The document discusses the disease burden of cervical cancer in India, providing statistics showing that India accounts for approximately 25-27% of new cervical cancer cases and deaths worldwide despite having a smaller population than other parts of the world. It then discusses the role of HPV in causing cervical cancer, noting that HPV types 16 and 18 cause over 70% of cases. The document recommends HPV vaccination between ages 9-13 when immune response is strongest, and suggests it can provide benefits even for some sexually active women who have not been exposed to all HPV types covered by the vaccine. Long-term follow-up studies show the vaccine continues to provide nearly 100% effectiveness against HPV 16/18-related cervical diseases for many years.

1. HPV Vaccination
&
Ca. Cervix Screening
Update
Dr. Sharda Jain
Director :-
Sec General : Delhi Gynae Forum

2. What is the Disease burden
of
Ca. Cervix in India
?

3. India ~1,34,000
World ~ 5,29,000
India ~25% of new
Cervical Cancer cases in world
India ~ 73,000
World ~ 2,75,000
India ~25%
Rest of World - 75%
India ~27% of deaths
due to Cervical Cancer in world
Rest of World - 73%
India - 27%
Cervical Cancer – Disease Burden
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

4. 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
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/ hpvcentre

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

6. Death Due to Ca cervix
• The cervical cancer death rate of 16 per 100 000 reported
in table 2 suggests that a 30-year old Indian woman has
about 0·7% risk of dying from cervical cancer before 70
years of age in the absence of other diseases.
• By contrast, the risk of dying during pregnancy for Indian
women aged 15–49 years is about 0·6%.31
30 yr old woman has more risk of dying
due to cervical cancer than
dying during pregnancy.
2. Dikshit et al, Cancer mortality in India: a nationally representative survey, Published online
March 28, 2012 DOI:10.1016/S0140-6736(12)60358-4 www.thelancet.com

7. What is the Relation of
HPV
With Cervical Cancer ?

8. HPV 16
HPV 18
HPV 6
HPV 11
Cancer causing Types
High risk group-16,18,
31,33,45,52,58
Non-cancer causing types
Low risk group- 6,11.
• >75% of Cervical Cancer5,6
• >50% of Vaginal & Vulvar Cancer5
90% 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)
Need for multivalent HPV vaccine for broader HPV protection

9. 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.
Palliative
care
Cancer treatment
Secondary prevention:
Screening and treatment
of precancers
Primary prevention:
Vaccination

10. 0
5
10
15
20
25
20–24 25–29 30–34 35–39 40–44 45–49 50–54 55–59 60–64
Age Group (Years)
HPV infection
Cervical Cancer
HPVPrevalence(%)
CancerIncidenceRate(×105
)
25
20
15
10
5
0
(n=3752)
* Two different cohorts (cross-sectional study) followed during the same time span to measure the rate of high-risk HPV infection in one and the rate of cervical cancer in the other.
1. Adapted from Bosch FX, Lorincz A, Muñoz N, Meijer CJLM, Shah KV. J Clin Pathol. 2002;55:244–265, with permission from the BMJ Publishing Group.
Peak of HPV infection
Peak of cervical cancer
Age-Specific Rates of HPV Infection & Cancer*
Age for vaccination
9 – 26 years

11. Adapted from Pinto AP et al. Clin Obstet Gynecol. 2000;43:352–362.
Natural History of HPV Infection:
Surrogate Markers for Cervical Cancer
0–1 Year 0–5 Years 1–20 Years
Invasive
Cervical
Cancer
Cleared HPV Infection
CIN 1
Initial
HPV
Infection
Continuing
Infection
CIN 2/3
or AIS
Primary efficacy objective
of quadrivalent HPV
vaccine program:
Demonstrate prevention of
HPV 16/18-CIN 2/3 + AIS
CIN = cervical intraepithelial neoplasia.
AIS = adenocarcinoma in situ.

