cdc.gov/uscs
    10. 10. Cervical Cancer Facts
    11. 11. Causes of Cervical Cancer <ul><li>HPV- Human Papillomavirus. </li></ul><ul><ul><li>40 different type of virus. </li></ul></ul><ul><ul><li>Strain 16 - 60% of cases </li></ul></ul><ul><ul><li>Strain 18 – 20% of cases </li></ul></ul>
    12. 12. Oncogenic HPV Types Are a Necessary Cause of Cervical Cancer <ul><li>Infection with oncogenic HPV types is the most significant risk factor in cervical cancer etiology. 1 </li></ul><ul><li>First ever identified cancer solely attributed to an infectious agent. 2 </li></ul><ul><li>Analysis of 932 specimens from women in 22 countries indicated prevalence of HPV DNA in cervical cancers worldwide = 99.7%. 1 </li></ul><ul><li>Most common HPV types identified in cervical cancer: HPV 16, 18, 31, 33, and 45 </li></ul>1. Walboomers JMM, Jacobs MV, Manos MM, et al. J Pathol . 1999;189:12–19. 2. Bosch FX, Lorincz A, Muñoz N, Meijer CJLM, Shah KV. J Clin Pathol . 2002;55:244 –265. 3. Clifford GM, Smith JS, Plummer M, Muñoz N, Franceschi S. Br J Cancer. 2003;88:63 –73.
    13. 13. US HPV Statistics 1. Centers for Disease Control and Prevention. Rockville, Md: CDC National Prevention Information Network; 2004. 2. Cates W Jr, and the American Social Health Association Panel. Sex Transm Dis . 1999;26(suppl):S2–S7. 3. Weinstock H, Berman S, Cates W Jr. Perspect Sex Reprod Health . 2004;36:6–10. 4. Burk RD, Ho GYF, Beardsley L, Lempa M, Peters M, Bierman R. J Infect Dis . 1996;174:679–689. 5. Bauer HM, Ting Y, Greer CE, et al . JAMA . 1991;265:472–477. <ul><li>Lifetime risk for sexually active men and women is at least 50%. 1 </li></ul><ul><ul><li>By 50 years of age, at least 80% of women will have acquired genital HPV infection. 1 </li></ul></ul><ul><li>Estimated incidence: 6.2 million per year 1 </li></ul><ul><li>Estimated prevalence: 20 million 2 </li></ul><ul><li>In sexually active individuals 15 – 24 years of age, ~ 9.2 million are currently infected. 3 </li></ul>
    14. 14. Mechanisms of HPV Transmission and Acquisition <ul><li>Sexual contact </li></ul><ul><ul><li>Through sexual intercourse 1 </li></ul></ul><ul><ul><li>Genital – genital, manual – genital, oral – genital 2 – 4 </li></ul></ul><ul><ul><li>Genital HPV infection in virgins is rare, but may result from nonpenetrative sexual contact. 2 </li></ul></ul><ul><ul><li>Condom use may help reduce the risk, but it is not fully protective. 2 </li></ul></ul><ul><li>Nonsexual routes </li></ul><ul><ul><li>Mother to newborn (vertical transmission ; rare ) 5,6,7 </li></ul></ul>1. Kjaer SK, Chackerian B, van den Brule AJC, et al. Cancer Epidemiol Biomarkers Prev . 2001;10:101–106. 2. Winer RL, Lee S-K, Hughes JP, Adam DE, Kiviat NB, Koutsky LA. Am J Epidemiol . 2003;157:218–226. 3. Fairley CK, Gay NJ, Forbes A, Abramson M, Garland SM. Epidemiol Infect . 1995;115:169–176. 4. Herrero R, Castellsague X, Pawlita M, et al. J Natl Cancer Inst . 2003;95:1772–1783. 5. Smith EM, Ritchie JM, Yankowitz J, et al. Sex Transm Dis . 2004;31:57–62. 6. Ferenczy A, Bergeron C, Richart RM. Obstet Gynecol . 1989;74:950–954. 7. Roden RBS, Lowy DR, Schiller JT. J Infect Dis . 1997;176:1076–1079.
