Archive for cervical cancer
A recent announcement from the FDA came as no surprise to those of us following the changing guidelines for PAP smears. The FDA has approved the use of HPV high risk DNA detection as a sole screening tool for women!
Over the past decade or more, much research into the role of HPV has been performed. This has yielded the information that the majority of cervical cancers arise from the activity of the Human Papilloma Virus on the cervix. Prolonged inflammation from an active HPV infection causes changes on the cervix which can lead to cancer.
Most likely your recent PAP smears have included a test for high risk HPV DNA activity. This is a virus that is acquired through sexual activity, and most of us have been exposed to this virus at some time of our lives. The vast majority of us suppress the virus and it lies dormant, never causing a problem. A smaller percentage of us however, do not suppress the virus efficiently enough, and it becomes active from time to time.
Enough activity over enough time from the high risk strains of HPV can place us at risk for cervical cancer.
A PAP smear takes a superficial scraping of cells from the cervix and looks for abnormal looking cells. An HPV test indicates whether the virus is active at the time of the PAP smear.
A positive HPV test and a normal PAP smear would indicate active virus but no inflammation of the cervix. This sort of result indicates the necessity for regular yearly screening, looking for inflammation from prolonged HPV activity.
A negative HPV test and normal PAP smear indicates no activity and no abnormal cell. This normal result often means a PAP and HPV can be done every 3, or even 5 years. The process from HPV activation to a cancer is felt to be slow, often years. Therefor, most gynecologic professional societies feel this is a safe interval.
A positive HPV and an abnormal PAP smear indicates the virus is active and causing damage to the cervix. In most women, this abnormality will correct itself as the immune system activates to suppress the virus. In some cases however, the immune system cannot suppress the virus and it goes on to cause pre-cancer and the cancer cells of the cervix.
Detection of high risk DNA activity is the factor that often drives decision making on the screening interval for PAP smears. So it makes sense that a test using only this modality will become available and recommended.
This gives women and their providers an option for screening. It is important to realize however, that a recommendation from the professional gynecologic societies has not been evident yet.
The PAP smear still has a place in women’s screening. It can detect uterine problems that a HPV DNA test would not pick up. Whichever screening test you set your heart on for this year, remember that a pelvic exam is still recommended yearly. Not undergoing a PAP smear does not mean you do not need a yearly exam!
The identification of the HPV virus has been revolutionary for hopes of developing treatments for prevention of cervical cancer and genital warts. Little did we know years ago that genital warts and cervical cancer were linked.
The HPV virus includes many strains, and 4 strains in particular have been found to cause both of these conditions. A vaccine has been developed for protection against these strains of HPV, and it remains to be seen if we see a significant reduction in the occurrence of cervical cancer and genital warts.
One condition caused by HPV is on the rise however, and is poised to cause significant problems. That is throat cancer. You may have thought this was a cancer of tobacco users only, but sadly that is not correct.
While throat cancer from tobacco is on the decline, throat cancer from HPV is on the rise. In an era where it is felt that the majority of sexually active people are already infected with the HPV virus, the chance of being exposed to HPV through oral sex is assumed to occur. Research has shown that up to 7% of adults have oral HPV.
This is not to say that you definitely will get this virus, or that your immune system will not be strong enough to keep it suppressed. It is very important however, that you have an honest and open discussion with any potential new sex partner about STDs.
In addition to a strengthened immune system, not smoking and utilizing good oral hygiene are ways to decrease your susceptibility to the HPV virus. The only prevention is complete avoidance of sexual contact, however monogamous relationships with a healthy and non infected partner is the next best option.
It is important to understand that most HPV infections are cleared by the immune system, up to 90% are cleared within 2 years from the genital and anal area; researchers are determining how long for throat HPV. While very few oral HPV infections result in cancer, the majority of throat and tonsil cancers are from HPV.
What can you do if you think you may be at risk or an oral HPV infection? Check yourself regularly for any changes within your mouth, tonsils, and tongue. See your provider or see a specialist for changes, painful chewing or swallowing, or evidence of bleeding.
There is no screening test for oral HPV at this time, however research is under way to determine more about detection and prevention. For more information on a study under way, go to the following websites:
How many of us dread that yearly obligation of the screening PAP smear?
Most of us get accustomed to this exam over the years, but still may unconsciously avoid the exam by increasing the interval year to year. Good news! According to the USPSTF, we may very well not need to get this test yearly!
The USPSTF, United States Preventative Services Task Force, has issued new guidelines for women and PAP smear screening. When the PAP test is coupled with an HPV test, the sensitivity for screening for cervical cancer is increased.
The HPV virus is a sexually transmitted virus of which certain strains can cause cervical cancer. It is felt by experts that most sexually active women have already been exposed to this virus. The importance comes in identifying those women who have persistent activity of one of the high risk strains, as this can lead to cellular changes and sometimes to cancer. The majority of women will suppress the virus through their immune system, and not develop permanent or significant cellular changes on the cervix.
Cervical cancer usually develops relatively slowly, and experts have been attempting to identify a safe interval for screening. Long enough to give us a break from this yearly screening, but not so long as to miss an early sign of an abnormality. It is also been shown that many abnormalities resolve on their own before any intervention is required; usually due to a healthy immune system.
These new screening guidelines include:
- Women aged 21-65 can undergo PAP smears every 3 years provided they have normal results. For women over 30, this interval can be extended to 5 years if coupled with the HPV test.
- Women under 21 do not need to get a PAP smear. This is due to healthy immune systems in young women and probability that any abnormality will resolve in its own.
