CANCER CERVIX BURDEN OF HPV

NARENDRA MALHOTRAM.D., F.I.C.O.G., F.I.C.M.C.H

President FOGSI (2008-2009) Dean I.C.M.U. (2008) Director Ian Donald School of Ultrasound National Tech. Advisor for FOGSI-G.O.I.—Mc Arthur Foundation EOC

Course Practicing Obstetrician Gynecologist at Agra. Special Interest in

High Risk Obs., Ultrasound, Laparoscopy and Infertility, ART & Genetics

Member and Fellow of many Indian and international organisations Senior V. P. of FOGSI (2003) Vice Dean Indian College of Medical Ultrasound (2006) FOGSI Imaging Science Chairman (1996-2000) Awarded best paper and best poster at FOGSI : 5 times, Ethicon

fellowship, AOFOG young gyn. award, Corion award, Man of the year award, Best Citizens of India award

Over 30 published and 100 presented papers Over 50 guest lectures given in India & Abroad Organised many workshops, training programmes, travel seminars

and conferences Editor 8 books, many chapters, on editorial board of many journals Editor of series of STEP by STEP books Revising editor for Jeatcoate’s Textbook of Gynaecology (2007) Editor FOGSI Textbook 3rd Edition Very active Sports man, Rotarian and Social worker

MALHOTRA NURSING & MATERNITY HOME PVT. LTD.84, M.G. Road, Agra-282 010

Phone : (O) 0562-2260275/2260276/2260277, (R) 0562-2260279, (M) 98370-33335; Fax : 0562-2265194E-mail : [email protected]

Website : www.malhotrahospitals.comApollo Pankaj Hospitals, AgraCO-ORDINATOR DEPTT. OBS & GYN

HPV DISEASES Is it Relevant to Us?

Narendra Malhotra

Jaideep Malhotra

Neharika Malhotra

www.malhotrahospitals.com

“The woman is an axle around whom not only the family or society but the whole universe revolves”.

Her health is of utmost

importance in all stages of

her life…..

“The woman is an axle around whom not only the family or society but the whole universe revolves”.

Her health is of utmost

importance in all stages of

her life…..

A Woman is the pivot of the Universe!

A Woman is the pivot of the Universe!

HPV 16

HPV 18

HPV 6

HPV 11

Cancer causing Types1,2,4 Non-cancer causing types1,2

• >75% of Cervical Cancer5,6

• >50% of Vaginal & Vulvar Cancer590% of Anogenital warts5

HPV is a necessary cause of cervical cancer – 99.7%4

HPV

1.Schiffman M, Castle PE. Arch Pathol Lab Med. 2003;127:930–934. 2. Wiley DJ, Douglas J, Beutner K, et al. Clin Infect Dis. 2002;35(suppl 2):S210–S224. 3. Muñoz N, Bosch FX, Castellsagué X, et al. Int J Cancer. 2004;111:278–285. Reprinted from J Virol. 1994;68:4503–4505 with permission from the American Society for Microbiology Journals Department. 4. Walboomers JM, Jacobs MV, Manos MM, et al. J Pathol. 1999;189:12–19. 5. X. Castellsagué, S. de Sanjose, T. Aguado, K. S. Louie, L. Bruni, J.Muñoz, M. Diaz, K. Irwin, M. Gacic, O. Beauvais, G. Albero, E. Ferrer, S. Byrne,F. X. Bosch. HPV and Cervical Cancer in the World. 2007 Report. WHO/ICO Information Centre on HPV and Cervical Cancer (HPV Information Centre). Available at: www.who.int/hpvcentre6. Bhatla N et al.Vaccine (2008;26; 2811-17

Human Papillomavirus (HPV)

Estimated Annual Incidence of HPV-Related Diagnoses

Cervical cancer: 0.5 million cases/year1

~70% attributable to HPV types 16 and 182

High-grade precancerous lesions: 10 million3


Low-grade cervical lesions: 30 million3

~30% attributable to HPV types 6, 16, and 182

Genital warts: 30 million4


HPV infection: 660 million1

1. World Health Organization, Geneva, Switzerland. 2005:1–38. 2. WHO/ICO Information Centre on HPV and Cervical Cancer. Vaccine. 2007;25(suppl 3):C1–C230. 3. World Health Organization, Geneva, Switzerland. 1999:1–22. 4. World Health Organization. WHO Features. 1990;152:1–6. 5. Gissmann L et al. Proc Natl Acad Sci U S A. 1983;80:560–563.