12. • Quadrivalent vaccine can prevent HPV infection
aiming at prevention of precancerous lesions &
cervical cancer.
• More than 25,000 women worldwide have been
enrolled in trials across the globe in 33 countries.
• Highly successful in preventing precancerous
lesions & cervical cancer.
• It has also been studied in Indian women as per
local regulations.
HPV Infection can be prevented
1. Mao C et al. Obstet Gynecol. 2006;107:18–27. 2. Villa LL et al. Lancet Oncol. 2005;6:271–278. 3. Garland SM et al. New
Engl J Med. 2007;356:1928–1943. 4. The FUTURE II Study Group. New Engl J Med. 2007;356:1915–1927.

13. 1.Stanley M. Vaccine 2006; 24: S106-13, 2.Tindle, Nat Rev Cancer 2002; 2, 59,
3.Stanley M. Vaccine 2006; 24: S16-22, 4. Stanley M. HPV Today 2007; 11: 1-16
No viremia
Local immunosuppression
No inflammation, no danger signals
Uncertain whether natural HPV infection
will recall memory in vaccinated women
Natural HPV Infection Induces a
Weak Immune Response1-4

14. 1. Parr EL et al. J Virol 1997;71(11):8109-15, 2. Nardelli-Haefliger D et al. J Natl Cancer Inst 2003;95(15):1128-37, 3.
Schiller JT et al. Nat Rev Microbiol 2004;2(4):343-7, 4. Poncelet et al. ESPID, Porto, Portugal 2007; Abstract 37, session
ES2, 5. Stanley M. HPV Today 2007; 11: 1-16, 6. Einstein M, Cancer Immunol Immunother 2007; 57(4):443-51.
Vaccination Induces Higher Antibodies
in the Blood and Site of Infection
• Data show that vaccine-induced
antibodies in the blood can reach to
the site of infection1-3
• Higher antibody levels in the blood
mean higher antibody levels at the site
of infection4
• Antibodies neutralize the virus &
prevent entry into cells5,6

15. GARDASIL®
: The Only Quadrivalent
HPV Vaccine1
• HPV types 6, 11, 16, 18
• Manufactured in Saccharomyces
cerevisiae
• Amorphous aluminum
hydroxyphosphate sulfate (AAHS)
adjuvant – 225 μg per dose
• 0-, 2-, 6-month dosing regimen
• Does not contain viral DNA and
therefore not infectious
1. Worldwide Product Circular. GARDASIL®
[Quadrivalent Human Papillomavirus (Types 6, 11,
16, 18) Recombinant Vaccine]; WPC-GRD-I-122008.

16. What is the BEST AGE
for
HPV Vaccination?

17. BEST AGE
for HPV Vaccination?
• Since, the best immune response is
observed in the younger age groups1
the
vaccine is best administered in this age
group
• WHO recommends vaccination at the age of
9-13 yrs
1. Harper DM. Prophylactic human papillomavirus vaccines to prevent cervical
cancer: review of the Phase II and III trials. Therapy 2008 May 1;5(3):313-24

18. WHO SAGE Recommendations: Primary
Target Population for Vaccination1
SAGE = Strategic Advisory Committee of Experts; WHO = World Health
Organization.
1. World Health Organization. Wkly Epidemiol Rec. 2009;84:1–16.
Vaccination is most effective when given to femalesVaccination is most effective when given to females
nanaïïve to infection with vaccine-related HPV typesve to infection with vaccine-related HPV types
Primary target population is likely to be girls 9 or 10Primary target population is likely to be girls 9 or 10
through 13 years of agethrough 13 years of age

19. 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23
Age at Enrollment (Years)
500
700
900
1100
1300
1500
1600
SerumcLIAGMTWith
95%CI,mMU/mL
Adolescent Females Young Adult Females
Serum anti-HPV 6 responses 1 month after completion of vaccination regimen
Per-protocol immunogenicity population (ages 9–26)a
Higher Immune Response in Adolescents
Versus Young Adults1
a
Inclusive of protocols 007, 013, 015, 016 and 018; all GMTs measured using competitive Luminex®
immunoassay;
women 24–26 years of age were omitted in the figure because of small numbers. Similar results were observed for
HPV 11, 16, and 18.
GMT = geometric mean titer.
1. Giuliano AR et al. J Infect Dis. 2007;196:1153–1162.

