25/04/2016

Konsep Terkini Pencegahan

Kanker Serviks
Dwiana Ocviyanti
Departemen Obstetri dan Ginekologi
Fakultas Kedokteran Universitas Indonesia,
Jakarta

Infeksi HPV dan Kanker Serviks

Infeksi HPV ditemukan

pada 99.7% penderita
Kanker Serviks
Walboomers JMM et al. 1999. Journal of Pathology 189(1): 1219.

25/04/2016

HPV Natural History-Infeksi HPV

HPV Natural History-Infeksi HPV

75/100

25/04/2016

Global Prevalence of HPV

Estimated global prevalence is between 9% and 13%, or ~630 million people1
Estimated prevalence of HPV infection in selected geographic areas:
16.8%2a

British Columbia, Canada

6.5%910b

13.5%5a

South Wales, UK

USA

50.8%6a

17.1%3b

13.3%7ac

Zhejiang Province, China

Conakry, Guinea

11.4%8ad

Texcoco Sanitary
District, Mexico

Indonesia

41.1%4b

Rio de Janeiro, Brazil

aIncludes

female data only; bIncludes male and female data; cNo visual cervical lesions or history of abnormal cytology or HPV; dOnly married, widowed, or divorced women.
1. World Health Organization. Vaccine research and development. www.who.int/vaccines/en/hpvrd/shtml. Accessed December 10, 2010. 2. Moore RA et al. Cancer Causes Control. 2009;20:13871396. 3.
Parada R et al. BMC Infect Dis. 2010;10:223. 4. Carestiato FN et al. Braz J Infect Dis. 2006;10:331336.
5. Hibbitts S et al. Br J Cancer. 2008;99:19291933. 6. Keita N et al. Br J Cancer. 2009;101:202208. 7. Ye J et al. Virol J. 2010;7:66. 8. Vet JNI et al. Brit J Cancer. 2008;99:214218. 9. Centers for
Disease Control and Prevention (CDC). Fact Sheet: Genital HPV. www.cdc.gov/std/HPV/STDFact-HPV.htm. Accessed March 1, 2011. 10. US Census Bureau. US population estimates.
http://factfinder.census.gov/servlet/DTTable?_bm=y&-geo_id=01000US&-ds_name=PEP_2009_EST&-mt_name=PEP_2009_EST_G2009_T001. Accessed March 1, 2011.

HPV Natural History- Lesi PraKanker

75/1000

25/04/2016

HPV Natural History

6/10.000

HPV Natural History

1.2/10.000

25/04/2016

Insidens Kanker Serviks di Indonesia

13.6-20.6/100.000

Kematian akibat Kanker Serviks di

Indonesia 5.8-9.8/100.000 (7800/tahun)

25/04/2016

WHO (2013) Guidance note: comprehensive cervical cancer prevention and control: a healthier future for girls and women

25/04/2016

Program Skrining didasarkan pada

Natural History infeksi HPV
Untuk mendeteksi apakah seorang perempuan:
saat diperiksa terinfeksi oleh HPV onkogenik
(hrHPV)
Atau
Memiliki lesi prakanker
Menderita Kanker Serviks stadium awal

TES PAP/PAP SMIR

25/04/2016

SKRINING DENGAN TES PAP/PAP SMIR

Dilakukan pada pasien sehat (tidak ditemukan
lesi / kecurigaan kanker pada serviks)
Bila hasil positif (ditemukan sel yang dicurigai lesi
prakanker atau kanker ASCUS/+) harus
dilakukan kolposkopi dan bila ditemukan lesi
dilakukan biopsi pada lesi tersebut
Diagnosis akhir didasarkan pada hasil biopsi, dan
tindakan lebih lanjut hanya dilakukukan bila Lesi
Derajat Tinggi ( NIS 2/+)

Colposcopy

25/04/2016

WHO 2013. WHO guidelines for screening and treatment of precancerous lesions for cervical
cancer prevention.