    15. 15. Risk Factors for HPV Infection <ul><li>Women </li></ul><ul><li>Young age (peak age group 20 –24 years of age ) 1 </li></ul><ul><li>Lifetime number of sex partners 2 </li></ul><ul><li>Early age of first sexual intercourse 3 </li></ul><ul><li>Male partner sexual behavior 3 </li></ul><ul><li>Smoking 4 </li></ul><ul><li>Oral contraceptive use 4 </li></ul><ul><li>Uncircumcised male partners 5 </li></ul><ul><li>Men </li></ul><ul><li>Young age (peak age group 25 –29 years of age ) 1 </li></ul><ul><li>Lifetime number of sex partners 6 </li></ul><ul><li>Being uncircumcised 6 </li></ul>1. Insinga RP, Dasbach EF, Myers ER . Clin Infect Dis. 2003;36:1397 – 1403. 2. Burk RD, Ho GYF, Beardsley L, Lempa M, Peters M, Bierman R. J Infect Dis . 1996;174:679–689. 3. Murthy NS, Mathew A. Eur J Cancer Prev . 2000;9:5–14. 4. Winer RL, Lee S-K, Hughes JP, Adam DE, Kiviat NB, Koutsky LA. Am J Epidemiol . 2003;157:218–226. 5. Schiffman M, Castle PE. Arch Pathol Lab Med . 2003;127:930–934. 6. Svare EI, Kjaer SK, Worm AM, Osterlind A, Meijer CJLM, van den Brule AJ. Sex Transm Infect . 2002;78:215–218.
    16. 16. Risk of Acquiring HPV After First Intercourse in Female Adolescents From Collins S, Mazloomzadeh S, Winter H, et al. High incidence of cervical human papillomavirus infection in women during their first sexual relationship. Br J Obstet Gynaecol . 2002;109:96 – 98. Reprinted with the permission of the Royal College of Obstetricians and Gynecologists. Time Since First Intercourse (Months) Cumulative risk of cervical HPV infection in female adolescents with only 1 sexual partner Cumulative Risk of HPV (%) 0 10 40 50 70 60 30 20 0 10 40 50 70 60 30 20 36 48 60 24 12 0 Cumulative Risk 0 10 40 50 70 60 30 20
    17. 17. HPV Clearance <ul><li>In women 15–25 years of age, ~ 80% of HPV infections are transient. 1 </li></ul><ul><ul><li>Gradual development of cell-mediated immune response presumed mechanism 2 </li></ul></ul><ul><li>In a study of 608 college women, 70% of new HPV infections cleared within 1 year and 91% within 2 years. 3 </li></ul><ul><ul><li>Median duration of infection = 8 months 3 </li></ul></ul><ul><ul><li>Certain HPV types are more likely to persist (eg, HPV 16 and HPV 18). </li></ul></ul>1. Meijer CJLM, Helmerhorst TJM, Rozendaal L, van der Linden JC, Voorhorst FJ, Walboomers JMM. Histopathology . 1998;33:83 – 86. 2 . Schiffman M, Kjaer SK. J Natl Cancer Inst Monogr . 2003;31:14–19. 3 . Ho GYF, Bierman R, Beardsley L, Chang CJ, Burk RD. N Engl J Med . 1998;338:423–428.
    18. 18. HPV Is Associated With Many Conditions 1 Cervical Cancer Cervical Intraepithelial Neoplasia (CIN) Genital Warts Vulvar Cancer Vaginal Cancer Vaginal Intraepithelial Neoplasia (VaIN) Vulvar Intraepithelial Neoplasia (VIN) Cervical Adenocarcinoma in situ (AIS) 1. Braaten KP et al. Rev Obstet Gynecol . 2008;1(1):2–10.
    19. 19. Anatomy of a Pap <ul><li>What is my doctor looking for? </li></ul><ul><li>What is the pathologist doing? </li></ul><ul><li>Can I still get a pap if I am on my period? </li></ul><ul><li>What if my pap is abnormal? </li></ul>
    20. 20. Anatomy of a Pap
    21. 21. Pap Smear
    22. 22. Select Cancer Screening Rates in the United States 1 <ul><li>Screening rates for cervical cancer are greater than breast and colorectal cancer screening rates. 1 </li></ul><ul><li>81% of women have had a Pap smear within the past 3 years. 1 </li></ul>Cervical Breast Colorectal 1. National Healthcare Quality Report. Rockville, Md: US Dept of Health and Human Services; 2003:iii-v, 1–38. Percentage of Target Population (2000)
    23. 23. How do Pap tests help prevent cervical cancer? Routine cervical cancer screening (Pap test) detects abnormal cervical cells before they have a chance to turn into cancer. Detecting and treating abnormal cervical cells early can almost always prevent cervical cancer from developing. Between 60% and 80% of women diagnosed with cervical cancer had not had a Pap test within 5 years of their diagnosis.