20. Is it Worth Vaccinating
Sexually Active Women?

21. Women Remain at Risk for Acquiring
HPV Infection Throughout Their LifetimesCumulativeRiskofHPVInfection
(%)
Adapted from Muñoz N et al. J Infect Dis. 2004;190:2077-2087. Reprinted with permission from The
University of Chicago Press. Copyright © 2004 by the Infectious Diseases Society of America.
All rights reserved.
Cohort of Colombian Women
N=1610
Years
0
10
20
30
40
50
0 1 2 3 4 5
Age at Baseline (Years)
15-19
20-24
25-29
30-44
45+

22. Estimated coverage of cervical cancer screening in India, by age & study
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
Cervical Cancer Screening Practice in India
Overall 2.6%

23. 0%
20%
40%
60%
80%
100%
16-26 Years Old 24-45 Years Old
WomenVaccinatedWithGARDASIL
Estimated Benefit of Vaccination With
GARDASIL in Sexually Active Women
99.9% of
women will
benefit2
99.6% of
women will
benefit2
► Women who have been exposed to at least 1 but not all vaccine-
targeted HPV types will derive some benefit from vaccination.1
1. Wright TC Jr et al. Gynecol Oncol. 2008;109(2 suppl):S40-S47. 2. Data on file, MSD.
Infected with all 4 types
Infected with 3 types
Infected with 2 types
Infected with 1 typeWomen unexposed to any
vaccine-targeted type

24. Long Term
Protection

25. Rapid and Strong Anamnestic Response to Antigen
Challenge
Rapid and Strong Anamnestic Response to Antigen
Challenge
GMT = geometric mean titer
*Similar response with the other three types of HPV within vaccine
Olsson SE et al. Vaccine 2007;25:4931-4939.
5714
60 61
Time (months)
3018 24 36 540 3 6 72 12
3870
0
1000
2000
3000
4000
5000
6000
7000
Anti-HPV 16*
response
(GMT levels
with 95% CI)
n=78
Placebo n=70
108
4466
Immune
challenge
Immune
memory
Q HPV: Demonstrated Immune Memory

26. GARDASIL®
: Nordic Cancer Registry Extension
Evaluation of Long-Term Efficacy of Vaccination
• Nordic European countries have
organized mass screening programs.
– Compulsory reporting of Paps, biopsies,
CIN/cancer
• By enrolling phase III studies in the
region, we can evaluate:
– Duration of effectiveness
– Data for use in assessing interaction of
vaccination with cervical screening
programs
– Long-term safety
Denmark
Norway
Iceland
Sweden
CIN = cervical intraepithelial neoplasia.

27. Data on File
a
FUTURE= Females United to Unilaterally Reduce Endo/Ectocervical Disease
Registry-Based Follow-Up
Vaccination
Reports
6 years 8 years 10 years
US FDA
Approval
5 years 7 years3 years
2003 2004 2005 2006 2007 2008 20132010 2011 20122009
3.5 years
FUTUREa
II Study
Total Duration
Time since
approval
Report of 6-
yr F/U
Follow-Up Through Nordic Registries Provides
a Sentinel Cohort
(Vaccinated at the Start of Study)

28. Key Objectives
• Evaluate the long-term effectiveness of
GARDASIL
– Look for possible breakthrough disease from vaccine-
related HPV types
• Study possible HPV type replacement or cross-
protection effects in non-vaccine HPV types
• Characterize the long-term immune response
both serologically and through continued
effectiveness
• Assess long-term safety
Kjaer SK, An evaluation of the long-term effectiveness, immunogenicity and safety of the quadrivalent vaccine in previously vaccinated women, Presented at Eurogin 2011

