Read more recent updates on HPV: HPV vaccine for womyn over 25 and for men too (Added March 25 2012) PAP test: More is not better! (Added April 02 2012)
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.
We should make HPV-related cancers history.
You should help propagate this info.
Nice article! Written very clearly and with insight into the questions people seem to have.
I do want to quibble with some information on the effectiveness of the two vaccines.
The vaccines only work for viral types that have not yet reached the patient. They don’t prevent reactivtion of a virus contracted before immunization, or reinfection with a viral type that has already caused infection.
Also I believe the Cervarix vaccine only contains oncogenic virus immunization. It is not expected to be effective at preventing warts.
And I agree with you about vaccinating boys. We rely on “herd immunity” in all our vaccines–you don’t expect 100% response, but you can effectively prevent viruses from running through a community if enough people are immunized.
Thanks for a nice patient-centered summary!
Thank you for your valuable input. I agree with you on Cervarix. As for patients with previous infection, FUTURE I and II studies showed that among between the ages of 16 and 26 years who were seropositive for HPV at baseline, Gardasil was still 100% effective against Cervical intraepithelial neoplasia CIN, Genital warts and vulvar intraepithelial neoplasia VIN despite prior infection.