CERVICAL CANCER ECHO by Dr Kamfwa .pptx

Cervical cancer presentation

1. MOH HIV/TB ECHO CERVICAL CANCER 2 nd September 2024 Dr Paul Kamfwa Gynae -oncologist/Cervical Cancer focal point, MoH No conflicts of interests or disclosures

2. L earning objectives Explain cervical cancer basics Describe the Epidemiology and Public Health in Zambia Discuss prevention and screening Explain HPV vaccination and policy

3. Poll Question 1 What are the two most prevalent types of HPV that causes 70% of cervical cancer worldwide? (a) 6 and 11 (b) 11 and 16 (c) 16 and 18 (d) 6 and 18

4. HPV AND CERVICAL CANCER Cervical cancer is caused by persistent infection with the human papillomavirus (HPV) Cervical cancer can be cured if diagnosed at an early stage and treated promptly More than 100 HPV types have now been identified. HPV types are classified as high-risk (HR) or low-risk (LR). Low-risk HPV types 6 and 11 cause nearly all genital warts and a minority of subclinical HPV infections. The HR HPV types include 16, 18, 31, 33, 35, 45, and 58

5. HPV AND CERVICAL CANCER More than 75% of sexually active men and women get HPV at some point in their lives HPV is highly transmissible and is the most common STI HPV 16 and 18 accounts for 70% cervical cancer worldwide 30 to 40 HPV types have an affinity for infecting the lower anogenital tract HPV can cause cancer of the vagina, vulva, anus , throat etc

6. Poll Question 2 How many years does it take for women with weakened immune systems, such as those with untreated HIV infection to develop cervical cancer following the infection with HR- HPV? 1 to 2 years 5 to 10 years 15 to 20 years 20 to 30 years COVID-19 SARE INSTITUTE

7. Pathogenesis of HPV infection Typically, it takes 15–20 years for abnormal cells to become cancer, but in women with weakened immune systems, such as untreated HIV, this process can be faster and take 5–10 years .

8. How does HPV infection lead to cervical cancer ?

9. Symptoms of advanced cervical cancer HPV infection is often asymptomatic Symptoms appear after cancer reaches an advanced stage Main symptoms include: Irregular vaginal bleeding or bleeding after sexual intercourse Back, leg or pelvic pain Fatigue, weight loss, loss of appetite Vaginal discomfort or odorous discharge Single swollen leg More severe symptoms (usually more advanced): Severe anaemia Renal failure Vesco vaginal fistulae Lymphoedema Human papillomavirus

10. S cheme of unstable cervical epithelium following HPV infection

11. Poll Question 3 What is the incidence of cervical cancer in Zambia ? (a) 49.4/10,000 (b) 49.4/100,000 (c) 71.5/10,000 (d) 71.5/100,000

12. Cervical c ancer Epidemiology in Zambia Most common cancer in Zambia and leading cause of cancer related deaths Accounts for over 41% of new cancer cases among females of all ages in Zambia 3, 640 new cases in 2020 with 2,285 deaths Most frequent cause of cancer related deaths Incidence 71.5/100,000 and Mortality 49.4/100,000 WLHIV are 5-6X at risk of cervical cancer 12 Cancers Today: Globocan https://gco.iarc.fr/

13. Poll Question 4 5.What is the current recommendation by WHO as the primary screening test and treatment approaches among both the general population of women and women living with HIV. A .VIA and VILI B. cytology C. colposcopy D .HPV DNA

14. HPV testing CYTOLOGY VIA 16

15. Cervical screening and treatment of precancers Women should be screened for cervical cancer every 5–10 years starting at age 25. Women living with HIV should be screened every 3 years starting at age 25. The global strategy encourages a minimum of two lifetime screens with a high-performance HPV test by age 35 and again by age 45 years. Precancers rarely cause symptoms, which is why regular cervical cancer screening is important, even if someone been vaccinated against HPV

16. Poll Question 5 HPV vaccination is part of A .Primary Prevention of cervical cancer B. Secondary prevention of cervical cancer C. Tertiary prevention of cervical cancer

17. Progress towards primary prevention 2019 2020 2020 2021 2021 2022 2022 Dose Dose 1 Dose 1 Dose2 Dose 1 Dose 2 Dose1 Dose2 Coverage 75% 72% 62% 45% 36% 71% 41% WHO Strategy :90% of girls fully vaccinated with HPV vaccine by 15 years of age. Target population- 9-14yr old girls Models of delivery :At health facility, in the community and Schools HPV vaccine offered during child health week One dose HPV regimen MAC was successful