29. 0 0 0
100 % 100 % 100 %
0
20
40
60
80
100
Zero number
of cases
Vaccine
Effectiveness
Vaccine
Effectiveness
Vaccine
Effectiveness
(N=1,080) (N=921) (N=1.032)
HPV 16/18-Related
CIN 2 or Worse
HPV 16-Related CIN
2 or Worse
HPV 18-Related CIN
2 or Worse
Zero number
of cases
Zero number
of cases
Vaccine effectiveness measures the relative reduction of the disease incidence in vaccine recipients compared to the baseline incidence rate of 0.0287 per 100 person-years established from the
incidence rate in an unvaccinated cohort and under the assumption vaccine efficacy is 90%.
Per Protocol Efficacy Population
Percentage
Data on File
Effectiveness Against HPV 16/18-Related
CIN 2 or Worse

30. 0 0 0 0 0
0
20
40
60
80
100 Vaccineeffectiveness
(N=1,080)
Vaccineeffectiveness
Vaccineeffectiveness
Vaccineeffectiveness
Vaccineeffectiveness
Zero number
of cases
Zero number
of cases
Zero number
of cases
Zero number
of cases
Zero number
of cases
(N=1,080) (N=1,080) (N=1,080) (N=1,080)
CIN 2 CIN 3 CIN 3 + AIS CC
Vaccine effectiveness measures the relative reduction of the disease incidence in vaccine recipients compared to the baseline incidence rate of 0.0287 per 100 person-years established from the
incidence rate in an unvaccinated cohort and under the assumption vaccine efficacy is 90%.
Percentage
Per Protocol Efficacy Population
100 % 100 % 100 % 100 % 100 %
Data on File
Effectiveness By Lesion Type

31. Safety

32. Post licensure: Health authorities reaffirm the positive
safety profile of Gardasil®
1. EMEA statement on the safety of GARDASIL®
. EMEA/CHMP/103339/2009. http://www.emea.eu/humandocs/PDFs/EPAR/gardasil/Gardasil_press_release.pdf - last accessed on 16.04.10. 2. Centers for Disease control website.
Available at: http://www.cdc.gov/vaccinesafety/vaers/gardasil.htm- last accessed on 16.04.10. 3. RELEVE EPIDEMIOLOGIQUE HEBDOMADAIRE, No. 15, 2009, 84, http://www.who.int/wer 4. Press release Spain MINISTERIO
DE SANIDAD Y POLÍTICA SOCIAL 23.04.2009

33. Genital Warts
What is the importance of other HPV
diseases eg. Genital Warts?

34. Australia experience

35. Standardized Incidence Ratios (SIRs) of Cancer among women
diagnosed of GW in Denmark during 1978–2009
2.8
1.5
5.9
7.8
14.8
4.7 4.8
0
2
4
6
8
10
12
14
16
All HPV related
cancers
Cervix
uteri
Vagina Anus Vulva Tonsils HPV
Associated
StandardizedIncidenceRatios(SIRs)
CI: 2.4- 3.1 CI: 5.5- 9.2 CI: 2.2-12.9 CI: 5.4- 11.0 CI: 11.7-18.6 CI: 2.3-8.4 CI: 2.7-8.0
Diagnosis of GW was strongly related to anal, vulvar, vaginal,
cervical & subsites of HN cancer with confirmed HPV association.
3. Blomberg et al Genital Warts and Risk of Cancer: A Danish Study of Nearly 50 000 Patients With Genital Warts, J Infect Dis.
(2012) 205 (10): 1544-1553. doi: 10.1093/infdis/jis228

