HPV INFECTIONS WITH RECENT ADVANCES IN CARCINOMA CERVIX

1. DR. SONAL SAHNI
ASSOCIATE PROFESSOR
DEPARTMENT OF OBSTETRICS AND
GYNAECOLOGY
NSCB MEDICAL COLLEGE JABALPUR

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Educational Program 2015 3
CERVIX

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India ~1,32,000
World ~ 4,93,000
India ~27% of new
Cervical Cancer cases in world
India ~ 74,000
World ~ 2,73,000
India ~27%
Rest of World - 73%
India ~27% of deaths
due to Cervical Cancer in world
Rest of World - 73%
India - 27%
Cervical Cancer – Disease Burden
New Cervical Cancer Cases Deaths due to Cervical cancer
India ~27%
Rest of World - 73%

5. May 2018: WHO Director General’s Call to Action to Eliminate
Cervical Cancer as a Public Health Problem

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Educational Program 2009 6
Is it possible
to get
protection
against
cervical cancer?

7.  PRIMARY PREVENTION
Understanding of HPV infection and role of
vaccination.
 SECONDARY PREVENTION
By screening & early treatment of pre-
cancerous lesions.

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Preventing aspects-lifestyle change
Social change –avoid early marriages
Multiparity_ role of family planning
Avoid multiple partners
Use of condom to avoid STD,and HPV diseases
Improve nutrition and personal hygiene
Prevents smoking ,alcoholism ,etc
Regular exercise
Health awareness-health check up

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HPV 16
HPV 18
HPV 6
HPV 11
Cancer causing Types1,2,4 Non-cancer causing types1,2
• >75% of Cervical Cancer5
• >50% of Vaginal & Vulvar Cancer5
90% of Anogenital warts5
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/hpvcentre
Human Papillomavirus (HPV)

10. Normal
Cervix
HPV
Infection
Pre-cancer Cancer
Infection
Progression Invasion
Regression
Clearance
 Persistence

11.  HPV type and viral load
 Persistent HPV infection
 Smoking- carcinogenic
 Tobacco-specific N-nitrosamines have been
demonstrated in cervical mucus of smoker
 Sexually transmitted infectious agents-
Chlamydia trachomatis has been associated
with increased HPV persistence
 Dietary factors- low intake of vitamin C,
carotenoids, vitamin E and folate

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09-2009-GRD-2008-AP-(IN)-1601-SS

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HPV Vaccines- made by
recombinant DNA technology

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 This vaccine can be given to any girl
above 9 years. Recommended for
women of 9-45 years age group
 The most effective time to vaccinate
girls and young women is before they
become sexually active.
Educational Program 2009 14

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 Three doses
 First .(as elected date)
 Second (after 2 month of first dose)
 Third (after 6 month of first dose)
Cerverix – 0,1 & 6
Educational Program 2009 15
6
months
2
Months
0

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Beware of this symptoms
Consult your doctor immediately if you have
• Continuous vaginal discharge,inspite of treatment
• Foul smelling, thick discharge,
• Repeated vaginitis and UTI
• Post coital bleeding(bleeding after sex)
• Non healing or recurrent cervical erosion
• Irregular or intermenstrual bleeding specially in pre
menopausal phase

18.  Early detection by screening all women in the target
age-group, followed by treatment of detected
precancerous lesions, can prevent the majority of
cervical cancers.
 Cervical cancer screening should be performed at
least once for every woman in the target age group
where most benefit can be achieved.
 Devices that can detect HPV, cytology and VIA play an
important role in cervical cancer prevention
programs.
 Accordingly, effective and appropriate technologies
for the treatment of precancerous lesions be used:
LEEP, cryotherapy, or thermal ablation.
Target: 70% of women screened with an HPV test at 35 and 45 years of age
& 90% of the one screened positive managed appropriately
*2030 targets & elimination threshold are subject to revision depending on outcomes of the modeling & the WHO approval
process.

