Preventing Cervical Cancer in Ireland - HSE.ie€¦ · Preventing Cervical Cancer in Ireland....
Transcript of Preventing Cervical Cancer in Ireland - HSE.ie€¦ · Preventing Cervical Cancer in Ireland....
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Preventing Cervical Cancer in Ireland
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Trends
Incidence Mortality
46 years
56 yearsComparison to other countries
9th most frequently diagnosed cancer in women (270)
Mortality has been increasing since 1978
Ireland relatively more cancers
12th most common cause of cancer death in women (103)
The average age at diagnosis
The average age of death
Cervical cancer in Ireland-key statistics
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Cervical cancer rates
2012
European Comparison
• Ireland had the same cervical cancer incidence rate as Poland
• Higher incidence than most of western Europe
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Infection is very common Only a minority of infections persistMost women are infected within 18 months of becoming sexually active
This is a necessary step in the development of precancer and cancer
The Natural history of HPV infection
•Transmission by sex•Lifetime risk 80% ‐most within 18 months
Exposure
•Transient•Most resolve within 18 months
Infection•Less than 20% persist
•No antibodies detectable
Persistence
•Virus integrates into host DNA
Malignant Transformation •Loss of tumour
supressor gene E2•Uncontrolled cells division
Pre‐cancer
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Strategies aimed at preventing deaths from cervical cancer
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Vaccination against the HPV virus
Primary prevention Secondary protection Early detectionScreening for precancerous changes of the cervix
Prompt assesment and referral for women who have symptoms
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2014201320122011201020092008
Timeline
CervicalCheck startsNational Screening Programme.
HPV vaccination Catch up 18 year olds.
Death of Jade GoodyUnprecedented levels of screening
HPV vaccination For secondary school first years.
HPV testing post treatmentAt colposcopy.
Colposcopy follow up
Cervical cancer control in Ireland –2008‐2017
2015
HPV triage of LSIL and ASCUS
HPV testing for uncertainty
2016
HIQA HTAHPV as primary screen
Expansion ofcolposcopy.
2017
Next steps?
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Cervical cancer is preceded by precancerous condition called CIN
CIN does not have symptoms and can be present for ten to fifteen years before it turns into cancer
Smear tests take scrapings of cells from the cervix which the pathologist can categorise as normal or not according to the size of the cell’s nucleus
Rationale for Cervical Screening
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Cervical screening programmes aim to
Detect and treat precancerous abnormalities
Reduce the chance of developing cervical cancer.01 02
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Cervical Screening Programmes
Taking the tests, tracking and analysingThe test
Maintaining the register and keeping it up to date
Population register
Colposcopy and histology.Diagnosis and treatment
Quality Assurance
Organisation
Coverage
Organised cervical screening programmes reduce the incidence and mortality from cervical cancer
Ingredients for success
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Define the population of women to be screened?
Not women >60• Anatomical Changes• Prevalance of high grade CIN is low
• Cytology performs poorly
Not Below 25• Incidence of cancer is low
• Prevalence of transient changes relatively high
• Screening not protective Exceptions – colposcopy, post transplant, dialysis and HIV
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Key target of CervicalCheckMore than 80% of the population (1.1 million women) should be up to date with their cervical screening
Coverage
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CervicalCheck ‐ Screening Promotion
Communication Change behavior Target Research
Screening promotionmessages
Making screening easy and popular
Populations/areas of low uptake
Interventions that influence behaviour change
Develop Distribute Encourage Specific
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Improving screening –helping women to remember
Information service • Freephone 1800 45 45 55
• Freepost • Email [email protected]
• Website www.cervicalcheck.ie
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CervicalCheck Coverage
Geographical
Coverage> = 80%71 - 80%< = 70%
Eligible Women ScreenedSeptember 2010 - August 2015
Age groups
Current Coverage – 79.7%
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Five year coverage – trends since 2014
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Smear takers / Healthcare professionals
5000 smeartakers contracted to CervicalCheck accessible via website
Training programme for nurses and gp trainees
CME for registered smeartakers
On line training resource
41% of women first heard of the programme
from health care professional
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The test ‐ cytology
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Outsourcing Irish LabsChallengesBethesda terminologyGeographical challenge for MDTDisruption of training in Cytology
2013 – repatriation of half of the cytology testing to Ireland to two laboratories
60/40 Layout
US Labs
Irish labs
Cytology
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Cytology
NormalMost results show no abnormality
High gradeThese abnormalities need further investigation
Low gradeSome of these abnormalities will need further investigation
Cytology results N % NAD (no abnormality detected) 260,748 90.06% Low Grade ASCUS 11,582 4.00%
AGC (borderline glandular) 366 0.13%
LSIL 11,806 4.08% High Grade ASC‐H 1,290 0.45% HSIL (moderate) 1,813 0.63% HSIL (severe) 1,780 0.61% Query invasive squamous carcinoma 39 0.01% AGC favour neoplasia
54 0.02%
Query glandular neoplasia / (AIS) / adenocarcinoma
49 0.02%
Total 289,527 100.00%
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Advantage of HPV testing as a second line or triage test
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HPV testing and CervicalCheck
Primary testing –HIQA report awaitesd
Post Treatment 2012
Management of Uncertainty 2014
Triage of low grade smears 2015
HPV testing
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Cervical Screening – reality check
Screening aims to detect asymptomatic disease
Screening doesn’t always prevent cancer
Screening tests are not 100% accurate; abnormalities may be missed or wrongly identified.
