Highlights of the 27th International Papillomavirus Conference

How many men are infected with HPV of which type? Does HPV also cause non-melanoma skin cancer? Is HPV DNA screening cost-effective? No prevention, no early detection, almost no treatment possibilities: Cervical cancer in Africa

Harald zur Hausen, honorary president of the 27th International Papillomavirus Conference, has been advocating for many years that boys should also be vaccinated against cancer-causing human papillomaviruses (HPV). ""This could accelerate the eradication of these viruses, which is not impossible," he emphasizes. Anna Giuliano of Moffitt Cancer Center in Florida has now been the first to analyze how often cancer-causing HPVs are found in men and how long the infections persist before being cleared. Giuliano's conclusions: Men with many female sexual partners are particularly frequently infected with HPV and infections persist for a longer time. Infections with HPV16, the most important HPV type causing cervical cancer, persist in men for a mean duration of 12 months, which is twice as long as with most of the other HPV types. They usually do not cause any symptoms and can be transmitted unnoticed to female partners during this time.

In another recent study, Giuliano has demonstrated that the HPV vaccine Gardasil® also protects young men from precancerous lesions (and genital warts). "Taken together, the results of our two studies provide good reasons for carefully evaluating the cost-effectiveness of HPV vaccination for boys," said Giuliano.

Do we have to add to the list of HPV-induced cancers? New results obtained by virologist Lutz Gissmann of the German Cancer Research Center in Heidelberg suggest that this is indeed so. Gissmann has discovered that specific human papillomaviruses render the skin of mice light sensitive and, thus, play a causal role in the development of non-melanoma skin cancer. "If our results are confirmed, we may start thinking about an immunization for persons at high risk," says Lutz Gissmann. Persons at risk include, for example, organ transplant recipients who have to take immunosuppressants all their lives and are therefore susceptible to all infections. These people suffer from non-melanoma skin cancer one hundred times more often than the general population.

Numerous studies have demonstrated by now that precancerous stages of cervical cancer can be identified much more accurately by detection of HPV DNA than by an annual cytological examination of a cervical smear, which has been offered for early cancer detection by statutory health insurance funds in Germany since the 1970s. However, it has been unclear up to now what the costs of introducing such a screening concept in Germany would be. Karl Ulrich Petry of Wolfsburg City Hospitals has now evaluated various screening strategies differing in examination intervals, test combinations (HPV test alone or in combination with Pap cytology test) and age limits.
The analysis has shown that all other screening strategies are more effective than the currently recommended annual cytology. The most effective and cost-effective strategy was found to be HPV screening at two-year intervals starting at age 30, preceded by biennial cytology for women aged 25-29 years. For this concept, costs per additional life year gained are 23,400 euros (current screening strategy, annual cytology test: 142.000 euros!). "In our experience, longer DNA screening intervals of three years may also be considered under certain circumstances. Thus it would be possible to further reduce costs substantially," said Petry.

Pap smear or detection of HPV DNA, HPV vaccination only for girls or also for boys - such considerations are pure luxury in many parts of the world. Eighty-five percent of cervical cancer deaths occur in developing countries. Rose Anorlu, gynecologist at the University Hospitals of Lagos, Nigeria, reports about the situation in Africa. In Sub-Saharan Africa, cervical cancer accounts for 22.2 percent of cancer cases and is not only the most frequent type of cancer (Germany: 12th place, about 2.8 percent of cancer cases) but also the most frequent cause of cancer death in women (Germany: 13th place, about 1.5 percent of cancer deaths).

Early marriage combined with male polygamy promotes high infection rates. Poverty, lack of access to medical care, many births and inadequate hygiene as well as infectious diseases such as malaria, HIV and tuberculosis, which weaken the immune system, are factors promoting the development of cervical cancer.

Few Sub-Saharan Africa women have ever had a Pap test for early cancer detection; less than one percent in West Africa. As a result, cancer is usually detected in a very advanced stage. In Lagos, only 10 percent of cervical cancers are detected in an operable stage. For all other patients, radiation therapy remains as the last treatment option. But this often cannot be accomplished due to a dramatic lack of devices. In 2003, there was not a single radiotherapy device in 15 African countries. Therefore, relief of pain is what most patients urgently need. However, there is a lack of morphine for treating chronic severe pain - the drug is available only in 11 out of 47 African countries.

What is central for women in Africa is a possibly efficient distribution of extremely few resources available in the healthcare sector. "If we could only achieve for every woman in Africa to have a Pap smear test for early detection once in her life, this would already make a big difference," says Rose Anorlu.