Bridging the Gaps in HPV Cancer Prevention

Bridging the Gaps in HPV Cancer Prevention

Cervical cancer is a largely preventable disease but worldwide it remains one of the most common cancers and causes of cancer-related death in women. In 2020, the World Health Organization launched the global strategy to accelerate the elimination of cervical cancer as a public health problem.1 Elimination of cervical cancer as a public health problem will be reached by achieving fewer than four new cases per 100,000 women in every country. To achieve this goal, three targets have been clearly identified to accelerate elimination and achieve this goal.

• 90% of girls to be fully vaccinated with the Human Papilloma Virus (HPV) vaccine by age 15,
• 70% of women to be screened by age 35 and again by age 45 using a high-performance test (equivalent to or better than an HPV test),
• 90% of women identified with cervical disease (precancerous lesions or invasive cancer) to receive treatment.

In Ireland, the current cervical cancer rate is estimated at 10.1 per 100,000 women,2 with almost 290 new cases being diagnosed annually. Ireland is in an excellent position to move rapidly towards cervical cancer elimination, having access to excellent population-based cervical screening and HPV vaccination programmes. Indeed, the HSE have recently published a roadmap and action plan to align with the WHO targets setting 2040 as a target date for Ireland to achieve cervical cancer elimination.2 Since the introduction of CervicalCheck The National Cervical Screening Programme in 2008,3 Ireland has seen a year on year 2.8% decline in the incidence of cervical cancer. Furthermore, following the introduction of HPV vaccination in 2010, some early data is emerging on the positive impact of HPV vaccination in reducing the number of women presenting with abnormal cervical screening tests.4

Virtually, all cases of cervical cancer are caused by HPV, however, HPV infection also increases the risk of other cancers such as vulval, vaginal, penile, anal and head and neck cancer. Ongoing research in Ireland suggests there remains a lack of awareness of the role HPV plays in these other cancers. Moreover, the incidence of most of these other HPV associated cancers is increasing in Ireland.5 HPV vaccination reduces the risk of these cancers too, and we must do more to increase uptake of the HPV vaccine among girls and boys, by increasing awareness of the role of HPV in these other cancer types and the benefits of HPV vaccination for the prevention of these cancers in both men and women.

Our research group CERVIVA is a multi-investigator consortium led by Professor John O’Leary and Professor Cara Martin of Trinity College Dublin, encompassing researchers at several national and international academic institutions, and health agencies (www.cerviva.ie). The consortium was established in 2005, with the purpose to advance high quality peer-reviewed research programmes in HPV associated diseases and it continues to conduct transformative research in this area.

Our research programme is focussed developing new improved cervical screening approaches, for both vaccinated and unvaccinated populations, understanding barriers to screening and vaccinations among certain groups and developing new screening approaches and biomarkers for early detection of other HPV associated cancers including vulva, vagina cancers, anal cancer, and oral cancers. Some of our flagship research programmes that support the HSE’s plan for cervical cancer elimination include the following:

CERVIVA HPV Primary Screening Study

Molecular triage strategies for HPV positive women, funded by the Health Research Board. This is an observational cohort study which has recruited over 13,000 women (aged 25-60years) who attended primary care for their routine cervical smear. The study led by TCD was established in partnership with CervicalCheck the National Cervical Screening Programme in Ireland, to evaluate a range of different HPV and novel biomarker tests and technologies for use in cervical screening, specifically in the context of HPV-based primary screening. Our study assesses a range of different biomarker and triage options for use with HPV based screening to help stratify those women at risk of developing cervical cancer and show the potential benefits of including additional biomarkers such as for example partial HPV genotyping, methylation biomarkers and p16ink4a/ki67 biomarkers into the screening algorithm.6, 7 The study is the first of its kind internationally that is looking at this range of molecular triage tests and their performance longitudinally. The study is ongoing and will continue to collect data for 10 years following participants initial enrolment in the study.

CERVIVA-Vax: Monitoring the impact of HPV vaccination in Ireland, funded by the Health Research Board

The introduction of HPV vaccination and changes to cervical screening protocols with introduction of HPV testing, raise important clinical challenges for cervical screening programmes, most notably regarding the impact of HPV vaccination on screening as it is currently organised and how this will affect the disease landscape and sub-type of human papilloma virus (HPV), present in the Irish population. Monitoring the impact of vaccination on screening is hugely important. CERVIVA-Vax will generate Irish data relating to the early impact of HPV vaccination on cervical screening. By investigating the early impact of HPV vaccination on screening in Ireland, CERVIVA-Vax will be able to inform policy and practice in relation to the best cervical screening approaches for vaccinated and unvaccinated women. Indeed, together with the National Screening Service, some early evidence is available on the impact of HPV vaccination at reducing the number of women presenting with abnormal cervical screening tests.4

What influences cervical screening uptake in older women and how can screening programmes translate this knowledge into behaviour changing strategies? A CERVIVA-Cervical Check co-production project

Well-organised cervical screening is effective in reducing cervical cancer incidence and mortality. To achieve these benefits, high coverage is essential. In Ireland, the coverage target is 80%.2 While overall coverage has risen from 74.7% in the first 5 years to 78.3% in the 5 years to 2020, it has consistently been lower in older (50-60years) than younger (25-49years) women.8 This distinctive pattern is not seen in other countries with organised programmes and the reasons for it are unknown. This CERVIVA CervicalCheck co-production project is generating evidence on the influences on cervical screening participation among older women in Ireland, to inform development and implementation of evidence-based strategies to increase screening coverage in this group. We are learning more about the barrier’s women in this group face with respect to participation in screening, ranging from previous experiences to ease of arranging appointments for example.

On this Cervical Cancer Prevention Week, we continue to work towards the vision of an Ireland where cervical cancer and indeed all HPV associated cancers are rare in every community. Our research programme supports the National Action Plan for Cervical Cancer Elimination. We encourage all eligible woman to avail of cervical screening and encourage all parents to vaccinate their children are to ensure they are protected against HPV.

References available on request

Authors Cara M Martin and John J O’Leary on behalf of the CERVIVA consortium

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