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24th November 2023
Vaccination against human papillomavirus (HPV) appears to have changed the mix of HPV strains in circulation, say researchers who have spotted the ‘strain replacement’ for the first time.
An analysis of data from 60,000 young women in Finland who took part in a trial of the HPV vaccine where different cities adopted different approaches also found a decrease in more strains of the virus where girls and boys were both vaccinated.
Four years after vaccination, they found that the vaccine had markedly depleted targeted cancer-causing HPV types in the girls-only vaccine groups as well as the communities where boys and girls had been immunised.
Where boys and girls were vaccinated, there was also an increase of HPV types with lower cancer risks filling the gap left by the cancer-causing vaccine targeted strains around four to eight years after the vaccine was given.
The findings raise questions over potential changes to cervical cancer screening programmes in the future but UK experts said it was too soon to come to any conclusion.
Writing in the journal Cell Host and Microbe, the team said the diversity of strains found were similar to communities where no vaccination had been done, only without the cancer-causing strains targeted by the vaccine.
Study leader Dr Ville Pimenoff, an evolutionary biologist from the Karolinska Institute, Sweden, and University of Oulu, Finland said: ‘HPV vaccine is effective to clear most cancer-causing HPVs, and what we have observed here is the subsequent new equilibrium of untargeted HPV types interacting with the host communities.’
He added: ‘Importantly, the increase of vaccine-untargeted low-cancer-risk HPVs do not increase the risk of cancer.’
The researchers suggested that the findings could lead to the redesign of HPV screening approaches for cervical cancer prevention, which include testing for HPVs with lower cancer risks.
With the increase of low-cancer-risk HPV types in the vaccinated population, ‘current screening is likely to result in over-diagnosing individuals who are not at risk, he added. ‘That would be a huge burden for the healthcare system.’
Professor Anne Mackie, director of the UK National Screening Committee said the study was very welcome but more research was needed and the committee has commissioned a modelling study to help understand the likely impact of potential alternative screening strategies on the vaccinated cohort in the future.
She said: ‘The routine offer of HPV vaccination for girls started in 2008 and has successfully reduced the risk of infection in younger age groups.
‘However, most women in the eligible age range for screening (25 to 64) have not received the vaccine and may have been exposed to infection previously.
‘A high-quality cervical screening programme will continue to prevent cases of cervical cancer in this non-vaccinated population over the coming decades.’
Professor Stephen Duffy, professor of cancer screening at Queen Mary University of London said a major finding from the research was that immunising both boys and girls is the best policy.
‘While we should not rush to change screening policy as a result of one study, it would be prudent to check if these results are replicated elsewhere, and to consider the implications for which populations we screen and how we screen them.’
This comes as NHS England announced plans to eliminate cervical cancer by 2040 through increasing uptake of the HPV vaccine and cervical screening.
As part of a new vaccination drive, NHS England will support health and care professionals to identify patients in most need of the HPV vaccine via ‘targeted outreach’ and offering jabs in convenient local places such as libraries and community centres.
The NHS App will undergo expansion so that people can view their full vaccine record and book appointments in a ‘new dedicated space’ – currently only Covid and flu vaccination status is visible, but this will be increased to all 15 routine vaccine-preventable diseases, including HPV.
The NHS will also look to boost cervical screening by trialling ‘self-sampling’ to see if it could become part of national screening.
Last year, over five million people aged 25 to 64 were invited for screening, which NHS England said is ‘more…than ever before’.
NHSE’s national director for vaccinations and screening Steve Russell said vaccination and screening are ‘some of the most powerful tools’ for preventing disease.
‘We have learnt invaluable lessons from the pandemic, with our hugely successful Covid-19 vaccine programme saving thousands of lives, and our vision for the future of vaccination draws on those learnings, with plans to educate millions more people on the importance of vaccination, while making it easier than ever before to access vaccines online,’ he added.
NHS Providers’ director of policy and strategy Miriam Deakin said they ‘welcome’ the pledge and ‘innovative strategies’ that demonstrate a ‘forward-thinking approach to healthcare’.
She said: ‘These measures not only aim to improve accessibility but also ensure that health services are more responsive to the needs of diverse communities.
‘Ensuring healthcare staff have the resources and training needed to effectively implement these plans is crucial for success.
‘A focus on education and increasing public awareness about the importance of HPV vaccination and regular cervical screening is also vital.’
According to the World Health Organization, cervical cancer is considered to be eliminated when its incidence rate is lower than four per 100,000 women.
Versions of this story were originally published by our sister publication Pulse.
9th November 2023
A short course of induction chemotherapy (IC) ahead of standard treatment with chemotherapy and radiation reduces the rate of relapse and death in women with locally advanced cervical cancer, according to preliminary study findings presented at the European Society for Medical Oncology (ESMO) Congress 2023.
The INTERLACE phase 3 trial enrolled 500 women with squamous, adeno or adenosquamous carcinoma stages IB1/2 to IVA from hospitals in the UK, Mexico, India, Italy, and Brazil over 10 years.
