Cervical Cancer Prevention:

HPV Vaccination vs HPV Test

Oleh:
Dr. dr. Teguh Prakosa SpOG(K)
CERVICAL CANCER SITUATION

World’s cervical cancer statistics (Globocan, 2018)

CERVICAL CANCER SITUATION

Cervical cancer incidence and mortality rate based on country

(Globocan, 2018)
CERVICAL CANCER SITUATION

Indonesia’s cervical cancer statistics (Globocan, 2018)

 CERVICAL CANCER
PREVENTION STRATEGIES
• WHO recommendation to cervical cancer prevention includes:

Primary • HPV vaccination

prevention
Secondary • Cervical screening
prevention
Tertiary • Treatment & palliative care
prevention
 CERVICAL CANCER
PREVENTION STRATEGIES

• The combination of HPV vaccination and cervical cancer

screening has the potential to prevent tens of thousands of cancers
caused by HPV each year and to eliminate cervical cancer as a public
health problem in the coming decades (American Cancer Society,
2020)
 HPV VACCINATION
• There are currently 3 types of HPV vaccine available  bivalent
(HPV 16, 18); quadrivalent (HPV 6, 11, 16, 18); nanovalent (HPV 6,
11, 16, 18, 31, 33, 45, 52, 58)
• Seroconversions occurs in 99 – 100% of women receiving HPV
vaccine while only in 70 – 80% of women after natural infection
• Administration of HPV vaccine is effective in reducing the incidence
of cervical lesions

Askandar (2020), Zhu et al (2014), Herweijer et al (2016)

 HPV VACCINATION
Benefits Harms

• Decrease HPV-related carcinoma in • Increased new onset back pain,

situ
• Decrease HPV-related external
genital lesions
• Decrease HPV-related treatment
procedures
• Decrease new onset gynecological
chlamydia infection and vaginal
infection
myalgia, headache
• May cause adverse reaction, such
as anaphylaxis, syncope, chronic
fatigue syndrome, Guillain-Barre
syndrome, postural orthostatic
tachycardia syndrome, premature
ovarian failure

Jorgensen et al (2020), Phillips et al (2020)

 HPV VACCINATION
• ACOG Recommendation for HPV Vaccination (2020)
• HPV vaccination is recommended for girls and boys at the target age of 11
– 12 years as part of the adolescent immunization platform
• Obs-gyn should assess and vaccinate girls and young women during the
catch-up period (ages 13 – 26) if they were not vaccinated in the target age
• For women aged 27 – 45 years who are previously unvaccinated, obs-gyn may
use shared clinical decision making regarding the HPV vaccination
• HPV vaccination is recommended for women through age 26 years even if the
patient is tested for HPV DNA and the results are positive
 HPV VACCINATION
• HOGI Recommendation for HPV Vaccination (2018)
• HPV vaccination can be given to girls and women age 10 – 55 years
• HPV vaccination is proven to lower the incidence of HPV-related cancers in
women tested positive for HPV
• HPV vaccination is not meant to treat cancer or pre-cancerous lesion
• HPV vaccination does not replace/change cervical cancer screening schedule
 HPV VACCINATION
• HPV vaccination in Indonesia
• HPV vaccine is not included in the mandatory immunizations program
• Pilot project to add HPV vaccine into the national immunization program has
been initiated since 2016 in several regions in Indonesia  the vaccination
coverage mostly > 90%
• Only quadrivalent and bivalent HPV vaccine available in Indonesian market
• The current prices of HPV vaccines are considerably high and Indonesia
has entered the GAVI accelerated transition phase  not eligible for co-
financing policy implementation scheme

Ayuningtyas & Sutrisnawati (2018), Setiawan et al (2020)

 HPV VACCINATION
Pros Cons

• Protect against the risk • Not included in

of HPV infection mandatory
• Reduce the risk of HPV- immunization program
related lesions • Considerably expensive
• Can be used as primary
prevention
 HPV TESTING
• A growing body of evidence supports high-risk HPV testing alone
without initial cytology as an option for primary cervical cancer
screening
• High-risk HPV can be detected with fluorescence in situ hybridization
and PCR
• HPV testing every 5 years is the preferred strategy for regular cervical
cancer screening

Castle (2011), Abreu et al (2012), Dillner (2013), Hoffman et al (2016), American Cancer Society (2020)
 HPV TESTING

• Twice as sensitive as a single Pap

test
Benefits
• Earlier detection of high grade
neoplasia

• Increased numbers of colposcopies,

Harms
biopsies, and treatments

Hoffman et al (2016)
 HPV TESTING
• ACOG Recommendations on HPV Testing (2016)
• HPV test can be used to determine the need for colposcopy in women with
abnormal cytology result (reflex testing)
• HPV test can be used as an adjunct to cytology for cervical cancer screening
in women aged 30 – 65 years and older (cotesting)
• Testing should be performed only to detect the presence of high-risk HPV
• HPV DNA genotyping is recommended for women aged 30 – 65 years who
are undergoing cotesting and have negative Pap results but positive high-risk
HPV test results
 HPV TESTING
• HOGI Recommendations on HPV Testing (2018)
• HPV DNA test using hybrid capture or genotype method can be used to detect
high-risk HPV
• HPV DNA test may increase negative predictive value of cervical cancer
screening
• HPV DNA test gives a better and more objective prediction for
precancerous lesions compared to cytology test alone
 HPV TESTING
Pros Cons

• Early detection of HPV • Only available in large

infection hospital/medical
• Early detection of high centers
grade neoplasia • Considerably expensive
• Can only be used as
secondary prevention
 HPV VACCINATION & HPV
TESTING
HPV vaccine alone
• Reduce cervical cancer incidence
from 19,8 to 2,1 cases/100.000
women over the next century
• May avert 61 million new cases
• May achieve cervical cancer
elimination between 2059 – 2102
HPV vaccine + screening
• Reduce cervical cancer incidence
from 19,8 to 0,7 cases/100.000
women over the next century
• May avert 78,1 million new cases
• May accelerate cervical cancer
elimination by 11 – 31 years
Brisson et al (2020)
 TAKE HOME MESSAGES
• Combination of HPV vaccination and cervical cancer screening may
reduce the risk of cervical cancer
• It is important that all individuals with a cervix, regardless of whether
they have been vaccinated, get screened according to current
guidelines
• All approved cervical cancer screening strategies dramatically reduce
a woman’s lifetime risk for developing or dying from cervical cancer
Thank You