New HPV Vaccine - outlook for OB/GYN

[juddson]

I'm suprised this has not been asked on this forum yet. As many of you no doubt know, a clinical trial for a new HPV vaccine just punlished last week and by all accounts, it cuts infection by close to 100%. By all other accounts, HPV is intimately (if not inextricably) associated with cervical dysplasia and, if untreated, cervical cancer.

Two questions:

If most cases of cervical cancer, cervical dysplasia, CIS, whatever, go the way of the carrier pigeon, what impact will that have on the basic practice of an OB/GYN - many of whom (as I understand it) do not only most of the pap smears in the country, but also most of the leep procedures (and even cold knife biopsies/cones, etc.)?

Secondly, assuming that this sort of work does NOT represent a significant chunk of the OB/GYN's revenue stream, doesn't the anual pap smear also represent ONE OF the MAJOR reasons a woman comes into the see an OB/GYN on a yearly basis anyway (call it a "gateway" procedure).

What does this new vaccine protend for the profession? For the Gyn/Onc people?

Judd

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[neilc]

well, as i understand it, it protects against HPV 16 only. so, other oncogenic strains may still be out there causing cervical CA. this would prob justify continued pap exams. hopefully the vaccine will drastically decrease the incidence of cervical CA and the associated procedures/screening/office visits.

additionally, if young women are vaccinated now, it will be several decades before the effect is really noticable in reduced CA deaths. given that 50% of women between 18-22 are said to be infected, this group (and all the women that begin sexual activity before the vaccine comes out, as well as all women that don't get the vaccine) will need to be screened. so, for most of us in the field (or going into it) we will still have a lot of annual paps to do!


but, i think it is really kind of early to begin guessing what this will do to the practice of ob/gyn's in general. i have a feeling that there will be something to fill the holes in the schedule, though!

 

[mustangsally65]

I have been trying to find out more info about this vaccine since I heard about it a few weeks ago. It sounds great.

I need to be tested for HPV, because my mom had cervical cancer in 1988 and other dysplasia in 2002, so I'm assuming I'm at risk. If I already have it then I can't get the vaccine, but if I don't I'd really like to be vaccinated.

Is it a series of vaccines, or just one?

Has anyone heard anything about when it will be available to the public?

How much will it cost? Will insurance pay for it?

I"m gonna ask my doctor the next time I see her, but I was wondering if anyone could answer my questions or direct me to a good website.

Thanks!

 

[Flea girl]

I have been trying to find out more info about this vaccine since I heard about it a few weeks ago. It sounds great.

I need to be tested for HPV, because my mom had cervical cancer in 1988 and other dysplasia in 2002, so I'm assuming I'm at risk. If I already have it then I can't get the vaccine, but if I don't I'd really like to be vaccinated.

Is it a series of vaccines, or just one?

Has anyone heard anything about when it will be available to the public?

How much will it cost? Will insurance pay for it?

I"m gonna ask my doctor the next time I see her, but I was wondering if anyone could answer my questions or direct me to a good website.

Thanks!

I do no think that cervical cancer is genetically inherited. It is sexually transmitted. If I am wrong, someone please speak up.

 

[mustangsally65]

I do no think that cervical cancer is genetically inherited. It is sexually transmitted. If I am wrong, someone please speak up.

I've been told something similar recently. I was under the impression that transmission of HPV could be genetic, as well as sexual.

Thanks!

 

[tiredmom]

I've been told something similar recently. I was under the impression that transmission of HPV could be genetic, as well as sexual.

Thanks!

The latest I've seen said they were applying for FDA approval towards the end of this year. It's a 3 shot series.

 

[Alician]

HPV is a virus that is sexually transmitted. It's estimated that well over half of women who have had multiple sexual partners have it. It's not inherited from your mom, it's just very common. It mostly shows up in the teen years because that is when most woman make their "sexual debut" and because the cervix is most vulnerable at that time due to increased ectropion. In order for this vaccine to be effective it would need to be given to young girls and it would only prevent HPV 16 which causes most cervical dysplasia and cancer. It however would not prevent genital warts.

I've been told something similar recently. I was under the impression that transmission of HPV could be genetic, as well as sexual.

Thanks!