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type

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type

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geni

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61%

Data source: IARC, Globocan 2008

Available at: HPV Information Centre. Human Papillomavirus and Related Cancers in World. Summary Report 2010. [Accessed: July 2010]. Available at www. who. int/ hpvcentre

of countries cervical cancer ranks among the 3 most frequent cancers among women from all ages

WOMEN ALL AGES

Ranking Of Cervical Cancer To Others Cancers According To Incidence Rates

Asia ~ 43% of new Cervical Cancer cases in world

Asia ~ 44% of deaths due to Cervical Cancer in world

New Cervical Cancer Cases Deaths due to Cervical Cancer

43%

Global2 529,409

SE Asia1 *

122,132 44%

Rest ofThe World

Global2 274,883

Rest ofThe World

Global Population

17 %

Rest ofThe World

SE Asia1 *

229,589

1. WHO/ICO Information Centre on HPV and Cervical Cancer (HPV Information Centre). Human Papillomavirus and Related Cancers in Asia. Summary Report 2010..2. WHO/ICO Information Centre on HPV and Cervical Cancer (HPV Information Centre). Human Papillomavirus and Related Cancers in World. Summary Report 2010. [Accessed on 11th Jul 2011.3. http://www.prb.org/Publications/Datasheets/2010/2010wpds.aspx 2010 population Bureau [Accessed on 11th Jul 2011

SE Asia3*

1238.45

*Excluding China

Cervical Cancer – Disease Burden

India ~134,000 World ~ 529,000

India ~25% of new Cervical Cancer cases in world

India ~ 73,000World ~ 274,000

India ~25%

Rest of World - 75%

India ~27% of deaths due to Cervical Cancer in world

Rest of World - 73%

India - 27%

Incidence Mortality

India ~27%

Rest of World - 73%

HPV and Cervical Cancer in the World. 2010 Report. WHO/ICO Information Centre on HPV and Cervical Cancer (HPV Information Centre). Available at: www.who.int/hpvcentre

Cervical Cancer – Disease Burden

WHO/ICO Information Centre on HPV and Cervical Cancer (HPV Information Centre). Human Papillomavirus and Related Cancers in India. Summary Report 2010. [Accessed on 5th July,2010]. Available at www. who. int/ hpvcentre

Key Statistics on India

72,825

Deaths

Annually

Approx. 200 women die every day

Every 7 minutes a women dies

Approx. 8 women die every hour


Burden of Disease in India

Three year report of PBCR 2006-08 chapter 6.

Age Adjusted Incidence Rates (AARs) for Ca Cervix: Population based cancer registry


Incidence of Cervical Cancer


Rates per 100,000 women per year. ** No rates are available

Age-standardized incidence rates


Mortality Rate

0 5 10 15 20 25 30

Cervical Breast (Female) Ovarian

Years of Life Lost to Cervical Cancer*

*In women in the United States (2003)1. Ries LAG, Harkins D, Krapcho M, et al. (eds). SEER Cancer Statistics Review, 1975–2003, National Cancer Institute. Bethesda, MD; 2006.

26

19

18

26 Average years of life lost in women with Cervical Cancer

Cervical cancerHPV

1983/1984Zur Hausen group detects HPV DNA in cervical cancers

new HPVs – HPV 16 and HPV 18

Nobelprize for Medicine 2008Harald zur Hausen

Source: WHO/ICO Information Centre on HPV and Cervical Cancer, second edition 2009 (www.who.int/hpvcentre). Estimates are based on 4 reviews: Bosch et al, 2002; Kreimer et al, 2005; De Vuyst et al, 2008; Miralles-Guri et al, 2009.

> 99%

84.3%

69.9%

47.0%

40.4%

35.6%

23,5%

HPV DNA detection

: 95% CI for the proportion

5% of all cancersare HPV associated

UK15053 05/11

Estimated HPV Contribution To Cancer

What is HPV? Non enveloped dsDNA virus, simple

capsid of 2 proteins L1 and L2

Common virus with >100 types identified

Infects cutaneous and mucosal epithelia

30–40 infect the mucosal epithelia of women and men 2 groups low risk types causing warts

HPV 6,11

high risk types causing cancer 15 oncogenic types HPV 16,18 – most important

India Southern AsiaWHO/ICO Information Centre on HPV and Cervical Cancer (HPV Information Centre). Human Papillomavirus and Related Cancers in India. Summary Report 2010. [Accessed on 5th July,2010]. Available at www. who. int/ hpvcentre

