Spotlight on Cervical Cancer Screening Cervical Cancer Screening

Spotlight on Cervical Cancer Screening

Cervical Cancer Screening • https: //www. cancercare. on. ca/pcs/screening/cervscr eening/

Ontario Cancer Statistics 2013 Cancer Type # New Cases Cervical 3 610 (F) # Deaths 150 (F) 3

Burden of Disease in Ontario • Estimated 610 women will be diagnosed and 150 will die of cervical cancer in 2013 • Up to 80, 000 abnormal Pap tests require assessment each year • 4 th most common cancer among women under age 50 4

Sensitivity and Specificity Cancer Test Site Cervical Pap test Cervical HPV test Sensitivity Specificity 44% to 78% 91% to 96% 88% to 93% * 86% to 93% *Sensitivityfor CIN II 5

Effectiveness of Screening Cancer Site Cervical Effectiveness of Screening With Pap testing: Incidence and mortality reduced by up to about 80% with regular screening Type of Studies Observation al studies and Global incidence data 6

Cervical Abnormalities Cancer (0. 015%) Atypical Glandular Cells (0. 1%) Atypical Squamous Cells: HSIL Cannot be Excluded (0. 1%) High-Grade Squamous Intraepithelial Lesion (HSIL) (0. 3%) Pre-cancer lesions/ Pap abnormalities: 80, 000 Low-Grade Squamous Intraepithelial Lesion (2. 1%) Atypical Squamous Cells of Undetermined Significance (2. 3%) Negative for Intraepithelial Lesion or Malignancy (95. 0%) Women (aged 20– 69) Eligible for Cervical Cancer Screening 7 7

Ontario Screening Data • 65% of women aged 20 to 69 screened (2009 to 2011) • Ontario Cancer Plan provincial target is 85% participation for cervical screening • Of the 454 women diagnosed with invasive cervical cancer in 2008, 60% were under-/never-screened and 40% were screened 8

Cervical Cancer Causes • Persistent infection with high risk (oncogenic) types of HPV (human papillomavirus) • HPV is commonly found in sexually active men and women and transmitted through any skin to skin sexual contact • Most HPV infections are transient; about 90% will clear within 2 years 9

Cervical Cancer Causes • Pap tests detect cervical cell changes that are a result of HPV infections • Some abnormal Pap tests are also a reflection of premalignant change • Other co-factors (like smoking), that are not well-understood, are also involved in oncogenesis 10

Cervical Cancer Natural History

HPV Vaccine • Two vaccines—bivalent (Cervarix®) and quadrivalent (Gardasil®)—prevent 2 high risk HPV types that cause 70% of cervical cancers • Injected in 3 doses over 6 months 12

HPV Vaccine • Provides best protection if received prior to HPV exposure • Natural infection does not reliably result in immunity • Does not replace regular cervical cancer screening 13

Ontario HPV Vaccination Program • Publicly funded school-based immunization program for grade 8 girls • New catch-up program since September 2012 for girls in grades 9 -12 • 59% uptake in grade 8 girls (2009/2010) • More vaccine program information at www. hpvontario. ca 14

Current Guidelines • Clear evidence for primary HPV screening with cytology triage, starting at age 30, every 5 years • Must implement within organized program • Must be publicly funded • Follow cytology-based guidelines during transition to funded HPV screening 15

Comparison of 2005 and 2011 Guidelines Question Initiation Interval after Negative Test Cessation 2005 Guidelines 2011 Guidelines Within 3 years of first vaginal sexual activity with cytology (Pap test) Age 21 Annual until 3 consecutive negative cytology tests, then every 2 to 3 years Every 3 years Age 70 if adequate and negative screening history in previous 10 years (≥ 3 negative tests) No change Management guidelines for follow-up of abnormal cytology did not change Guidelines summary: www. cancercare. on. ca/screenforlife

Screening Initiation Start at age 21 in sexually active women (includes intercourse as well as digital and/or oral sexual activity involving the genital area with a partner of either gender) • Cervical cancer rare < 25 years and extremely rare < 21 years • 10 to 15 years to develop cervical cancer 17