 

[ellehcim]

HPV is a virus that is sexually transmitted. It's estimated that well over half of women who have had multiple sexual partners have it. It's not inherited from your mom, it's just very common. It mostly shows up in the teen years because that is when most woman make their "sexual debut" and because the cervix is most vulnerable at that time due to increased ectropion. In order for this vaccine to be effective it would need to be given to young girls and it would only prevent HPV 16 which causes most cervical dysplasia and cancer. It however would not prevent genital warts.

My understanding is that vertical transmission is possible, but rare, and also that there is a subset of cervical cancer not caused by HPV which may have a genetic link - also very rare.

Here we go, a meta-analysis (goes straight to the pdf): http://www.scielosp.org/pdf/csp/v21n4/03.pdf

So possible but rare.

From a personal anecdotal view, when I was 20 I had a friable cervical erosion, symptoms of which led me to get my first Pap - which showed a CINIII lesion, but repeated PCR's failed to show HPV. It's possible I do have HPV and it simply didn't show up, but I was advised to let my three sisters know they should hot foot it to the Dr and get a Pap, just in case there was a genetic link, given my age and the difficulty isolating the virus.

 

[daisyduke]

From a personal anecdotal view, when I was 20 I had a friable cervical erosion, symptoms of which led me to get my first Pap - which showed a CINIII lesion, but repeated PCR's failed to show HPV.

FYI- CIN III is a histological diagnosis only made by biospy (i.e. colposcopy). Pap smears provide cytological diagnoses: LGSIL, HGSIL, ASCUS, AGCUS, etc. which lead your Gyn to do a colposcopy, visualize the lesion, biopsy it and come up with a histological diagnosis (CIN I-III, CIS, or cancer). Good to know when you are on your Gyn-Onc rotation b/c attendings get annoyed when you say a pap shows CIN III!!!

Regardless if you think that you could be at risk for HPV via vertical transmission at birth.... remember that you are WAY more likely to contract HPV by sexual contact, so if you are sexually active, take care of yourself and get a pap every year!!!!

 

[primadonna22274]

To the OP:
I think there shall be relatively little impact on the workload of OB-GYNs for at least the next 20 years. Why? Because the HPV vaccine is only offered to those under 18; there are still PLENTY of 20-50 y/o women with abnormal pap smears and cervical dysplasia who will need follow-up and treatment.
Lisa PA-C

 

[Alician]

My understanding is that vertical transmission is possible, but rare, and also that there is a subset of cervical cancer not caused by HPV which may have a genetic link - also very rare.

Here we go, a meta-analysis (goes straight to the pdf): http://www.scielosp.org/pdf/csp/v21n4/03.pdf

So possible but rare.

From a personal anecdotal view, when I was 20 I had a friable cervical erosion, symptoms of which led me to get my first Pap - which showed a CINIII lesion, but repeated PCR's failed to show HPV. It's possible I do have HPV and it simply didn't show up, but I was advised to let my three sisters know they should hot foot it to the Dr and get a Pap, just in case there was a genetic link, given my age and the difficulty isolating the virus.

Thanks for the reference! However, I wonder if vertical transmission leads to the clinically significant outcome of dysplasia. Isn't it possible that these moms are transmitting it to their babies who then clear the virus and are reinfected later in life with sexual intercourse. What evidence is there that the HPV acquired at birth is what causes cervical ca later in life? Wouldn't we see cervical cancer at earlier ages based on the natural history of HPV? I am skeptical that infection at birth is clinically significant, but that's just my bias.

That's interesting about your personal experience. You must have had a colpo to get the CINIII diagnosis. If it's not too personal, what was your treatment and has it recurred. What happend with your sisters? The thing I am most scared of is adenocarcinoma of the cervix. We have yet to figure out a good way to screen for it and it seems to not follow the usual rules.

 

[mustangsally65]

To the OP:
I think there shall be relatively little impact on the workload of OB-GYNs for at least the next 20 years. Why? Because the HPV vaccine is only offered to those under 18; there are still PLENTY of 20-50 y/o women with abnormal pap smears and cervical dysplasia who will need follow-up and treatment.
Lisa PA-C

Is it true that the HPV vaccine will only be offered to women under 18? Shouldn't the requirements be based on current lack of infection and no history of sexual activity, rather than age?

