The recommendations for cervical cancer screening appears to be changing rapidly in the last decade. This will cause more confusion among physicians and patients as well. It is important to stay aware of the latest research and findings.
When in comes to PAP tests, more is not better. This can be clearly observed if we compare two countries: USA and Netherland. American women undergo 3 to 4 times as many Pap tests as their Dutch counterparts. Despite the vastly different screening rates, the overall mortality data suggest no substantially different trends between the 2 countries. This suggests that more frequent screening for cancer of the cervix using PAP testing is not necessarily more beneficial.
So what make physicians do more than a patient needs? Most physicians will follow guidelines. With more research and evidence guidelines change and some physicians takes longer to catch up than others. Some physicians are resistant to change: “We have always done it this way and it always worked”. Others believe screening more often would not harm, a belief contradicted by evidence. Frequent PAP testing can result in more anxiety and unnecessary interventions, additional cost to the patient and system.
On the other hand, all patients I diagnosed with cervical cancer had not had a PAP test for the last 7 years or more. I have yet to see a patient with cancer of the cervix who had recent normal PAP tests. So less can be dangerous.
Here is the latest, all you need to know in a nutshell:
Begin screening at age 21 regardless of sexual activity.
Younger than 21? There is no need for PAP or HPV testing regardless of sexual history. Cervical cancer is rare and HPV is very common in this age group.
Between 21 & 29? PAP is needed every 3 years. HPV testing is not needed.
Between 30 & 65? You need both PAP and HPV testing every 5 years (preferred) or PAP alone every 3 years (acceptable).
Older than 65? No need for PAP testing if you never had cervical dysplasia (precancerous cells) in the past 20 years.
Older than 65 with new sexual partner? No need for PAP testing
Following a total hysterectomy (surgery to remove uterus and cervix)? No need for PAP testing
Following a partial hysterectomy (surgery to remove uterus and retain the cervix)? Follow the same recommendations as if you did not have a hysterectomy.
Following the HPV vaccine? Follow the same recommendations as if you did not receive the vaccine.
It is worth noting that the above guidelines are for general screening and do not address high-risk populations as patients with a history of cervical cancer, exposure in utero to diethylstilbestrol, or those who are immunocompromised (example: patients with HIV/AIDS or organ transplant).
The above concerns performing a PAP test. Every woman will still need an annual pelvic examination (some call it ‘vaginal exam’, ‘speculum exam’, ‘bimanual exam’, and the misnomer ‘PAP test’) wether a PAP test is being obtained or not. Such exam is essential to assess the vulva, vagina, cervix, uterus, tubes and ovaries for any masses or abnormalities.
This post is about a recent study released online on Feb. 10th 2012 in The Lancet Oncology as an early publication. In brief the study assessed “children who were prenatally exposed to maternal cancer staging and treatment, including chemotherapy.” They examined 68 pregnancies who were exposed to 236 cycles of different kinds of chemotherapies. 70 children were assessed at age 18 months, 5—6, 8—9, 11—12, 14—15, and 18 years. Assessment included examining neurological and cognitive functioning or IQ, heart functioning, general health and development, hearing, memory, attention and behaviour.
The study concluded that “fetal exposure to chemotherapy was not associated with increased CNS, cardiac or auditory morbidity, or with impairments to general health and growth compared with the general population.”
The importance of this study lies in providing a perspective on long-term outcomes of newborns after exposure to chemotherapy during pregnancy. With such reassuring findings, we should consider avoiding early deliveries that subjects those newborns to risks of prematurity.
It is important to realize that not all chemotherapies are safe and the ones included in this study are those that are know to be tolerated during pregnancy.
أثبتت دراسة أوروبية حديثة أن إخضاع السيدة الحامل للعلاج الكيميائي لا يؤثر على صحة الجنين، خاصة إذا حدث ذلك في الفترة الممتدة ما بين الشهر الرابع والسادس من الحمل.حيث قام أخصائيون أوروبيون تابعون لـLeuven Catholic University في علاج السرطان بمراجعة حالة 68 سيدة حامل أنجبن 70 طفلا بعد أن خضعن لعلاج الكيميائي ضد السرطان، وفحصوا صحة الأطفال عند مولدهم كما عند بلوغهم 18 شهرا، ثم بعد ذلك عند بلوغهم سن الخامسة وحتى بلوغهم 18 عاما.وقد شمل الفحص الحالة الصحية العامة للأطفال، كما تم تفحص ما إذا كان لديهم قصور في الجهاز العصبي المركزي أو القلب أو السمع وتم اختبار مهاراتهم المعرفية والعقلية كذلك.
