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![Risk Factors for Female Genital
HPV Infection
• Sexual behavior of her male sexual partners
Risk increased if he has had > 3 partners1
Risk increased if he has had a same sex partner (s)
[bisexual contact(s)].
• Increased number of male sexual partners (>3)1
(increases the risk of encountering an HPV infected
male !)
• Sexual Intercourse at a young age (before the age of 24 in the U.S)
-the maturing cervical epithelium (T-Zone) is felt to be more easily
infected by HPV.
1. Ley et al. J Natl Cancer Inst. 1991.83.997](https://image.slidesharecdn.com/cancervaccinepresentation2-200129071301/85/Cancer-vaccine-presentation2-8-320.jpg)
![Other Possible Mechanisms of HPV
Transmission & Infection
• Non-Sexual Transmission
– Mother to newborn [respiratory tract
papillomatosis] (vertical transmission)2
– Skin to skin (thought to require breaks in
skin surface)
1. Winer RL, et al. Am J Epidemiol. 2003:157:318-226
2. Smith EM et al. Sex Transm Dis. 2004.31;57-62.](https://image.slidesharecdn.com/cancervaccinepresentation2-200129071301/85/Cancer-vaccine-presentation2-9-320.jpg)
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Cancer vaccine presentation2
- 1. Cervical cancer: Because thevaccine is not the worst case scenario Jennifer L. Young, MD, MPH National Organization for Women Panel September 23, 2008
- 2. Objectives • Answer 2questions – Is cervical cancer worth preventing? – How do we prevent it – the easy way or the hard way?
- 3. Epidemiology of cervicalca • 11,070 new cases each year • 3,760 deaths from cervical ca • Risk factors same as for HPV infection for majority of patients – Early age of sexual debut – Multiple sexual partners – Smoking – HIV – History of sexually transmitted disease • 50% higher risk in black compared to white
- 4. Risk factors forcervical cancer • Risk of HPV – Lifetime risk for women 80% • Not having adequate screening – No pap smear in last 3 years – Decreased access to medical care • Immunosuppressed – HIV – Diabetic – Other
- 5. Cervical cancer bystate
- 6. Incidence of cervicalcancer by race in Virginia
- 7.
- 8. Risk Factors forFemale Genital HPV Infection • Sexual behavior of her male sexual partners Risk increased if he has had > 3 partners1 Risk increased if he has had a same sex partner (s) [bisexual contact(s)]. • Increased number of male sexual partners (>3)1 (increases the risk of encountering an HPV infected male !) • Sexual Intercourse at a young age (before the age of 24 in the U.S) -the maturing cervical epithelium (T-Zone) is felt to be more easily infected by HPV. 1. Ley et al. J Natl Cancer Inst. 1991.83.997
- 9. Other Possible Mechanismsof HPV Transmission & Infection • Non-Sexual Transmission – Mother to newborn [respiratory tract papillomatosis] (vertical transmission)2 – Skin to skin (thought to require breaks in skin surface) 1. Winer RL, et al. Am J Epidemiol. 2003:157:318-226 2. Smith EM et al. Sex Transm Dis. 2004.31;57-62.
- 10. Cervical cancer prevention •Pap smears performed once per year until age 30 • >30 yo- once every 3 yrs if pap and HPV negative • 75% reduction in cervical cancer in countries with adequate screening • At what cost? – 3 million abnormal pap smears a year – 300,000 high grade dysplasia – 11,000 cervical cancers
- 11. Financial burden ofHPV disease in the US1
- 12. Emotional cost • Mostwomen describe feelings of being dirty or unclean after the diagnosis of an abnormal pap smear – Decreased sexual drive – Poor self image – Decreased feelings of intimacy with their partner
- 13. What is thetreatment for an abnormal pap smear? • Microscopic examination of the cervix for abnormal cells • Removal of the abnormal cells – Laser – Freeze abnormal cells – Excise abnormal cells with a scalpel or by burning
- 14. Costs to society •Risks of cervical procedures – Cervical scarring – infertility – Cervical weakening – pregnancy risk • 2.5x increased risk of preterm labor • 2.5x increased risk of low birth weight • 3x increased risk of cesarean section
- 15. Cervical Cancer Treatment •Surgical management – Radical hysterectomy with lymph node removal – Goal is removal of all tumor – If LN positive – pt will need postop radiation • Chemoradiation – External beam radiation – usually 25 days – Weekly chemotherapy – Internal radiation 2-6 days
- 16. Complications of treatment •Gynecologic – Vaginal scarring – Poor sexual function – Menopause • Gastrointestinal – Chronic diarrhea – Bowel obstruction – Fistula • Urologic – Blockage of ureters with kidney failure – Hemorrhagic cystitis – Fistula • Other – Chronic back pain – Skin changes – Lymphedema in legs
- 17.