36. Organizations That Have Issued Guidelines
for Quadrivalent HPV Vaccine
• Advisory Committee on Immunization Practices (ACIP)
• American College of Obstetricians & Gynecologists (ACOG)
• American Cancer Society (ACS)
• American Academy of Pediatrics (AAP)
• American Academy of Family Physicians (AAFP)
• American College Health Association (ACHA).
• World Health Organization (WHO) - Consultation on HPV vaccines
• Canada (National Advisory Committee on Immunization)
• Australia and New Zealand HPV Project
• High Council of Public Health - France
• The International Union Against Cancer (IUCC)
• Canadian Pediatric Society
# MMWR, March 12, 2007 / Vol. 56 , # Report of the Consultation on Human Papillomavirus Vaccines World Health Organization, Geneva, April 2005 National Advisory
Committee on Immunization. # Can CommunDisRep. 2007; 33:1-32, # Guidelines for the Management of Genital HPV in Australia and New Zealand, 5th Edition -2007, #
Notice regarding vaccination against human papillomavirusstrains 16 and 18 by a bivalent vaccine –14 December 2007, # www.uicc.org, # Paediatr Child Health 2007
12(7): 599 –603, # http://www.acog.org/from_home/publications/press_releases/nr08-08-06.cfm, visited on7th March 2008, CA Cancer J Clin2007;57:7–28, #
PEDIATRICS Volume 120, Number 3, September 2007, #Am Physician. 2007;75(9). Available at: http://www.aafp.org/afp/20070501/practice.html. Accessed May 30,
2007. # American College Health Association (ACHA). Vaccine Preventable Diseases Committee. Recommendations for institutional prematriculation immunizations.
August 2006. Available at: http://www.acha.org/info_resources/guidelines.cfm. Accessed May 16, 2007.

37. WHO Position Statement 2009
Quadrivalent HPV vaccine Bivalent HPV vaccine
Licensed for Cervical Precancers &
Cancers in females
Yes Yes
Licensed for vulvar/ vaginal Precancers &
Cancers in females
Yes No
Licensed for anogenital warts in females Yes No
Licensed for anogenital warts in males In some countries No
Data available up to 5 – 6.5 yrs Yes Yes
Data in HIV patients Yes Data not available
Co-administration with other vaccines Can be give with other
vaccines
Can be give with other
vaccines
Partial Efficacy against HPV 31 & 45 Yes Yes
Efficacy against CIN2/3 99% 90%
May be given in lactating women Yes Safety data not available
Weekly epidemiological record, 10 APRIL 2009, 84th YEAR, No. 15, 2009, 84, 117–132 available on http://www.who.int/wer accessed on 24th April 2009

38. FOGSI Recommendations
• The HPV vaccine is a prophylactic vaccine.
• Both the bivalent and quadrivalent vaccine protects against
infection of
HPV genotypes (HPV-16 and HPV-18) that account for about 70% of
HPV-related cervical cancers.
• Routine HPV vaccination is recommended for females
http://www.fogsi.org/prevention_of_Cervical_Cancer.html

39. IAP Recommendations
• The recommended age for initiation of HPV
vaccination is 10-12 years.
• As of current licensing regulations in India, catch up
vaccination is permitted up to the age of 45 years.
• The currently available vaccines are safe and
efficacious.
• The HPV vaccines are thus of public health
importance
IAP guidebook on immunization

40. Cervical Cancer
Screening Guidelines for
Average-Risk Women
2013

41. 1. American Cancer Society (ACS)
2.American Society for Colposcopy and Cervical
Pathology (ASCCP),
3. American Society for Clinical Pathology (ASCP)
4. U.S. Preventive Services Task Force (USPSTF)
5. American College of Obstetricians and Gynecologists
(ACOG)
Endorsed by

42. FOCUS Of
Cervical Cancer Screening
Guidelines 2013
• When to start screening
• Screening method and intervals
• When to stop screening
• Screening after Hysterectomy
• Pelvic exams
• Screening among women who have been
vaccinated against human papillomavirus (HPV)

43. 2013 Guidelines for Screening of
Cervical Cancer
When to start Age 21 regarding of age of sexual initiation
Screening methods and interval
1. Cytology (21-65 yrs)
2. 2. If HPV Co- test done
a. (21 – 29 yrs)
b. (30-65 yrs)
3. Primary HPV testing
Every 3 years
Not used if less than 30 yrs
5 yrs
30-65 yrs HPV test not recommended
When to stop > 65 yrs
Screening post hysterectomy Pt with total hysterectomy – Stop screening
Pt. with supra – cervical hysterectomy –
continue
Screening in HPV Immunised Done as Routine
Statement about annual screening Not to be screened annually