وقد تبين للباحثين عدم وجود أي دليل على تضرر صحة الأطفال من جراء العلاج الكيميائي الذي خضعت له والداتهن أثناء الحمل بهم، إلا أن الأطفال الذين ولدوا قبل الميعاد الطبيعي أظهروا مهارات معرفية أقل من الباقين، ولكن هذه مشكلة عادة ما تصيب كل الأطفال الذين يولدون قبل الميعاد، حتى دون تعرضهم لعلاج كيميائي.
وقد أوصت الدراسة بعدم القلق في إخضاع الأم الحامل للعلاج الكيميائي، ونصحت الأطباء بألا يحثوا المرأة الحامل المصابة بالسرطان بالولادة قبل ميعادها لإخضاعها لاحقاً للعلاج.
وأشارت الدراسة إلى أنه “يمكن إخضاع السيدة الحامل للعلاج الكيميائي بدءاً من الأسبوع الرابع عشر من الحمل، ولكن كي يستعيد النخاع العظمي قوته ولتقليل مخاطر تسمم الأم والجنين أو حدوث نزيف يجب أن يتم التخطيط للولادة على الأقل بعد ثلاثة أسابيع من آخر جرعة كيماوية تعطى للحامل، كما يجب أن تتوقف الجرعات عند الأسبوع الـ35 وذلك تلافيا لحدوث ولادة تلقائية في ذلك الوقت”.
ولكن يقر فريق الباحثين بوجود حاجة لعمل المزيد من الدراسات لمعرفة ما إذا كان للعلاج الكيميائي تأثير على هؤلاء الأولاد في الأمد البعيد. المصدر
من المهم أن نتذكر أن هذا الحديث لا ينطبق على كل علاج كيميائي انما على بعض الأدوية التي كنا نعتقد أنها أمنة، فتأتي هذه الدراسة الآن لتؤكد ذلك.
Here is my mom’s reaction to my persistent requests for a PAP test (فحص المسح المهبلي او فحص القزازة): “I am not comfortable on the exam table with that thing shoved down there.” Well, who is? I would start to worry if she actually liked it!
Two years ago, I gave a seminar about sexually transmissible infections to a group of women belonging to human rights organization in Beirut. Their awareness about HIV, Chlamydia, Gonorrhea, Herpes and the other culprits was optimal. Little did they know about HPV. Eyebrows were raised when I spoke about how common it is, how easily transmissible and how it can cause cervical cancer.
Social media campaigns in Lebanon have tackled breast cancer, diabetes and other diseases. Little has been done to raise awareness about the Human Papilloma Virus or HPV (فيروس الورم الحليمي البشري) and cancer of the cervix (سرطان عنق الرحم), options for early detection and prevention.
The Lebanese Ministry of Health website has awareness campaigns for Breast cancer, diabetes and Hepatitis, prevention campaigns for smoking and HIV, surveillance sections for different infections and cancers. A search for HPV returns 0 results. Even on a page dedicated for vaccination, there is no mention of the cervical cancer vaccine.
So why is HPV awareness suboptimal in Lebanon?
No research has addressed this issue and I do not claim to have the answers. I welcome your feedback and comments. Feel free to add theories that you believe might be a factor. Here are few that I could think of:
Is it lack of interest by the medical field in Lebanon?
Very little research is done on HPV disease in Lebanon. A quick PubMed search using “HPV” and “Lebanon” brings up only a handful of articles. The questions remains: Why is there lack of interest?
Is it lack of interest by pharmaceutical companies?
Unfortunately, most of the current health awareness campaigns in Lebanon, like anywhere in the world, can be driven by pharmaceutical and medical equipment companies. Does cervical cancer sell less? Will having the new vaccines on board change that?