18. HPV Vaccine Deployment Strategy A nnual single-week campaign Integrated in Child Health Week services School based outreach – 90-99% target Coordination with Ministry of Education School Management teams (Private schools) Parent-Teacher Associations Community outreach – Out-of-school Coordinated through CBVs Community mobilisers/gate keepers

19. HPV vaccination and other prevention steps As of 2023, there are 6 HPV vaccines available globally. All protect against the high-risk HPV types 16 and 18, which cause most cervical cancers Safe and effective in preventing HPV infection and cervical cancer HPV vaccines should be given to all girls aged 9–14 years, before they become sexually active. The vaccine may be given as 1dose.It is less costly, less resource intensive and easier to administer. It facilitates implementing catch-up campaigns for multiple age groups People with reduced immune systems should ideally receive 2 or 3 doses.

20. HPV vaccination and policy Zambia conducted an initial HPV vaccination pilot 2013-15 (3 Districts) Countrywide introduction and roll-out in June 2019 Decision made to targeted a single-age cohort – 14 year old girls (Vaccine supply constraints) Two dose vaccination schedule – one year apart Additional dose a month after first dose for HIV+ girls Conducted HPV MAC vaccination campaign – September 2023 Targeting 9 to 14 years Single-dose schedule Three dose for HIV+ girls

21. Summary of Key Points Cervical cancer is the most common cancer in Zambia. Cervical cancer is caused by persistent infection with the human papillomavirus (HPV )   Women living with HIV are 6 times more likely to develop cervical cancer compared to women without HIV . Cervical cancer can be cured if diagnosed at an early stage and treated promptly. HPV screening is now the recommended primary form of screening Prophylactic vaccination against HPV and screening and treatment of pre-cancer lesions are effective strategies to prevent cervical cancer and are very cost-effective.

22. Re-Poll Question 1 What are the two most prevalent types of HPV that causes 70% of cervical cancer worldwide? (a) 6 and 11 (b) 11 and 16 (c) 16 and 18 (d) 6 and 18

23. Re-Poll Question 2 How many years does it take for women with weakened immune systems, such as those with untreated HIV infection to develop cervical cancer following the infection with HR- HPV? 1 to 2 years 5 to 10 years 15 to 20 years 20 to 30 years COVID-19 SARE INSTITUTE

24. Re-Poll Question 3 What is the incidence of cervical cancer in Zambia ? (a) 49.4/10,000 (b) 49.4/100,000 (c) 71.5/10,000 (d) 71.5/100,000

25. Re-Poll Question 4 5.What is the current recommendation by WHO as the primary screening test and treatment approaches among both the general population of women and women living with HIV. A .VIA and VILI B. cytology C. colposcopy D .HPV DNA

26. Re-Poll Question 5 HPV vaccination is part of A .Primary Prevention of cervical cancer B. Secondary prevention of cervical cancer C. Tertiary prevention of cervical cancer

27. References DM Parkin, J Ferlay , M Hamdi-Cherif . Cancer in Africa: Epidemiology and Prevention. IARC Scientific Publications. No.153. 2003; IARC Press: Lyon DM Parkin, SL Whelan, J Ferlay . Cancer Incidence in Five Continents, Vol VIII. IARC Scientific Publication No.155. 2002; IARC: Lyon. Harris T. G., Burk R. D., Palefsky J. M., et al. Incidence of cervical squamous intraepithelial lesions associated with HIV serostatus , CD4 cell counts, and human papillomavirus test results. JAMA 2005;293(12):1471-76. [PMID: 15784870] Kelly H., Weiss H. A., Benavente Y., et al. Association of antiretroviral therapy with high-risk human papillomavirus, cervical intraepithelial neoplasia, and invasive cervical cancer in women living with HIV: a systematic review and meta-analysis. Lancet HIV 2018;5(1):e45-58. [PMID: 29107561 Massad L. S., Hessol N. A., Darragh T. M., et al. Cervical cancer incidence after up to 20 years of observation among women with HIV. Int J Cancer 2017;141(8):1561-65. [PMID: 28670714] Davies O., Rajamanoharan S., Balachandran T. Cervical screening in HIV-positive women in the East of England: recent CD4 as the predictive risk factor. Int J STD AIDS 2015;26(13):945-50. [PMID: 25505037 ] Stelze , Dominik et al. Estimates of the global burden of cervical cancer associated with HIV.  The Lancet.  2020.  https://doi.org/10.1016/S2214-109X(20)30459-9 Guida , F., Kidman, R., Ferlay , J.  et al.  Global and regional estimates of orphans attributed to maternal cancer mortality in 2020.  Nat Med  28, 2563–2572 (2022). https://doi.org/10.1038/s41591-022-02109-2 COVID-19 SARE INSTITUTE