1. Meg Watson, MPH Recent Trends in HPV-Associated Cancers among Women Epidemiology and Applied Research Branch Division of Cancer Prevention and Control National Center Chronic Disease Prevention and Health Promotion Centers for Disease Control and Prevention, Atlanta, GA.

2. Background: HPV-associated cancer  Human papillomavirus (HPV) associated with several cancers: Cervical Vaginal Vulvar Penile Anal Certain oral cavity/oropharyngeal sites

3. Background  Changes in screening and prevention HPV vaccine HPV DNA test Extended screening intervals  Current guidelines successful for cervical cancer; other HPV-associated cancers rare  Monitoring impact of future changes is important National need for surveillance to document vaccine impact Cancer registries uniquely positioned

4. Cervical cancer ages 15-29 Cervical cancer ages 12-99 Source: Chesson & Markowitz, International Society for Sexually Transmitted Diseases Research, London, 2009 Background: Estimated reduction in cervical cancer after onset of HPV vaccination program

5. Background: Rates of HPV-Associated Cancers among Women, 1998-2003 Adapted from Watson et al. Using population-based cancer registry data to assess the burden of human papillomavirus-associated cancers in the United States: Overview of methods. Cancer,113:10;2841-2854.

6. Background: Trends in HPV-associated cancers, 1973-2004 Adapted from Gillison, Chaturvedi, and Lowy. HPV prophylactic vaccines and the potential prevention of noncervical cancers in both men and women. SiteAPC Cervix-2.3 Vulva0.4 Vagina-1.3 Anus (includes males)2.3 Oropharynx (includes males)0.5

7. Cancer registries included in our analysis, NPCR/SEER NPCR SEER NPCR/SEER PUERTO RICO ALASKA Atlanta Detroit San Francisco/ Oakland Los Angeles San Jose/ Monterey Seattle/ Puget Sound NM UT IA CA LA KY * National Program of Cancer Registries (CDC) † Surveillance, Epidemiology, and End Results Program (NCI) * † NJ CT PACIFIC ISLAND JURISDICTION HAWAII Excluded from analysis

8. Methods  NPCR and SEER incidence data, 1999-2004 92% of the U.S. population Invasive cancers only  Race/ethnicity Race: white, black, Asian-Pacific Islander (API), American Indian/Alaska Native (AI/AN) Ethnicity: Hispanic  Annual percent change (APC) Weighted least squares Statistical significance based on APC different from zero (p<0.05)

9. Methods: Defining HPV-associated cancers SiteICD-O-3 Histology code Cervix Carcinomas 8010-8671,8940-8941 Vulva Vagina Anus (including rectal SCCs) Oral cavity and oropharynx:  Base of Tongue and Lingual Tonsil  Tonsil (including Waldeyer ring)  Other oropharynx, potentially HPV-associated Squamous cell carcinomas (SCCs) 8050-8084, 8120- 8131

10. Results

11. Trends in HPV-associated cancers among US women, 1999-2004 * Denotes statistical significance based on APC different from zero (p<0.05)

12. Trends in HPV-associated cancers among US women, NPCR/SEER, 1999-2004 (excluding cervical, for larger scale) * Denotes statistical significance based on APC different from zero (p<0.05)

13. Trends in cervical cancer by race/ethnicity, NPCR/SEER, 1999-2004 * Denotes statistical significance based on APC different from zero (p<0.05)

14. Trends in vulvar SCC by race/ethnicity, NPCR/SEER, 1999-2004 * Denotes statistical significance based on APC different from zero (p<0.05)

15. Trends in anal SCC among women by race/ethnicity, NPCR/SEER, 1999-2004 * Denotes statistical significance based on APC different from zero (p<0.05)

16. Trends in oral cavity/oropharyngeal SCC among women by race/ethnicity, NPCR/SEER, 1999-2004 * Denotes statistical significance based on APC different from zero (p<0.05)

17. Summary and discussion of results Site Overall trend By race/ethnicity CervixAll races/ethnicities Vulva = Black women only Vagina = Black women only AnusBlack and white women OP/OC = No trends statistically significant = overall trend stable

18. Strengths and Limitations  Large population coverage  Ability to examine trends by race/ethnicity of rare cancers  Important in the context of vaccine and screening changes  Potential mis- classification of HPV status  Unknown co-factors such as smoking  Inconsistent reporting of some precancers known to be strongly HPV- associated

19. Conclusions  Cervical screening programs continue to be effective  Despite common risk factor (HPV), cancers vary by site  Changes evident in some HPV-associated cancers among women, prior to the vaccine  These changes should be taken into account in future efforts to monitor the potential impact of the HPV vaccine on these cancers.

20.  Co-authors: Mona Saraiya, Hannah Weir, Cheryll Thomas  Deblina Datta  The findings and conclusions in this presentation are those of the presenter, and do not necessarily represent the official position of the Centers for Disease Control and Prevention.  Contact: eze5@cdc.gov Acknowledgements