Cervical cancer hpv

2
Presentation Overview
• Cervical cancer 101
– Cause: Human Papilloma Virus (HPV)
– “Natural history”
– Treatment
• Preventing cervical cancer
– Avoiding exposure to HPV
– Current screening guidelines
– The new HPV vaccines

3
Cervical Cancer 101
• Abnormal cell growth on cervix (lowest
part of the uterus)
• Caused by HPV infection, especially
during the first years after puberty
• Pre-cancerous changes long before
invasive cancer develops
• Rarely fatal in this country
• A major cause of death worldwide

4
Human Papillomavirus (HPV)
• Long known to cause warts
• Found in many cancers too
• Over 100 types identified
• Most benign, but 15-20 can
cause cancers
• Very common
– 20,000,000 current cases in US
– 6,200,000 new cases annually
– 80% of women have HPV by age 50
– 50% of college students are infected

5
HPV & Cervical Cancer
• HPV recognized as the underlying cause ofHPV recognized as the underlying cause of
cervical cancer since 1996cervical cancer since 1996
– NIH Consensus Conference on Cervical Cancer,
1996
– World Health Organization/European Research
Organization on Genital Infection and Neoplasia,
1996

6
Common HPV Types and their effects
HPV Types Lead to:
Low-Risk
High-Risk
HPV 6, 11,
40,, 42, 43, 44,
54, 61, 70, 72, 81
HPV 16, 18,
31, 33, 35, 39,
45, 51, 52, 56,
58, 59, 68, 73, 82
Benign cervical changes
Genital warts
Precancer cervical changes
Cervical cancer
Anal and other cancers
1. Cox. Baillière’s Clin Obstet Gynaecol. 1995;9:1.
2. Munoz et al. N Engl J Med. 2003;348:518.

7
Human Papillomavirus
Cancer of cervix 100%
Cancer of esophagus .
Cancer of skin .
Cancer of X,Y,Z…. .
Cancer of mouth 3%
Cancer of throat 12%
Cancer of penis 40%
Cancer of vulva, vagina 40%
Cancer of anus 90%
Parkin DM et al. CA Cancer J Clin 2005; 55:74-108.

8
Natural History of HPV Infections
• Sexually transmitted
• Usually no symptoms
• No treatment for HPV infection before symptoms
• Immune system clears most cases; some persist
• HPV present in >99% of cervical cancers
• High risk types (16, 18) associated with cancer
• Low risk types (6, 11) are associated with genital
warts
• All can cause abnormal Pap tests
Human Papillomavirus. ACOG Practice Bulletin No. 61. 2005; 105: 905-18.

9
Co-factors for HPV Infection
•Smoking
•HIV infection
•Other immune system defect
•Pregnancy
•Oral contraceptive use
Ferris et al. Modern Colposcopy. 2004.

10
HPV and Cervical Cancer Rates
by Age
1. Sellors et al. CMAJ. 2000;163:503.
2. Ries et al. Surveillance, Epidemiology and End Results (SEER) Cancer Stats NCI, 1973-1997. 2000.
Age (Years)
HPVPrevalence(%)
40-4415-19 20-24 25-29 30-34 35-39 45-49 50-54
0
5
10
15
20
25
30
0
5
10
15
20
25
30
Cancerincidenceper100,000

11
HPV Infections: Summary
• Most people are infected by HPV at some time
• Immune system usually clears HPV, but not always
• Persistent low-risk HPV can lead to genital warts
• Persistent high-risk HPV can lead to pre-cancer
HPV
Long persistence of HPV can
lead to cancer

12
Preventing Cervical Cancer
• Screening for precancerous changes
(and treatment if problems found)
• Vaccination against HPV

13
History of the Conventional
Pap Smear
• Developed by Dr. George N.
Papanicolaou in 1940’s
• Most common cancer
screening test
• Key part of annual
gynecologic examination
• Has greatly reduced cervical
cancer mortality in U.S.
Ferris et al. Modern Colposcopy. 2004: 2-4, 49.
Photo accessed from http://www.cytology-iac.org/Cytopaths/1998/cytoFall98.htm

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Screening with the
Conventional Pap Smear
• Widely available
• Inexpensive
• But not perfect
– Screening test – not diagnostic
– 7-10% of women need further evaluation
– Low sensitivity – need regular repeats
Cervical Cytology Screening. ACOG Practice Bulletin No. 45. 2003; 102:417-27.

