Professor Linda Sharp
Position: Professor of Cancer Epidemiology
Linda Sharp is Professor of Cancer Epidemiology at Newcastle University, England. Before that, for 10 years, she led the research programme at the National Cancer Registry Ireland and, prior to that, was Senior Lecturer in Epidemiology at the University of Aberdeen. She first began working in the area of cervical screening and HPV while at Aberdeen and was one of the lead investigators of the MRC-funded TOMBOLA trial which sought to determine the most effective and efficient management (including the role of HPV testing) for women with low-grade cervical cytology. She has been a member of the CERVIVA consortium since its inception and has led studies on women's and health professionals' views and experiences of cervical screening, colposcopy and HPV testing. Currently, she is working with Mairead O'Connor on the development of a psycho-educational intervention to alleviate post-colposcopy distress. She is also working with Alan O'Ceilleachair on identifying the best screening options in the "HPV vaccination era" and with Aoife Harvey on investigating HPV in oral cancer in Ireland.
Newcastle upon Tyne
Tyne and Wear
CERVIVA-Vax: Monitoring the impact of HPV vaccination in Ireland
Infection with Human Papillomavirus (HPV) can lead to development of cervical cancer. For this reason HPV now plays an important role in cervical cancer prevention. For example, HPV vaccination programmes are established in several countries worldwide, including Ireland, where a national school based HPV vaccination programme began in 2010.
The vaccine does not protect against all HPV as it only targets the main HPV types. So it is important that all women, aged 25- 60, continue to have regular cervical smear tests through the CervicalCheck programme. Very soon the first set of women who have received the vaccine through the school programme, will be eligible to attend for their first CervicalCheck smear. It is important that we monitor the impact of vaccination in those that have received the vaccine to identify if it reduces the prevalence of HPV and cytological abnormalities. It is also important that we look at how the current tests we use for cervical screening in unvaccinated women perform in women who have received the vaccine. Furthermore, it is vital to understand if whether a woman is vaccinated (or not) affects whether she attends for screening.
In CERVIVA-Vax, we will (1) investigate the number and type of HPV infections detected in women who have received the HPV vaccine and attend cervical screening; (2) explore how current screening tests perform in women who are vaccinated; (3) observe screening uptake in vaccinated women compared to unvaccinated women.
Changes in screening uptake, HPV infections and detection of cervical abnormalities may have an adverse effect on how well screening works for individual women and the population. By investigating the early impact of HPV vaccination on screening in Ireland, CERVIVA-Vax will be able to inform CervicalCheck, and international screening programmes, of the best cervical screening approach for both vaccinated and unvaccinated women.
Optimising cervical screening in the HPV vaccination era
The entry into the cervical screening programme of women who have been vaccinated against HPV will impact on screening effectiveness and, hence, cost-effectiveness. Vaccinated women have a much lower risk of having cervical intra-epithelial neoplasia, and this will affect the performance of the screening test and other investigations. It is likely that new screening protocols will need to be developed (for example, based on primary HPV screening, or less frequent screening, or starting screening at an older age). The challenge for decision-makers and service providers is to decide how screening should be organised for maximum effectiveness and cost-effectiveness in the “HPV vaccination era”.
This workpackage has two main objectives: (1) to ascertain the likely impact of HPV vaccination on current cervical screening protocols and (2) to investigate the effectiveness and cost-effectiveness of alternative screening scenarios in the “HPV vaccination era”.
To achieve this CERVIVA will, in conjunction with key stakeholders: identify a set of plausible and feasible alternative screening scenarios; assess available mathematical and economic models; and identify and parameterise the model most suitable for the Irish setting. This model will then be used to estimate the impact of HPV vaccination on current screening practice, the likely changes over time as more of the screening population are vaccinated, and to make recommendations on the most effective and cost-effective screening options.
