The New Normal: An update from CervixCheck on HPV, Pap testing and the future of cervical cancer screening in Manitoba Ki m be r l y Te m pl e t on Ma n a ge r Ma y 9 t h , 2 0 1 4
Disclosure of Potential for Conflict of Interest Kimberly Templeton The new normal: An update from CervixCheck on HPV, Pap testing and the future of cervical cancer screening in Manitoba Grants/Research Support: none Speakers Bureau/Honoraria: none Consulting Fees: none Other: none
Agenda 1. Screening guidelines, activity and strategies for adherence 2. HPV and the vaccines 3. Technology 4. Future directions
Screening guidelines, activity and adherence strategies
Assessing the Benefits and Harms of screening with Pap tests Harms Benefits False positives Reduced incidence and mortality False negatives Early detection = simpler tx, Anxiety, discomfort, more tx options, less bleeding need for chemotherapy Tx from LLETZ can increase risk for reduced reproductive performance
Initiation of Screening Recommendation : Screening should be initiated at 21 years of age for all women who have ever been sexually active Rationale : The harms of screening women under 21 years of age outweigh the benefits
Popadiuk et al
Natural history
% women who had at least one Pap test by age group, 2012 vs 2013
Screening Interval Recommendation : In the absence of abnormal cytology, routine screening should be performed every 3 years . Rationale : Screening every 3 years maintains the benefits of screening while decreasing the harm from overscreening.
% reduction in cumulative rate of invasive cervical cancer in women (aged 35-65) screened at different intervals Screening % reduction in Number of interval (years) incidence lifetime tests 10 64.1 3 5 83.6 6 3 90.8 10 2 92.5 15 1 93.5 30 Source: International Agency for Research on Cancer (IARC). Handbooks of cancer prevention: cervix cancer screening. 2005;Vol 10
Are we over-screening? • 27% of women who had a negative Pap test in 2013 also had a negative Pap test in the previous 18 months.
Should I screen? Screening History Requests By fax: By phone: (204) 788-8626 1 (866) 616-8805
Cytology Volumes 2012 = 173,273 2013 = 133,933
67.3% of women who had at least one Pap test in 3 years (2009-2011) by RHA (n=254,270) National target: ≥ 80%
Recall Letters for Overdue Women • Manitoba resident • no Pap test in 39 mo • no hysterectomy • no gyne cancer
Summary Report • 40-68 years of age • 42,912 letters sent since Sept. 2013 • 1,914 “responses” from women (phone, email, etc) • mail return (923) • “where can I go for a Pap test?” (712) • “I had a hysterectomy” (133) • “don’t send me anymore letters” (78) • other
Uptake as of Apr. 15, 2014 • 3,340 (8%) of women who received a recall letter have had a Pap test after the date their letters were sent
Education and Resources TellEveryWoman.ca/resources
Manitoba Pap clinics
Pap Test Competency TellEveryWoman.ca/module Video username: cervix Video password: MCCSP21
iClicker question… Would you use a cervical cancer screening guidelines app? a) Yes b) No
iClicker question… Would you actually use a cervical cancer screening guidelines app? a) Yes b) No
% of women who had an abnormal Pap test result by diagnostic category (2009 – 2011)
iClicker question… What percentage of women with a HG Pap test result had a colposcopy within 6 weeks? a) 84% b) 41% c) 12% d) 56%
iClicker question… What percentage of women with a HG Pap test result had a colposcopy within 6 weeks? c) 12%
Time to colposcopy: % of women who had a HG Pap test result and who had colposcopy within 6 weeks, 12 mo and 2 years (2009-2011) National target: 90% in 6 weeks
Fail safe letters to providers and women HG HG Pap test No colp report? Letter to HCP Letter to woman
Fail Safe Letters ~5% Women Lost to Follow-Up # with # with # with # Letters to # Direct # Lost to High Grade Recommen Outstanding HCP (% ) Letters to Follow Up (% ) Results ded Follow Follow Up Women Up (% ) (% ) 2,485 2,056 429 384 212 114 (17.5% ) (15.5% ) (8.5% ) (4.8% )
High grade letters to women HG HG Letter Pap to test woman
Colposcopy quality assurance CME Colposcopy Quality Quality Training indicators Assurance Time to colposcopy
HPV and the Vaccines
Manitoba HPV Immunization Program Eligibility Criteria (Gardasil) (as of March 31, 2014 ) All females in Grade 6 (school-based program). • Females who missed the vaccine in Grade 6 and are • born on or after January 1, 1997. Females born between 1986 and 2005 with • increased risk of HPV infection who started the vaccine series before March 31, 2014.