15
New Liquid Pap Tests
• More accurate test
– Thin, uniform layer of cells
– Screening errors reduced by
half
• Screening needed less often
• Can test for HPV with same
specimen if abnormal cells
found
• Expensive
Linder J. et al. Arch Pathol Lab Med. 1998; 122: 139-144.

16
Cervical Cancer Screening Guidelines
• First screen 3 years after first
intercourse or by age 21
• Screen annually with regular Paps or
every 2 years with liquid-based tests
• After three normal tests, can go to
every three years
• Stop at 65-70 years with history of
negative tests
• Still need annual check-ups
Cervical Cytology Screening. ACOG Practice Bulletin No. 45. 2003; 102:417-27.

17
NEW! The HPV Vaccine
Gardasil ® (Merck)
• Protects against types 16, 18, 6, 11
• FDA approved for use in females 9-26 years of age
• Prevents HPV infection; doesn’t treat existing infection
• Virus-like particles (VLP)
• Highly effective
• Safe, few serious adverse side effects
• Requires 3 injections
• Expensive ($360 + administrative fees)
Smith, RA et al. Cancer. 2003;53(1): 27-43.

18
HPV Vaccine
ACOG Recommendations
VACCINATE allVACCINATE all females 9-26 years old,
regardless of sexual activity
• Less potential benefit with increasing age & number of sexual
partners
Special populations – vaccine less effective
• Previous abnormal Pap tests or genital warts
• Immunocompromised
Continue screening with Pap tests!Continue screening with Pap tests!
Human Papillomavirus Vaccination. ACOG Committee Opinion No. 344. 2006; 108: 699-705.

19
NOT CURRENTLY RECOMMENDEDNOT CURRENTLY RECOMMENDED
(Awaiting more evidence)(Awaiting more evidence)
• Women over age 26
• Pregnant women
– If vaccine started before pregnancy, give
remaining dose(s) post-partum
• Breastfeeding women
• Men
HPV Vaccine
ACOG Recommendations

Medical Treatment with Herbs
20
• Habbatussauda (Nigella sativa
Linn/Black Cumin)
Black cumin can cure cancer. Black cumin Medicinal Plants contain
fatty acids that can prevent the growth of cancer cells. And not only
that's just black cumin also has the ability to be able to stimulate the
bone marrow production. Intereron production and can improve the
immune system in the body's cells. and by consuming black cumin then
normal body cells that still can be properly maintained and have the
ability to fight and to kill cancer cells in the body.

21
• Selaginella doederleinii Hieron
Sri Handayani research results SFarm Apt MSi of Chemistry LIPI
Research Center, proving Selaginella doederleinii Hieron
extract can kill breast cancer cells. "The study was the first step in order to
scribble recognized as standardized herbal as required by the Food and
Drug Monitoring Agency (BPOM)," said the alumnus of Gadjah Mada
University.
Furthermore Handayani test the inhibitory concentration (IC) 50 to 96
Selaginellaextract cell cultures of MCF - 7 breast cancer cells resistant
to chemotherapy. IC50 value indicates the level of concentration of the
extract to menghazmbat or shut down 50% of the test cell. The results
showed the IC50 value reaches 61 ug / ml. That is, with a concentration
of 61 ug / ml, chicken claw extract is able to inhibit or shut down 50% of
cancer cells.

