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Cervical Cancer and HPV
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Resource Description: 
National Cancer Institute, the primary National Institutes of Health organization for research on cervical cancer and HPV virus, offers a complete range of detailed information.
In its Health Topics section, MedlinePlus offers and exhaustive collection of links to sites containing background information and news about cervical cancer.
Find accurate and up-to-date information about human papillomavirus (HPV) and cervical cancer at American Social Health Association's National HPV and Cervical Cancer Prevention Resource Center site.
From educational materials to stories from survivors of cervical cancer, an abundance of information and resources are available from the National Cervical Cancer Coalition (NCCC), a grassroots nonprofit organization dedicated to serving women with, or at risk for, cervical cancer.
Get the facts about the development of cancer vaccines from the National Cancer Institute.
In a November 21, 2002 broadcast, the NewsHour on PBS aired a segment that explored a major clinical trial of a vaccine for HPV. Video and a transcript are available on PBS.org.
Second Opinion panelist Christine Baze is the Executive Director of Popsmear.org
Episode number: 
103

While deaths from cervical cancer have declined dramatically over the past several decades, it continues to be one of the most critical health threats facing women today.  The American Cancer Society estimates that, in 2004, 10,520 women in the United States will get this disease, and 3,900 will die from it. In this episode of Second Opinion, you will learn about the causes of cervical cancer, how to reduce your risk of getting it and, if you are diagnosed, how to survive it.

Thanks in large part to widespread screening with a test called the Pap smear , cervical cancer deaths among U.S. women have dropped by 74% since the mid 1950s. Although this form of cancer remains a serious health problem, it is nearly 100% preventable and, in most cases, curable. What is more, cancer vaccines may one day have as dramatic an impact as the Pap smear in reducing deaths from this disease.

Cervical cancer , most prevalent in women between the ages of 35 and 55, starts in the lining of the cervix  when normal cells change to cancerous cells. Like all cancer cells, the ones in the cervix divide rapidly and produce excess tissue, which form tumors. The process usually takes years, but it also can happen much more quickly. This, combined with the fact that there usually are no obvious physical symptoms to warn you that your cells are changing, underscores the need to have regular pelvic exams and Pap tests, which can help your doctor detect and treat these precancerous cells before they turn into cancer.

Among women who receive regular screening, the first sign of the disease is usually an abnormal Pap test result. Symptoms of more advanced disease may include:

  • Abnormal vaginal bleeding (e.g., spotting after sexual intercourse, bleeding between menstrual periods, increased menstrual bleeding)
  • Abnormal vaginal discharge
  • Low back pain
  • Painful sexual intercourse
  • Painful urination

The Pap smear, a cervical cancer screening test pioneered in the 1940s, has saved the lives of countless women over the years through early detection of precancerous and cancerous cells on the cervix. It is still the best method doctors have for cervical cancer screening. In recent years, laboratory technology, and the way in which healthcare providers interpret and report results have been updated to incorporate the latest knowledge about the biology of Pap abnormalities and to improve test accuracy.  Still, the Pap test is only a screening tool. Women with abnormal test results require additional tests to determine whether or not a precancerous change or cancer are present.

Another fundamental element in today's fight against cervical cancer is a prevention strategy that encourages women to avoid risk factors known to cause precancers. Most of these risks involve exposure to certain strains of human papillomavirus (HPV) . Considered the leading cause of cervical cancer, HPV is a wart virus that is transmitted from one person to another during sexual contact.

Other risk factors for cervical cancer are:

  • Smoking: Women who smoke are about twice as likely as nonsmokers to get cervical cancer.
  • Human immunodeficiency virus (HIV) infection: HIV bypasses the body's immune system and puts women at greater risk for HPV infections and cervical cancer.
  • Chlamydia infection: Women with past or current chlamydia infection are at greater risk for cervical cancer than are women with no history of the disease.
  • Diet: Women with diets low in fruits and vegetables and women who are overweight may be at increased risk for cervical cancer.
  • Oral contraceptive use: Long-term use of oral contraceptives increases the risk of cancer of the cervix.
  • Multiple pregnancies: Women who have had many full-term pregnancies are at increased risk.
  • Low socioeconomic status: Women with low incomes who do not have ready access to health care services, including Pap tests, are at greater risk.
  • Exposure to Diethylstilbestrol (DES): DES is a hormonal drug that was prescribed between 1940 and 1971 for some women thought to be at increased risk for miscarriages. If your mother took DES, there is a slightly higher risk that you could develop cervical cancer
  • Family history of cervical cancer: Women whose mother or sisters have had cervical cancer are more likely to develop the disease themselves.

Women who get cervical cancer have a number of treatment options, depending on the stage of the disease and other factors. The main treatments, which may be used alone or in combination with each other, are surgery (several different types are used), radiation therapy, and chemotherapy. According to the American Cancer Society, five-year survival rates for cervical cancer patients are close to 100% for cancer caught in its earliest stages; 92% when the cancer is slightly more advanced but has not spread beyond the cervix; and 71% for all stages combined.

 

Quick Facts

In 2004, 10,520 women in the U.S. are expected to get cervical cancer, and about 3,900 are expected to die from it. Worldwide, 450,000 cases are diagnosed each year, 200,000 women die from it.

Invasive cervical cancer occurs most often in women over the age of 40.

Precancerous changes of the cervix usually do not cause pain. In fact, they generally do not cause any symptoms and are not detected unless a woman has a pelvic exam and a Pap test. 

Catching cervical cancer early is critical. More than half the deaths from this type of cancer occur in women who were not adequately screened.