STI Screening • The new guidelines for cervical screening do no affect the guidelines for STI screening • Asymptomatic sexually active females under age 25 should be screened annually for chlamydia, or more often if there are multiple partners 18

Harms of Screening Adolescents • 90% will clear infection within 2 years • High rates of low-grade mostly transient and clinically inconsequential abnormalities • Unnecessary anxiety from detection, biopsies and treatment • Treatment linked to possibility of adverse future pregnancy outcomes • No protective effect with screening 19

Screening Interval • Cytology screening every 3 years unless immunocompromised or previously treated for dysplasia • No incremental benefit of screening more frequently than every 3 years • Aligns with other jurisdictions 20

Screening Cessation Stop screening at age 70 if adequate and negative screening history • Low incidence of cancer in women who have been adequately screened • Potential discomfort of procedure • Difficulties visualizing squamocolumnar junction 21

Cervical Screening Participation Rate 100 Ontario Cancer Plan target 2010: 85% 95 90 85 80 75 70 65 60 55 2000 -2002 2003 -2005 2006 -2008 2009 -2011

Cervical Screening Participation Rate by Age 100 Ontario Cancer Plan target 2010: 85% 90 80 70 60 50 40 30 20 10 0 20 -29 30 -39 2000 -2002 40 -49 2003 -2005 2006 -2008 50 -59 2009 -2011 60 -69

Cervical Screening Participation Rate by LHIN 100 Ontario Cancer Plan target 2010: 85% 90 80 70 60 50 40 30 20 10 0 n n ir st st st al al io in nt ka East o o r r a a e r e a e r a t t l o l a l E E B g t n n k d- ral W a Ha al th mp t. C uth W ellin h. W us orth Ce Ce r On t n a u t S r t o en N So ie Ch oe M No So o W Hldm Cen saug ront C Er c s m rlo To gr ssi e i Si t N a h M t W ltn or m N H 2000 -2002 2003 -2005 2006 -2008 2009 -2011

Colposcopy Rate Following a High-Grade Abnormal Pap Test at 6 Months 100 95 90 85 80 75 2008 2009 2010 2011

Challenges • Cervical cancer screening often linked to periodic health exam, hormonal contraception and bimanual exam • Difficult for physicians/providers to track 3 year screening interval • Roll-out of program correspondence started in 2013 26

CCO Initiatives Underway Phased correspondence to women started in Fall of 2013 • Privacy notification • Result (normal, abnormal, unsatisfactory) letters • Followed by recalls and invitations 27

Opportunities • Updated guidelines reflect new evidence • Increase awareness of balance between benefits and potential harms of screening • Reduce interventions in young women whose abnormal Pap tests are due to transient and inconsequential HPV infections • Increase screening rates for under-/neverscreened groups 28

Opportunities • Improve appropriate follow-up after abnormal Pap test result • Continue to encourage primary prevention through HPV immunization • CCO and Public Health Ontario evaluating impact of primary and secondary prevention of HPV-related disease 29

Screening: Future State • Clear evidence for primary HPV screening • Must be implemented within an organized program • HPV test must be publicly funded • Updated cytology guidelines to bridge transition 30

Future Considerations CCO working with ministry regarding implementation of primary HPV screening • Public funding of HPV test • Family physician/primary care provider education/information • Laboratories • Organization of colposcopy services 31

Clinical Case Study 1 • A 17 -year-old female sees you to initiate birth control pill • She started having unprotected intercourse 2 months ago Do you screen her for cervical cancer? 32

Clinical Case Study 2 • A 69 -year-old female had a normal Pap test when she was 59 years old, an abnormal test when she was 63 years old and a normal Pap test most recently when she was 66 At what age can she safely stop screening? 33

Cervical Cancer Resources For more information: https: //www. cancercare. on. ca/pcs/screening/cervscreening/hcpresources/ https: //www. publications. serviceontario. ca/pubont/servlet/ecom / https: //www. cancercare. on. ca/pcs/screening/cervscreening/patient_education/

Questions? Thank You 35