19.  Visual Inspection with Acetic Acid (VIA) is a
technique for the detection of pre-cancerous or
cancerous lesions in the cervix.
 The application of dilute acetic acid on such lesions
triggers whitening of these regions.
 VIA is a relatively simple, low-cost
method presenting immediate results.
 A positive result can be followed by
immediate treatment (i.e. single-visit
approach).
 VIA is subjective and depends on the
skills and experience of the provider.
VIA Screening Results:
Negative Positive
Image source: Jhpiego, 2015

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 “prevention is better than cure’-holds true for
cervical cancer
 This can be achieved by regular health
check up and regular pap smear test
 Pap- smear is cancer screening which is easy
,painless and reliable method in which the
discharge from vagina is taken on slide and
sent for examination for presence of
abnormal cells
 Routine pap smear has reduced ca cx by 75%
in developed world
 Repeat pap is advised if it shows abnormal
cells & than advised colposcopy & biopsy.
 It can give early diagnosis of cancer before
its sets in and hence early treatment can
avoid disease

21.  Rosche cobas HPV test
 Cobas 4800 system test includes
CT,NG,HSV1,HSV2,SA,MRSA
 Hybride capture -2 HR HPV DNA test
 Cervista HPV HR and genfind DNA extraction kit
 APTIMA HPV assay- 14 HR HPV – m HPV RNA Test

22. ABLATIVE
METHODS
(THERAPEUTIC ONLY)
EXCISIONAL
METHODS
(DIAGNOSTIC+THERAPEUTIC)
• Cryotherapy
• Laser ablation
• Electrocautery
• LEEP
• Laser excision
• Conisation
• Hysterectomy

23.  The equipment is simple &
relatively inexpensive.
 External gas is not required.
 Electricity is not necessarily required; can function
off of portable batteries/power-supply.
 In the context of a screen & treat approach, a
screen-positive result can be followed by an offer of
treatment at the same visit, maximizing treatment
coverage and reducing loss to follow-up.
 This treatment method does not produce a
specimen for pathological examination.

24.  The equipment is simple &
relatively inexpensive.
 Electricity is not required.
 In the context of a screen & treat approach, a
screen-positive result can be followed by an
offer of treatment at the same visit, maximizing
treatment coverage and reducing loss to follow-up.
 This treatment method does not produce a specimen
for pathological examination.

25.  LEEP – Loop Electrosurgical Excision Procedure – is the removal of
abnormal areas from the cervix and the entire transformation zone
using:
 A thin wire loop powered by an
electrosurgical unit (ESU), which
cuts and coagulates at the same
time; after which,
 A ball electrode is used on the
tissue to complete the coagulation.
 Tissue removed can be sent for
examination to the histopathology
laboratory, allowing the extent of the lesion to be assessed.
 The procedure can be performed under local anesthesia on an
outpatient basis and usually takes 10-15 minutes; however, a patient
should stay in-facility for a few hours to assure bleeding does not
occur.
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2
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3
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26.  Women diagnosed with early invasive cervical cancer
can usually be cured with effective treatment.
 It is important for health-care providers at all levels
to be able to recognize and promptly manage
common symptoms and signs of cervical cancer.
 The definitive diagnosis of invasive cervical cancer is
made by histopathological examination of a biopsy.
 Treatment options include surgery, radiotherapy and
chemotherapy; these may be used in combination. If
left untreated, invasive cervical cancer is almost
always fatal.
Target: 30% reduction of mortality from cervical cancer

27. 2020-2030 Acceleration plan towards elimination
The 2030 targets and elimination threshold are subject to revision depending on the outcomes of the
modeling and the WHO approval process
Vision: A world without cervical cancer
Goal: below 4 cases of cervical cancer per 100,000 woman-years
90%
of girls fully vaccinated
with HPV vaccine by 15
years of age
70%
of women screened with
an HPV test at 35 and 45
years of age and 90%
managed appropriately
30%
reduction in mortality
from cervical cancer
2030
TARGETS

28. Guiding principles: life course and public health approach, social justice and
equity, integrated people-centered health services
Increased
coverage of HPV
vaccination
Increased
coverage of
screening &
treatment of pre-
cancer lesions
Increased
coverage of
diagnosis &
treatment for
invasive cancer
and palliative care
Accelerators
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2
3
KEY OUTPUTS

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