Ap#ma HPV. Un test E6/E7mRNA para uso en los protocolos de screening

Transcripción

1 Ap#ma HPV. Un test E6/E7mRNA para uso en los protocolos de screening Madrid Junio 2012 F. Xavier Bosch Instituto Catalán de Oncología

2 agenda Racional para el uso de test VPH en cribado Tests ADN. Cocktails de tipos virales de alto riesgo (referencia) Test especificos de tipo Test E6/E7 mrna Sensibilidad comparable, superior especificidad y experiencia clinica considerable ICO+centre. Servei/Unitat

3 Historia natural Peristencia de marcadores Analisis de tumores parcialmente asociados a VPH genital vs head and neck ICO+centre. Servei/Unitat

4 Fraccion Etiologica de VPH y cancer primario Prevalence in cases according to different markers DNA p16* RNA* Cervix (C53) Penis (C60) ? Vulva (C51) ? Vagina (C52) ? Anus (C21) ? Oropharynx (C01, C09- C10) Sources: 1: De Martel et al 2012 Lancet Oncol. 2: Halec et al in preparation. IPV2012 Puerto Rico abstract number VVAPO study ICO in preparation. 4: Holzinger et al Cancer Res 2012 (German data). * Percentage of positive cases among HPV DNA positive cases Cancer Epidemiology Research Program

5 Ciclo reproductivo del VPH en el cervix Cervical canal Mature squamous layer Squamous layer Virus particles are assembled and virus released Virus uses host cell to replicate viral DNA and express virally encoded proteins Parabasal cells Basal (stem) cells Basement membrane Normal epithelium Infected epithelium HPV infects basal layer of cervical epithelium Adapted from Frazer IH. Nat Rev Immunol 2004; 4: Cancer Epidemiology Research Program

6 Los Anticuerpos inducidos por la vacunación trasudan al moco cérvico-vaginal y exudan a las lesiones epiteliales Blood vessel Connective tissue Basal membrane Cérvix Vagina Squamous epithelium CVS Antibodies HPV VLP-specific IgG in CVS ~10-fold lower than in the serum after intramuscular vaccination Schwarz TF, et al. Vaccine 2009; 27: ; Nardelli-Haefliger D, et al. J Natl Cancer Inst 2003; 95: Cancer Epidemiology Research Program

7 HPV infection and lifecycle Mature Squamous Layer Squamous Layer Parabasal Cells Cervical Surface Basal (Stem) Cells Basement Membrane Normal Epithelium Infected Epithelium Shedding of Virusladen Epithelial Cells Viral Assembly (L1 & L2) Viral DNA Replication (E6 & E7) Episomal Viral DNA in Cell Nucleus (E1 & E2, E6 & E7) Infection of Basal Cells (E1 & E2) Frazer IH. Nat Rev Immunol. 2004;4:46 54

8 Mecanismos de infección por el VPH & de la prevención mediada por anticuerpos Schiller J; Lowy D DNA + & RNA - Trasudation: Es un mecanismo importante (el titulo de IgG en fluido vaginal puede ser muy superior al serológico). Fluctúa con la ovulación Exudacion: Los anticuerpos fluyen con el suero en epitelios lesionados. Explica la protección frente a VG en varones.

9 Natural History of the HPV Infection E6/E7 mrna levels HPV DNA levels Nakagawa et al, J Med Virol 2000, 62(2): Wheeler et al, JNCI 2009, 101: Coutlee et al, J Med Virol 2011, 83:

10 HPV Clearance and Progression Very few HPV infected women progress to disease (CIN2+) Infections (%) Persistent HPV Infections Cleared HPV Infections Years since carcinogenic HPV infection detected - CIN2+ 90% of HR-HPV infections clear within 2 years. Only 10% of HR-HPV infections are persistent after 3 years. Only 5% of Hr-HPV infections progress to CIN2+ in 3 years Even small errors in risk classification can have large impacts in the quality of screening Adapted from M. Schiffman, Lancet Oncology 2008

11 HPV Clearance and Progression Median age CIN3 in Guanacaste vs. NZ: 27 vs % of CIN3 progresses to cancer in 5 years 50% of CIN3 progresses to cancer in 30 years 1. Schiffman et al., JNCI 2011; 2. Rodriguez et al., J. Natl. Can. Inst ;McCredie et al., Lancet Oncol. 2008

12 HPV Integration HPV DNA Human gdna L2 L1 LCR E6 E7 E1 E2 Human gdna HPV DNA must linearize to integrate into human DNA

13 Potential Deletion of Genomic Information L1 region can be affected when HPV DNA integrates into human DNA HPV assays that only targets the L1 region are at risk for false negatives Deletions may occur during integration Opening of circular DNA during integration

14 Integration Affects Cancer Risk HPV DNA Cancer Risk? 1 Risk of L1 false negative? 2 Human gdna L2 L1 LCR E6 E7 E1 E2 Human gdna YES NO HPV DNA Human gdna E1 E2 L2 L1 Human gdna NO NO HPV DNA Human gdna LCR E6 E7 E1 E2 Human gdna YES YES 1. Lambert PF, et al Proc Natl Acad Sci U S A. 90(12): Walboomers,et al. J.PATHOL. 189: (1999)