- Women over 65 can stop getting PAP smears if they have had 3 normal PAP smears in recent years, and are not at high risk for cervical cancer. These risks would include being immuno-compromised, having a history of cervical cancer or a high grade precancerous lesion.
- Women who have had a hysterectomy do not need to undergo PAP tests unless their hysterectomy was do to cervical or a high grade precancerous lesion.
The above is the guidelines of the USPSTF, and they are NOT in agreement with the American Academy of Obstetricians and Gynecologists (ACOG); The American Medical Association(AMA); American Cancer Society (ACS); American Academy of Family Physicians (AAFP) and the American College of Preventative Medicine (ACPM) as well as other organizations.
- The above organizations all agree with beginning PAP smears at age 18 or within 6 months of onset of sexual activity
- Thin Prep PAP smears every 1-2 yrs until 30, at which point every 3 years with an HPV test unless an abnormal reading occurs at which point resume yearly screening.
- Option for discontinuing screening age 65-70 if no risk factors of cervical cancer exists and no abnormal PAP readings in prior 10 yrs.
This represents quite a difference for the USPSTF recommendations and you may be wondering what you should do.
It is important to discuss this with your medical provider as they have your medical history and results of past PAP tests. They can discuss your risk factors and help you come to a decision regarding what interval is safe for you. Regardless of how often you and your provider decide you should be screened, it is still essential that you get a yearly general exam. This should include a breast exam, skin exam and review of risk factors for other medical problems based on your history, family history, and your lifestyle and habits.
Let me know your thoughts and comments about these new guidelines. It is curious that the guidelines of the USPSTF should differ so from the many medical societies. I would love to know you thoughts on this subject!
Many of you may feel that you no longer need PAP smears if you have gone through menopause, or you are over 50 years of age. It is important to review your PAP history with your provider because you still may be at risk for an HPV related problem.
This may come as a surprise for many, especially if you have been in a monogamous relationship or been abstinent from sexual activity. You may still be at risk as HPV can resurface after years or even decades of dormancy, due to menopause and the effect on the immune system.
Menopause is considered a time of immuno-suppression because of the fluctuating hormone levels. Many illnesses can be more active during this period because of this immuno-suppression. HPV is acquired from sexual activity, either a new partner or from a prior partner. It may have lain dormant for many years, however it can cause cervical abnormalities if it become active again. If you stop having PAP smears, these abnormalities may not be discovered until a cancer has formed.
The current recommendations are for women over 30 to have the HPV test done every 3 years, to ensure there is no persistent activity of the HPV virus on the cervix resulting in dysplasia or cancer. You may not need a yearly PAP smear, but you should have a yearly exam including pelvic and breast exam. These recommendations include menopausal and post menopausal women, often into the mid to late 70′s.
Our life spans are getting longer, and the quality of our older years are improving. Continuing to screen for life altering and ending illnesses can help us stay healthy as we age. I welcome your comments and thoughts regarding this topic!
I hear this all the time in the clinic, patients will ask me if they still need to get PAP smears now that they have gone through
Yes! It is extremely important to continue to monitor for cervical cancer, although maybe not as often as younger years.
What is one of the risk factors for any sort of cancer?
Age. As we get older, the negative forces on our bodies will wear our body systems down and eventually the immune system may not be able to suppress the causes of cancer.
In relation to the cervix, the most important cause is the HPV virus.
The HPV virus is felt to be the main cause of cervical cancer as certain strains cause inflammation and cellular damage, which can result in cellular atypia (a type of inflammation). Cellular atypia can then progress to cancer. Not all women who have the HPV virus get cervical cancer, and not all women are aware they have ever been exposed to HPV. The HPV virus is transmitted through sexual intercourse and can remain dormant for many years, even decades. So unless a couple has only had sexual relations with each other, exposure can happen unknowingly from past partners.
So why does this matter during menopause? Menopause is considered a period of time during which the immune system is compromised. This can allow a dormant HPV virus to become active and cause inflammation and irritation. And this is the guiding reason for continuing PAP smears after menopause.
The American College of Gynecologists (ACOG) has put forth guidelines for frequency of PAP smears. Women over 30 who have had 3 normal PAP smears in a row can decrease frequency of screening to every 3 years. Many specialists feel that one of these normal readings should include a negative HPV test. And, if your sexual partner changes, you may need to resume yearly PAP smears for a while. Certain risk factors would dictate continuing with yearly PAP’s. These would include HIV infection, other causes of immuno-compromise (anything that decreases immunity like chemotherapy), exposure to DES in utero( DES is a hormone given to pregnant women in the past), prior treatment for CIN2 or CIN3. CIN stands for cervical intraepethelial neoplasia – (inflammatory changes in the cells of the cervix as seen on pap smear – some are pre-cancerous and some are early cancer).
When Can I Stop PAP Smears?
As recommended by ACOG, women can stop screening at age 65-70 if they have had 3 or more normal PAP and no abnormal test in past 10 years. HPV vaccinated women are encouraged to follow these same guidelines.
Cervical cancer rates have fallen by 50% in the last 30 years thanks to vigilant screening . Don’t treat this easy screening test casually, or think it is not important - continue with your screening!
What questions do you have? I can’t tell you what to do but I can help you understand this information better so you can communicate with your doctor more clearly. Leave me a comment. Let me know what you think. And do sign up for the content I have prepared as part of your free membership.
Bruce and I discuss the new cervical cancer screening guidelines. In this discussion we will explain the organization – USPSTF – that issues guidelines and discuss the mission it receives from the Department of Health and Human Services. We review the new guidelines, interject our own non-academic opinions, and give you plenty of information to discuss with your health care provider.
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