The median patient age was 46 years, overall most women (77%) had stage II cancer, and more than half (57%) were lymph node negative, researchers reported in an abstract simultaneously published in the Annals of Oncology.
Patients were randomised to receive standard chemoradiation (CRT), consisting of external radiation with weekly cisplatin and brachytherapy, or an initial six-week course of IC with carboplatin AUC2 and paclitaxel 80mg/m2 followed by standard CRT.
Researchers found women who received IC followed by CRT had five-year progression-free survival rates of 73% compared to 64% in the women who had received CRT alone.
The corresponding five-year overall survival rates were 80% for the IC and CRT group versus 72% for the standard care group.
Given these results, the study authors said IC with CRT should be considered a new standard of care, adding that carboplatin and paclitaxel were cheap, accessible and already approved for patient use.
Lead investigator Dr Mary McCormack, honorary lecturer at UCL Cancer Institute and consultant clinical oncologist at University College London Hospitals, said the trial showed this short course of additional chemotherapy could reduce the risk of the cancer returning or death by 35%.
‘This is the biggest improvement in outcome in this disease in over 20 years,’ she added.
The median overall treatment time for CRT was 45 days in both arms, the researchers reported, with a median interval of seven days between IC and CRT.
They added that 92% of IC patients had five or six cycles of carboplatin and paclitaxel.
Of the IC and CRT group, 84% had four or five cycles of cisplatin while the figure was 89% in the CRT alone group.
Grade ≥3 adverse events were seen in 59% of patients in the IC and CRT group compared with 48% of patients in the CRT alone group.
Commenting on the findings, Professor Ana Oaknin, head of the gynecologic tumors unit at the Vall d´Hebron University Hospital, Barcelona, Spain, called the results encouraging, given the high unmet need for new treatments for advanced cervical cancer.
‘However, it is important to consider the population recruited and the large proportion of patients who had node-negative disease, as we know that positive lymph nodes are indicative of a high risk of relapse,’ she added.
‘Further analysis, in terms of nodal status, would be useful in determining the suitability of the induction chemotherapy approach for different relapse risk groups.’
Professor Oaknin, who was not involved in the research, said ongoing, planned trials might provide information on other ways to improve outcomes beyond CRT alone in high-risk locally advanced cervical cancer.
These included the phase 2 ATOMICC trial investigating anti-PD1 therapy with dostarlimab and the phase 3 e-VOLVE Cervical Study trial assessing the use of the monovalent bispecific human IgG1 monoclonal antibody volrustomig.
11th July 2022
Cancer screening for breast, colorectal and cervical cancers was significantly reduced during the period of the pandemic compared to pre-pandemic levels according to the results of a systematic review by a group of Italian and US researchers.
According to GLOBOCAN in 2020 there were an estimated 19.3 million new cancer cases and almost 10.0 million cancer deaths and that cancer screening has contributed to a decrease in both cancer morbidity and mortality. As a result, any reduction in screening could potentially lead to a surge in cases. In fact, modelling studies have already indicated a possibly large increase in cases due to the pandemic.
Moreover, in a UK-based modelling study, the authors estimated that as a consequence of the pandemic, there would be a 7·9-9·6% increase in the number of deaths due to breast cancer up to year 5 after diagnosis and for colorectal cancer a 15·3 – 16·6% increase in additional deaths.
However, because of differences in the start date and duration of lockdown measures across the world, for the present study, the researchers wanted to examine how this variation impacted on screening. They focused on breast, colorectal and cervical cancer screening since the beginning of the pandemic and made a comparison with pre-pandemic levels.
The team searched all the major databases for observational studies and articles that reported data from cancer registries and which compared the level of screening tests performed before and during the pandemic and in different areas of the world.
Cancer screening reductions during the pandemic
A total of 39 articles were identified and included in the analysis with 21 related to breast, 22 colorectal and 11 for cervical cancers.
For the period between January and October 2020, there was an overall 46.7% (95% CI -55.5% to -37.8%) decrease in breast cancer screening in comparison the pre-pandemic level.
For colorectal cancer, the overall reduction was 44.9% (95% CI -53.8% to -36.1%) and this included a 52.5% reduction in colonoscopy, a 37.8% decrease in faecal occult blood testing and a 37.8% decrease in immuno-chemical testing.
With cervical cancer, the overall reduction was -51.8% (95% CI -64.7% to -38.9%).
Commenting on their findings, the authors noted that these reductions in screening occurred across the world but that there were some obvious differences. For example, Europe saw the largest reduction in mammography compared to North America. although the decrease for both colorectal and cervical cancer screening was similar in both areas.
The authors suggested that the most likely explanation for the reduced screening was the ‘stay at home’ order introduced during the early stages of the pandemic.
They concluded that there was a large reduction in cancer screening as a consequence of the COVID-19 pandemic and which could be associated with an increased number of deaths and called for further work to investigate the relationship between cancer diagnosis and treatment during the pandemic.
Citation
Teglia F et al. Global Association of COVID-19 Pandemic Measures With Cancer Screening: A Systematic Review and Meta-analysis JAMA Oncol 2022
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