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Cervical Cancer Prevention Promises and Perils in a Changing Landscape

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Cervical Cancer Prevention Promises and Perils in a Changing Landscape DISCOURSE Emerging trends and recommendations CERVICAL CANCER PREVENTION Promises and perils in a changing landscape Eduardo L. Franco, MPH, DrPH, Marie-Hélène Mayrand, MD, MSc, FRCSC and Helen Trottier, MSc PhD Top-line summary Cervical cancer is the malignant neoplastic dis- Universal deployment of organized or opportunistic ease for which public health prevention initiatives screening with Pap cytology in high-income countries has substantially reduced cervical cancer morbidity have had the greatest success. Organized or and mortality during the last 50 years. Cervical can- opportunistic screening with the Papanicolaou cer remains a critical public health problem, however, cytology technique (Pap test) has reduced the because in many low-income countries, Pap screening cervical cancer burden by about 75% in high- has not yet been effectively implemented or it has failed to reduce cervical cancer rates. Infection with income countries during the last 50 years. certain human papillomavirus (HPV) types is now rec- ognized as a necessary cause of this disease. Testing In comparison, lung cancer control via tobacco cessation is for the presence of the DNA of these HPVs in genital still far from its target of 80% reduction in disease incidence, samples shows great promise as a screening tool, with and screening efforts for other neoplasms have much less much greater sensitivity but slightly lower specificity ambitious targets. than Pap cytology. Combining both methods has the In Canada, the early experiences of British Columbia and potential to improve the negative predictive value of other provinces are considered a model for implementation cytology, thus allowing testing intervals to increase of organized programs. Unfortunately, however, few devel- and lowering program costs with acceptable safety. oping countries have fully reaped the benefits of screening. As well, recent research on the safety and efficacy of Cervical cancer remains an important public health problem: with 493,000 new cases diagnosed in 2002 — 83% of them candidate prophylactic vaccines against HPV has in developing countries — it is the second most common shown nearly 100% efficacy in preventing persistent malignant neoplasm affecting women worldwide.1 The infections and development of cervical precancerous highest-risk areas for cervical cancer are in Southern and lesions. Licensed HPV vaccines will be available in Eastern Africa, Melanesia, the Caribbean, and Central and 2006–7. To achieve cost-effectiveness, policymakers South America, with average incidence rates well above are urged to consider screening and immunization as 30 per 100,000 women per year (Figure 1, page 10). Less integrated preventive approaches. than 50% of women affected by cervical cancer in developing countries survive longer than 5 years whereas in developed countries the 5-year survival rate is about 66%.2 Recent understanding of the necessary causal connection Eduardo L. Franco, BSc, MPH, DrPH is Professor and Director, between infection by certain types of human papillomavirus Division of Cancer Epidemiology, Departments of Oncology and (HPV) — the so-called high-risk, or oncogenic types — and Epidemiology & Biostatistics, McGill University, Montreal. cervical cancer3,4 has paved the way for new approaches to Marie-Hélène Mayrand, MD, MSc, FRCSC is a gynecologist at cervical cancer prevention. For secondary prevention (i.e. Hôpital St-Luc du CHUM in Montreal and a PhD candidate in the screening), both the Pap test and a DNA test for the oncogenic Department of Epidemiology & Biostatistics, McGill University, Montreal. HPVs are available. HPV vaccination has also emerged as a Helen Trottier, MSc, PhD is an epidemiologist in the Division of promising new front in primary prevention of cervical cancer. Cancer Epidemiology, McGill University, Montreal. Address for correspondence: Professor E.L. Franco, Division of Cancer SCREENING TECHNOLOGIES Epidemiology, McGill University, 546 Pine Avenue West, Montreal, The available screening technologies can be classified into QC H2W 1S6; Tel: (514) 398-6032; Fax: (514) 398-5002; morphology- and molecular-based approaches to recognizing Email: [email protected] cytologic or tissue-level abnormalities or molecular markers ©2006 Parkhurst, publisher of Oncology Exchange. All rights reserved Œ VOL. 5, N0. 