22
• Hedyotis corymbosa
Hedyotis corymbosa contains hentriakontane, stikmasterol, ursolic acid,
sitosterol, D-glucoside, p- coun Maric acid, flavonoids glycossides and
oleic acid. Members familli Rubiaceae This is a sweet, slightly bitter,
soft neutral and rather cold. Boondoggle to remove heat and toxic anti-
inflammatory, diuretic, heals ulcers and activate blood circulation.
Lymphosarcoma cancer, gastric cancer, cervix, breast cancer, rectal
cancer, nasopharyngeal cancer: About 50 gr crops washed, then boiled
with 14 cups water to boil, culture up to 2 cups of water, then remove
from heat. When cool, strain the decoction and drink 2 times a day,
each 1 cup.

23
• Andrographis paniculata Ness
CHEMICAL CONTENT: Leaves and branched containing laktone
consisting of deoksiandrografolid, andrographolide (bitter
substances), neoandrografolid, 14-deoxy-11-12-
didehidroandrografolid, and homoandrografolid. Also there are
flavonoids, alkane, ketone, aldehyde, minerals (potassium,
calcium, sodium), acid grit, and resin. Flavotioid isolated most of
the roots, namely polimetoksiflavon, andrografin, pan.ikulin,
mono-0- metilwithin, and apigenin-7,4- dimetileter. The active
substance andrographolide proved efficacious as
hepatoprotektbr (protects liver cells from toxic substances).

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• Garlic / Aglio
Garlic Herbal Anti-Cancer
Wowwww, at least that's the reaction been discovered by researchers when
researching properties of garlic for the most dangerous disease of
cancer. Garlic is worth mentioning as herbal / plant anti-cancer, contain
allyl sulfides contained in garlic as a herbal anti-cancer causes.
One of the clear evidence that the researchers discovered is the content of
PhIP, one form of heterocyclic amines (HCAs), which are substances
that can trigger breast cancer for women. From various studies
conducted diallyl sulphide substances contained in garlic inhibits the
growth and transformation into a carcinogen PhIP that can eventually
lead to breast cancer.
But you should remember that garlic has anti-cancer agent that is effective
to prevent the growth of cells of various types of cancer that are harmful
to you.

25
HPV Vaccine
Important Considerations
• Vaccine is most effective before first sexual
intercourse – less effective in sexually active
women
• HPV testing before vaccine not
recommended
• Vaccine is not a treatment for current HPV
infection, genital warts, or pre-cancer

26
HPV Vaccine FAQ
• Vaccine will not cause HPV
– Virus-like particle vaccine (not live virus)
• HPV vaccines appear to be very safe
– Few major adverse events, but limited data
• Most side effects are minor
– Injection site reaction
• Potentially effective in preventing cervical cancer
(and other HPV-related cancers)
– BUT not all cancer-causing HPV types are covered by the
vaccine

27
HERBS
ANT NESTS HERBAL CAPSULE (DRUG DISEASEANT NESTS HERBAL CAPSULE (DRUG DISEASE
CANCER / TUMOR) HIUCANCER / TUMOR) HIU
BPOM POM TR 133 373 081
• Treating cancer and tumors
• Treating Coronary Heart and various cardiovascular disorders
• Treating Stroke heavy and light,
• Treat Lupus, Ambien (Hemorrhoids) • Eliminate the lumps in the breast
• Troubleshooting kidney and prostate, tuberculosis and lung problems
• Ambien (Hemorrhoids) new and old
• Blood circulation
• Overcoming stiff and sore muscles • Increase vitality • Improve and increase stamina
Composition:
Myrmecodia pendans 100%
ATTENTION!
Not recommended for pregnant women, nursing mothers and children under 2 years
Price Rp. 99.000, - (Excluding Shipping)
Please contoact (For All Herbs Products)
SMS / WA / skype + 62856-4O-53-5O-8I
email / fb: gudangmuslimindo@gmail.com
PIN: D7C0456A

