Posts Tagged ‘cervical cancer’

PAP test: More is not better!

Posted: April 3, 2012 in Health
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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.

You might be interested in reading:
HPV: Can a sexually transmitted virus cause cancer?
HPV vaccine for womyn over 25 and for men too

HPV vaccine for womyn over 25 and for men too

Posted: March 25, 2012 in Health
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HPV: a virus that can cause cancer

In 2006, the quadrivalent human papillomavirus (HPV) vaccine was authorized in Canada for use in females between the ages of 9 and 26 years for the prevention of infection caused by HPV types 6, 11, 16 and 18. Types 16 and 18 are most common cause of  cervical cancer. They can also cause vulvar, vaginal and anal cancers. Types 6 and 11 are most common cause of genital warts.

In Feb. 2010, the vaccine was approved for use in boys between ages 9 and 26. The vaccine was found to decrease the odds of genital warts. Since males are usually a silent carrier of the virus, vaccinating boys is thought to decrease the incidence of cervical cancer in females by decreasing transmission.

In April 2011, the quadrivalent vaccine was approved for use in females up to age 45. A new indication for prevention of anal cancer was also added.

The quadrivalent vaccine is now the standard of care. It has been recommended by the National Advisory Committee on Immunization (NACI) for use in womyn ages 9 to 45 for prevention of cervical cancer and anogenital warts, and in men ages 9 to 25 for prevention of anal cancer and anogenital warts. NACI also recommends the vaccine to men who have sex with men (MSM) from the age of 9 onwards. Stronger evidence was found for the quadrivalent vaccine (Gardasil) as compared to the bivalent vaccine (Cervarix).

This vaccine decreases the risk of cancer in men and womyn. It is essential to make it available and accessible. With all the strong evidence that is now available for the benefits of such vaccination, it becomes unethical to withhold such intervention. Having said that, vaccination alone is not enough. We should continue to raise awareness about practices that reduce the risk of transmission of this and other sexually transmitted viruses, like abstinence and monogamy whenever feasible, condom use (limited role with HPV transmission) and targeting marginalized groups like sexual minorities (lesbian, gay, bisexual and transgendered LGBT) underprivileged and uninsured, among others.

 
You might be interested in reading:
PAP test: More is not better! (Added April 02 2012)
HPV: Can a sexually transmitted virus cause cancer? (Added Oct. 09 2010)

HPV in Lebanon: Silent disease empowered by silent society

Posted: October 23, 2010 in Health
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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.

HPV vs HIV media attention

"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:

  1. 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.”
  2. Lebanon tops the world’s charts for plastic surgeries performed per capita. “Official estimates place the number of cosmetic surgeries carried out annually in the country at 1.5 million”.

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?

Food for the thought,

 
You might be interested in reading:
HPV: Can a sexually transmitted virus cause cancer?
HPV vaccine for womyn over 25 and for men too
PAP test: More is not better!