44. When to start screening ?

45. SHOULD NOT BE SCREENED REGARDLESS
OF THE AGE OF SEXUAL INITIATION OR
OTHER RISK FACTORS.
(STRONG RECOMMENDATION)
Age 21.
Women aged <21 years

46. •Most HPV infections are transient
•When HPV infection persists, transit to cancer is quite long
•Spontaneous regression of low grade lesions is common
•Invasive cervical cancer is very rare in 15-19 year olds
-14 cervical cancers annually
-1-2 cases per 1 million women
•In teens, screening does not reduce mortality
-Cervical cancer rates have not changed since 1973-
1977, before practice of screening at 18 or first
intercourse
Why Start Cervical Cytology at 21?
ACOG Practice Bulletin No. 109, Dec 2009

47. Screening method and intervals
21 to 65 Years
• Cytology 21-29 years of age EVERY 3 YEARS.
(conventional or 30-65 years of age
liquid based)
Strong recommendation
Second Recommendation

48. Statement about annual screening
FOR SCREEN NEGATIVE
If Screening Negative
Repeat after 3 years
Women of any age should not be screened annually
by any screening method.
(Strong recommendation)
However , they should come for annual check-up

49. HPV co-testing SHOULD NOT
BE USED for women
aged <30 years.
HPV Co -Test
(cytology + HPV test administered together)
21-29 years of age

50. 30 – 65 years of age
• If Screen Negative
Every 5 years
(Strong recommendation)
• THIS IS THE PREFERRED METHOD
• (Weak recommendation).
HPV co-test
(cytology + HPV test administered together)

51. Proposed Algorithm for the
Management of Women ≥30
HPV Negative HPV Positive
Repeat both
tests at 5
years
HPV 16 - / 18 –
Other HR HPV
+
HPV 16 + and /
or HPV 18 +
ColposcopyRepeat both
tests at 1 year
Cytology
Negative
+ HPV
Testing

52. Annual cervical cancer screening
should NOT be performed. (Level A
evidence)
Patients should be counseled that
annual well-woman visits are recommended
even if cervical cancer screening is not
performed at each visit.
HPV Co- Test
Screen Negative
in women aged 30–65 years

53. Primary HPV testing (alone)
For
Screening
screening by HPV testing alone is not
recommended in most clinical settings.
(Weak recommendation)

54. When to Stop Screening
• Stop at age 65 for women with adequate
negative prior screening, no CIN2+ within
the last 20y.
Definition of adequate negative screening:
• 3 consecutive negative Paps or
• 2 consecutive negative HPV tests

55. Rationale for stopping at 65 years
• CIN2+ is rare after age 65
– Most abnormal screens, even HPV+, are false
+ and do not reflect precancer
• HPV risk remains 5-10%
• Incident HPV infection unlikely to lead to
cancer within remaining lifetime
Chen HC et al. JNCI 2011;103:1387-96;
Rodrigues AC et al. JNCI 2009;101:721-8

56. When NOT to stop at age 65 years
If history of CIN2, CIN3, or AIS
– Continue “routine screening” for at least 20
years, “even if this extends screening past age
65.”

57. When to stop screening - 2
• Stop after HYSTERECTOMY with
removal of cervix and no history of
CIN2+
• “Evidence of adequate negative
prior screening is not required”

58. Rationale for stopping after
Hysterectomy
• Vag cancer rate is 7/million/year
• 663 vag cuff Paps needed to find one VAIN
• 2,066 women followed after hyst. for average 89
months
– 3% had VAIN, 0 had cancer
• Risk of Pap abnormality after hyst = 1%.
Pearce KF et al. NEJM 1996;335:1559-62;
Piscitelli JT et al. AJOG 1995;173:424-30

