Cervical Cancer Screening

Strategies

Z Mike Chirenje MD FRCOG

mchirenje@uzchs-ctrc.org
 Tragedy of Cervical Cancer- A Preventable Disease

• Globacan 2012 reported 527,624 incident

cervical cancers globally with 50% deaths,
4th cause cancer deaths in F (after breast,
colo-rectal, lung)
• Majority (85%) of cases ICC occur in low
resourced countries with inadequate
infrastructure to initiatie or maintain cervical
cancer screening and treatment programs
• In SSA 62% of 93,225 women die yearly
from ICC
Estimated Cervical Cancer Incidence Worldwide in 2012
 Magnitude of Cervical Cancer
Problem in Zimbabwean women:
Female cancers registered in 2015 by site:
• Cervix uteri 34.8 %
• Breast 11.6%
• Kaposi Sarcoma 4.6%
• Eye (SCC) 2.4%
• NHL 4.7%
• Oesophagus 4.6%
• Ovary 2.6%
• Cervix corpus 2.0%
Zimbabwe National Cancer Registry Aug 2017
Target age groups of different interventions and
links with cervical cancer prevention

15 years 30 years 45 years

Vaccination Screening Treatment
 Cervical Cancer Overview

• One of the earliest observations in cancer

epidemiology was that cancer of the
uterine cervix rarely occurred among
celibate nuns (Rigoni-Stern, 1842).
Rigoni-Stern D.A, Fatti statistici relativi alle
mallattie cancrose. Giovnali per servire ai
progressi della Patologia e della
Terapeutica (1842); 2: 507 – 517.
Epidemiology and Treatment of Cervical
Cancer in Zimbabwe
• Majority (63.3%) are from rural communities
(Chirenje et. al 2000) where a mean age at
diagnosis is 46 year old woman has 3 to 4
children (oldest 24 years youngest 8 years of
age) left behind as young orphans.

• Majority (80%) present at FIGO > stage 2b not

amendable to surgical cure
Risk factors for HPV acquisition
cigarette smoking (decreases Langerhans cells on
cervix)
steroidal contraceptive use for > 10yrs
sexual intercourse with hrHPV infected new
partner.
deficiency in CMI (transplant recipient, steroids,
chemotherapy)
Early sexual debut

130 HPV types have been identified out of which

40 infect female genital tract, low risk and high
risk (hr), types 16 and 18 are most common hr
 HPV Epidemiology

• HPV prevalence is highly age dependent

• woman aged 20 - 25 years prevalence of
20 - 46% whereas women > 30 years
prevalence is 6%).
• Among women with abnormal cytology
10-20% prevalence of HPV
• CIN 2/3 (up to 50% HPV types 16, 18)
• and ICC ( up to 70 % HPV types 16, 18).
 HPV Epidemiology in Female
Genital Tract
• HPV infection are transient in HIV –ve women

• Progression to ICC (10-20yrs): CIN I 1%

CIN 2 5%
CIN 3 12%
• In immunosuppressed individuals HPV, CIN
prevalence's are 2 - 6x higher and progression
to ICC is more rapid, treatment outcomes
poorer
 HPV Epidemiology
 Persistence of HR HPV (16,18,26,31,
33,35,39,45,51,52,53,56,58,59,66,68,73
and 82) is necessary for development,
maintenance and progression of CIN the
known precursor for ICC.
• ICC cases attributed to HPV genotype
16(53.5%),
18(17.2),45(6.7%),31(2.9%),33(2.6%),52
(2.3%),58(2.2%)
 Infectious cycle of high-risk
HPVs
•No viraemia, no cytolysis or death, long infectious cycle

Virus-laden cells ready for 6–12 weeks

desquamation and infection of
Virus particles assembled
naïve individual
L1, L2, E4
Differentiated cells
E and L viral genes Viral genomes at 1,000s per cell
expressed E6, E7, E1, E2, E5
Viral DNA amplification in
non-dividing cells
Dividing cells
Only E genes Virus and cell replicate
•
togetherE1, E2
expressed,very low levels of
protein made Virus infects a primitive
basal keratinocyte at low
(<10) copies per cell
0 weeks

