The New Normal: An update from CervixCheck on HPV, Pap testing and - - PowerPoint PPT Presentation

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

• 1. Screening guidelines, activity and

strategies for adherence

• 2. HPV and the vaccines
• 3. Technology
• 4. Future directions

Agenda

Screening guidelines, activity and adherence strategies

Assessing the Benefits and Harms of screening with Pap tests

Benefits

Reduced incidence and mortality Early detection = simpler tx, more tx options, less need for chemotherapy

Harms

False positives False negatives Anxiety, discomfort, bleeding 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 interval (years) % reduction in incidence Number of 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%

• Manitoba resident
• no Pap test in 39 mo
• no hysterectomy
• no gyne cancer

Recall Letters for Overdue Women

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

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

iClicker question…

% of women who had an abnormal Pap test result by diagnostic category (2009 – 2011)

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%

iClicker question…

National target: 90% in 6 weeks

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)

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 High Grade Results # with Recommen ded Follow Up # with Outstanding Follow Up (% ) # Letters to HCP (% ) # Direct Letters to Women (% ) # Lost to Follow Up (% )

2,485 2,056 429 (17.5% ) 384 (15.5% ) 212 (8.5% ) 114 (4.8% )

High grade letters to women

HG HG Pap test Letter to woman

Colposcopy quality assurance

Colposcopy Quality Assurance

CME

Training

Time to colposcopy

Quality indicators

HPV and the Vaccines

• 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.

Manitoba HPV Immunization Program Eligibility Criteria (Gardasil) (as of March 31, 2014)

CervixCheck Registry

Cancer

MB Population

(≥18-69)

Pap tests (2001)

Colposcopy Reports

(2003)

Hysterectomy (1984)

HPV vaccines (≥18-69)

• 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)

Integrated CervixCheck Registry

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

• ne HPV infection within

their lifetime

• Most common STI
• Easily transmitted
• Does not mean infidelity
• r 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

5x clockwise

• 2. Drop
• 3. Label & send

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 >30 with ASCUS on Pap

• 3. Pilot trials/ Research
• 4. Follow up for treatment
• 5. Triage in women > 30

with ASCUS or postmenopausal women with LSIL/ASC-US Information currently not available

• 3. Pilot

trials/Research

• 4. Follow up for

treatment

• 4. Triage in women > 30

with ASCUS or women > 50 with LSIL. (HVP triage) Saskatchewan Manitoba Ontario Quebec New Brunswick

• 2. Personal request

(only)

• 3. Pilot trials/Research
• 3. Pilot trials/Research
• 3. Pilot trials/Research
• 3. Pilot trials/

Research Triage in women > 30 with ASCUS in 2014

• 4. Triage in women > 30

with ASCUS or women > 50 with LSIL Nova Scotia Prince Edward Island Newfoundland/Labrador Options 1. Routine primary screening 2. Personal request (only) 3. Pilot trials/Research 4. Follow up for treatment 5. Other (specify)

• 3. Pilot trials/Research
• 2. Personal Request (only)

at the cost to the woman. Guidelines suggest HPV testing following a ASCUS for women over 30 but not funded at this time.

• 4. ASCUS Triage for

women over 30 years of age

April 2014

“The greatest reduction in cervical cancer will be achieved by screening eligible women who have not previously been screened…” Participation = 67.3%

Contact us for…

Manager Kimberly Templeton

Kimberly.templeton@cancercare.mb.ca (204) 788-8648

Health Promotion Lesley Baldry

Lesley.baldry@cancercare.mb.ca (204) 788-8627

• Screening histories
• Education and resources
• Questions about screening

and patient management

• Education opportunities
• To host a Pap clinic in your

community