Is HPV less prevalent in Lebanon as compared to western countries?
A study by Dr. Adnan Mroueh published in 2002 showed that up to 5% of Lebanese women between ages 18 to 76 carry the virus. This is similar to Arab countries but significantly less western countries (40 – 60%). This might be a valid reason. However, the study by Mroueh tested for only few types of HPV which might explain the low prevalence.
Is it the social taboo of sexuality?
HPV is sexually transmitted and many would like to believe or claim that extramarital or premarital sexuality do not exist in Lebanese communities. In October 2007, Al-Akhbar publishes “Who remains silent about HPV disease is a mute devil” or “H.P.V: الساكت عن المرض شيطان أخرس”. This very interesting and rare article in the Lebanese media addresses the lack of awareness and invites people to discuss HPV and cervical cancer more openly. It includes true stories of how societal prejudice can ostracize some Lebanese womyn diagnosed with HPV.
"Media attention to HIV vs. HPV"
Is it the social fear from and ignorance about cancer?
The further you go away from Beirut and big cities the weirder the alternative names for cancer get. You reach my village and there they call it “The Evil Disease” or “المرض الخبيث” and “The one whose name we shall not say” or “هيدا يلي ما بيتسمى”. But then why breast cancer awareness is at its peak?
Is cervical cancer less disfiguring to “female prototype”?
I feel appalled by even typing that. You might feel it is a remote possibility especially if you are not familiar with the Lebanese societal dynamics. Before you proceed here are two facts about Lebanon:
Lebanese banks offer plastic surgery loans. Read “Nip’n'tuck loans offer in Lebanon” by BBC news. AFP took it a step further and described the situation as ‘a national duty for women to look the best‘ in their article “Sea, sun and scalpel.”
Here is an eye-opening perspective from a Lebanese woman who wrote “HPV: Is it Really Worth the Shot?” for Bekhsoos, the queer arab online magazine. She writes: “I for one refuse for health workers to tell me that my breasts are much more important than my uterus. Both forms of cancer are dangerous and can lead to death, yes…. However one can be prevented but is associated with sexual conduct and therefore isn’t accepted. While the other deals with aesthetics- and therefore gains more sympathy.”
Lebanon has a Chauvinistic framework but could it be that bad? Does she make a valid point?
Two weeks ago, a nice young woman presented to my office for excessive vaginal discharge that she had for the past year. The moment I saw her cervix, I knew what I was looking at: Cancer. Her last gynecological exam was 5 years ago.
Who is to blame? Is it the responsibility of the patient, the physician or the health care system? With all the recent advancements in cancer prevention and early detection, it becomes unacceptable to allow any woman to develop cervical cancer. We are all responsible.
Breaking cancer news to my patients and their families is the second least favorite part of my job. We have the means to put an end to cervical cancer. We should raise awareness about this cancer and its causes, more so in less developed countries. My next post will be about cervical cancer awareness and barriers encountered in Lebanon.
Can a virus cause cancer?
Human Papillomavirus or HPV is the most common sexually transmissible infection. It is the leading cause of cancer of the cervix. HPV can also cause cancer of the vagina, vulva, penis and anus. There are more than 100 different types of HPV. Low risk types like 6 and 11 usually cause warts. High risk types like 16 and 18 are responsible for 75% of cervical cancer cases. Generally, men and womyn are silent carriers. They will carry and transmit the virus without having any symptoms at all.
There are no medications to treat the virus. It takes months to years for your immune system to defeat it. Cigarette smoking, high risk sexual behavior and having multiple sexual partners are among factors that might make the progression to cancer faster.
Is my partner unfaithful?!
If you are in a long-term monogamous relationship and were recently diagnosed with HPV, do not jump to conclusions about the faithfulness of your partner. Attempts to know who gave it to the other are futile. I tell my patients that there is no need to start using condoms or dental dams for the sole reason of preventing transmission of the virus to your monogamous partner. He or she likely has the same HPV types already.
Now, it is not all gloomy! Here is the bright side. For womyn, a vaccine can prevent HPV infection and a PAP test can detect early cancer allowing complete cure.