Cancer MB HPV Population vaccines ( ≥ 18-69) ( ≥ 18-69) CervixCheck Registry Pap tests Hysterectomy (1984) (2001) Colposcopy Reports (2003)
Integrated CervixCheck Registry Annual upload of HPV vaccine information, women • ≥ 18-69 all three data sources: MIMs, DPIN, medical claims • dates and number of doses • type of vaccine (Gardasil or Cervarix) • age of woman at time of dose(s) •
Surveillance and Evaluation Monitor the impact of the HPV vaccine on • cervical dysplasia and cervical cancer, and Evaluate the impact of the HPV vaccine on • Pap test performance, HPV status and HPV typing.
Vaccinated Women in CervixCheck Registry ( ≥ 18–69) Age Group Number of Women 18-19 5195 20-29 4774 30-39 288 40-49 118 50-59 39 60-69 12 TOTAL 10,428
Are there different screening guidelines for vaccinated women?
GIRLS: What message are we sending??
GIRLS: What message are we sending??
iClicker question… Which of the following messages from the GIRLS video was true? a) “Planes don’t go down for people who are really scared of flying” b) Males can get tested for HPV c) HPV causes warts and cervical cancer d) “My gynecologist was calling with news about my vagina” e) Women with HPV infection can’t have children
iClicker question… Which of the following messages from the GIRLS video was true? c) HPV causes warts and cervical cancer
Patient education messages • Normalize • Over 80% of sexually active Canadians will have at least one HPV infection within their lifetime • Most common STI • Easily transmitted • Does not mean infidelity or promiscuity
Patient education messages cont… • Most infections clear and do not progress into cancer • Condoms should not be relied upon to reduce infection • Pap tests still required after HPV vaccine • Best protection is regular Pap tests
Technology
Liquid Based Cytology: Broom Sampling 1. Collect – turn 2. Drop 3. Label & send 5x clockwise
LBC Sampling Technique
LBC Sampling Technique
Future Directions
HPV Testing?
Primary HPV Testing Cuzick et al. 2008
Advantages Increased detection for pre-cancerous lesions and cancer Higher adenocarcinoma detection rate Self sampling Increase screening interval and earlier cessation HPV testing more attractive as vaccinated cohorts reach screening age Monitoring and evaluation
Considerations Increased colposcopy referral rate … Increased risk of harms associated with surveillance … Stigma/anxiety of HPV positive result …
Planning considerations Screening Guidelines • Labs • Colposcopy volumes and guidelines • Public and Provider Education • Cost-effectiveness • Evaluation •
HPV DNA Testing Is the use of HPV DNA testing a standard of practice in your province or territory? If yes, in what capacity is it being used? Nunavut Northwest Territories Yukon British Columbia Alberta Aids triage in women 3. Pilot trials/ Research Information currently not 3. Pilot 4. Triage in women > 30 >30 with ASCUS on 4. Follow up for treatment available trials/Research with ASCUS or women > Pap 5. Triage in women > 30 4. Follow up for 50 with LSIL. (HVP triage) with ASCUS or treatment postmenopausal women with LSIL/ASC-US Saskatchewan Manitoba Ontario Quebec New Brunswick 2. Personal request 3. Pilot trials/Research 3. Pilot trials/Research 3. Pilot trials/ 4. Triage in women > 30 (only) Research with ASCUS or women > 3. Pilot trials/Research Triage in women > 50 with LSIL 30 with ASCUS in 2014 Options Nova Scotia Prince Edward Island Newfoundland/Labrador 1. Routine primary screening 3. Pilot trials/Research 2. Personal Request (only) 4. ASCUS Triage for 2. Personal request (only) at the cost to the woman. women over 30 years of 3. Pilot trials/Research 4. Follow up for treatment Guidelines suggest HPV age 5. Other (specify) testing following a ASCUS for women over 30 but not funded at this time. April 2014
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