Don't miss our upcoming webinars! Subscribe today! In this webinar, Dr. Durand will review the changing landscape of HPV-related diseases and cancers. She will discuss methods of HPV prevention for current cancer patients and cancer survivors. Attendees will learn about the evidence for HPV vaccination in adults. Practical tips will be provided on how to access HPV vaccination. View the YouTube video: https://youtu.be/wFgpmqOpzC4 Follow CCSN on social media: Twitter - https://twitter.com/survivornetca Facebook - https://www.facebook.com/CanadianSurvivorNet Instagram: https://www.instagram.com/survivornet_ca/ Pinterest - https://www.pinterest.com/survivornetwork

1. HPV Prevention for
Cancer Survivors and Caregivers:
identifying our risk and preventing disease
Nancy Durand, MDCM, FRCSC
Sunnybrook Health Sciences Centre
Associate Professor, University of Toronto
Department of Obstetrics and Gynaecology
Toronto, Ontario, Canada

2. Presenter Disclosure:
• Presenter: Dr. Nancy Durand
Sunnybrook Health Sciences Centre
Toronto, Ontario, Canada
• Relationships with commercial interests:
– Speakers Bureau/Honoraria: Merck Canada, Merck Global
– Consulting Fees: Merck Canada & Merck Global Advisory Boards
• Other: Associate Professor,
University of Toronto
Dept. of Obstetrics and Gynaecology
Sunnybrook Health Sciences Centre

3. Objectives:
• The changing burden of HPV-related diseases
• Presentation and management of HPV-related diseases
• Methods of prevention of HPV-related diseases
• Practical steps to access HPV vaccination

4. Burden of HPV-related Diseases

5. What is HPV?
• Most common sexually transmitted infection
worldwide

6. What is HPV?
• Most common sexually transmitted infection
worldwide
• >75% adults have at least 1 genital HPV infection
during lifetime

7. What is HPV?
• Most common sexually transmitted infection
worldwide
• >75% adults have at least 1 genital HPV infection
during lifetime
• 30-65% of adults infected at any given time

8. HPV Types:
LOW RISK TYPES: HPV DISEASES:
6, 11 anogenital warts
low-grade pre-cancer
HIGH RISK TYPES:
16, 18, 31, 33, 35, 39, 45, low-grade pre-cancer
51, 52, 56, 58, 59, 66, 68 high-grade pre-cancer
cervical cancer
vulvar / vaginal cancer
penile cancer
anal cancer
oropharyngeal cancer

9. HPV- Clinical Course
1. Asymptomatic (carrier)

10. HPV- Clinical Course
1. Asymptomatic (carrier)
2. External genital warts

11. HPV- Clinical Course
1. Asymptomatic (carrier)
2. External genital warts
3. Pre-cancer / cancer
• Cervix
• Vulva
• Vagina
• Penis
• Anus
• Mouth and throat

12. 18–59 Years
NHANES Survey 2007–20101
18–70 Years
HIM Study2
aInfectionwith any of 37 HPV types.
NHANES= NationalHealthand NutritionExamination Survey; HIM = Human Papillomavirus Infectionin Men study.
1. Shi R et al. BMC Res Notes.2014;7:544. 2. GiulianoAR et al. Cancer EpidemiolBiomarkersPrev. 2008;17:2036–2043.
70%
60%
50%
40%
30%
20%
10%
HPV Prevalence
HPV Infection Is Common Among Adultsa
25–29
years old
35–39
years old
45–49
years old
20–24
years old
30–34
years old
40–44
years old

13. 52%
45–70 years
32%
31–44 years
23%
18–30 years
42%
45–64 years
15%
<25 years
25%
25–34 years
27%
35–44 years
Persistent HPV Infection Increases With Age1,2,a
aPersistentinfection with any of 37 HPVtypes in males and >40 types in females.1,2
1. Nyitray AG et al. J Infect Dis. 2011;204:1711–1722.2. Castle PE et al. J Infect Dis. 2005;191:1808–1816.
Costa Rica study
HIM study