    24. 24. Pap Smears: Accuracy and Limitations <ul><li>Pap smears, including conventional and thin-layer liquid based: </li></ul><ul><ul><li>Relatively wide range of reported sensitivity, specificity, and positive predictive value 1 –4 </li></ul></ul><ul><ul><li>Specific challenges for Pap smears include 2,5,6 : </li></ul></ul><ul><ul><ul><li>Lack of sampling of lesions below the surface (they do not exfoliate) </li></ul></ul></ul><ul><ul><ul><li>Imperfect collection methods (some lesions are missed) </li></ul></ul></ul><ul><ul><ul><li>Inaccessibility of certain areas of the cervix </li></ul></ul></ul><ul><ul><ul><li>Errors of interpretation </li></ul></ul></ul>1. Parham GP. Am J Obstet Gynecol . 2003;188:S13 –S 20. 2. Schink JC. OBG Management. 2003;(suppl):5 – 8. 3. Uyar DS, Eltabbakh GH, Mount SL. Gynecol Oncol. 2003;89:227–232. 4. Kulasingam SL, Hughes JP, Kiviat NB, et al. JAMA . 2002;288:1749 – 1757. 5. Selvaggi SM. JAMA . 2001;285:1506 –1508. 6 . Chacho MS, Mattie ME, Schwartz PE. Cancer. 2003;99:135 – 140.
    25. 25. Timing is of the Essence <ul><li>Recommendations are based on the basics of screening tests. </li></ul><ul><ul><li>Preclinical detection of disease improves patient outcome. </li></ul></ul><ul><ul><li>Morbidity or mortality occurs if disease is left untreated. </li></ul></ul><ul><ul><li>Cost Effectiveness </li></ul></ul>
    26. 26. Timing is of the Essence <ul><li>Differing opinions </li></ul><ul><ul><li>USPSTF, ACS, ACOG. </li></ul></ul><ul><li>Why not screen everyone every year? </li></ul><ul><ul><li>Cost Effectiveness </li></ul></ul><ul><ul><li>Discomfort associated with pap smear. </li></ul></ul><ul><ul><li>Anxiety associated with abnormal pap. </li></ul></ul>
    27. 27. ACOG <ul><li>Prior recommendations </li></ul><ul><ul><li>First pap smear to be done </li></ul></ul><ul><ul><ul><li>Age 21 </li></ul></ul></ul><ul><ul><ul><li>Or three years after first intercourse </li></ul></ul></ul><ul><ul><li>Then </li></ul></ul><ul><ul><ul><li>Every year until age 30 </li></ul></ul></ul><ul><ul><li>Then </li></ul></ul><ul><ul><ul><li>may do every 2-3 years. </li></ul></ul></ul><ul><ul><li>Stop </li></ul></ul><ul><ul><ul><li>At discretion of physician- 70. </li></ul></ul></ul><ul><ul><ul><ul><ul><li>Cervical Cytology Screening. </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>ACOG Practice Bulletin Number 45, August 2003. </li></ul></ul></ul></ul></ul>
    28. 28. ACOG <ul><li>New guidelines </li></ul><ul><ul><li>First pap to be done at </li></ul></ul><ul><ul><ul><li>Age 21 regardless of intercourse history. </li></ul></ul></ul><ul><ul><ul><ul><ul><li>Cervical Cytology Screening. ACOG Practice Bulletin number 109; December 2009. </li></ul></ul></ul></ul></ul>
    29. 29. HPV Clearance <ul><li>In women 15–25 years of age, ~ 80% of HPV infections are transient. 1 </li></ul><ul><ul><li>Gradual development of cell-mediated immune response presumed mechanism 2 </li></ul></ul><ul><li>In a study of 608 college women, 70% of new HPV infections cleared within 1 year and 91% within 2 years. 3 </li></ul><ul><ul><li>Median duration of infection = 8 months 3 </li></ul></ul><ul><ul><li>Certain HPV types are more likely to persist (eg, HPV 16 and HPV 18). </li></ul></ul>1 3. Meijer CJLM, Helmerhorst TJM, Rozendaal L, van der Linden JC, Voorhorst FJ, Walboomers JMM. Histopathology . 1998;33:83 – 86. 2 . Schiffman M, Kjaer SK. J Natl Cancer Inst Monogr . 2003;31:14–19. 3 . Ho GYF, Bierman R, Beardsley L, Chang CJ, Burk RD. N Engl J Med . 1998;338:423–428.