28
HERBS
KELADIKAPS simplisia Typhonium flagelliforme Rhizoma CAPSULEKELADIKAPS simplisia Typhonium flagelliforme Rhizoma CAPSULE
EXTRACT (Herbal Cancer Tumor)EXTRACT (Herbal Cancer Tumor)
Contents: 60 capsules
Permits: POM TR 103 310 201
Some recent studies mentioned plants simplisia Typhonium flagelliforme Rhizoma proved to have
efficacy to destroy cancer cells, but it would be difficult to find this plant sanagat let alone cultivate it to
be consumed as a drug. Now comes, the solution easily consume taro mice with the rodent tuber
extract KELADIKAPS.
composition:
simplicia Typhonium flagelliforme Rhizoma (tuber taro rat)
Keladikaps efficacy of rodent tuber extract:
In tradisisonal used for cancer patients
Drinking rules:
Taken 2 times daily morning and afternoon 2 capsules
WARNING !!!!
• Pregnant women are prohibited from taking this medicine.
• After the operation should not immediately drink taro rat, wait 2 weeks.
• The first two days after drinking may be nausea, diarrhea sedikti, black dirt, and lethargic.
Sometimes vomiting or nausea after drinking simplisia Typhonium flagelliforme Rhizoma , put an end
to or subtract.
ATTENTION!
Not recommended for pregnant women, nursing mothers and children under 2 years
Price Rp. 59.900, - (Excluding Shipping fee)

29
HERBS
CYSTOGA CV Toga NusantaraCYSTOGA CV Toga Nusantara
(Herbal Overcoming cancer and(Herbal Overcoming cancer and
cysts)cysts)
PRODUCT BRIEF:
Contents: 50 Capsules @ 500 mg
Permit BPOM: POM TR 113 328 011
Composition:
• Curcumae zadoaria rhizome extract 175 mg
• herb Andrographis extract 125 mg
• Gynura Folium 100 mg
• Curcumae Xanthoria rhyzoma extract 100 mg
Drink suggestion:
-Adults 3 x 2 capsules a day, taken 1 hour
before meals
Price Rp. 59.950,-

30
HERBS
HERBAL HERBAMED "BENCALANG" ANTI CANCER /HERBAL HERBAMED "BENCALANG" ANTI CANCER /
TUMORTUMOR
1 Pack Contains 2 Bottle @ 50 capsules @ 250mg
Permit BPOM: POM TR. 103 310 911
Ben Ca Lang, with 2 Bottles, Efficacy of more than 2 x. EXTRAORDINARY!
In 1 Package Ben Ca Lang, there are two bottles of herbal capsules Ben Ca Lang Herbamed
1. Ben Ca Lang Cancer
Composition:
Each capsule contains extracts:
1.) Thyponium Flagelliforme 50 mg 2.) CentellaAsiatica 40 mg 3.) Androgs 35 mg 4.) Merremia
Raphis Panic 40 mg 5.) LoranthuMammosa 30 mg 6.) Curcumae zedoaria 30 mg 7.) Gynura
Precumbents 25 mg
benefit
1. Helps Turn off the cancer cells by splitting the nucleus of cancer cells
2. Inhibit the growth and spread of cancer cells
3. To revitalize the entire network and spread of cancer cells
4. Improving the body's cells
5. Increase endurance and stamina
MUST BE CONSIDERED!
Ben Ca Lang cancer must be taken together with Ben Ca Lang Angion

31
HERBS
HERBAL HERBAMED "BENCALANG" ANTI CANCER /HERBAL HERBAMED "BENCALANG" ANTI CANCER /
TUMORTUMOR
11 Pack Contains 2 Bottle @ 50 capsules @ 250mg
In 1 Package Ben Ca Lang, there are two bottles of herbal capsules Ben Ca Lang
Herbamed
MUST BE CONSIDERED!
Ben Ca Lang cancer must be taken together with Ben Ca Lang Angion
Ben Ca Lang Angion
Composition
Each capsule contains extracts:
1.) Arecha catechu 50 mg 2.) Phyllanthus urinary 38 mg 3.) Catharanthus roseus 50
mg 4.) Ganoderma Lucidum 38 mg 5.) Eleuthorine Americana 74 mg
property
1. Stopping the formation of new blood vessels, without blood cells, tumor cells /
cancer will die
2. Destroying cancer cells
3. Preventing the cancer cell division
4. Inhibits cancer cell growth
5. Strengthening the immune system
How to use
3 x 3 capsules / day. 30 minutes before meals (Price Rp. 175.000,-)

