HVD 2023: Cervical Cancer May Be the First Eliminated Malignancy. What Paths Will Lead to This Goal in the Czech Republic?
Cervical cancer is the 3rd most common cancer among women aged 15–44. Annually, it is diagnosed in 750–800 women in our country, and every 29 hours, one woman dies from it in the Czech Republic. However, it could become the first oncological disease that can be eliminated. How to achieve this was discussed by the chairman of the Czech Vaccinological Society ČLS JEP and Dean of the Faculty of Military Medicine at the University of Defense in Hradec Králové, Prof. MUDr. Roman Chlíbek, Ph.D., at a symposium supported by MSD during the October XVIII. Hradec Vaccinology Days (HVD).
„In 2020, 105 women died on Czech roads due to traffic accidents, while 398 died from cervical cancer,“ stated the speaker at the beginning. The incidence of cervical cancer in the Czech Republic is lower than in Eastern Europe but higher than in Western European countries. Its occurrence and associated mortality have been declining long-term in our country due to better screening and treatment.
The unequivocal cause of cervical cancer development is infection with the human papillomavirus (HPV), which is also a risk factor for other diseases.
Elimination of Cervical Cancer – A Common Goal of WHO, EU, and the Czech Republic
The threshold at which this malignancy should no longer pose a threat to the healthy population, and thus could be considered eliminated, is an age-adjusted incidence of < 4 cases per 100,000 women per year. Even if elimination is achieved, the need for vaccination, screening, and treatment will remain – these are the 3 pillars on which the path to accelerating the achievement of this goal stands. By 2030, it is necessary to reach values of 90/70/90 (i.e., 90% of girls up to 15 years old will be fully vaccinated, 70% of women aged 35 and 45 will undergo screening with a highly effective test, and 90% of women with cervical disease will have access to treatment) and maintain them.
In line with these ambitions is the European Cancer Plan (2020), which also aims to significantly increase boys' vaccination rates and is included in the Czech National Cancer Plan 2030. Therefore, there is a need to raise health literacy and interest in vaccination among doctors and patients, minimize regional disparities, and adopt a gender-neutral approach to HPV vaccination.
As an example of a successful strategy for eliminating cervical cancer, the author of the message offered Australia. If the current HPV screening and vaccination are maintained there, this malignancy could be considered eliminated within the next 20 years.
Vaccination of the Primary Cohort – Reimbursement From 11 Years Old
HPV vaccination is currently reimbursed for children aged 13. Since it became available for girls in 2012, the first significant change occurred in 2018 when it also became reimbursed for boys. Subsequently, in 2024, the reimbursement is expected to extend to children from 11 up to the age of 15. For adolescents not covered by full reimbursement, health insurance companies contribute to this vaccination, and some even cover it for adults.
According to data from the National Register of Reimbursed Health Services (NRHZS) concerning primary vaccination against HPV, the statistical prediction for 2022 is 37,544 vaccinated 13-year-old girls. From the number of girls who turned 13 in 2021 (58,721), we can predict at least 64–69% vaccinated in 2022, and in the case of boys, 44–48% vaccinated. (The year 2022 is not yet „closed“ as children from the same calendar cohort were vaccinated this year as well.)
4-valent vs. 9-valent Vaccine?
And how do the available vaccines compare? Clinical experiences gained with the 4-valent vaccine are relevant for the 9-valent as well – they have shown consistent immunogenicity, efficacy, and safety, are manufactured similarly, and the antigens from HPV types 6, 11, 16, and 18 are the same in both vaccines. It is therefore believed that the results of studies on the 4-valent vaccine can be applied to the 9-valent. The efficacy of the 4-valent vaccine against HPV in the study population treated according to the protocol in women aged 15–26 was 98%, while the efficacy of the 9-valent vaccine in women aged 16–26 was 96.7%. Thus, the 9-valent vaccine was found to be noninferior to the 4-valent.
Routine vaccination of boys and men would be very significant. For example, authors of a study comparing existing vaccination programs with alternatives found that routine vaccination of boys and girls aged 11 and 12, compared to vaccinating girls alone, could increase the resilience of the vaccination program to coverage drop by approximately 7-fold, and in the case of routine vaccination of men up to 26, even 13-fold. This confirmed the effectiveness of a strategy based on catch-up vaccination of both women and men in terms of accelerating HPV prevalence reduction.
(esr)
Sources:
1. Chlíbek R. Is HPV elimination achievable with new approaches and data? XVIII. Hradec Vaccinology Days, Hradec Králové, October 5, 2023.
2. Elfström KM, Lazzarato F., Franceschi S. et al. Human papillomavirus vaccination of boys and extended catch-up vaccination: effects on the resilience of programs. J Infect Dis 2016: 113: 199–205, doi: 10.1093/infdis/jiv368.
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