    30. 30. Exposure to HPV at a Young Age Increases the Risk of Cervical Lesions and Cancer in Women1 aMantle-Haenszel estimates adjusted for age only. CIN = cervical intraepithelial neoplasia. 1. La Vecchia C et al. Cancer . 1986;58:935 – 941. Data from a case-control study of 206 cases of CIN and 237 cases of invasive cervical cancer compared with 206 and 327 age-matched outpatient controls, respectively. (n = 206) Relative Risk Estimatea Relative Risk for CIN and Invasive Cervical Cancer Increases With Decreasing Age of First Sexual Intercourse (n = 327) Reference population: First intercourse  23 years of age or never  17 18 to 22 Age at first intercourse, y
    31. 31. ACOG <ul><li>New Guidelines </li></ul><ul><ul><li>Age 21-29 </li></ul></ul><ul><ul><ul><li>Screening on a biennial basis is acceptable. </li></ul></ul></ul>
    32. 32. ACOG <ul><li>New Guidelines </li></ul><ul><ul><li>After age 30 may do pap smears every 3 years </li></ul></ul><ul><ul><ul><li>If getting HPV testing done on pap. </li></ul></ul></ul><ul><ul><ul><li>If HPV test is positive then would still require an annual pap. </li></ul></ul></ul><ul><ul><ul><ul><ul><li>Cervical Cytology Screening. ACOG Practice Bulletin number 109; December 2009. </li></ul></ul></ul></ul></ul>
    33. 33. What is an HPV DNA Test? <ul><li>This test checks for HPV’s genetic material (DNA). </li></ul><ul><li>Like a Pap test, an HPV test is done on a sample of cells collected from the cervix to: </li></ul><ul><ul><li>Check for high-risk types of HPV in women who had a Pap test that showed abnormal cells called atypical squamous cells (ASC) </li></ul></ul><ul><ul><li>Check for high-risk types of HPV in women older than 30 at the same time as a Pap test </li></ul></ul>
    34. 34. Special Exceptions <ul><li>Hysterectomy for benign disease </li></ul><ul><li>History of abnormal paps </li></ul><ul><li>History of cervical cancer </li></ul><ul><li>HIV patients </li></ul><ul><li>Medicare patients </li></ul>
    35. 35. Too Good to Be True <ul><li>Does this mean I may not need to see my Gynecologist every year???? </li></ul><ul><ul><li>Young women </li></ul></ul><ul><ul><ul><li>STD screening. </li></ul></ul></ul><ul><ul><ul><li>Birth Control. </li></ul></ul></ul><ul><ul><li>Over age 21 </li></ul></ul><ul><ul><ul><li>Annual breast exams. </li></ul></ul></ul><ul><ul><ul><li>Annual pelvic exams. </li></ul></ul></ul>
    36. 36. Myths About Pap Smears <ul><li>What if I am on my period? </li></ul><ul><li>What does a repeat pap smear mean? </li></ul><ul><li>Pap smears also check for STDs. </li></ul>
    37. 37. What if Your Pap Smear is Abnormal? <ul><li>Repeat pap smears- 3 month interval. </li></ul><ul><li>Colposcopy </li></ul><ul><ul><li>Magnified view of cervix. </li></ul></ul><ul><li>Excisional biopsy </li></ul><ul><ul><li>LEEP- in office </li></ul></ul><ul><ul><li>Cone biopsy- in operating room </li></ul></ul>
    38. 38. What else can I do to help protect myself from cervical cancer?