ECHO (Epidemiology of HPV infection in Oral cancer in Ireland)
Human papillomavirus (HPV) is the single most important aetiological agent in the pathogenesis of cervical cancer and pre-cancer. It is increasingly recognised that HPV is causally implicated in other cancers, including head and neck cancer. The incidence of head and neck cancer, and more specifically oropharyngeal cancer, has been increasing over the last decade. An average of 411 cases are now diagnosed annually in Ireland. Oropharyngeal carcinoma is increasing in younger age groups and among females, who are less likely to have strong tobacco or alcohol histories, suggesting the importance of HPV in these cohorts. In the US, approximately 35% of oropharyngeal tumours are HPV-positive. The prevalence of HPV in other head and neck cancers – notably those of the oral cavity and larynx – is less firmly established. In addition, it is unclear whether the survival advantage associated with HPV-positivity in some clinical series and trials persists at the population-level.
In this project, CERVIVA will extend its scope into HPV associated cancers beyond the cervix, by generating the first data on HPV prevalence and genotype distribution, and associations between HPV status and outcome, in head and neck cancers in Ireland.
Development of a theory-based psychoeducational intervention for cervical cancer screening
The aim of this project is to develop a theory-based psycho-educational intervention to alleviate the adverse psychological after-effects of colposcopy and related management procedures, such as punch biopsies and LLETZ.
This workpackage is building directly on our work in CERVIVA Phase 1, including our longitudinal quantitative study of psychological impact and health-related quality of life in women attending colposcopy. As part of this workpackage, we conducted a qualitative study involving in-depth interviews with women about their experiences of colposcopy and psychological after-effects. The findings of this study have been written up and submitted for review at a scientific journal. We undertook the first ever systematic review of the adverse psychological after-effects of colposcopy and related procedures.
Currently, we our using the results of the longitudinal quantitative study, qualitative study on women’s experiences of colposcopy and the systematic review to inform the development of an appropriate based psycho-educational intervention to alleviate the adverse psychological after-effects of colposcopy and related procedures.
The workpackage is leveraging the experience that the CERVIVA investigator, Dr Sharp, has gained in the investigation of the psychosocial impact of low-grade smears in the UK population-based TOMBOLA trial and is also taking advantage of the expertise the team have gained in the development of theory-based interventions in the ATHENS (A Trial of HPV Education and Support) study. ATHENS is an add-on to CERVIVA in which we are currently developing a behavioural change intervention to support GPs and practice nurses in dealing with issues around HPV infection, vaccination and testing in their clinical practice. The team investigator, Dr O’Connor, has worked extensively on studies conducted in CERVIVA Phase 1. This has enabled her to gain experience and knowledge of the psychological aspects of cervical screening and the challenges facing policy makers and women attending for cervical screening. CERVIVA Workpackage 3/CERVIVA ICE is also benefiting from with two experienced health psychologists, one at Dublin City University and one at University College London, to develop the most effective and appropriate intervention.
ATHENS (A Trial of HPV Education and Support)
GPs and practice nurses play a key role in cervical cancer prevention activities in Ireland. In addition to providing smear tests, they are likely to be key sources of information and advice for patients on HPV infection, vaccination and testing. As public knowledge and awareness of the role of HPV in cervical cancer grows, it is likely that more and more people will seek advice from their GP or practice nurse on whether to have an HPV test, or how to prevent HPV infection. Thus primary care practitioners’ views and knowledge in this area – and their ability to impart this information to their patients – will have a major influence on cervical cancer prevention activities in Ireland over the coming years.
ATHENS (A Trial of HPV Education and Support), which is being conducted under the umbrella of the CERVIVA research consortium, aims to develop a practical, theory-based resource (intervention) to support GPs and practice nurses in their practice in relation to HPV infection, vaccination and testing. The first stage of the study involved two primary research studies to inform intervention development. Firstly, a qualitative interview study was conducted among GPs and practice nurses to identify key HPV-related clinical behaviours and explore influences on these behaviours. The findings of this study have been published in Implementation Science (see publications page). Secondly, a national postal survey of GPs and practice nurses was carried out to: (a) establish frequencies of the key behaviours in relation to HPV and; (b) identify significant predictors of behaviours. The findings from this phase are being written up for publication. This stage of the study was funded by the FRIENDS of the COOMBE.
The second stage will - once funding is secured - evaluate the efficacy of the resource(s) in improving knowledge and influencing clinical practice in a randomised controlled trial.