Europe’s new Beating Cancer Plan provides a launchpad for a new effort to eliminate all the cancers caused by HPV across the EU and the wider European region. To discuss next steps, the European Cancer Organisation’s HPV Action Network hosted a well-attended webinar for its members and stakeholders on 25 February 2021.
Dr Matti Aapro, President of the European Cancer Organisation, opened the webinar by highlighting the significance of the Beating Cancer Plan’s commitment to eliminating all the cancers caused by HPV and to gender-neutral vaccination. Dr Aapro reminded attendees that Stella Kyriakides, the European Commissioner for Health and Food Safety, has stated that the aim is to vaccinate at least 90% of the EU target population of girls and to increase significantly the vaccination of boys by 2030.
The webinar’s first presentation was from the keynote speaker, Walter Ricciardi, Chair of the EU Cancer Mission and Professor of Hygiene and Public Health at the Università Cattolica del Sacro Cuore in Rome. Prof Ricciardi observed that although Europe has less than 10% of the world’s population, it has a quarter of its cancer cases because of ageing populations, unhealthy lifestyles and unfavourable environmental conditions. Without strong action, the number of cancer cases in Europe will increase by 25% by 2035.
The Cancer Mission aims to save more than three million lives in the EU by 2030 through research, preventing what is preventable, optimising diagnostics and treatment, supporting quality of life and ensuring equitable access. Preventing cancers caused by infections has a central role, as highlighted in WHO’s global strategy to accelerate the elimination of cervical cancer as a public health problem. But there is still a long way to go with HPV vaccinations, especially in low-income countries. Coverage is increasing but only 15% of girls worldwide are fully protected and, although there is a growing number of gender-neutral programmes, just 5% of young males received the vaccine in 2019. There is now growing concern that progress will be slowed by the increasing problem of vaccine hesitancy.
Prof Ricciardi called for an approach to vaccination based on the principles of Value Based Healthcare. This would involve going beyond traditional cost-effectiveness modelling and looking at the wider health, social and economic benefits of vaccination, including decreasing long-term health costs, fewer days of work lost, increased health equity and reduced poverty. A value-based immunisation strategy puts the citizen/patient at the ‘centre’. Because infectious diseases do not recognise geographical or political boundaries, a global value-based approach to prevention and control is required.
The second speaker, Alessandra Moretti MEP, spoke of the long wait for a comprehensive plan for cancer in Europe and that this came about not by chance but as the result of a sustained campaign by many people and organisations. She emphasised the importance of the European Cancer Organisation’s support for implementation, including the recommendations on HPV. The cancers caused by HPV are among the few that can be eliminated in the near future and gender-neutral vaccination is essential. Ms Moretti said that it is unacceptable that some member states do not yet vaccinate boys and that action is needed to address the current differences between countries in prevention and screening.
Dr Laia Bruni, from the Cancer Epidemiology Research Program at the Catalan Institute of Technology, provided an overview of the current state of HPV vaccination and cervical cancer screening in Europe. 77% (33) of 43 European countries, including 89% (24) of the EU 27 states, report having introduced HPV vaccination in their national schedule. Of the 33 programmes, 58% (19) are girls-only and 42% (14) are gender-neutral. The mean coverage levels across all countries are 66% for the first dose and 58% for the last dose. The largest share of cervical cancer burden is in countries that have not yet introduced HPV vaccination. Many populations with the highest incidence and mortality of disease still remain largely unprotected.
95% (41) of 43 European countries now have identifiable official recommendations for cervical cancers screening and many are scaling up to population-based screening programmes that include personal invitations to screening. Almost half of the countries now recommend primary HPV based screening but most of them are still transitioning from cytology-based screening. Across Europe, most countries report screening coverages above 70%. However, screening is part of a process, not only a test, and it is important that women with a positive screening result have access and adhere to subsequent diagnostic tests and treatment.
Challenges and opportunities in HPV vaccination were discussed by Prof Margaret Stanley, President of the International Papillomavirus Society. Prof Stanley emphasised that HPV is a potent carcinogen that causes cancers in both men and women. But vaccination offers significant protection, with one study showing that while there are 94 invasive cervical cancer cases per 100,000 in unvaccinated women aged under 30, the rate falls to 4 cases per 100,000 in women who were vaccinated below the age of 17.
But vaccination is only effective if coverage in boys and girls is high (over 80%). The achievement of this target across Europe is inhibited by inequities in health case, poor awareness of the links between HPV and cancer, myths that infectious diseases are under control, anti-vaccination misinformation in spread via social media, and ignorance of vaccines among healthcare workers. While the COVID-19 pandemic has put HPV vaccination programmes at additional risk, it has also created some new opportunities. Public awareness of viruses and the role of prevention in general and vaccination in particular, has increased and a new vaccine infrastructure that could be used for HPV vaccination has been created.
Prof Murat Gultekin, Chair of the Prevention and Advocacy Committee at the European Society of Gynaecological Oncology (ESGO), addressed the next steps in cervical cancer screening. He highlighted the east-west divide in Europe in respect of cervical cancer incidence and mortality and the need for action especially in the eastern countries. Prof Gultekin also stressed the limitations of cytology-based screening programmes – with very low sensitivity for CIN2+ lesions and high false negative rates, for example – and the many advantages of HPV DNA testing. HPV testing is objective, has higher sensitivity, can be offered with longer intervals between screens and is organisationally easier and cheaper to provide. It can also be offered on a self-sampling basis. It is important, however, to ensure that the test kits used are properly validated.
COVID-19 has had a major impact on cervical cancer screening with interruptions to 88% of programmes in Europe. A quick recovery in screening is needed which prioritises at-risk women and which utilises self-sampling. There may be opportunities to use COVID testing systems for HPV and to repurpose innovative products developed for the pandemic.
David Winterflood, Chief Executive of the Anal Cancer Foundation, discussed one of the often-overlooked cancers caused by HPV. 90% of anal cancers are caused by HPV. There are some 4,500 new cases a year in Europe, with 65% in women and 35% in men, and the incidence is rapidly increasing, as is mortality. There are no routine screening guidelines and significant variations in five-year survival rates across the region. Anal cancer is often misdiagnosed as haemorrhoids and there is considerable stigma associated with the disease which further delays detection and treatment.
Action is needed on prevention (gender-neutral vaccination and screening), education (including tackling stigma) and treatment (e.g. new immunotherapies). Mr Winterflood believes that the Beating Cancer Plan offers a ‘golden opportunity’ to end forever the suffering caused by anal and other HPV-caused cancers.
The webinar concluded with a presentation by Prof Daniel Kelly, co-chair of the HPV Action Network, on the Network’s recent and planned future work. The activities for 2021 include making the case for action on HPV across the European region, working with the EC on implementation of the Beating Cancer Plan, and starting a new project to create national HPV champions and networks in countries which are falling behind and where action is particularly required.
The webinar was moderated by the Network’s co-chairs, Profs Rui Medeiros and Daniel Kelly.