• The HPV genome encodes eight genes:

– Six encode the ‘early’ or non-structural proteins (E1, E2, E4, E5, E6, E7);
– Two encode the ‘late’ or structural proteins (L1, L2).
• Stanley MA.
MA. J Natl Cancer Inst Monographs 2003;
2003; 31:
31:117–
117–124
124..
 HPV lifecycle in the cervix
•Shedding of virus-
laden epithelial cells
•Cervical canal
•Viral assembly
•Mature
squamous •• •
• ••
•• •• ••
(L1, L2, E4)

layer
•• •• •• •Viral DNA
•Squamous
layer •• •• •• replication

•• •• ••
(E6 & E7)

Parabasal •Episomal viral DNA

cells
•• •• •• in cell nucleus
(E1 & E2, E6 & E7)

Basal (stem)
cells
•• • • •Infection of basal
cells (E1 & E2)
•Basement membrane
Normal Infected
epithelium epithelium
• Adapted from Frazer IH. Nat Rev Immunol 2004; 4:46–54.
 Oncogenic Pathway
• HPV E7 oncoprotein binds to retinoblastoma
protein (pRB) allowing increased transcription
by E2F-DP transcription factors that lead to
proliferation
• p16 (presence is indicative of HPV infection) is
upregulated by E2F-DP by blocking the pRB-
activating kinase complex
• In presence hrHPV pRB is permanently
inactivated and p16 transcription continues
 Risk of progression to cervical
cancer: Global
Healthy, uninfected individuals

Subclinical HPV infection

Progression 27% cases
(214,275,360 cases†)
HPV 16/18+

Low-grade dysplasia 27% cases

(CIN1) HPV 16/18+

High-grade
dysplasia 52% cases
Regression* (CIN2/3) HPV 16/18+
Cancer
Usually several years
(500,000 70% cases
cases)
HPV 16/18+
(up to > 20 years)
•* Most cases of CIN 1 regress; less likely with higher-grade lesions (cervical cancer does not regress).
•† Estimated from total number of global females aged > 15 years.
Data available at: http://www.who.int/hpvcentre/en (accessed September 2009);
Castellsagué X, et al. Vaccine 2007; 25S:C1–C26;
25S:C1–C26; Clifford GM, et al. Lancet 2005; 366:991–998.
366:991–998.
 Cervical Cancer Prevention Strategies

• Primary prevention by HPV vaccination, must

target correct age group (HPV uninfected)
• Secondary prevention for women 25-70 yrs
aims to detect CIN 2/3 pre-cursor of ICC
Cervical cytology (good spec, low sensitivity)
Visual Inspection with AA (poor specificity)
HPV DNA test (high sensitity, high specificity)
• Choice of screening test must consider test
performance, resources including lab capacity
 Cytology Based Screening
15-30% false -ve rates (specificity 85-95%)
Most commonly used screening method world-
wide (has reduced ICC deaths incidence by up to
90% in Scandinavian countries)
Start screening 20-30yrs, every 3-5yrs, until 70
yrs.
Must recall all test positive(HGSIL/AGUS) for
colposcopy (biopsy or LEEP done under low
magnification x4 to x16)
Liquid based cytology samples are transferred into
a vial therefore not lost in sampling device
 Visual Inspection with Acetic
Acid (VIA)
• Is affordable, acceptable, sensitivity 70-80%,
good alternate in low resource settings where
cytology is difficult to implement
• Immediate treatment with cryotherapy for test
positive cases (aceto white changes from
protein degredation, indicative of CIN disease)
• Specificity of 50-80% (false positive from
polyps, HPV, inflammation, ectropion)
• See Chirenje ZM et al Lancet 1999
 HPV DNA Screening Test
• First commercially available was Hybrid Capture
(HC 1 and 2) a nucleic acid hybridization assay
for detecting DNA of 14
HPV(16,18,31,33,35,39,45,51,52,56,58,59,68)
• Detection is combined probe mix, -ve or +ve HR
• Several PCR based of sequencing target DNA
with high sensitivity to detect < 10 copies of
HPV DNA
• Several commercial kits can detect can detect
37 anogenital HPV genotypes (HR and LR)
 Treatment Options for CIN
• Cervical Cancer screening is designed to
detect CIN
• If CIN is present treatment should
theoretically avoid subsequent cancer by
100% (i.e. effective cure rate or zero
percent failure rate).
• Threshold for treatment is CIN2/3
Treatment Options for CIN disease
• LEEP (Loop Electrosurgical Excision Procedure)
• Cryotherapy (Cryocautery) at −60°-90°C
• LASER Vaporization
• Radical (Deep) Electro Diathermy at 300°C
• Cold (Thermal) Coagulation at 100-120°C
• Knife Cone Biopsy
• Hysterectomy in presence of other
gynecological disease like fibroids
 CIN Treatment Options
• LEEP - (Loop Electrosurgical Excision
Procedure) uses thin wire electrode with low
voltage high frequently alternative current:
An outpatient procedure that provides a
histological specimen but may remove an
excessive amount of cervical stroma. High
cure rates of upto 96%
See Mitchell MF et al, Obs & Gyn 1998
Chirenje ZM et al, Journal Lower Ganital
Tract Disease 2003
Treatment Options for CIN