    39. 39. Vaccinations <ul><li>Gardasil </li></ul><ul><ul><li>Quadrivalent </li></ul></ul><ul><ul><ul><li>Protects against 4 strains of HPV </li></ul></ul></ul><ul><ul><ul><li>FDA approved for several years. </li></ul></ul></ul><ul><li>Cervarix </li></ul><ul><ul><li>Bivalent </li></ul></ul><ul><ul><ul><li>Protects again 2 strains of HPV. </li></ul></ul></ul><ul><ul><ul><li>FDA approved since fall 2009. </li></ul></ul></ul>
    40. 40. GARDASIL ® [Human Papillomavirus Quadrivalent (Types 6, 11, 16, and 18) Vaccine, Recombinant]
    41. 41. HPV Is Associated With Many Conditions 1 Cervical Cancer Cervical Intraepithelial Neoplasia (CIN) Genital Warts Vulvar Cancer Vaginal Cancer Vaginal Intraepithelial Neoplasia (VaIN) Vulvar Intraepithelial Neoplasia (VIN) Cervical Adenocarcinoma in situ (AIS) 1. Braaten KP et al. Rev Obstet Gynecol . 2008;1(1):2–10.
    42. 42. Introduction <ul><li>GARDASIL was approved by the FDA in June 2006. 1 </li></ul><ul><li>More than 40 million doses of GARDASIL have been distributed worldwide as of February 2009. 2 </li></ul><ul><li>Professional societies’ HPV vaccine recommendations. 3 – 6 </li></ul><ul><ul><li>The quadrivalent HPV vaccine received an ACIP recommendation in June 2006. 1 </li></ul></ul>1. Markowitz LE et al. MMWR Recomm Rep. 2007;56(RR-2):1-24. 2. Merck & Co., Inc., company data. 3. Centers for Disease Control and Prevention (CDC). http://www.cdc.gov/vaccines/recs/schedules/downloads/adult/2009/adult-schedule.pdf. Accessed August 26, 2009. 4. Centers for Disease Control and Prevention (CDC). http://www.cdc.gov/vaccines/recs/schedules/downloads/child/2009/09_7-18yrs_schedule_pr.pdf. Accessed August 26, 2009. 5. American College of Obstetricians and Gynecologists (ACOG). Obstet Gynecol . 2006;108:699–705. 6. Middleman AB et al. J Adolesc Health . 2006;38(3):321–327. FDA = Food and Drug Administration; AAFP = American Academy of Family Physicians; AAP = American Academy of Pediatrics; ACIP = Advisory Committee on Immunization Practices; ACOG = American College of Obstetricians and Gynecologists; ACP = American College of Physicians; SAM = Society for Adolescent Medicine . GARDASIL® [Human Papillomavirus Quadrivalent (Types 6, 11, 16, and 18) Vaccine, Recombinant] Routine vaccination in females 11–12 years old Catch-up vaccination in 13- to 26-year-olds Females 9–10 years old can be vaccinated Recommendations ACIP 3,4 ACOG 5 AAFP 3,4 ACP 3,4 AAP 3,4 SAM 6
    43. 43. Select Information About GARDASIL <ul><li>Indication </li></ul><ul><li>GARDASIL is a vaccine indicated in girls and women 9 through 26 years of age for the prevention of cervical, vulvar, and vaginal cancers; precancerous or dysplastic lesions; and genital warts caused by HPV Types 6, 11, 16, and 18. </li></ul><ul><li>GARDASIL is indicated in boys and men 9 through 26 years of age for the prevention of genital warts caused by HPV Types 6 and 11. </li></ul><ul><ul><li>Just approved by FDA for boys. </li></ul></ul>GARDASIL® [Human Papillomavirus Quadrivalent (Types 6, 11, 16, and 18) Vaccine, Recombinant]
    44. 44. Gardasil's Administration <ul><li>Intramuscular injection </li></ul><ul><ul><li>Arm or upper hip </li></ul></ul><ul><li>Three separate injections. </li></ul><ul><ul><li>Baseline </li></ul></ul><ul><ul><li>2 months after baseline </li></ul></ul><ul><ul><li>6 months after baseline </li></ul></ul><ul><li>No boosters necessary. </li></ul>
    45. 45. Gardasil's Limitations <ul><li>Gardasil DOES NOT </li></ul><ul><ul><li>Eliminate the need for pap smears. </li></ul></ul><ul><ul><li>Provide protection against vaccine and non-vaccine strains of HPV that patient may have already been exposed to through sexual activity. </li></ul></ul><ul><ul><li>Treat active external genital lesions; cervical, vulvar, or vaginal cancers; CIN, VAIN, VIN. </li></ul></ul><ul><ul><li>Protect against strains of HPV not contained in the vaccine. </li></ul></ul>