16 + 18 = 82.5%

Ten Most Frequent HPV Types of Cervical Cancer

Type-specific HPV prevalence in women in India

HPV Type

HPV Prevalence (%)

Low Grade Lesions High Grade Lesions Cervical Cancer

India1 Asia2 India1 Asia2 India1 Asia2

6 8.1 1.6 -- 1.0 0.3 0.3

11 -- 1.5 -- 1.5 0.7 0.3

16 23.5 18.1 48.0 36.8 67.6 53.3

18 5.9 17.6 8.0 8.0 14.9 15.2

1.WHO/ICO Information Centre on HPV and Cervical Cancer (HPV Information Centre). Human Papillomavirus and Related Cancers in India. Summary Report 2010. [Accessed on 5th July,2010]. Available at www. who. int/ hpvcentre2. WHO/ICO Information Centre on HPV and Cervical Cancer (HPV Information Centre). Human Papillomavirusand Related Cancers in Asia. Summary Report 2010. [Accessed on 5th July 2010]. Available at www. who. int/ hpvcentre

SQUAMOUS CELL CARCINOMA ADENOCARCINOMA

Data source: IARC Infection and Cancer Epidemiology Group. Clifford et al Br J Cancer 2003, Clifford et al Int J Cancer 2007

Available at: HPV Information Centre. Human Papillomavirus and Related Cancers in World. Summary Report 2009. [Accessed: 27 May 2010]. Available at www. who. int/ hpvcentre

Ten Most Frequent Hpv Types Among Cervical Cancer Cases Worldwide By Histology

1.7

4.7

7.1

8.8

9.0

9.2

10.0

10.7

13.0

14.0

15.3

17.4

19.6

21.4

33.6

35.4

0 10 20 30 40

Western AsiaNorthern America

Southern AsiaSouthern EuropeWestern EuropeNorthern Africa

Northern EuropeEastern Asia

Central AmericaSouth-Eastern Asia

South AmericaSouthern AfricaWestern Africa

Eastern EuropeEastern Africa

Caribbean

HPV prevalence (%)

Bruni et al, JID 2010

Adjusted HPV prevalence standardized by the geographical structure

HPV prevalence

11.7%(95%CI=11.6-

11.7%)

CERVICAL HPV PREVALENCE IN WOMEN WITH NORMAL CYTOLOGY Meta-analysis of 1,016,719 women

Estimated coverage of cervical cancer screening in India, by age & study


Cervical Cancer Screening Practices

Overall 2.6%

HPV causes more than cervical cancer

80+%

~40%

~100%

60-90%

~100%

Percentages represent cases atrributable to HPV infection

Cervical Cancer1,3

Vulvar Cancer1

Vaginal Cancer1

Anal Cancer1-3

Genital Warts1,3

12-70%Head &

Neck Cancer3

45%Penile Cancer3

Braaten KP et al. Rev Obstet Gynecol. 2008;1:2–10.

Hoots BE et al. Int J Cancer. 2009;124:2375–2383.

IARC. IARC monographs on the evaluation of carcinogenic risks to humans. Human papillomaviruses. Vol 90. Lyon, France: IARC, 2007.

*Ray K et al, Indian J Med Res 2006; 124: 559-568

18%

6%

11% 10.5%

0

2

4

6

8

10

12

14

16

18

20

1990-93 1994-97 1998-01 2002-04

Study Period

Per

cen

tag

eGenital Warts – Disease Burden: India*

Increasing trend of Genital warts in India

HPV Vaccination: The Basis of Cancer Control

World Health Organization, United Nations Population Fund. Preparing for the Introduction of HPV Vaccines: Policy and Programme Guidance for Countries. Geneva, Switzerland: World Health Organization; 2006.

Palliativecare

Palliativecare

Cancer treatmentCancer treatment

Secondary prevention:Screening and treatment

of precancers

Secondary prevention:Screening and treatment

of precancers

Primary prevention:Vaccination

Primary prevention:Vaccination

Summary India is one of the worst hit country in the world in terms of

incidence and mortality for cervical cancer. HPV is a necessary cause of cervical cancer HPV is also responsible for other cancers as well as

genital warts. HPV 16 and 18 are the main culprits in the causation and

progression of cervical cancer Poor awareness, screening practices and under utilized

HPV vaccines can be the primary reasons for high mortality and morbidity due to cervical cancer

Its time to join hands and fight against cervical cancer

SAVE US FROM HPV

Cervical Vaccine can be the best wedding gift a mother can give to her daughter

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Health & Medicine

CANCER CERVIX BURDEN OF HPV