The false‐negative rate of smears was found to be 18 percent in a New Zealand audit (2004)
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Predictive value of cytology versus HPV testing
Cytology – problems with sensitivity – Needs to be repeated at regular intervals
HPV testing improves the CIN3 negative prediction
Challenge – how to manage HPV positive women
Dillner BMJ 2008
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Primary HPV testing
• HPV testing more sensitive
• Especially in women over 30
• HPV vaccinated cohort is now aged 23 years.
• HTA due to be published by HIQA in 2017
Back to main
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Normal HPV Infection Precancer Cancer
Infection
Clearance
Progression
Regression
Invasion
Relative risk HPV, CIN and cancer
Schiffman, Wentzensen et al. JNCI 2011
Pop
ulat
ion
prev
alen
ce
Age
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Facilities
Staffing
Systems Management
Information Technology
Governance
Diagnosis and treatment for women -quality assured colposcopy
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Diagnosis – a balanced view
• Low grade CIN ‐ the majoritywill resolve ‐ Emphasis is on reassurance and follow up
.
• High grade CIN – Likely to persist and some will develop cancer
• Emphasis is on treatment
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60/40 LayoutTreatment works Follow upTreatment of CIN reduces the risk of cervical cancer by 90%Most are done in OPD under local anaesthetic
After treatment – women are still at risk and need close follow up
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11.8 8.9 2.9 4.6 7.5 6.5020406080
100120140160180
Cumulative rate of invasive
cancer per 100
0 wom
en
Treatment of precancerous changes
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Long term considerations –effect of Excision on Pregnancy
Meta‐ analysis suggested increased risk preterm delivery and
midtrimestermiscarraige
Related to the depth of excision
More common if multiple treatment
Recent evidence –depth of excision less than 1 cm no increased
risk
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In 2007 – 7000 new patient appointment
opportunities
2008‐ new patient capacity increased
to 16,500
2015 – capacity increased to 19,500 to accomodate HPV traige of low grade abnormalities
CervicalCheck colposcopy services
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CervicalCheck growth in annual new patient attendances
10,094
16,811
17,437
16,621
14,796
15,786
16,549
17,909
0 2,000 4,000 6,000 8,000 10,000 12,000 14,000 16,000 18,000 20,000
Year 1
Year 2
Year 3
Year 4
Year 5
Year 6
Year 7
Year 8
Number of first visits
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Improving access to colposcopy – reducing waiting times
Target
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Improving access to colposcopy –Impact on follow up attendances
10,094
16,811
17,437
16,621
14,796
15,786
16,549
17,909
9200
30884
20769
43202
44,341
40,869
39557
38835
0 5,000 10,000 15,000 20,000 25,000 30,000 35,000 40,000 45,000 50,000
Year 1
Year 2
Year 3
Year 4
Year 5
Year 6
Year 7
Year 8
Number of follow‐up visits Number of first visits
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Improving Diagnosis – Biopsy Rate – Year eightresults
It is good practice to perform a biopsy in the presence of an atypical Transformation Zone to confirm the diagnosis. Target >90%
The biopsy should be suitable for analysis more than 95% of the time
95%
99%
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CervicalCheck ‐Detection of high grade abnormalities – the first seven years
2,036
3,212 3,253
4,666 4,439
5,407
6,4927,114
4,037
5,518 5,296
6,462
5,421
7,0347,649
8,885
100 145 129 151 160 175 222 1870
1,000
2,000
3,000
4,000
5,000
6,000
7,000
8,000
9,000
10,000
Year 1 Year 2 Year 3 Year 4 Year 5 Year 6 Year 7 Year 8
Num
ber
Low grade CIN High grade CIN Cancer
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Number of women screened. Five year coverage is now 79.5%
Number of women have been treated for high grade precancer
Number of cancers detected.
1,000,000 + 50,000 + 1,200 +
Achievements to date
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0
50
100
150
200
250
2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014
Numbers of cervicalcancers according to age
<25 25‐50 51‐60 61+
0
500
1000
1500
2000
2500
3000
3500
4000
2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014
Carcinoma in Situ (CIN3/AIS) according to age
<25 25‐50 51‐60 61+
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Cervical cancer rates
Figures to 2014
NCRI, 2017
Incidence dropped by 7% between 2010 and
2014
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Trends in presentation of Cervical Cancer in Ireland according to age group
0% 50% 100%
2001
2003
2005
2007
2009
2011
2013
Presentation of cancers Age 25‐50
UnknownAutopsyIncidentalSymptomsScreening‐total
0% 50% 100%
2001
2003
2005
2007
2009
2011
2013
Presentation of Cancers age 51‐60
UnknownAutopsyIncidentalSymptomsScreening‐total
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Prevent more cancers
Prevent precancer –
Screen smarter
The future why high uptake of HPV vaccination is important to CervicalCheck
• Vaccination prevents
against glandular
cancers
• Reduce need for
treatment which can
effect pregnancy
outcome
• Allow us to use
smarter screening
tools
Cervical Cancer Control
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nowledgements