14. Burden of HPV-Related Disease in Males Is Increasing
None of the available HPV vaccines are indicated to prevent oropharyngeal cancer, penile cancer, or recurrent respiratory papillomatosis.
HPV = human papillomavirus.
1. Greer CE et al. J Clin Microbiol. 1995;33:2058–2063. 2. Freed GL et al. Int J Pediatr Otorhinolaryngol. 2006;70:1799–1803. 3. De Vuyst H et al. Int J Cancer. 2009;124:1626–1636. 4. Miralles-Guri C et al. J Clin Pathol. 2009;62:870–878.
5. Kreimer AR et al. Cancer Epidemiol Biomarkers Prev. 2005;14:467–475.
There are no routinely available, recommended
screening methods for cancers caused by HPV in men
≈30%–90% caused
by HPV 16 and 183–5
>90% caused by
HPV 6 and 111,2
Genital warts
Recurrent respiratory papillomatosis
Anal cancer
Penile cancer
Oropharyngeal and oral cavity cancers

15. Anal Cancer Incidence and Mortality in US Is Increasing:
2001–20151
SCCA = squamous cell carcinoma of the anus.
1. Deshmukh AA et al. J Natl Cancer Inst. 2019. [Epub ahead of print]
Anal Cancer Incidence
Anal Cancer
Mortality
(2001–2016)
Females: 7,391
Males 4,270
Incidence of anal cancer
has also increased across:
All races
Age > 50 years
All stages of
diagnosis
5,000
7,500
10,000
12,500
15,000
17,500
20,000
2001–2005 2006–2010 2011–2015
Males
Females
Cases,
n

16. US: Males Diagnosed With HPV-Related
Oropharyngeal Cancer Doubled Over the Past 15 Years1
6,966
15,479
0
2,000
4,000
6,000
8,000
10,000
12,000
14,000
16,000
Oropharyngeal Cancer (Males)
In Canada, HPV vaccines are not yet indicated to prevent oropharyngeal cancer.
HPV = human papillomavirus; SCC = squamous cell carcinoma.
1. Van Dyne EA et al. MMWR Morb Mortal Wkly Rep. 2018;67:918–924.
Annual
number
of
HPV
–Associated
Cancers

17. Van Dyne et al MMWR 2018 Aug 24;67(33):918-924
0
2
4
6
8
10
Male Female
Incidence Rate per 100,000
Incidence
Rate
per
100,000
US NPCR and SEER data 2015
HPV Oropharyngeal Cancer Incidence Significantly
Higher in Males Compared to Females

18. USA: Rates of Cervical Cancer Are Declining While
HPV-Related Oropharyngeal Cancer in Males Is Rising1
In Canada, HPV vaccines are not indicated to prevent oropharyngeal cancer.
HPV = human papillomavirus; SCC = squamous cell carcinoma; AAPC = average annual percent change.
1. Van Dyne EA et al. MMWR Morb Mortal Wkly Rep. 2018;67:918–924.
0
2
4
6
8
10
1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015
Rate
(No.
of
Cases
per
100,000)
Oropharyngeal SCC (male);
AAPC = 2.7
Year of Diagnosis
Cervical carcinoma;
AAPC = –1.6

19. Presentation and Management of
HPV-related Diseases

20. External Genital Warts
• Develop soon after exposure to HPV (weeks to months)
• Treatments:
– Liquid nitrogen cryotherapy
– Trichloroacetic acid
– Cautery / CO2 laser
– Surgical excision
• Each episode often requires
multiple treatments / visits
• Recurrence rate high: > 40%
genital warts

21. Abnormal Pap Test from HPV
dysplasia (pre-cancerous cells)
• No symptoms
• Takes months – years to develop after exposure
• Repeat testing in 6 months or referral to colposcopy specialist for
magnification and biopsy
• Treatments:
– Ongoing colposcopy surveillance – may resolve
– LEEP, laser
– Cone biopsy
• Recurrence rate: 10%
normal cervix
pre-cancerous cells

22. Cervical Cancer
• Usually in unscreened women or those with screening interval > 5 years
• Possible symptoms: bleeding after intercourse, excessive vaginal discharge,
pelvic pain or back pain
• Referral to colposcopy specialist, Gyn oncologist for biopsy
• Treatments:
–LEEP, cone biopsy
–Removal of cervix
–Radical hysterectomy, lymph nodes
–Chemotherapy, radiotherapy
cervical cancer
cervical cancer

23. HPV Oropharyngeal Cancer
Painless enlarged lymph node
• Cancer location:
− Tonsils
− Base of tongue
− Soft palate
• Symptoms:
− Sore throat
− Difficulty swallowing
− Hoarse voice
• Treatment:
− Surgery
− Radiation
− Chemotherapy
Usually presents with painless
enlarged lymph node (gland) in neck