 

[ellehcim]

FYI- CIN III is a histological diagnosis only made by biospy (i.e. colposcopy). Pap smears provide cytological diagnoses: LGSIL, HGSIL, ASCUS, AGCUS, etc. which lead your Gyn to do a colposcopy, visualize the lesion, biopsy it and come up with a histological diagnosis (CIN I-III, CIS, or cancer). Good to know when you are on your Gyn-Onc rotation b/c attendings get annoyed when you say a pap shows CIN III!!!

Regardless if you think that you could be at risk for HPV via vertical transmission at birth.... remember that you are WAY more likely to contract HPV by sexual contact, so if you are sexually active, take care of yourself and get a pap every year!!!!

Thanks for the nitpick! Oversimplification on my part really. I should have said, the pap result was actually "inconclusive", probably because of the local effects of the erosion - you're right, diagnosis was made on the biopsy.

That's interesting about your personal experience. You must have had a colpo to get the CINIII diagnosis. If it's not too personal, what was your treatment and has it recurred. What happend with your sisters?

Well, to be one of those ladies who shares with all, whether they want to know or not :

After the pap I was sent for a colposcopy. It took me ages to find a gyn who wasn't part of my faculty. The clinic my GP is part of automatically refers to the colp clinic at my teaching hospital, where I also happen to work in maternity - so know a lot of the staff, and wasn't keen to have it done there (it's a great facility, but I wasn't keen to share my gyn problems with my work colleagues). In the end I had to settle for faculty from the other med school in town, but it meant I found a lovely gyn I'm really happy with, so it worked out OK!

Anyway! Had the colp, had the biopsy, got the diagnosis and scheduled a LLETZ (as we call it in Australia - I believe you call it a LEEP) for straight after my end of year exams. Margins were clear and everything was fine. I then had follow-up at one, three and six months. I haven't had any problems since, and it's been three years.

No worries with surveillance, lucky me gets a colp every year. I'm actually happy to leave it at that, after my last colp my gyn was happy for me to go back to yearly paps, but I find the discomfort fairly equal and would rather just get it all done at once - if there's a problem found, I only have to have the colp rather than a pap followed by a colp, and it is covered by my insurance. Plus, my gyn has a video attachment so I can see for myself what she's talking about - that's probably too much information but I find it morbidly fascinating .

A friend of mine who now has to have a mammogram every year organises to have that done on the same day - we have a day of poking and prodding then go have a nice dinner and a whole tub of ice cream. So not so bad really!

And my sisters were fine, one did get a positive result for HPV, but no cytological changes - as I said I'm suspicious that I too have HPV, and if I do I'm not blaming it on vertical transmission

 

[primadonna22274]

Sally,
I believe the labeling is slated to be for women under 18 when it gets FDA approval. I haven't got anything solid to back this up yet. As you know we often bend the rules in medicine and I may just want to get it too, but would be worth an HPV test first (although my paps have always been normal, but after being divorced a few years and trying out a few boyfriends, I'm a bit more concerned than I used to be).
We shall see....
L.

Is it true that the HPV vaccine will only be offered to women under 18? Shouldn't the requirements be based on current lack of infection and no history of sexual activity, rather than age?

 

[tiredmom]

Check out this link - the vaccine will be targeted to kids and teens, but is also being tested in the 23-45 yr old range.

http://www.scienceblog.com/community/article3219.html

 

[chicklett1]

In other loosely related news...I work at a large urban Planned Parenthood, and our GYN Dept recently roled out a new pap protocol.

You know how we used to say get a pap every year from the time of first sexual activity or from age 18? The new protocol says start at 3 years FOLLOWING first sexual activity or age 21. Old protocol, paps every year; new protocol says every year until age 35, and then if no history of abnormal cells, you can switch to every three years.

The reasoning behind this was that while HPV infection is endemic in young sexually active women, many are able to clear non-agressive strains within the first few years of infection to barely detectable levels. Delaying testing is a means of reducing cost and unnecessary anguish to the pt.

Unfortunatly, this will also have the negative effect of seeing some of our patients less frequently, limiting opportunities to provide other care and education (contraceptives, STD screening, etc).