Talking Hope: Cervical cancer and HPV: What’s the connection?

Darrin Godin:

Hello and welcome to another episode of Talking Hope, where we have breakthrough conversations about preventing, treating, and curing cancer. I'm your host, Darrin Godin. You may not know this, but January is Cervical Cancer Awareness Month and today we're unraveling the truth about HPV and cervical cancer with two leading experts. We're joined today by Dr. Christopher Zimmerman, a leader at the County’s Department of Health. He is the strategic mind in communicable disease control. We're also joined by Dr. Joshua G. Cohen, our leading expert in gynecologic cancer care here at City of Hope Orange County. Thank you both for joining us tonight.

Dr. Christopher Zimmerman:

Pleasure.

Dr. Joshua G. Cohen:

Thank you, Darrin.

Darrin Godin:

We're going to dive into dissecting myths, uncovering facts, and shining the light on the strides being made in prevention, early detection and treatment of cervical cancer. So let's get started.

Dr. Zimmerman, can you break down for us what HPV is and the kind of health issues it can bring about?

Dr. Christopher Zimmerman:

Sure. So HPV stands for human papillomavirus. It's a virus and it only affects humans. It's spread from person to person. Papilloma comes from, the virus was first found in warts. HPV is spread by direct contact from either skin to skin or skin to what's called mucus membrane. So the lining inside people's mouth, their throat, the lining of people's rectum, and certainly in women, that includes the lining of their vagina and cervix.

There are over 200 types of HPV. The overwhelming majority of them cause no symptoms and your body clears them usually within a few months time. Some types of HPV cause things like, as I mentioned, warts, common hand warps, but also genital warts. In fact, HPV is the most common sexually transmitted disease in the US. But some types of HPV can cause more serious infections and most commonly, that's cervical cancer, although it's been associated with cancers of the mouth and throat as well as rectal cancers, penile cancers in men. That I think covers the range of what HPV can cause.

Darrin Godin:

Thank you. And in our Orange County community as compared to the entire US, how often are we seeing HPV infections?

Dr. Christopher Zimmerman:

We don't look for HPV. We don't track it because, as I said, most infections don't cause any symptoms. People don't know when they get HPV nor when it goes away. So we don't have a system for really tracking that. We know that HPV is very common. I talked about it's the most common sexually transmitted disease. People frequently acquire it at the onset of sexual activity. So in their late teens, early 20s.

I was going to make another point. We don't have any data on disease here, but we know that nationally, HPV is associated with on the order of 30,000 cancers a year, most of those are cervical cancer. Although, as I said, there are other cancers of the mouth and throat as well as rectum that have been associated with HPV.

Darrin Godin:

Okay, thank you Dr. Zimmerman. And Dr. Cohen, along those same lines then, so how widespread is cervical cancer, both here in our county and then also across the country?

Dr. Joshua G. Cohen:

Thank you and thank you Darrin and Dr. Zimmerman. This is an important month for us being Cervical Cancer Awareness Month. As a gynecologic oncologist, this is our opportunity to bring attention to this disease and we're talking about something very important, which is HPV vaccination.

Cervical cancer is still here in the US. 13,000 women will be diagnosed with cervical cancer this year sadly, and 4,000 women will die from cervical cancer this year in the US. We have patients diagnosed in Orange County every month with cervical cancer. If you look at the exact numbers, there's about 60 women a year who are diagnosed with cervical cancer in Orange County specifically, but that does not include all HPV driven cancers. As you heard Dr. Zimmerman say, HPV causes the majority of cervical cancers upwards of 95%, but it also causes the majority of anal cancer, penile cancer, oropharyngeal cancers, vaginal cancers.

So if you add those cancers up, we're talking about hundreds if not thousands of people in Orange County are impacted on some level by HPV related cancers every year.

Darrin Godin:

Wow. So if you get vaccinated for HPV, are you completely protected from say, cervical cancer or some of the other cancers you mentioned, or how does it actually impact your risk?