24. Methods of Prevention

25. HPV Prevention Strategies
Primary - prevention of HPV acquisition
• safer sex practices - # partners, condoms
• prophylactic vaccination
Secondary – prevention of disease
• cervical screening programs
• vulvar, vaginal, anal detection
• treatment of pre-invasive disease

26. HPV Prevention Strategies
Secondary – prevention of disease
• cervical screening programs
• treatment of pre-invasive disease

27. HPV Prevention Strategies
Primary - prevention of HPV acquisition
• safer sex practices - # partners, condoms
• HPV vaccination

28. HPV Prevention Strategies
Primary - prevention of HPV acquisition
• safer sex practices - # partners, condoms
• prophylactic vaccination
Secondary – prevention of disease
• cervical screening programs
• vulvar, vaginal, anal detection
• treatment of pre-invasive disease

29. HPV Vaccination

30. 16
HPV Vaccines : 2v, 4v, 9v (are not live vaccines)
16 18
4v HPV Vaccine2
Gardasil
6 11
16 18 6 11 31 33 45 52 58
9v HPV Vaccine3
Gardasil 9
2v HPV Vaccine1
Cervarix
18
High-risk genotypes
(cancer)
Low-risk genotypes
(anogenital warts and
recurrent respiratory papillomatosis)
1. Cervarix Canadian Product Monograph, GlaxoSmithKline Inc.; 2020
2. Gardasil Canadian Product Monograph, Merck Canada Inc.; 2015
3. Gardasil 9 Canadian Product Monograph, Merck Canada Inc.; 2020

31. Provincial HPV Vaccination Programs
• Programs vary between provinces and territories:
– Grade 4 – grade 7
• All provinces Except Quebec are 2 doses of Gardasil 9
(Quebec: 1st dose Gardasil 9; 2nd dose Cervarix 2vHPV
• Funded doses: MSM, HIV
• Alberta and Yukon:
– Now funded vaccine up to and including age 26
MSM – men having sex with men

32. Ontario HPV Vaccination Program – low uptake
https://www.publichealthontario.ca/-/media/documents/i/2020/immunization-coverage-2018-19.pdf?la=en

33. Evidence for HPV Vaccination in Adults

34. 4vHPV: Mid-Adult Women Trial
Females (24–45 Years)
aRelated to HPV types 6, 11, 16, and 18.
bEGL includes condyloma, VIN, and VaIN.
4vHPV= 4-valent human papillomavirus; CIN = cervical intraepithelial neoplasia; DOF = data on file; EGL = external genital lesions; ASCUS = atypical squamous cells of undetermined significance; LSIL = low-grade squamous intraepithelial lesion;
VIN = vulvar intraepithelial neoplasia; VaIN = vaginal intraepithelial neoplasia, AIN = anal intraepithelialneoplasia; MSM = men who have sex with men
1. CastellsaguéX et al. Br J Cancer. 2011;105:28–37. 2. Data on File. MSD. 3. Data presented by Walia A on Nov 14, 2019 at “6th NCI cancer centers HPV Vaccination Summit.”
4. Giuliano AR et al. N Engl J Med. 2011;364:401–411; 5. Goldstone S, et al. EUROGIN 2018. FC 4-2.
Up to
10
years
75%
reduction in high-grade
anal pre-cancers
(MSM subset)b
89%
reduction in genital wartsa
4vHPV: Male Trial
Males (16–26 Years)
89%
Reduction in
persistent infection,
abnormal paps and
genital wartsa,b

35. HPV Vaccination in Those with
History of Disease

36. 4vHPV Vaccine Reduces Disease Recurrence in
Adult Females With Previous Disease
aRelated to HPV types 6, 11, 16, and 18.
bWomen previouslytreated for cervical squamous intraepitheliallesion.
4vHPV= 4-valent human papillomavirus; CIN = cervical intraepithelialneoplasia; LEEP = loop electrosurgicalexcision procedure.
1. Kang WD et al. GynecolOncol.2013;130:264–268.2. Ghelardi A et al. GynecolOncol.2018;151:229–234.3. PieralliA et al. Arch GynecolObstet..2018;298:1205–1210; 4. Ghelardi A et al. Vaccines2021; 9:83-94.
HPV vaccination reduces
recurrence of abnormal paps
70-80%
HPV vaccination reduces
recurrence of genital warts
75%
HPV vaccination reduces
recurrence of VIN2/3
78%

