best practices in cervical cancer: prevention and treatment_a.pdf · 2019-04-16 · and cervical...
TRANSCRIPT
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Amy Brockmeyer, MDBoard Certified in Gynecologic Oncology
Obstetrics and Gynecology& Hospice and Palliative Care
Banner MD Anderson Cancer CenterApril 14, 2019
Best Practices in Cervical Cancer:Prevention and Treatment
I have no disclosures.
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Learning Objectives
• Understand the most up to date screening guidelines and its implications for patients.
• Understand how the HPV vaccine can prevent and treat cervical cancer and precancer and how we can successfully increase vaccination.
• Understand recent breakthroughs in care.
Cervical Cancer Incidence
2015: 12,845 US cases, 241 AZ cases4,175 US deaths
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HPV infections cause cancer of the gynecologic tract
Necessary, but not sufficient
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Two targets for cervical cancer prevention
• Early detection and treatment of precancer and cancer via cytology and HPV detection
– Use screening guidelines avoid overtreatment
• Infertility and preterm birth
• Anxiety, unneeded uncomfortable exams
– Test for HPV to identify those with persistent infection
– Examine/refer appropriately
• Abnormal bleeding, bleeding after sex, pain, visible lesion
• Prevent HPV infection that causes Cervical Cancer
Pap Smear
NILASCUSLSILHSIL
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The American College of Obstetricians and Gynecologists. Practice bulletin 131: Screening for cervical cancer. Obstet Gynecol. 2012;120(5):1222‐1238.
Pap with reflex is essentially cytology alone.
Choice may be affected by lab availability, insurance payment, physician recommendations.
Early Detection‐ Pap Guidelines Update 2015
ACS‐ASCCP‐ASCP Cervical Cancer Guideline Committee
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American Society for Colposcopy and Cervical Pathology website/mobile App
Who should still get a pap after age 65? Exam?
‐20% of cases occur >65yrs‐Must obtain pap history‐Pelvic exam is not a pap‐Abnormal PAP or +HPV must be followed for 20 years‐Symptoms/abnormal exam always warrant biopsy &/or a referral.
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A Brief History of the HPV vaccine
• 80s/90s– HPV 16/18 are linked to 70% of all cervical cancers
• 2006– 4‐valent vaccine approved for females age 9‐26 to prevent HPV disease
and cervical cancer
• 2009– Indication expanded to include vaginal and vulvar cancer– Indication expanded for use in males
• 2010– Indication expanded for prevention of anal cancer/AIN
• 2014– 9‐valent vaccine approved (covers 20% more cervix cancers)– Only 2 doses are needed for 9‐14 year olds
• 2018– Indication expanded for warts, cancer and precancers in males and
females– Indication expanded for 3 dose regimen up to age 45
Vaccinate ages 11/12 (2 shots) completed by 13
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New approval for women up to age 46
In 3200 women aged 27‐45, Gardasil demonstrated an 88% efficacy rate in preventingpersistent infection, warts, vulvar and vaginal precancer, and cervical cancer related to HPV 6, 11, 16, 18.
HPV Vaccination Successes in Australia & Rwanda
• Australia & Rwanda have been successful in achieving high vaccination rates. (>85%)
– Government Action
• Equitable access
• Free
• School‐Based
– Commitment to Education
• Taking a stance against fear and misinformation
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Successful IRL? Why?
Efficacy is 80‐90%, Cross protection, herd immunity,
By 2028 < 4/100,000 women could be diagnosed with Cervix cancer annually, by 2066 <1 woman/year.
How are we doing in Arizona?
• US coverage: 49%; AZ coverage 50‐59%
• AZ House Health & Human Services Committee
– HB2470 expand exemptions for religious/personal beliefs, eliminate the requirement of forms for parents who opt out
– HB2471 and HB2472 require parents get a booklet about vaccine risks prior to vaccination and that titers are offered prior to vaccinating
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The Future may be Treatment Vaccination
• New immune‐based therapeutic injection– Placebo controlled trial of 129 women
• TS had significantly higher resolution of CIN II/III and CIN III• Benefit was regardless of prior HPV status
Cervical Cancer Treatment in the Headlines
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Minimally Invasive Surgery (MIS) for Cervical cancer
Prospective, randomized trial of 2,221 women who underwent open vs MIS for early cervical cancer
Minimally Invasive Surgery
Straight Stick Laparoscopy Robotic Assisted Laparoscopy
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Radical Hysterectomy for Cervical Cancer
Results show that Survival is worse with MIS
• MIS RH was associated with 3 fold increase in disease progression compared to open RH
• The rate of DFS at 4.5 years was 86% with MIS and 96.5% with open surgery
• The 3 year OS was 91.2% for MIS vs 97.1% in the open arm
• CRITICISMS– ?Faulty randomization
– ?Skill of the surgeons
– Some unknown selection criteria
– Postsurgical treatment was not standard
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Resources
• ASCCP website or App
• ACOG practice bulletins
• CDC website
• Contact [email protected]
• American Academy of Pediatrics
THANK YOU
QUESTIONS?