Dr. Joshua G. Cohen:

The current available vaccine here in the US is a 9-valent vaccine, which means there are nine strains of HPV that are protected by with this vaccine. The nine strains are the most common. As you heard, there are hundreds, if not thousands of strains of HPV, many of which do not cause cancer commonly. Here in the US, the most common strains that do cause cancer are HPV 16 and 18. The most common causes of genital warts are 6 and 11. The current HPV vaccine covers against those strains. So if someone gets vaccinated, they really are covered against 95% risk of cervical cancer. There are some extremely rare forms of cervical cancer that are not protected or not caused by HPV, and as a result, the HPV vaccine does not prevent, but this is a preventable cancer.

When you have a preventable cancer with a safe vaccination, as a gynecologic oncologist, it breaks my heart when I see patients who are not getting vaccinated, because we can prevent the vast majority of those 13,000 women from being impacted by cervical cancer. We can prevent the majority of anal and oropharyngeal cancers and this is our opportunity to discuss that and get the word out. But really the HP vaccine offers significant protection against cervical cancer.

Darrin Godin:

Great, thank you. Let's talk about some of the myths that we hear about HPV and vaccination as well. Dr. Zimmerman, let's start with you. Fact or myth, only women can get HPV?

Dr. Christopher Zimmerman:

We talked about, men can get HPV as well as women. In terms of the worst outcomes, cervical cancer is the most common, but rectal cancer, penile cancer, which although rare, is almost all associated with HPV. So yes, it can affect both men and women.

Darrin Godin:

All right. Fact or myth, the HPV vaccine is unsafe?

Dr. Christopher Zimmerman:

So let me talk a little bit more detail about the HPV vaccine and then I'll come back to the safety issue. We've had a vaccine against HPV since 2006 was when the first vaccine was approved and recommended. Initially it only covered two types of the vaccine, the 16 and 18 that are the most common ones associated with cervical cancer.

The vaccine is recommended routinely for adolescents at 11 to 12 years of age. In that age group it's just two doses, one dose, and then 6 to 12 months later a second dose. But it can be given as young as nine years of age. In fact there's evidence that in that younger cohort, you get a better response from it. The vaccine is approved for up to 45 years of age, not beyond that. But the recommendation is, again, 11 to 12 year olds, up to age 26 if they haven't had it before, can receive the vaccine, both men and women, boys and girls. From 27 to 45, it's a discussion with your provider whether you would benefit, because most HPV as we talked about is acquired when people have onset of sexual activity. And depending on your circumstances, you may or may not benefit from HPV vaccination after 27.

But the vaccine has been around for nearly 20 years now and is extremely safe. In fact, I have a 10-year-old daughter and last year she got the vaccine. The most common side effects are sore arm, some redness, rarely some fever. We do see, particularly in the adolescents and the younger age groups, that fainting can happen. In fact, that happened to my daughter when she got it. She fainted, but we were prepared for that and there was no harm done. So it is a very safe vaccine and in fact we have data showing that we are already seeing lower rates of cervical cancer, particularly in young women. So I think it's a highly effective vaccine.

Darrin Godin:

Excellent, thank you. We're just going to continue with the facts or myths, even though you've hit on some of these. Fact or myth, you must have sexual intercourse to get HPV?

Dr. Christopher Zimmerman:

Certainly that is one way it's transmitted, but we talked about it, it's any skin to skin or mucus membrane to mucus membrane transmission.

Darrin Godin:

All right. Fact or myth, women with HPV will have warning signs or symptoms?

Dr. Christopher Zimmerman:

As was touched upon, most infections don't cause any symptoms at all and they may persist for months and then be cleared on their own. But for some of these types, particularly the ones associated with cancer, the virus can persist and that may be part of the process where it leads to damages in the cell and leading to cancer over time.