59. Women who have had a SUPRA-CERVICAL
HYSTERECTOMY (cervix intact) should
continue screening
according to Age guidelines.
(Strong recommendation)
SCREENING IN
POST – HYSTERECTOMY CASE

60. Women at any age with a history
of HPV Vaccination should be
screened according to the age
specific recommendations for the
general population.
Screening among those immunized
against HPV 16/18
5th Recommendation

61. SCREENING A VACCINATED COHORT
• Vaccination against HPV 16/18
– Reduces CIN3+ by 17-33%
– Reduces colposcopy by 10%
– Reduces treatment by 25%
• “ Recommended screening practices
should not change on the basis of HPV
vaccination.”
Paavonen J et al. Lancet 2009;374:301-14

62. The need for a BIMANUAL PELVIC EXAM
in subsequent yearly check-ups
<21 – No need
21 - shared decision

63. Let’s
Recap
2013 Guidelines

64. AGE SCREENING
< 21 No Screening
21-29 Cytology alone every 3 years
30-65 Acceptable: Cytology alone every 3 years*
Preferred ??: Cytology + HPV every 5 years* OR
> 65 No screening, following 3 consequetive neg prior
screens in last decade
After total hysterectomy No screening, if no history of CIN2+ in the past 20
years of cervical cancer ever
HIV-positive
-Immunosuppressed (e.g., Annually
2013 Guidelines : ACS, ASCCP,
American Society for Clinical Pathology
CA Cancer J CLIN March 2012
• 1st
time that all 3 organizations involved with cervical cancer prevention and the
USPSTF have endorsed equivalent guidelines

65. Management of Abnormal PAP smear
(According to ASSCO Guidelines)
20 yrs and
younger
21 years and older and
pre – menopausal;
Post – menopausal;
(any age)
Pregnant
ASC-US Repeat Pap
test in 12
months
HPV test or repeat Pap
test in 6 months and 12
months or colposcopy
HPV test or repeat pap
test in 6 months or 12
months or colposcopy
In women 20 yrs and younger
repeat pap test in 12 months .
in women 21 yrs and older HPV
test or colposcopy (without
endocervical sampling)
LSIL Repeat pap
test in 12
months
Colposcopy HPV test or repeat pap
test in 6 months and 12
months or colposcopy
In women 20 years and younger
repeat pap test in 12 months in
women 21 years and older :
colposcopy (without endocervical
sampling) or further testing may
be delayed until after birth

66. Management of Abnormal PAP smear
(According to ASSCO Guidelines)
HSIL Colposcopy Colposcopy or
LEEP
Colposcopy or LEEP Colposcopy without
endocervical sampling
ASC – H Colposcopy (but without endocervical sampling in pregnant women)
AGC – all
Subcategories
Except
atypical
endometrial
cells
Colposcopy with endocervical sampling and
HPV testing and endometrial sampling (if
older than 35 years or risk of endometrial
neoplasia)
Colposcopy and HPV
testing (without
endocervical or
endometrial sampling)
AGC- atypical
endometrial
cells
Endometrial and endocervical sampling
followed by colposcopy and HPV testing
Colposcopy and HPV
testing (without
endocervical or
endometrial sampling

67. How to prepare for your pap test
- Not to schedule during periods.
- If you are going to have a pap testing in the next two days
• You should not douche (rinse the vagina with water or another fluid).
• You should not use a tampon
• You should not use a birth control foam, cream or jelly
• You should not use a medicine or cream in your vagina

68. Summary
1. 27% of the world burden of Cervical Cancer is seen in India.
2. Screening is recommended in women of >21yrs 2013
3. No screening required before 21 yrs
4. Screening should stop at 65 yrs and after hysterectomy
“The biggest gain in reducing cervical cancer incidence and mortality
would be achieved by increasing screening rates among women rarely
or never screened. . .
Clinicians, hospitals, health planners, and public health officials should
promote HPV vaccination and screen women between 21 – 65 yrs .”
ACS, 20002

71. Every
Wednesday
of The Month
F
R
E
E

72. Thank You
Say No
to
Cervical
Cancer