    46. 46. Gardasil's Limitations <ul><li>Gardasil DOES NOT </li></ul><ul><ul><li>Eliminate the need for pap smears. </li></ul></ul><ul><ul><li>Provide protection against vaccine and non-vaccine strains of HPV that patient may have already been exposed to through sexual activity. </li></ul></ul><ul><ul><li>Treat active external genital lesions; cervical, vulvar, or vaginal cancers; CIN, VAIN, VIN. </li></ul></ul><ul><ul><li>Protect against strains of HPV not contained in the vaccine. </li></ul></ul>
    47. 47. Gardasil's Limitations <ul><li>Not all vulvar and vaginal cancers are caused by HPV </li></ul><ul><ul><li>Gardasil will only protect against those cases of cancer caused by HPV types 16 or 18. </li></ul></ul>
    48. 48. Select Information About GARDASIL ( cont ) <ul><li>Select Safety Information </li></ul><ul><li>GARDASIL is contraindicated in individuals with hypersensitivity, including severe allergic reactions to yeast, or after a previous dose of GARDASIL </li></ul><ul><li>Because vaccinees may develop syncope, sometimes resulting in falling with injury, observation for 15 minutes after administration is recommended. Syncope, sometimes associated with tonic-clonic movements and other seizure-like activity, has been reported following vaccination with GARDASIL. When syncope is associated with tonic-clonic movements, the activity is usually transient and typically responds to restoring cerebral perfusion. </li></ul>GARDASIL® [Human Papillomavirus Quadrivalent (Types 6, 11, 16, and 18) Vaccine, Recombinant]
    49. 49. Select Information About GARDASIL ( cont ) <ul><li>GARDASIL is not recommended for use in pregnant women. </li></ul><ul><li>The most common adverse reaction was headache. Common adverse reactions that were observed among recipients of GARDASIL at a frequency of at least 1.0% and greater than placebo were fever, nausea, dizziness; and injection-site pain, swelling, erythema, pruritus, and bruising. </li></ul>GARDASIL® [Human Papillomavirus Quadrivalent (Types 6, 11, 16, and 18) Vaccine, Recombinant] GARDASIL is a registered trademark of Merck & Co., Inc. Copyright© 2010 Merck & Co., Inc. All rights reserved. 20953247(3)-02/10-GRD
    50. 50. Behavior reported in an independent study suggests minimal exposure to HPV at ≤ 11 years of age 1. Markowitz LE et al. MMWR Recomm Rep. 2007;56(RR-2):1–24. 2. Hoff T et al. National Survey of Adolescents and Young Adults: Sexual Health Knowledge, Attitudes and Experiences . Henry J. Kaiser Family Foundation; 2003. A national survey of adolescents and young adults aged 15 to 24 years (N=1,552) focused on sexual health knowledge, attitudes, and experiences; these data reflect 1,014 participants who reported having had an initial sexual intercourse encounter.2 Cohorts that have had intercourse, % Age at first intercourse, Years Suggests minimal exposure to HPV at  11 years of age  11 0 20 40 60 80 100 12 to 13 14 to 15 16 to 17 2% 7% 40% 28% Adapted from Henry J. Kaiser Family Foundation
    51. 51. Reasons for Routine Vaccination in 11- to 12-Year-Old Girls 1 <ul><li>According to the CDC, the most effective time to vaccinate is prior to exposure. </li></ul><ul><li>Robust antibody titers responses are seen in this age group after vaccination. </li></ul><ul><li>Patients coming to pediatric offices. </li></ul>1. Centers for Disease Control and Prevention (CDC). http:www.cdc.gov/vaccines/recs/ACIP/defaul.htm. Accessed June 15, 2009. CDC= Centers for Disease Control and Prevention.
    52. 52. Sexual Activity Among US High School Students 1 Centers for Disease Control and Prevention 2007 US Youth Risk Behavior Survey (N = 14,103) 1 Individuals Who Have Had Sexual Intercourse (%) Percentage of US High School Students Who Have Had Sexual Intercourse2 7.1% of US adolescents reported sexual debut before age 131,2 14.9% of US adolescents reported  4 lifetime sexual partners by Grade 121,2 1. Eaton DK et al. MMWR Surveill Summ. 2008;57(SS04);1–131. 2. Gavin L et al. MMWR Surveill Summ. 2009;58(SS06):1–58.