15 HPV Detection Strategies Hologic Gen-Probe APTIMA HPV 1 E4 E5 Oncogenes L2 L1 LCR E6 E7 E1 E2 HPV Viral mrna APTIMA HPV Probes Hologic Gen-Probe Cervista HPV 2,3 E4 E5 L2 L1 LCR E6 E7 E1 E2 HPV Viral DNA* Cervista HPV Probes Roche cobas HPV 4 E4 E5 L2 L1 LCR E6 E7 E1 E2 HPV Viral DNA Roche HPV Primers Qiagen hc2 5 E4 E5 L2 L1 LCR E6 E7 E1 E2 HPV Viral DNA hc2 probes * Each HR HPV type is detected by more than one probe and at least one is in the E6 or E7 gene 1 APTIMA HPV Assay package insert # Rev A Cervista HPV HR package insert # Bartholomew, et al. J Clin Virol. 2011;51(1): cobas 4800 HPV Test US Package Insert # EN Rev Hybrid Capture 2 High-Risk HPV DNA Test package insert #L00665 Rev

16 Coste clínico y social de la calidad del test de cribado- balance entre sensibilidad y especificidad Estado clínico Test de cribado patología normal positivo negativo Tratamiento adecuado Progresión clínica FALSO - Sobre-diagnóstico FALSO + Seguimiento adecuado Program Research Epidemiology of Cancer

17 What Matters Most in Cervical Cancer Screening? Transient HPV infections detected that do not cause disease can cause: Patient anxiety Unnecessary follow-up procedures Increased healthcare cost Overtreatment Clinical diagnostics for cervical cancer must balance sensitivity and specificity for optimal results Excellent Sensitivity Excellent Specificity

18 Tests especificos de tipo Utilizados en paralelo a la detección viral para tipos seleccionados y sensibilidad clínica (i.e. Roche, Abbott) Utilizados en réflex en los casos VPH+ para tipos seleccionados y sensibilidad clínica (i.e. Aptima, Qiagen) Utilizados en primera instancia para todos los tipos de alto y bajo riesgo. Alta sensibilidad analítica (i.e. Genomica, SPF10) Hasta 125 propuestas comerciales Poca validación clínica Apenas publicaciones auditadas ICO+centre. Servei/Unitat

19 Incidencia cumulativa a 10 años de CIN3+ en mujeres (edad 30 +) según un test de VPH especifico de tipo al ingreso 25% CUMULATIVE INCIDENCE RATE OF CIN3 20% 15% 10% 5% hpv16 positive hpv18 positive hpvpositive non hpv16/18 hpv negative HPV DNA test cytology % FOLLOW-UP TIME (MONTHS) Program Research Epidemiology of Cancer KHAN ET AL. J NATL CANCER INST 2005

20 ALTS TRIAL 2013: Women aged less than 30 years. Absolute risks of CIN2+ and CIN3+ in 2 years given category of HPV genotyping results by referral cytology. Any HPV : 16,18,31,33,35,39,45,51,52,56,58,59 & 68,... Gage J C et al. Cancer Epidemiol Biomarkers Prev 2013;22:

21 ALTS TRIAL 2013: Women aged 30 and above. Absolute risks of CIN2+ and CIN3+ in 2 years given category of HPV genotyping results by referral cytology. Any HPV 16,18,31,33,35,39,45,51,52,56,58,59 & 68, Gage J C et al. Cancer Epidemiol Biomarkers Prev 2013;22:

22 ALTS. CONCLUSIONES DE ESTE ESTUDIO Los tests de VPH específicos de tipo discriminan el valor pronostico entre lesiones citológicas ASCUS / LSIL. Tests (+) para VPH 16 discriminan el máximo. Añadir VPH 18 / 45 reducen la discriminación pronostica. (adenocarcinoma. Segundo y tercero mas importante en cáncer) Una parte importante de los Ascus / LSIL VPH negativos están en el limite de riesgo de progresión estimado para referir a colposcopia según el protocolo ALTS (10% a dos años) Lesiones de LSIL VPH 16+ en mujeres 30+ predicen riesgo de progresion a CIN 3+ de 50% a dos años. Tratamiento? Análisis completado a dos años. Los tipos 45, 31,33 etc progresan mas lentamente que el 16 o el 18. Valos pronostico mejorara con el seguimiento ICO+centre. Servei/Unitat

23 APTIMA HPV Assay Assay design Detection of HPV E6/E7 mrna Transcription Mediated Amplification (TMA) 14 high risk types Internal process control Clinical Performance Equivalent Sensitivity vs hc2 Improved Specificity vs hc2 Genotyping option APTIMA HPV 16 18/45 Genotype Assay (TIGRIS) PANTHER CE IVD scheduled for May 31,