Darrin Godin:

Thank you. Dr. Cohen, fact or myth, a regular PAP test is enough to protect women against cervical cancer?

Dr. Joshua G. Cohen:

It's really the most important thing is HPV vaccination. HPV vaccinations by far and away the most important thing to protect women from cervical cancer. I think that the PAP smear is extremely important and it's a screening test. It's not meant to prevent cancer necessarily. It's meant to find pre-cancers. And if we find pre-cancers, what can prevent them is treating them. And that's why it's important to see your OBGYN or your primary care doctor and discuss cervical cancer screening with HPV testing and pap smears. So that's an important way to evaluate whether you may have a pre-cancer. There are different treatment modalities, which you can talk about with your OBGYN or gynecologic oncologist. But again, the most important thing is the HPV vaccine.

I just want to touch upon briefly what Dr. Zimmerman said. This vaccine has been around for 20 years now. There have been 135 million doses given since it was approved by the FDA worldwide, and really we found it to be extremely safe. My kids are nine years old, they're going to get vaccinated in the next year or two. So I think you're hearing from medical providers that we all feel very comfortable and believe in the safety data of this vaccine.

Darrin Godin:

Great, thank you. If you receive the HPV vaccination, can you skip things like a PAP test or regular PAP test?

Dr. Joshua G. Cohen:

No, that's a myth to skip. And we are determining, and this is changing a little bit, the frequency of PAP smears. There is now data coming out about doing HPV testing alone to see if someone tests positive for high risk HPV and whether that's more effective or more sensitive than doing a PAP smear itself. So the frequency of PAP smear testing is changing a little bit based on people's age and their risk factors such as immunosuppression or other medical comorbidities, meaning other medical conditions they're dealing with. But it's something that you would still want to continue with routine PAP smear screening with your OBGYN or primary care doctor, whether you've had the HPV vaccine or not.

There are still, again, a small group of rare forms of cervical cancer that are not prevented by HPV vaccination and that's another reason to continue routine screening with PAP smears.

Darrin Godin:

Great. Thank you, Dr. Cohen. Have you come across HPV vaccine hesitancy in Orange County, Dr. Zimmerman, and if so, what do you think could help some people with their reluctance to getting that particular vaccine?

Dr. Christopher Zimmerman:

Well, I think vaccine hesitancy is certainly a significant problem, not just for HPV but for a wide variety of vaccines right now. We live in a time where there is a lot of mistrust of authoritative information. There is a lot of misinformation that's available on the internet and through social media. So I think it's a challenging time for vaccination. In fact, there was an article I was just reading this morning, raising concerns that we're at the tipping point because we're seeing even routine child vaccines are becoming... People are raising questions and avoiding them without good reason.

I would say to people that it's important, people should have a healthcare provider that they trust and if they have questions, they should talk to their provider. That it's perfectly fine to ask questions and say, what about this or what about that? You should have your questions answered, but it's also important to have someone that you trust for medical information. If you had cancer, you would talk to your oncologist. If it's for something like routine vaccination, if you're going to your primary care doctor or if you get your vaccines at your pharmacy, talk to your pharmacist.

Darrin Godin:

Thank you. Let's talk about awareness about cervical cancer and screening for that, Dr. Cohen. Is this something that you think we need to increase awareness about in Orange County?

Dr. Joshua G. Cohen:

We do. I want to start by discussing some data about vaccination rates, and I know Dr. Zimmerman and the Orange County Department of Public Health are a huge part of that. The rate of vaccination for 12 to 13 year olds in California is approximately 62%. The rate I think in Orange County for two doses is 31% and for one dose, meaning if they've just gotten one dose of the vaccine, it's about 50%. The national goal is upwards of 80% and that's what we're working towards.