32
HERBS
ALBIMOR Al Biruni (Herbs for Cancer / Tumor)ALBIMOR Al Biruni (Herbs for Cancer / Tumor)
Contents: 50 Capsules
COMPOSITION:
• Nigella sativa, Selaginella doederleinii, Hedyotis corymbosa, Andrographis paniculata, etc.
Recommendation:
Reduce consumption of bean sprouts, longan, jackfruit, MSG, durian, tape, pineapple, soft drinks,
ice, chicory, kale, chili, salt, salted fish, and avoid alcohol.
Not for pregnant women and children
DESCRIPTION:
Benefits:
• Killing cancer cells
• Inhibit the growth of cancer cells
• Increase endurance
• Reduces pain from cancer
• Strengthening the tissue cells around the cancer
• Reducing the adverse effects of chemotherapy
Rp. 69.100,-

33
HERBS
GARLIC OIL CAPSULES (OIL ONION)GARLIC OIL CAPSULES (OIL ONION)
Composition:
Made from 100% garlic oil
Contents: 60 capsules
MOH license: No. IKOT 442/1077-KES / V / 10
Which has properties as:
• Helps boost immunity
• Overcoming headaches
• Overcoming fever
• Flu
• Indigestion
• Antiseptic
• Antibiotics
• Antimicrobials
• Stroke
• Heart
• Anti-tumor / cancer
• Potent Antioxidant...
Price Rp. 61.000,-

34
References
Advisory Committee on Immunization Practices. ACIP provisional recommendations for the use of quadrivalent HPV vaccine.
August 14, 2006. Accessed from http://www.cdc.gov/nip/recs/provisional_recs/hpv.pdf.
American Cancer Society. Cancer facts and figures 2003. Atlanta (GA): ACS 2003. Available at
http://www.cancer.org/downloads/STT/CAFF2003PWSecured.pdf.
Apgar BS, et al. “The 2001 Bethesda System Terminology.” Am Fam Physician. 2003;68:1992–1998.
Cannistra SA, Niloff JM. “Cancer of the Uterine Cervix.” N Engl J Med. 1996;334:1030–1038.
Cates W Jr, and the American Social Health Association Panel. “Estimates of the incidence and prevalence of sexually
transmitted diseases in the United States.” Sex Transm Dis. 1999;26(suppl):S2–S7.
Centers for Disease Control and Prevention. Rockville, Md: CDC National Prevention Information Network; 2004.
Cervical Cytology Screening. ACOG Practice Bulletin No. 45. American College of Obstetricians and Gynecologists. Obstet
Gynecol 2003; 102:417-27.
Cox. Baillière’s Clin Obstet Gynaecol. 1995;9:1.
Ferris et al. Modern Colposcopy: Textbook and Atlas. 2nd ed. Dubuque, Iowa: Kendall/Hunt; 2004: 2-4, 49, 78-82.
Howley PM. In: Fields BN, Knipe DM, Howley PM, eds. Fields Virology. 4th ed. Philadelphia, Pa: Lippincott-Raven;
2001:2197–2229.
Human Papillomavirus. ACOG Practice Bulletin No. 61. American College of Obstetricians and Gynecologists. Obstet
Gynecol 2005; 105: 905-18.
Human Papillomavirus Vaccination. ACOG Committee Opinion No. 344. American College of Obstetricians and
Gynecologists. Obstet Gynecol 2006; 108: 699-705.
Hutchinson ML. et al. “Homogeneous sampling accounts for the increased diagnostic accuracy using the ThinPrep
Processor.” Am J Clin Pathol. 1994; 101:215-219.
Jansen KU, Shaw AR. ”Human Papillomavirus Vaccines and prevention of cervical cancer.” Annu Rev Med. 2004;55:319–
331.
Kodner CM, Nasraty S. “Management of genital warts.” Am Fam Physician. 2004;70:2335–2342.
Lacey CJN. “Therapy for genital human papillomavirus-related disease.” J Clin Virol. 2005;32(suppl):S82–S90.
Linder J. et al. “ThinPrep Papanicolaou testing to reduce false-negative cervical cytology.”Arch Pathol Lab Med. 1998; 122:
139-144.
Management of Abnormal Cervical Cytology and Histology. ACOG Practice Bulletin No. 66. American College of
Obstetricians and Gynecologists. Obstet Gynecol 2005; 106: 645-64.
Maw RD, Reitano M, Roy M. “An international survey of patients with genital warts: perceptions regarding treatment and
impact on lifestyle.” Int J STD AIDS. 1998;9:571–578.

