Monitoring HPVrelated cervical precancers in Oregon Sean Schafer

Monitoring HPVrelated cervical precancers in Oregon Sean Schafer, MD HIV/STD/TB Program Office of Disease Prevention Oregon State Public Health

I’m going to tell you… 1 2 3 In Portland since HPV vaccine introduction, the number of …. Paps smears done Pre-cancers diagnosed… have declined The number of … Cervical pre-cancers occurring… might have declined Proportions of HPV types found in Portland precancers have changed

Papillomaviruses • Diverse • skin, mucous membranes • Cottontail rabbit wart, 1933 • Species specific

Papillomaviruses • >100 types • Non-oncogenic (6, 11) • Oncogenic (16, 18, 45, 31, 33, 35, 52, 58, 51, 56, 59, 39, 68, [66])

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Lowry DR, Schiler JT. Prophylactic human papillomavirus vaccines. J Clin Inv. 2006; 116(5)

Lowry DR, Schiler JT. Prophylactic human papillomavirus vaccines. J Clin Inv. 2006; 116(5)

Lowry DR, Schiler JT. Prophylactic human papillomavirus vaccines. J Clin Inv. 2006; 116(5)

Monitoring HPV-related CIN 2+, Portland

Cervical Dysplasia Surveillance Methods • Case definition – 18 years of age or older – Reside in 28 -zip-code area in Portland metro area – Biopsy confirmed Cervical Intraepithelial Neoplasia (CIN) 2, CIN 3, CIN 2/3, Adenocarcinoma -in-situ (AIS) • Data – Pathology report – Demographics – from lab or provider – HPV vaccine history – from ALERT or provider • Specimens for HPV typing 10

Oregon’s Surveillance Area Columbia River Portland Metropolitan Area: Oregon

HPV Monitoring Objectives • Incidence of high-grade cervical dysplasia (precancers, “CIN 2+”) • Prevalence and distribution of HPV types

Incidence (per 100, 000) 250 CIN 2+ Diagnoses, Portland, OR, Ages 18– 21 y, by Year 2008– 2014 200 150 100 50 0 2008 2009 2010 2011 2012 2013 2014

History of American Cancer Society Cervical Cancer Screening Guidelines Pap Conventional or liquid Pap Yearly, every 3 years if consecutive negative Yearly, “less frequent” if 3 consecutive negative Yearly if conventional Pap, every 2 years if liquid Pap Every 3 years (21– 29) ≥ 20 y or upon first vaginal intercourse ≥ 18 y or upon first vaginal intercourse 3 y after first vaginal intercourse 21 y Pap Part of regular checkup None Pap (21– 29) Pap plus HPV test (30 – 65) None 1980 None 1987 Every 5 years (30– 65) 70 y if 3 consecutive neg. 2002 65 y 2012

CIN 2+ Incidence and Proportion of Women Aged 18– 20 y with ≥ 1 Pap by Year, Portland OR, 2008– 2014 200 25 Incidence Screening Rate 150 15 100 10 50 5 0 0 2008 2009 2010 2011 2012 2013 2014 15 20 Screening Rate (%) Incidence (per 100, 000) 250

CIN 2+ Incidence and Proportion of Women Aged 21– 29 y with ≥ 1 Pap by Year, Portland OR, 2008– 2014 40 Incidence Screening Rate 500 30 400 300 20 200 10 100 0 0 2008 2009 2010 2011 2012 2013 2014 16 Screening Rate (%) Incidence (per 100, 000) 600

CIN 2+ Incidence and Proportion of Women Aged 30– 39 y with ≥ 1 Pap by Year, Portland OR, 2008– 2014 40 Incidence Screening Rate 300 30 20 100 10 0 0 2008 17 2009 2010 2011 2012 2013 2014 Screening Rate (%) Incidence (per 100, 000) 400

I’m going to tell you… 1 2 3 In Portland since HPV vaccine introduction, the number of …. Paps smears done Pre-cancers diagnosed… have declined The number of … Cervical pre-cancers occurring… might have declined Proportions of HPV types found in Portland precancers have changed

HPV Typing by Age Group, CIN 2+, Portland 2008– 2016 N=1728 806 665 No HPV Vaccines 203 31 9 18– 20 14 21– 29 Age Group 30– 39 ≥ 1 HPV Vaccine

HPV Types, CIN 2+, Portland Oregon, 2008– 2016 600 N=1728 Count 400 200 16 18 31 33 35 39 45 45 52 53 56 58 59 6 66 68 70 73 82 IS 39 HPV Type

Gardasil Cervarix (HPV 6, 11, 16, 18) (HPV 16, 18) 2006 2009 Gardasil 9 (HPV 6, 11, 16, 18, 33, 31, 45, 51, 58) 2014

HPV Types, CIN 2+, Portland Oregon, 2008– 2016 YES Percent Vaccinated NO 16, 18 33, 31, 45, 51, 58 HPV GROUPS All Others

HPV Types, CIN 2+ Cases in Women Aged <30 years, By Year, Portland, OR, 2008– 2014 60 HPV Groups: 16, 18 33, 31, 45, 51 58 All other types Pct 40 2008 2009 2010 2011 Year 2012 2013 2014

HPV Types, CIN 2+ Cases in Women Aged <30 years, Portland, OR, by Race, 2008– 2016 NH White NH Black Hispanic Other/Unk 50 Pct 40 20 10 0 16, 18 33, 31, 45, 51, 58 All other

I told you… 1 2 3 In Portland since HPV vaccine introduction, the number of …. Paps smears done Pre-cancers diagnosed… have declined The number of … Cervical pre-cancers occurring… might have declined Proportions of HPV types found in Portland precancers have changed