The reason I bring that up is that we're not doing well enough in Orange County to meet our goal. We've just mentioned that we have a vaccine that can prevent cancer, and we're at a rate of barely 50% for the two doses, and one dose is 30% at the recommended age, which is not enough. It's not good enough. So we want to help get the word out. I think cervical cancer is a horrific cancer. We've made strides in it, but when you have a preventable cancer, it's always heartbreaking when someone develops this cancer. The patients that do have cancer, we do have better treatments for, which we can talk about a little bit later, but I want us to get the word out about cervical cancer.

I think it's something where, to be honest, things that are communicated sometimes with this thought process of sexually transmitted diseases, it's taboo to talk about, and as a result, women are fearful to mention this or families are. We need to review this. We need to discuss this. We need to have an open dialogue with our patients and advocate for them. And so we need to get the word out, including money for research as well, which City of Hope is a part of, but this is our month to do that, so thank you.

Darrin Godin:

Great. Thank you as well. If someone finds out they have HPV, and you've already been talking about this, but what's the first thing they should do? I guess they wouldn't even know they have HPV, do they?

Dr. Joshua G. Cohen:

Yeah, I think a couple of things there. One, 80% of the population is exposed to HPV over their lifetime. It's a very common thing. There are so many different strains. There are currently 42 million people in the US with HPV. There will be 13 million new infections this year approximately. So it's very common. When you have a common virus like this, the vast majority of patients, it's there and our immune systems help clear it. We really don't know why some patients clear up HPV and some patients don't. It's likely partly related to the immune system and how the immune system interacts with the virus or the different strains.

I think that from an infection standpoint, if someone tests positive based on a PAP smear, which is probably the most likely place someone will find out they're positive for HPV, just know that it's common and it's important to discuss it with your OBGYN or your primary care doctor whether there's further testing that needs to be done. I view this as a chronic condition just like high blood pressure or diabetes in that if you go to your doctor and you're following up with them for your high blood pressure, they're going to keep you safe. And the same thing, if you have HPV and hopefully it goes away, but if it doesn't, if you do your regular checkups with your OBGYN or your primary care doctor, the vast majority of the time they're going to keep you safe. But you need to do that. You need to do that follow up and keep an eye on things.

I think there are nuances depending on the strain, and it will come up with patients, younger patients in particular, about HPV and the risk to spread to their partners. I will say that that's something we can delve into further, but that's why it's important for men and women to get vaccinated, that we're in this together and that's why my son and my daughter, everybody, they're going to get vaccinated both because in society everybody should be protected.

Darrin Godin:

And if it's cervical cancer that has been diagnosed, what are a couple of key next steps that person should take?

Dr. Joshua G. Cohen:

So if someone has been diagnosed with cervical cancer or a high grade pre-cancer of the cervix, I think you definitely discuss with your primary care and OBGYN doctor, what the next step is. Usually with cervical cancer, it's going to be a referral to someone like me, a gynecologic oncologist at a comprehensive cancer center. We're fortunate that City of Hope is here in Orange County. Wherever you seek your care, ask to see a specialist, a gynecologic oncologist who's board certified so you can get some really hopefully strong recommendations about how to manage that cervical cancer. Again, we've made great strides in the treating of this disease process, and I'm confident that if you see a gynecologic oncologist, they will be able to give you the right direction to help keep you safe.

Darrin Godin:

And this is really your area, Dr. Cohen. You are an expert in this and this is why we're so glad you're in Orange County, but talk a little bit more about that. What are the latest advances in research and treatment that we are currently making and that are making a difference in outcomes, and what is looking promising on the horizon?

Dr. Joshua G. Cohen:

Yeah, I think there are two major aspects to the treatment of cervical cancer. One is the role of surgery, and then the other is the role of treatment with radiation and/or chemotherapy. When I say chemotherapy, I'm including other treatments like immunotherapy and targeted therapies, which are the great new horizon for cancer treatment.