37. 4vHPV= 4-valent human papillomavirus; MSM = males who have sex with males; HGAIN = high-grade anal intraepithelial neoplasia.
1. Swedish KA et al. Clin Infect Dis. 2012;54:891–898. 2. Swedish KA et al. PLoS One. 2014;9:e93393.
HPV vaccination reduces
recurrence of high-grade
anal pre-cancerous cells
52%
HPV vaccination reduces
recurrence of genital warts
50%
4vHPV Vaccine Reduces Disease Recurrence in Adult
Males With Previous Disease

38. Gardasil 9:
HPV types 6,11,16,18 +31,33,45,52,58
females age 9-45
• Cervix pre-cancer and cancer
• Vulvar and vaginal pre-cancer and cancer
• Anal pre-cancer and cancer
• External genital warts
males age 9-45
• Anal pre-cancer and cancer
• External genital warts
Cervarix Canadian Product Monograph, GlaxoSmithKline Inc.; November 25, 2014; Gardasil Canadian Product Monograph, Merck Canada
Inc.; March 10, 2015; Gardasil 9 Canadian Product Monograph, Merck Canada Inc.; Aug 30, 2020
Health Canada: HPV Vaccine
approved indications (Aug 2020)

39. Canada: NACI Recommendations
(National Advisory Committee on Immunization)
• Recommends HPV vaccination in individuals age 9-26
• Supports vaccination over age 26 (no upper age limit)
• Recommends vaccination of those with current or past history
of HPV-related disease
https://www.canada.ca/en/public-health/services/publications/healthy-living/updated-recommendations-
human-papillomavirus-immunization-schedule-immunocompromised-populations.html

40. GOC (Society of Gyn Oncology of Canada)
“Opportunistic HPV Vaccination: An Expanded Vision”
White Paper June 2018
• Actively recommend universal HPV vaccination in Canada
• Health care systems, institutions and care providers should
encourage opportunistic HPV vaccination
https://g-o-c.org/wp-content/uploads/2015/01/18_EEE_WhitePaper_FINAL_Jun18-1.pdf

41. Rationale for Adult HPV Vaccination

42. Efficacy of
vaccination at
reducing disease
Risk of new
exposure
Rationale for Adult HPV Vaccination
Vaccination reduces
recurrence in
previously exposed
adults

43. Efficacy of
vaccination at
reducing disease
Risk of new
exposure
Rationale for Adult HPV Vaccination
Vaccination reduces
recurrence in
previously exposed
adults
Partners should also be vaccinated for HPV

44. Practical Tips to Access
HPV Vaccination

45. Logistics of HPV Vaccine (not live vaccines)
• 9vHPV – Gardasil 9 (since 2015)
• 3 doses: 0 mo, 2 mo, 6 mo
• (School programs < age 15: 2 doses at 0 and 6 months)
• If you miss a dose, resume where left off
• Most common side effects: injection site reactions
– Pain
– Swelling
– Redness

46. Where can I get vaccinated?
• Doctor or nurse practitioner:
–Rx
–Pick up at pharmacy
–Bring back to office to inject
–Some clinics stock vaccine in office
• Sexual health clinic
• Travel vaccine clinic
• Pharmacists can immunize in several provinces

47. HPV Vaccine and COVID-19 Vaccine
• If you get HPV vaccine dose:
 wait at least 14 days to get any COVID-19 vaccine dose
• If you get any COVID-19 vaccine dose:
 wait at least 30 days to get HPV vaccine
• Covid-19 vaccine should be our priority
• HPV vaccine dosing intervals can be adjusted

49. It’s never too late!
HPV infection is common in adults1,2
Long-term vaccination efficacy in adult women3
Vaccination efficacy in previously exposed adults5–9
1. Shi R et al. BMC Res Notes.2014;7:544. 2. GiulianoAR et al. Cancer EpidemiolBiomarkersPrev. 2008;17:2036–2043.3. Data on File, MSD. 4. Data presented by Walia A on Nov 14, 2019 at “6th NCI cancer centers HPV
VaccinationSummit.”. 5. Kang WD et al. GynecolOncol.2013;130:264–268.6. Ghelardi A et al. GynecolOncol.2018;151:229–234.7. PieralliA et al. Arch GynecolObstet. 2018;298:1205–1210.8. Swedish KA et al. Clin Infect
Dis. 2012;54:891–898.9. Swedish KA et al. PLoS One. 2014;9:e93393.
Let’s end HPV-related cancers

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