24 APTIMA HPV ASSAY: INTENDED USE ASC-US/LSIL Triage Co-testing or adjunctive screening (US only: women 30 years of age) Primary Screening (women 30 years of age) Test of Cure (women after treatment of CIN or CxCa)

25 AHPV Clinical Study Meta-Analysis Triage of ASCUS with APTIMA vs HC2. Outcome: CIN2+ Triage of LSIL with APTIMA vs HC2. Outcome: CIN2+ Arbyn et al Meta-Analysis 2013: Int J Cancer 25

26 Triaje de lesiones ASC-US: Test validados clinicamente segun criterios de Meijer et al I.J.C Relative accuracy compared to HC2 Test N. of Studies Pooled relative sensitivity (95% CI) Pooled relative specificity (95% CI) HC2 - Reference Reference Abbott ( ) 1.18 ( ) Cobas ( ) 0.99 ( ) APTIMA ( ) 1.19 ( ) Arbyn M. et al. Evidence HPV test. Vaccine 2012 Cancer Epidemiology Research Program

27 Triaje de lesiones de bajo grado (LSIL) Test validados clinicamente Segun criterios de Meijer et al I.J.C Relative accuracy compared to HC2 Test N. of Studies Pooled relative sensitivity (95% CI) Pooled relative specificity (95% CI) HC2 - Reference Reference Abbott ( ) 1.23 ( ) APTIMA ( ) 1.37 ( ) Arbyn M. et al. Evidence HPV test. Vaccine 2012 Cancer Epidemiology Research Program

28 APTIMA Clinical Sensitivity for CIN2+ 100,0% 90,0% 80,0% 70,0% 60,0% 50,0% 40,0% 30,0% 20,0% 10,0% 0,0% APTIMA HC2

29 APTIMA Clinical Sensitivity Referral + screening population data Sensitivity CIN2+ Sensitivity CIN3+ APTIMA 93.2% (1,825 / 1,958) 97.0% (1,174 / 1,210) Hybrid Capture % (1,850 / 1,955) 97.4% (1,177 / 1,208) Total population tested = 39,959 Dockter 2009, Szarewski 2008, Szarewski 2012, Reuschenbach 2010, Clad 2011, Ratnam 2011, Wu 2010, Monsonego 2011, Iftner 2012, Cuzick 2011, CLEAR 2011

30 APTIMA Clinical Specificity for CIN2+ 100,0% 90,0% 80,0% 70,0% 60,0% 50,0% 40,0% 30,0% 20,0% 10,0% 0,0% APTIMA HC2

31 APTIMA Clinical Specificity for CIN2+ Referral + screening population data Specificity CIN2+ APTIMA HPV 85.5% (23,887 / 27,949) Hybrid Capture % (22,631 / 27,934) Total population tested = 39,959 Dockter 2009, Szarewski 2008, Szarewski 2012, Reuschenbach 2010, Clad 2011, Ratnam 2011, Wu 2010, Monsonego 2011, Iftner 2012, Cuzick 2011, CLEAR 2011

32 APTIMA: Clinical Sensitivity compared to the Roche system Referral + screening population data Sensitivity CIN2+ Sensitivity CIN3+ APTIMA 95.7% (425 / 444) 97.9% (237 / 242) Roche cobas 95.5% (424 / 444) 97.5% (237 / 243) Total population tested = 7,625 Szarewski 2012, Cuzick 2011, Ovestad 2011

33 APTIMA Clinical Specificity for CIN2+ compared to the Roche system Referral + screening population data Specificity CIN2+ APTIMA 80.3% (5,770 / 7,181) Roche cobas 74.4% (5,340 / 7,181) Total population tested = 7,625 Szarewski 2012, Cuzick 2011, Ovestad 2011

34 Impact of Specificity on False Positives Across all reported data, APTIMA had 23.3% fewer false positives than Hybrid Capture <CIN1 CIN2+ CIN3+ APTIMA HC2

35 Impact of Specificity on False Positives Across all reported data, APTIMA had 23.3% fewer false positives than the Roche cobas HPV test <CIN1 CIN2+ CIN3+ APTIMA Roche cobas

36 Local Approvals of AHPV England Sentinel Approval for ASCUS/LSIL Triage Sentinel screening pilot with AHPV Bristol (ThinPrep) Liverpool (SurePath) Netherlands Approved according to Meijer Guidelines AHPV is non-inferior to GP5+/6+ PCR

37 AHPV Clinical Studies: Conclusions Referral or ASCUS/LSIL Triage Populations The APTIMA HPV test is as sensitive as Hybrid Capture II to detect CIN2+ or CIN3+ in women with ASC-US or LSIL The specificity of APTIMA HPV is on average 19% more specific in triage of ASC-US 37% more specific in triage of LSIL The APTIMA HPV test might be considered for use to identify those who need further diagnostic assessment with colposcopy and biopsy not only for triage of women with ASC-US but also for triage of women with LSIL Arbyn et al Meta-Analysis 2013: Int J Cancer 37

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