Cryotherapy - destroys abnormal cells by

freezing TZ (-60°C - 90°C): An
outpatient procedure. Is an ablative
technique, low cost, does not require
electricity, ease of use, low complication
rates, good cure rates up to 80% -90%
See Chirenje et al 2001 J Obs Gyn
Varawalla N et al 1996 J Obs Gyn
 CIN Treatment Options
• Knife Cone Biopsy (Cold KCB)
Is done under general anesthesia and still most
commonly performed option in low resource
settings.
Complications of hemorrhage, cervical stenosis,
infertility, recurrent miscarriages, pre-term
labor. Histological specimen is available.
 Terminology
Histological term Cytological term
• CIN I (mild dysplasia) mild dyskariosis
• CIN II (moderate dysplasia) moderate dyskariosis
• CIN III (severe dysplasia/
carcinoma in situ) severe dyskariosis

Based on scientific evidence that HPV is causative agent

for cervical neoplasia and ICC the Bethesda system of
classification (1988) was introduced.

• WNL LSIL (HPV alone and CIN I)

• Benign cellular changes HGSIL (CIN II/III)
• ASCUS/AGCUS ICC

• http://www.who.int/reproductivehealth/publications/cancers/9241547
006/en/

Click “guide” to access the publication.

 High antibody levels and
transudation
• Vaccination induces the production of Neutralizing
serum antibodies HPV antibody
• Vaccine-induced antibodies migrate to
the site of infection by transudation/ Cervical canal
exudation1–4
• High serum antibody levels correlate
with higher antibody levels at the site of Cervical
infection5 epithelium

• Higher peak antibody levels post-

Blood vessel
vaccination mean that, in the long term,
antibodies are likely to be sustained at Epithelial tear
higher levels6,7
• Antibodies neutralize the virus and
prevent viral entry into cells8,9 Basement membrane

1. Parr EL, et al. J Virol 1997; 71:8109–8115; 2. Nardelli-Haefliger D, et al. J Natl Cancer Inst 2003; 95:1128–1137;
3. Schiller JT, et al. Nat Rev Microbiol 2004; 2:343–347; 4. Kemp TJ, et al. Clin Vaccine Immunol 2008; 15:60–64;
5. Poncelet, et al. ESPID 2007; Abstract; 6. David MB, et al. ESPID 2008; Abstract; 7. Fraser C, et al. Vaccine 2007; 25:4324–4333;
8. Stanley M. HPV Today 2007; 11:1–16; 9. Einstein M. Cancer Immunol Immunother 2007; 57:443–451.
Active protection via vaccination is mediated by
neutralizing antibodies at the cervix
HPV Neutralizing antibodies