- 18. Recurrent cervical cancer •30% of cervical cancers will recur and most are fatal – If metastatic treated with chemotherapy – If localized, one potentially curative option • Pelvic exenteration curative 50% of the time
- 19. Conclusions • Cervical canceraffects women in our community • Cervical cancer is a serious disease – Risks just from preventing cancer – 30% mortality from cervical cancer – Long term effects after treatment for cervical cancer • Cervical cancer is preventable – Regular pap smears – HPV vaccination
- 20. HPV Vaccination: HotTopics Jennifer L. Young, MD, MPH University of Virginia September 23, 2008
- 21. HPV Vaccine Safety Informationobtained from the CDC VAERS website • NO PROVEN ASSOCIATION of death from Gardasil – 21 deaths occurred after Gardasil vaccine – 12 investigated and found to be unrelated – 5 no patient identification in the report thus unable to be investigated – 4 in foreign countries, unable to be investigated
- 22. HPV Vaccine Safety Informationobtained from the CDC VAERS website • Guillan-Barre Syndrome (GBS) – Neurologic illness occuring after viral infection in 1- 2/100,000 teenagers – 44 reported cases after Gardasil vaccination • 42 in US, 2 in foreign countries – 13 confirmed – 9 pending follow-up – 8 did not meet criteria for diagnosis – 11 unconfirmed – 1 had symptoms prior to vaccination – NO PROVEN ASSOCIATION • Rate is within range of that which would be expected by chance alone
- 23. Mandating the HPVvaccine • Racial differences in vaccination rates may widen the gap • Mandate for your doctors
- 24. Childhood vaccination racial disparities:closing the gap National Coverage with 4:3:1:3:3:1 Series by Race/Ethnicity 1. CDC. MMWR September 5, 2008; 57(35): 961-966.
- 25. Racial disparities in childhoodvaccinations • Since 2005, the CDC notes that racial disparities in childhood vaccines are closing1 – Largely attributed to Vaccines for Children (VFC) program – Remain large variation by state and between rural and urban – Virginia remains average with coverage rates 67-91% • Study of Hep B school mandate2 – Vaccination rates increased (85% vs. 37%) – Racial disparities decreased • Black vs. white (RR 0.94 from 0.70) • Hispanic vs. white (RR 0.97 from 0.88) 1. CDC. MMWR September 5, 2008; 57(35): 961-966. 2. Morita JY et al. Pediatrics 2008; 121(3): e547-e552.
- 26. HPV Vaccine Legislation •Funding allocations – 8 states considered – 3 states have passed • Educational campaigns – 24 states have considered – 14 states have passed • Mandatory insurance coverage – 18 states have considered – 5 states have passed into law (CA, CO, IL, NM, RI)
- 27. School mandates • Texas –Gov. Rick Perry signed Executive Order 4 Feb. 2, 2007 – H.B. 1098 reversed HPV mandate • New Mexico – HPV school mandate vetoed by the Governor • Virginia – HPV school mandate signed into law after revision – Increased ease of parental opt-out • District of Columbia – Mandate has passed City Council – Congressional review date has passed
- 28. Virginia school mandate •Only HPV vaccination mandate in the country • Signed into law April 2007 • Requires all girls to have initiated the HPV vaccination series prior to entry into the sixth grade starting October 2008 • Verbal parental opt-out • 3 bills introduced to overturn – All failed in committee in 2008 General Session
- 29. Debate continues inVirginia • 2008 General Assembly – HB 89 to repeal mandate – SB 722 to repeat mandate – HB 188 to delay mandate until 2010 • Out of committee with a 13/9 vote • Passed the House 57/39 • Defeated in Senate committee • School mandate to go into effect October 2008
- 30. “None of usis going to be satisfied if the only women getting the vaccine are the same women already covered by screening programs.” - John Schiller National Cancer Institute
- 31. Paying for theHPV vaccine
- 32. Current Coverage ofthe HPV vaccine • 3 shot regimen costing $120/injection or $360 total • Coverage ≤ 18 years old – Public: Federal Vaccines for Children program for Medicaid qualifiers – Private: Most insurance companies cover but age range and reimbursements differ • Coverage > 18 years old – Public: Medicaid coverage of women 18-21 at high risk – Private: Most insurance companies cover but age range and reimbursements differ
- 33. Cost effectiveness ofHPV vaccine • < $50,000 for QALY considered cost effective – Mammograms for breast ca $67,000 QALY – PSA for prostate cancer screening $113,000 • HPV vaccine in setting of current screening1 – $3,906-$14,723 per QALY – Lower if herd immunity achieved 1. Chesson HW. Emerg Infect Dis 2008 14(2): 244.
- 34. Future Information onVaccines • Booster? • Older women? • Women with prior HPV disease?
- 35. Immunogenicity of vaccines OlssonSE et al . Vaccine 2007; 25: 4931.
- 36. Breaking news: Quadrivalentvaccine • Efficacy in HPV + women1 – 100% effective in preventing CIN 2/3 from vaccine viral types for neg women – 94% effective in preventing vulvar/vaginal disease • Women aged 24-452 - Study of 3819 women - 67% naïve to 6,11,16,18 - Only 0.7% of women + for >1 vaccine viral types 1. FUTURE II Study Group. J Infect Dis 2007; 196: 1438. 2. Makhija S, FUTURE III Investigators. Gyn Oncology 2008, abstract.