35
References (Cont.)
McCrory DC, Matchar DB, Bastian L, et al. Evaluation of Cervical Cytology. Evidence Report/Technology Assessment
No. 5. AHCPR Publication No. 99-E010. Rockville, MD: Agency for Health Care Policy and Research. February
1999.
Moscicki, A.B. et al. “Updating the natural history of HPV and anogenital cancer.” Vaccine. 2006; 24S3; 42-51.
Munoz et al. “Epidemiologic classification of human papillomavirus types associated with cervical cancer.” N Engl J
Med. 2003;348:518.
Ostor, AG. “Natural history of cervical intraepithelial neoplasia: a critical review.” Int J Gynecol Pathol 1993; 12(2): 186-
92.
Parkin DM, Bray F, Ferlay J, Pisani P. “Global cancer statistics 2002.” CA Cancer J Clin 2005; 55:74-108.
Ries et al. Surveillance, Epidemiology and End Results (SEER) Cancer Stats NCI, 1973-1997. 2000.
Saslow D et al. “American Cancer Society Guideline for the Early Detection of Cervical Neoplasia and Cancer.” CA
Cancer J Clin. 2002;52:342-362.
Schiffman M, Castle PE. “Human papillomavirus: Epidemiology and public health.” Arch Pathol Lab Med.
2003;127:930–934.
Schiffman M ASCCP 2002 Biennial Orlando, Fl.
Sellors et al. “Prevalence and predictors of human papillomavirus infection in women in Ontario, Canada.” CMAJ.
2000;163:503-8.
Smith, RA et al. “American Cancer Society Guidelines for the Early Detection of Cancer, 2003.” Cancer. 2003;53(1):
27-43.
Solomon D, Davey D, Kurman R, et al, for the Forum Group Members and the Bethesda 2001 Workshop. JAMA.
2002;287:2114–2119.
Soper DE. In: Berek JS, ed. Novak’s Gynecology. 13th ed. Philadelphia, Pa: Lippincott Williams & Wilkins; 2002:453–
470.
Spitzer M, Johnson C. Philadelphia, Pa: WB Saunders Co; 2002:41–72.
Wiley DJ, Douglas J, Beutner K, et al “External genital warts: diagnosis, treatment and prevention.” Clin Infect Dis.
2002;35(suppl 2):S210–S224.
Winer RL et al. “Genital human papillomavirus infection: Incidence and risk factors in a cohort of female university
students.” Am J Epidemiol. 2003; 157:218-226.
Wright, T.C. et al. “2001 Consensus Guidelines for the Management of Women with Cervical Cytological
Abnormalities.” JAMA. 2002; 287: 2120-2129.
USPSTF. 2003. Available at http://www.ahrq.gov/clinic/uspstf/uspscerv.htm.

36
Questions?
Program sponsored by
Middle Earth
Slide set developed with help from
Dr. Kim Noyes
Preventive Medicine Resident, School of Public Health
Information provided by the New York State Department of Health,
Cancer Services Program
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Cervical cancer hpv

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