3, JULY 2006 9 DISCOURSE FIGURe . age-standardized* rates of cervical cancer per 00,000 women per year * based on the world population in 1960 consistent with cervical intraepithelial neoplasia (CIN) or fication bias indicated that the average sensitivity of Pap cervical cancer. Further distinctions can also be made based cytology to detect CIN was 51% and average specificity was on the use of aided or unaided microscopy or of physical 98%.6 The high false-negative rate has been the Pap test’s and electro-optical properties. Table 1 outlines the various most critical limitation, as false-negative diagnoses have technologies considered in cervical cancer screening, most important medical, financial and legal implications. In of which are still under evaluation. North America false-negative smears are among the most Cervical cancer screening imposes a substantial economic frequent reasons for medical malpractice litigation.7 The burden. In most Western countries, for each new case of advent of liquid-based cytology has helped mitigate the invasive cancer found by Pap cytology approximately 50–100 problem of efficiency in processing smears but the limitations other cases yield abnormal smears consistent with precursor of cytology remain. To compensate for the low sensitivity lesions requiring clinical management, such as squamous of individual testing, women whose initial smear is negative intraepithelial lesions (SIL), low- (LSIL) and high-grade should be retested at least twice over the next 2–3 years, (HSIL) lesions. Further, twice as many cases are found of before they can be safely followed at 2- or 3-year intervals. equivocal or borderline atypias, known as atypical squamous This brings the screening program sensitivity to acceptable cells of undetermined significance (ASC-US). ASC-US and levels but requires safeguards to ensure compliance, cover- SIL findings account for up to 10% of all Pap smears pro- age and quality — costly undertakings that have worked cessed in screening programs in Western countries.5 well only in western industrialized countries. Many devel- Despite its success, Pap cytology has important limitations. oping countries that have invested in screening programs It is based on highly subjective interpretation of morpho- have yet to witness a reduction in cervical cancer burden. logic alterations present in cervical samples that must be Of the molecular-based technologies for cervical cancer collected with proper attention to sampling transformation screening, HPV testing is eliciting the greatest interest, zone cells. The highly repetitive nature of screening many with 2 main technologies. The hybrid capture (HC) assay, smears leads to fatigue and invariably to errors in interpre- currently the most widely used in clinical and screening tation. A recent meta-analysis of studies unaffected by veri- settings, is a nucleic acid hybridization assay with signal ©2006 Parkhurst, publisher of Oncology Exchange. All rights reserved 0 Œ VOL. 5, N0. 3, JULY 2006 DISCOURSE amplification. It uses microplate chemiluminescence for the ing of women more than 30 years old tends to improve the qualitative detection in cervical specimens of HPV DNA of performance of HPV testing because viral infections in this 13 high oncogenic-risk genotypes associated with cervical age group are less likely to be of a transient nature than in cancer: 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, and younger women. Importantly, the combination of cytology 68. Different polymerase chain reaction (PCR) protocols and HPV testing attains very high sensitivity and negative have also been used to detect HPV. Based on target amplifi- predictive values approaching 100%, which could potentially cation with type-specific or consensus (general) primers fol- make longer screening intervals of 3–5 years safe (depending lowed by hybridization with specific oligoprobes, PCR on the population). The drawback of this approach is that techniques to detect HPV will soon be commercially available. an initially excessive number of patients would need to be HPV testing found its first application niche in triaging referred for colposcopy, with many turning out to be ASC-US smears. A recent meta-analysis found it to be a lesion-free. Over time this dual-testing screening approach suitable and cost-effective option in deciding whether or should be cost-saving because it will extend the screening not such cases need to be referred for colposcopy.8 Several interval for women who are cytology- and HPV-negative, studies assessing the value of HPV testing compared to the reducing patient flow in primary screening clinics. Pap test as a cervical cancer screening tool in European, A few large randomized controlled trials (RCTs) of HPV African, Asian, Latin American and North American popu- testing in primary cervical cancer screening are currently lations have found HPV testing to have 25% to 35% higher ongoing. Of note are the UK HART (HPV in Addition to sensitivity than cytology in absolute terms but 5% to 10% Routine Testing) investigation,12 the UK ARTISTIC trial lower specificity for detecting high-grade lesions.9-11 Screen- (A Randomized Trial In Screening To Improve
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