25/04/2016

Evaluasi metode skrining Kanker

Serviks di Amerika saat ini
Bila pemeriksaan tes hrHPV negatif, ternyata
kemungkinan kejadian CIN3/+ akan lebih rendah
dibandingkan hasil tes sitologi/Pap Smir
Karena efektifitas pemeriksaan skrining dengan
tes hrHPV lebih baik atau setidaknya setara
dengan pemeriksaan sitologi/Pap Smir, maka saat
ini tes hrHPV dapat dijadikan pemeriksaan primer
untuk skrining
Pap Smir saja atau kombinasi Pap Smir dengan
hrHPV tetap dapat digunakan sebagai pilihan
Warner K Huh. et.al. In:Gynecologic Oncology 136 (2015) 178182

Warner K Huh. et.al. In:Gynecologic Oncology 136 (2015) 178182

10

25/04/2016

Program Pencegahan Kanker Serviks di

negara lain di dunia
Berdasarkan pada:
Sitologi Pap smir, atau
Inspeksi Visual dengan Aplikasi Asam Asetat (IVA), atau
Tes Human Papilloma Virus (HPV)
Tatalaksana:
Pap Smir positif or tes HPV positif kolposkopi
biopsi histopatologi terapi , or
Pap Smir positif or tes HPV positif kolposkopi
eksisi dengan eksisi diatermi / loop dan
histopatologi(see and treat)
IVA positif (?) terapi Bedah Krio
Tes hrHPV positif(?) terapi Bedah Krio

11

25/04/2016

WHO 2013. WHO guidelines for screening and treatment of precancerous lesions for cervical
cancer prevention.

Skrining Kanker Serviks

Sitologi dan kolposkopi tidak boleh digunakan
sebagai teknik skrining tunggal, sehingga
harus dilanjutkan dengan kolposkopi +biopsi
dalam program skrining Kanker Serviks
Di negara dengan fasilitas pelayanan
kesehatan terbatas maka IVA atau tes HPV
dapat digunakan sebagai teknik skrining
tunggal dalam program skrining Kanker
Serviks

12

25/04/2016

Suggestion from WHO 2013

Use a strategy of screen with an HPV test and
treat, over a strategy of screen with VIA and
treat
In resource-constrained settings, where
screening with an HPV test is not feasible, the
panel suggests a strategy of screen with VIA
and treat

WHO guidelines for screening and treatment of precancerous lesions for cervical cancer prevention. 2013

Effective cervical cancer prevention

programs in low-resource settings
Can be implemented and should focus on three
critical factors:
achieving high screening coverage
offering an effective and acceptable test
ensuring appropriate treatment of testpositive women.

WHO guidelines for screening and treatment of precancerous lesions for cervical cancer prevention. 2013

13

25/04/2016

HPV in Indonesia
4.0% of women in the general population
are estimated to harbour cervical HPV16/18 infection at a given time
87.7% of invasive cervical cancers are
attributed to HPVs 16 or 18

Bruni L, Barrionuevo-Rosas L, Albero G, Aldea M, Serrano B, Valencia S, Brotons M, Mena M,

Cosano R, Muoz J, Bosch FX, de Sanjos S, Castellsagu X. ICO Information Centre on HPV and
Cancer (HPV Information Centre). Human Papillomavirus and Related Diseases in Indonesia.
Summary Report 2015-03-20. [Data Accessed]

Cervical Cancer Prevention in

Indonesia

Over the course of the 5-year project began at 2007, a total of 45 050 women
received VIA screening. They represented 24.4% of the total female population
aged 3050 in the catchment area of the 17 health centers.
A total of 145 women, or 0.3% of those screened over the 5-year period, were
suspected of having cervical cancer.
1.8% tested positive for cervical dysplasia (VIA positive)
83.1% of VIA-positive women sought cryotherapy

14

25/04/2016

HPV Vaccine in Indonesia

HPV vaccine licensure:
Bivalent vaccine (Cervarix)
Quadrivalent vaccine (Gardasil)

Cost of the vaccine:

one injection Rp. 700.000,- ( 50 USD)

Government pilot program in Jakarta

Girl 10-13 years Rp. 1.000.000,- (70 USD) for 2
(two) injection

HPV Vaccine acceptance in Indonesia

Methods: 746 parents, with at least 1 daughter aged 014, were interviewed using
questionnaires based on published and adjusted interviews. Interviews were done in sub
district public health centers, general governmental hospitals, and via house-visits, in 5
Indonesian provinces.

Results: Parental HPV vaccine acceptance was 96.1%.

15

25/04/2016

HPV Vaccine Program in Indonesia

Indonesia Adolescent data until 2013

31 million girls age 10-24 years
11.3 miilion girls age 10-14 years (450 thousands in Jakarta)

16

25/04/2016

Join the Indonesian forum at AOGIN!

17