With regard to surgery, we've gotten really, really good at defining who needs more invasive surgery or where we can do something called fertility preserving surgery. Where we're able to leave either some of the cervix behind, which is the bottom part of the uterus or the uterus and just remove the cervix. We're also doing a sentinel lymph node dissection now where we inject a special dye into the cervix for certain tumors and only remove the first lymph nodes next to the cervix to reduce the risk of something called lymphedema, which is swelling in the legs.

I think the other side of that, which is the treatment side that involves chemotherapy immunotherapy, we are now in the age of immunotherapy where for certain cervical cancers, not all of them, we can unlock the immune system with certain drugs and use your own immune system to attack cancer cells. This is an exciting time in the treatment of all cancers, but particularly cervical cancer because HPV, as we've mentioned, is partly driven by its interactions with the immune system. It's great that we can now use the immune system to attack these cancer cells.

We also have new targeted treatments called antibody drug conjugates. Antibody drug conjugates are basically smart bombs where we actually attach a high level of chemotherapy to a specific receptor found on cancer cells specifically, send that drug into the body, and just like a smart bomb, it attacks those cancer cells and hopefully avoids the toxicity of attacking normal healthy cells that don't express that receptor.

City of Hope is a leading institution in CAR T-cell therapy, CAR T-cell is another aspect of immune treatments where we basically harness the power of your T-cells to attack cancer. And while we're not quite yet ready to do this in the general population, City of Hope is really on the forefront of CAR T-cell therapy, including the treatment of cervical cancer in certain clinical trials.

So it's an exciting time. I think really the advances in fertility preserving surgery, in the use of the immune system are some of the latest and greatest advances for the treatment of cervical cancer.

Darrin Godin:

Wow. Thank you so much for that. To wrap this up, what are a couple of the most important takeaways for our audience today? Let's start with you, Dr. Zimmerman, and let's end with you Dr. Cohen.

Dr. Christopher Zimmerman:

As a public health person, as a primary care provider in internal medicine and pediatrics, prevention to me is always the best strategy and not having to deal with the challenges of fighting the disease. So parents should think about protecting their children. This is by vaccinating them in their adolescence and early adolescents. You can protect your children for their lifetime. The vaccine provides long-term effectiveness. So I think that's a thing. Get your children vaccinated. If you haven't been vaccinated, talk to your provider about getting vaccinated against HPV.

Darrin Godin:

Thank you. Dr. Cohen?

Dr. Joshua G. Cohen:

Yes, thank you. Two things. First, agree vaccination, vaccination, vaccination. This is a safe vaccine. As a parent, you can offer something to your children that is potentially lifesaving by preventing cervical cancer, anal cancer or pharyngeal cancers, vaginal cancers, vulvar cancers, general warts, by a simple, safe vaccine that's been tested and given over 135 million times. And so I think that's the most important thing, the take away is prevention. I agree completely with Dr. Zimmerman's statement.

The second thing is that if you do have cervical cancer or you think you might, which includes symptoms, abnormal vaginal discharge, abnormal vaginal bleeding, bleeding with sexual activity, new pelvic pain or pressure, new blood in the urine or stool, advocate for yourself. Seek out a primary care doctor or an OBGYN, get a PAP smear, ask to see a specialist. Ask to see a gynecologic oncologist if you've been diagnosed with cervical cancer, and I think you'll find that you'll be on the right path. But the second take home is advocate for yourself, seek out care if you're having symptoms.

Darrin Godin:

Thank you. Well, we hope you're all walking away with a valuable and helpful understanding about the connection between HPV vaccination and cervical cancer and others. A big thank you to you, Dr. Zimmerman, and to you, Dr. Cohen, for your insights on this very important subject. Thanks for shedding light today.

My takeaway is that there is so much hope when you lean into the power of prevention and early detection and what a major impact it can have when we do that. So remember, awareness is the first step to prevention.

I'm Darrin Godin. You've been listening to the Talking Hope podcast. Don't forget to subscribe and share this episode with your friends and family. Stay healthy, stay informed, and let's continue to fight cancer together. Until next time. Thanks for listening.