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.
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.
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.