January 17, 2014 | by Denise Heady
Cervical cancer, once one of the leading cancer killers in women, is now one of the nation's most treatable cancers — thanks in large part to early detection, preventive measures and increased knowledge about the human papillomavirus, which can lead to the disease.
In fact, cervical cancer is almost 100 percent preventable. Regular gynecologic care and pap smears can detect precancerous changes before they develop into cancer, and the precancerous changes themselves can often be prevented as well.
But much progress is needed in the treatment of patients with advanced disease, a fact especially relevant during January, which Congress has designated as Cervical Health Awareness Month. Annually, almost 12,000 women in the U.S. are diagnosed with cervical cancer, and almost 4,000 die from it, according to the Centers for Disease Control and Prevention.
Ernest Han, M.D., Ph.D., assistant professor and surgeon in the Division of Gynecologic Oncology at City of Hope, discusses some of the confusion and concerns about cervical cancer.
What is the most common question you get about cervical cancer?
One of the most common questions from patients is: “What’s the cause of cervix cancer?”
We know that the primary cause is the human papillomavirus (HPV), and we say that it causes almost 100 percent of cases. We don’t say that it causes 100 percent, because there are probably some cervix cancers that are very rare that are caused by other unknown factors or maybe other viruses or other things that are not as well understood. But those are rare, and predominantly everyone here has a cervical cancer that is HPV-related. That is really where the focus for our cancer prevention lies.
How many HPV strains are cancerous?
There are certain common strains that are cancer causing, there’s a whole other group that causes warts and then there are others that we don’t even know what they do. Every time we review data or recent research, the number of HPV strains keeps expanding. It started off with just a couple of strains, then it went to maybe 10 or 11, then to 40 to 50 and now to more than 100.
The cancer-causing strains, most specifically 16 and 18, are the strains that are the most often studied because of their connection to the disease. These two HPV types cause over 70 percent of cervix cancers.
If a patient is told she has precancerous cells that are caused by HPV, what does this mean?
I see patients who come in because they are given this label of precancer, and sometimes are mistakenly told they have cancer when they actually have a precancerous condition. They get sent over to us – and some are in tears – and I counsel them, letting them know that it is not cancer, but a precancerous condition, that they have.
Cervical cancer is one of the cancers where there seems to be a step-wise progression. Normal cells in the cervix that change over time – and when I say time, it can mean years and years – and can lead to a progression of cancer. Not all of the patients who have been infected or been exposed to HPV get cancer. But there is a step-wise progression from the precancer to the cancer condition. The interesting thing with cervix cancer is that the process takes a long time, and screening really helps because there’s a period of time where you can detect these things early. In some other cancers, there’s a more rapid progression, and there’s not a clear-cut precancerous step that they can be screened for.
I think this is kind of a unique opportunity, and I think that’s why cervix cancer screening works really well. The important aspect is that screening is essential, and precancerous conditions are very treatable.
How often should women be screened for cervical cancer?
Screening guidelines have changed over the past few years and continue to get modified. Just in the past year now, we have acquired all this knowledge on HPV, and now there’s more HPV testing being done. The initial testing was used to help with some of the very mild cancerous changes that were seen and how to triage or how to deal with that early change.
Pap smears are really the main testing done to screen for cervix cancer. There is also HPV testing, which has further evolved our screening. We are now utilizing it to further improve screening along with the common pap smear. We used the HPV testing in the past in certain situations with mild precancerous changes or specifically atypical squamous cells of undetermined significance to help determine if more testing is needed. For women over 30, there’s now a recommendation where you can get a pap smear – or a pap smear and this HPV co-testing. That would potentially allow you to screen less.
We used to perform pap smears annually, and now we’ve gone to every three years or every five years depending on the kind of level of testing. A lot of the pap smear guidelines have gone to less screening, but a lot of physicians — including myself — always worry that patients might think this equates to telling patients they don’t have to come in and see their doctor for a routine check up.
What are some of the symptoms for cervical cancer?
Patients who show symptoms often go in to get checked because they are bleeding, spotting or have some abnormal discharge, sometimes even pain or some bladder symptoms. A lot of times bleeding or discharge will be the first sign that something is not right and hopefully patients will go to their doctors and not ignore it.
How treatable is cervical cancer?
It’s very, very treatable, especially with all these important screening aspects. It’s probably one of the more curable cancers when found early. That’s why it becomes so frustrating when we see patients who haven’t gotten screened and who have an advanced cancer. At that point, the chances for a cure decline, as opposed to someone who has a really early cancer. For them, you can really impact their survival and really give them a potentially a curable procedure. It can be very treatable.
Are patients who are treated for cervical cancer still able to have children after treatment?
There’s a possibility for a patient to have children after being treated, but it depends on how early the cancer is detected. The earlier the cancer is found, the better the chance you may have to preserve your fertility.
Fertility-sparing issues are a big concern; especially for the patients we see that are still in their child-bearing years. We have gotten to a point where there are more options for young women potentially to still have children of their own while being treated. We have recently had a push to perform surgeries that do not require removal of the uterus, but just the cervix along with the cancer. We can still preserve the uterus and allow women to still have children.
What should a patient expect when she finds out she has cervical cancer?
It depends on the stage of cancer. The advanced cancers tend to be nonsurgical, so patients tend to go to the path of getting radiation and chemotherapy for treatments. The women who are very early in their cervical cancer course have more opportunities for surgical treatment. Both types of treatment regimens have an impact on their quality of life, and they all have different side effects. Early detection, early treatment is always the key.
What preventable measures can women take to help lower their risk of getting cervical cancer?
The HPV vaccine.
I’m still a little bit surprised that this hasn’t been widely accepted. This should be just like getting your tetanus shot. It should be part of that sequence. I’m just appalled that so many patients have not been vaccinated.
I don’t know if there’s still a stigma to this. We should already be talking about sex to our kids probably early on to let them know the potentials dangers and not let them just fall into it or become exposed without you being able to have that discussion with them. It’s obviously a very uncomfortable topic but it’s also important that you talk about it.
When you have something that can prevent these precancer changes, why would you not do that?