A Heavy Weight to Bear: HPV and Cervical Cancer in Africa

Julia C. Gage, PhD, MPH Division of Epidemiology and Genetics, National Cancer Institute, NIH, USA

Disclosure
I would like to disclose that I have recently collaborated with the Qiagen Corporation to evaluate their new low cost HPV test in rural Nigeria. They donated the tests and equipment for the study. No further compensation was provided.

Cervical Cancer 2008

Incidence of Cervix Uteri Cancer: Age standardized incidence rates (ASR) (World) (All ages)

ASR per 100,000 women

<7.0 <12.9 <20.2 <29.6 <56.3

GLOBOCAN 2008 (IARC) 12.7.2012

Cervical cancer ranks 1st for cancer in women

Top 5 cancers in women by region (All ages)
Northern Africa

Western Africa

Incidence Mortality

Eastern Africa

Southern Africa

Age-standardized rate per 100,000 women (world) GLOBOCAN 2008 (IARC) 16.7.2012

Cervical Cancer in Africa

Review published online by Denny and Anorlu in Cancer Epidemiology Biomarkers and Prevention:
80,000 women diagnosed in Africa annually, 60,000 deaths Most women present with advanced disease, often untreatable or suitable only for palliation (absolute 5-year survival rate 15.9 in Kampala and 26.5% in Zimbabwe vs. ~60% for African Americans in the USA). Access to anti-cancer therapies very limited (22% in Africa vs. 91% in Europe) Palliative care is very limited -- oral morphine only available in 11 countries ~10% of quantity required procured Contextual challenges: Lack of trained health care workers ~ 818,000 in 2006, in Sub-Saharan Africa possibly 792,000 in 2015 Competing health priorities HIV
Denny and Anorlu, CEBP, 2012

Cervical cancer is preventable

Cervical cancer mortality rates and hazard ratios (HR) for 131,746 women in a community randomized intervention trial in Maharashtra State, India (Jan 2000-April 2003)

Study group
Control HPV

Rate/100 000
25.8 12.7

HR (95% CI)
1.00 0.52 (0.33-0.83)

Cytology
VIA
CI: Confidence interval

21.5
20.9

0.89 (0.62-1.27)
0.86 (0.60-1.25)

Sankaranarayanan et al., NEJM, 2009

Unique HPV age trend in Africa

Age-specific prevalence of carcinogenic HPV
Central and South America North America

Southern Europe/Middle East

Africa

Smith, JS. et al. J Adol Hlth, 2008

Elevated HPV in older women & risk of cervical cancer

20%

Nigerian HPV Prevalence Study Project Itoju Concurrent cytology abnormality by age

15%

10%

5%

0%

15-29 (n=260)

30-39 (n=234)

40-49 (n=233)

50-59 (n=217)

60-69 (n=233)

70+ (n=105)
Gage et al., Int J Cancer, 2012

ASC-US

LSIL

HSIL

Cancer

HPV Positive

HPV and cervical cancer in HIV+ women

Compared to HIV- women, HIV+ women experience:
risk of HPV infection rates of HPV clearance risk of persistent infection with high-risk types of HPV risk of lesions progressing risk of developing cervical precancer Develop cervical cancer at a younger age Denny & Anorlu, CEBP, 2012
Clifford & Franceschi, Future Oncol,2009

Soweto, South Africa: 1123 HIV+ women

Compared to women not on HAART, those on HAART: 2X regression of cervical lesions Among women with a normal smear, risk of new cytologic abnormality
Adler et al., AIDS, 2012

Dar es Salaam, Tanzania: 120 HIV+ on HAART & 50 HIV- women

Compared to HIV- controls, women on HAART: risk of cervical lesions and cervical cancer
Mwakigonja et al., Inf Agents & Cancer, 2012

Screening in HIV+ women

% diagnosed with high-grade lesion among 149 HIV+ women randomly assigned in South Africa Screen-and-Treat Trial

Control VIA HPV

Denny et al., JAMA, 2005 Denny et al., JNCI, 2010