Cervical canal

Cervical
epithelium

Blood vessel

Epithelial tear

Basement membrane

• Stanley M. Vaccine 2006; 24:S16–S22;

24:S16–S22;
• Giannini S, et al. Vaccine 2006; 24:5937–5949;
• Nardelli-Haefliger D, et al. J Natl Cancer Inst 2003; 95:1128–1137;
 Generation of an immune response that
improves on natural immunity
• Vaccination aims to prevent HPV infection by inducing high1 and
sustained serum neutralizing antibody levels in all vaccinees2
• Natural immunity does not provide this response to infection3–5

Diagrammatic representation: characteristics of an effective HPV vaccine

Effective antibody response

after vaccination
Neutralizing
antibody
levels
•Suboptimal antibody response
after vaccination
•Antibody level
following natural
infection

Years
Vaccination
1. Stanley M, et al. Vaccine 2006; 24(Suppl 3):S106–S113; 2. WHO Department of Immunization, Vaccines and Biologicals,
2007;
3. Carter JJ, et al. J Infect Dis 2000; 181:1911–1919;
181:1911–1919; 4. Viscidi RP, et al. Clin Diagn Lab Immunol 1997; 4:122–126;
4:122–126;
5. Ho GY, et al. Cancer Epidemiol Biomarkers Prev 2004; 13:110–116.
13:110–116.
HPV Vaccination Programs
•Most low resource countries are benefiting from
GAVI 3 dosses about $5
•Vaccination before sexual debut, before HPV
exposure, school based programs F age 9-13 yrs. in
most countries
•Boys will benefit from herd immunity
•Coverage of 80% required for good public health
impact
•Duration if immunity now up to 17yrs from vaccine
cohorts(protection HPV infection, CIN, need 20yrs
follow for ICC protection
Current HPV Vaccines

• Bivalent vaccine (GSK) has HPV types 16,

18 coverage. Only one currently registered
in Zim. MOH adminstered in Marondera
and Beit-bridge 9-13 yr olds, roll out
commended in May 2018
• Quadrivalent (Gardasil-Merck) 6,11,16,18
• Nonavalent (Gardasil 9 –Merck) has HPV
types 6,11, 16, 18, 31, 33, 45, 52, 58
 Potential Impact of HPV
Vaccination
• Primary cervical cancer prevention by
vaccinating correct target group's has potentially
huge impact to prevent ICC in SSA which has <
5% women screened yr..
• Impact of vaccination may take up to 30 years
from initiation of vaccination to demonstrate
population effectiveness
• Will depend on level of coverage critically
 Algorithm for HPV primary
screening
Women aged 25–64 years
HPV DNA testing
Negative Positive

Normal 5-year VIA or Cytology

recall
Normal or ≥ Mild
borderline

HPV testing & cytology Colposcopy

at 6–12 months
Cytology-negative
Cytology ≥ mild
HPV-negative
HPV-positive & cytology < mild
HPV-negative & cytology
borderline

Normal 5-year HPV & cytology Colposcopy

recall at 6–12 months

Cuzick J, et al. Vaccine 2008; 26S:K29–K41.

 Future Research Questions
• Need for further research on therapeutic
vaccines for treatment HPV infections, CIN
disease and ICC
• Molecular markers for screening strategies
including HPV E6/E7 genes that are
overexpressed in HGSIL and ICC
• E6/E7 mRNA strongly associated with poor
histology grades and more specific to detect
CIN than HPV DNA
• Other molecular markers: gene methylation,
p16 a cell cycle regulation protein that
accumulates in cells infected by HR HPV
Role of Screening in advent of HPV
Vaccines
• The role of oncogenic HPV has been
establishes as necessary cause of ICC and
its precursor (CIN)
• Over 100 different genotypes identified of
which 40 detected in anogenital area
• http://www.who.int/reproductivehealth/publicati
ons/cancers/cervical-cancer-guide/en/
Genital Warts in HIV infected
Woman
http://www.who.int/reproductivehealth/publications
/cancers/cervical-cancer-guide/en/
http://www.iarc.fr/en/publications/pdfs-
online/prev/handbook10/index.php