Yes, we can prevent HPV infection!
Condoms do not offer full protection. HPV transmission can occur by skin-to-skin contact. The good news is that you can now be vaccinated against HPV.
Two HPV vaccines are available:
Gardasil (By Merck & Co, Inc.): Quadrivalent HPV vaccine (protects against 4 types of HPV: 6, 11,16 and 18). It was FDA approved in 2006 for use in females aged 9 through 26 years.
Cervarix (By GlaxoSmithKline): Bivalent HPV vaccine (protects against 2 types of HPV: 16 and 18). It was FDA approved in October 2009 for use in females aged 10 through 25 years.
The vaccine is given in three-dose series. Get in now. Your second shot will be in 2 months and the third in 6 months.
In addition to preventing cancer, the vaccine also lowers your chances of developing genital warts, which can be as psychologically burdening.
The vaccine works best when given to individuals who have never been sexually active. Nevertheless, there is still a proven benefit even if you are sexually active and had HPV or precancerous cells on your PAP test. The vaccine might prevent re-infection or re-activation of the virus.
Yes, we can detect cancer early (even before it happens)!
The Pap test has significantly lowered the incidence of cervical cancer among womyn. Cells are taken from the cervix and examined. If abnormal, your provider might ask you to have a colposcopy. With colposcopy, the vagina and cervix are washed with acetic acid or vinegar. A light and magnifying lens allow your doctor to visualize and biopsy any abnormal tissue. If early cancer or precancerous cells are confirmed after biopsy, your doctor can burn, freeze, laser or cut out the affected part of the cervix, thus slowing or arresting the progression to cancer.
So if you are between ages 21 and 29, you should get a PAP test every 2 years, then every 3 years once older than 30 according to the most recent guidelines by the American College of Obstetricians and Gynecologists. If, however, you have high risk factors or previous abnormal PAPs then you might need more frequent PAP tests. Always discuss with your doctor.
What lies ahead! Recent research, future approaches
Vaccinate the boys!
On October 16th, 2009, the FDA approved use of Gardasil for the prevention of genital warts (condyloma acuminata) due to HPV types 6 and 11 in boys and men, ages 9 through 26.
In July 2010, the 26th International Papillomavirus Conference in Montreal, Canada addressed the importance of the recent shift towards a “gender-neutral” vaccination policy. The conference discussed the significant decline in HPV-related disease in men and womyn after the Australian national HPV vaccination campaign was introduced in mid-2007.
Anal “colposcopy” for womyn!
The September 2010 issue of the Green Journal (Obstetrics & Gynecology) published a study that suggested screening for anal cancer (Anoscopy) all womyn with pre-cancerous cells in the cervix, vagina or vulva. I agree with Dr. Linda Eckert: “We are not ready for such recommendation” she wrote in Editorials of the same issue. More research is needed to support such guidelines.
Anal PAP test for men!
In Sept. 2010, the 28th Annual Conference of the Gay and Lesbian Medical Association (GLMA) in San Diego, USA took the discussion one step further. There were four plenary and breakout sessions on anal dysplasia and cancer, anal PAP test, and HPV vaccination in men. Even though recommendations for anal PAP testing have not been endorsed widely by medical organizations, few centers in USA have developed the experience in performing and reading anal PAP tests. The results are promising, but again, much more research is needed in this field.
Vaccinate womyn older than 26!
If you are between ages 26 and 45, you might be a candidate for the vaccine. Discuss it with your doctor. A large well-designed study published in the Lancet in 2009 showed favorable results for HPV vaccination in womyn ages 24 to 45. No recommendations for this age group have been made yet.
Can we do better?
It appears that we should do a better job at vaccinating. Over the three years since Gardasil was approved, only 18% of adolescent females have received all 3 doses. Many marginalized group of womyn do not receive adequate PAP testing.
It is unjust for a woman anywhere in the world not to benefit from the available means to fight cervical cancer.
We need to raise awareness.
We should aim at eradicating HPV like we eradicated small pox in 1977.
The recommendations for cervical cancer screening appears to be changing rapidly in the last decade. This will cause more confusion among physicians and patients as well. It is important to stay aware of the latest research and findings.