    53. 53. Summary of US HPV Vaccine Recommendations <ul><li>National guidelines recommend HPV vaccination in females regardless of previous HPV infection or abnormal Pap test results 1–4 </li></ul><ul><li>ACOG: Sexually active women and women with previous abnormal cervical cytology or genital warts can receive the quadrivalent HPV vaccine 3 </li></ul><ul><ul><li>Women with previous HPV infection will benefit from protection against disease caused by the HPV vaccine types with which they have not been infected </li></ul></ul>1. Centers for Disease Control and Prevention (CDC). http://www.cdc.gov/vaccines/recs/schedules/downloads/adult/2009/adult-schedule.pdf. Accessed August 26, 2009. 2. Centers for Disease Control and Prevention (CDC). http://www.cdc.gov/vaccines/recs/schedules/downloads/child/2009/09_7-18yrs_schedule_pr.pdf. Accessed August 26, 2009. 3. American College of Obstetricians and Gynecologists (ACOG). Obstet Gynecol . 2006;108:699–705. 4. Middleman AB et al. J Adolesc Health . 2006;38(3):321–327. Catch-up vaccination in 13- to 26-year-olds Vaccinate regardless of previous HPV infection or abnormal Pap test results ACIP = Advisory Committee on Immunization Practices; ACOG = American College of Obstetricians and Gynecologists; AAFP = American Academy of Family Physicians; ACP = American College of Physicians; AAP = American Academy of Pediatrics; SAM = Society for Adolescent Medicine. Recommendations ACIP 1,2 ACOG 3 AAFP 1,2 ACP 1,2 AAP 1,2 SAM 4
    54. 54. Cervarix <ul><li>Bivalent recombinant HPV vaccine. </li></ul><ul><li>HPV 16 and 18. </li></ul>
    55. 55. Cervarix <ul><li>Similar to prior Gardasil information. </li></ul><ul><ul><li>Females only </li></ul></ul><ul><ul><ul><li>Age 10-25 </li></ul></ul></ul><ul><ul><li>Intramuscular injection </li></ul></ul><ul><ul><ul><li>Baseline </li></ul></ul></ul><ul><ul><ul><li>One month after baseline </li></ul></ul></ul><ul><ul><ul><li>6 months after baseline </li></ul></ul></ul>
    56. 56. Cervarix <ul><li>Adverse reactions </li></ul><ul><ul><li>Local- pain, redness, swelling. </li></ul></ul><ul><ul><li>General- fatigue, headache, muscle aches, joint aches, GI upset. </li></ul></ul><ul><li>Contraindications </li></ul><ul><ul><li>Severe allergic reaction to any component </li></ul></ul><ul><ul><li>Not studied in pregnant or breastfeeding women. </li></ul></ul>
    57. 57. To Summarize <ul><li>Get your pap smears </li></ul><ul><ul><li>Age 21 </li></ul></ul><ul><ul><li>Age 21-29- biennial </li></ul></ul><ul><ul><li>Age 30-70- every three years </li></ul></ul><ul><li>Get vaccinated </li></ul><ul><ul><li>Gardasil or Cervarix </li></ul></ul><ul><li>See your Gynecologist at least annually regardless of pap needs. </li></ul>
    58. 58. Where do I Start Now? <ul><li>Make an appointment with your gynecologist. </li></ul><ul><ul><li>IBCCP </li></ul></ul><ul><ul><ul><li>1-888-522-1282 or http:cancerscreening.illinois.gov </li></ul></ul></ul><ul><li>Get vaccinated. </li></ul><ul><ul><li>Vaccines for children program </li></ul></ul><ul><ul><ul><li>www.cdc.gov/vaccines/programs.vfc </li></ul></ul></ul><ul><ul><ul><li>www.helppreventcervicalcancer.com </li></ul></ul></ul><ul><li>Quit smoking </li></ul><ul><ul><li>Illinois Tobacco Quit Line </li></ul></ul><ul><ul><ul><li>1-866-784-8937 </li></ul></ul></ul><ul><ul><ul><li>www.lungil.org/tobacco/quit.cfm </li></ul></ul></ul>
    59. 59. <ul><li>Any Questions??? </li></ul>

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