<![CDATA[From disease elimination to elimination of the oncogenic HPVs]]>

What is the purpose of the 5^th Helsinki symposia?
The purpose of the Helsinki symposia was and is to spread HPV-knowledge and awareness to all healthcare professionals in Finland, and also get together major “hard core” HPV-researchers to create fruitful discussions and new ideas on a timely topic.

Is the elimination of the HPV viral infections the new target of our preventive efforts?
The aim of eliminating HPV infections is very attractive, although almost impossible, at least on the short run. It will take decennia, before vaccination coverage will be high enough on this globe to achieve sufficient herd effect to decrease HPV prevalence and finally, possibly eliminate it. This, however, requires us to continue the fight. We have to develop the next generation vaccines, which would, for example, tolerate changing temperatures in storage, also therapeutic ones and of course improve screening programs throughout the world. Perhaps we can first decrease or almost eliminate cervical cancer during the next 50 years and later HPV infections!

How much can we do with vaccines and how much will rely on our screening programs?
The final answer will be the vaccines, but before they can be spread to all countries with good enough coverage, we have to continue to develop screening. The screening should happen in organized programs, but the screening method is obviously dependent on the countries’ resources and infrastructure.

What is the current policy for cervical cancer prevention in Finland?
I am a little sorry to say this, but Finland is not quite in the front row anymore. We have continued the same old organized screening program, which has achieved good results, undeniably. What is not very widely known is that we have had a very extensive opportunistic screening activity alongside. These two modalities together have provided more than 90% 5-yearly attendance rate to Pap-tests for the Finnish women, but this is not the most cost-effective way!
However, the programs and policy should follow the time. The total environment has changed during the last 30 years. Women are presently more exposed to the risk factors like HPV and smoking; the habits are not the same than earlier.
Fortunately, the vaccination program, which is now school based and free for the girls of 11-12 years of age, started in 2014, much later than in other countries. Next fall we will have a task force to plan the vaccination of boys.

What major changes is Finland introducing in the screening program?
The Finnish “HPV disease burden working group”, which I was chairing was established by the Finnish National Health and Welfare Institute to plan the best policy to cervical cancer prevention and to decrease the HPV disease burden. Already in 2011 reported and issued recommendations for screening and vaccination.
We recommended starting immediately the HPV vaccination program, which only started 3 years later. We recommended major changes to the organized screening program, including HPV primary screening with cytology triage from the age of 30-35 years on, continuing the screening until 65 year of age with HPV exit test. We also recommended discouraging the opportunistic screening, which is unfortunately flourishing here. The opportunistic screening naturally also decreases cervical cancer incidence by increasing the total attendance rate to screening, but it is not nearly as cost-effective as the organized program, at least here in Finland. The incremental costs per achieved QALY and per prevented cancer are enormous.
Now we have been waiting quite a number of years that the political decision makers would make the implementation possible. Nothing has happened yet! The other obstacle is that, all the municipalities, which are over 350 in Finland and are responsible to execute the screening, naturally can’t be aware of all things involved in screening. They desperately need some governmental guidance. We have a proverb here in Finland: “You can’t wait something good for too long …” Let’s hope, something will happen, sometime!

Is self-sampling an alternative to increase screening coverage in Europe?
Definitely! We and other groups in Europe have published studies, which show that it is possible to increase the coverage by 10-15% with self-sampling. It seems to be that the best combination is first a recall letter and if that’s not functioning, then to send a self-sampling device. However, we should encourage the women to come primarily to conventional screening and self-sampling will be the second or third option.

HPV vaccines have reported significant herd protection, what is it and how important it is?
If we can get the coverage of vaccination high enough (how high, depends on the virus), we can slow down the virus circulation in the population and people are not anymore so often exposed to the virus. Thus also unvaccinated persons are better protected against the infection. This is called herd protection. With HPV-vaccination and about 80% coverage seems to create a significant herd protection.

How would you combine HPV vaccination with an excellent screening program?
We are presently doing work on this. But to give a simple answer for Finland: we can’t continue with the conventional Pap-screening when the first vaccinated age cohorts reach the first screening age in few years. The positive predictive value (PPV) of the Pap-test will be too low. So we should soon change to HPV primary screening, simultaneously increase the vaccination coverage, which is presently just 70% and find out the best triage method after HPV screening, whatever it is, HPV typing, methylation markers or something else.
We can’t stop the screening program in the next 50 years, so it has to be a good one. My prediction is that when HPV vaccination has penetrated the whole population women will require only a couple of HPV-tests during the life time.

CONFERENCE REPORT
Selected and prepared by Pekka Nieminen and Matti Lehtinen, and reviewed by presenters. The quadrennial human papillomavirus (HPV) vaccination symposia arranged in Helsinki since 2000 cover 16 years of work in the field (Vaccine 19, 2001, [1] and HPV Today 32/33, 2016, [2]). The 5th Helsinki HPV Workshop, which took place on January 13, 2016 again gathered leading experts together to report and discuss impact of implementing HPV vaccination and screening in the already partially protected population. We report here nine selected presentations disclosing effectiveness of different HPV vaccination strategies and interactions with screening programs.

Chaired the sections:
Jorma Paavonen, University of Helsinki
Margaret Stanley, Cambridge University
Matti Lehtinen, University of Tampere and Karolinska Institute

References
1. Lehtinen, M., Dillner, J., Paavonen, J. Vaccinating women against premature death. Vaccine, 2001. 19: p.1347-1352.
2. Lehtinen M. Vaccinating women and men against premature death. HPV Today, 2016. 32/33: p.7-17.

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INTERVIEW WITH
Pekka Nieminen, MD, PhD
University of Helsinki Central Hospital
Helsinki, Finland
pekka.nieminen@hus.fi

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