Between 1955 and 1992, the number of deaths from cervical cancer declined by 74%, largely due to the advent of the Pap smear.

The five-year survival rate for early invasive cancer of the cervix is 91%. The overall 5-year survival rate for all stages combined is about 70%. For pre-invasive cervical cancer, the 5-year survival rate is nearly 100%.

Ask Your Doctor

This list of questions is a good starting point for discussion with your doctor; however, it is not a comprehensive list.

  1. What can I do to limit my risk of getting cervical cancer?
  2. Is the anything special I should do before getting a Pap smear to make sure the test is as accurate as possible?
  3. What other tests are used to screen for and diagnose precancerous cervical conditions?
  4. I've been diagnosed with HPV. Will I automatically get cervical cancer?
  5. What are the treatment options for HPV infection?
  6. Does having HPV mean that I need more frequent pelvic exams and Pap smears?
  7. I've been diagnosed with cervical cancer. What is the stage of my cancer?
  8. Can you recommend a specialist who can provide a Second Opinion?
  9. What are all my treatment options, and what are the risks and side effects of those treatments?
  10. What are the implications of not having treatment?
  11. Are there any clinical trials that might be appropriate for me?
  12. Are there any alternative or complementary therapies that can help?
  13. How will I feel after treatment?
  14. Will treatment keep me from my normal activities?
  15. How will it affect my sexual activity?
  16. Will I be able to have children after treatment?
  17. Can cervical cancer come back after it's been treated?
  18. How often will I need checkups after treatment?
  19. Is there a risk that my daughter will get cervical cancer, too?

Key Point 1

The purpose of a Pap smear is to sample the squamous cells of the cervix, looking for any changes away from normal. A Pap smear is the most reliable test to date for cervical cancer. It is also important to know that a Pap smear is not a test for ovarian or endometrial cancers (cancer of the uterus).

A Pap smear (also called a Pap test) is usually given as part of a pelvic exam. It is a screening test in which cells collected from the cervix are examined for abnormal cell changes that may indicate the presence of cervical cancer or a precancerous condition. If abnormalities are found, your doctor may order diagnostic exams to identify the cause.

The importance of having Pap tests on a routine basis cannot be overstated. Most invasive cervical cancers can be prevented if you have Pap tests regularly. That is because they can detect squamous cell  abnormalities that may lead to cervical cancer at their earliest stages. Early detection enables doctors to start you on a treatment before cancer develops, which increases the likelihood that your treatment will be successful.

Like all screening tests, the Pap test is not 100% accurate. Many factors can interfere with accuracy and can lead to false positive and false negative results. Newer testing methods, including liquid-based Pap tests, may improve sensitivity. However, until a foolproof test is developed, having Pap tests on a regular basis increases the likelihood  that any problems will be detected over time, from one exam to the next.

How often should you have a Pap test? That depends on what your doctor recommends, your age, and other factors. But conventional practice has changed in the past couple of years, and some women may not need a Pap test every year. For more information, see the revised cervical cancer screening guidelines issued by the American College of Obstetricians and Gynecologists. 
 
Preparing for a Pap test.
You should have this test when you are not menstruating; the best time is between 10 and 20 days after the first day of your menstrual period. For about two days prior to the test, do not douche or use vaginal creams, spermicidal foams, or jellies. Do not have intercourse within 24 hours before the Pap smear because it can cause inaccurate test results.

How the test is done.
The Pap test is a quick and painless procedure which involves taking a small sample of cells from the cervix, usually during a routine pelvic exam. The cells are sent to a laboratory where they are prepared and evaluated under a microscope by a cytotechnologist, who is looking for any abnormal features associated with cancerous or precancerous cervical cells.

What the results mean.
In reporting Pap results to your physician, the laboratory uses a set of standard terms called the Bethesda System . These terms are described in the chart below along with additional tests and treatments your doctor may order to gather more information about a particular result.

If your doctor tells you that your Pap test results are "abnormal," it is not necessarily cause for alarm. Cells on the surface of the cervix sometimes appear abnormal but are very rarely cancerous. Also keep in mind that abnormal cells do not always become cancerous. If you get an abnormal result, ask your doctor for specific information about what the result means.

Be aware that false positive and false negative results can happen. If one of these results comes back from your Pap test, you will save yourself a lot of worry and confusion if you know what these terms mean:

  • False positive: You are told that you have abnormal cells when, in fact, the cells are normal. A false positive means that there is no problem.
  • False negative: You are informed that your cells are normal when an abnormal change has actually taken place. This means you could have a problem and there may be a need for more tests.

Pap test result: What the test result means 

WNL Within normal limits - the cells are of healthy size and shape. A negative result. 

Follow-up tests/treatments may include:

  • No special procedures needed
  • Continue routine Pap tests

ASC-US Atypical squamous cells of undetermined significance (ASCUS). The squamous cells do not appear completely normal, but doctors are uncertain about what the cell changes mean. Sometimes the changes are related to HPV infection. Considered mild cell abnormalities. 

Follow-up tests/treatments may include:

  • HPV testing
  • Repeat Pap test
  • Colposcopy and biopsy
  • Estrogen cream

ASC-H Atypical squamous cells cannot exclude a high-grade squamous intraepithelial link to glossary) lesion. The cells do not appear normal, but doctors are uncertain about what the cell changes mean. ASC-H may be at higher risk of being precancerous.

Follow-up tests/treatments may include:

  • Colposcopy and biopsy 

AGC Atypical glandular cells. Glandular cells are mucus-producing cells found in the endocervical canal (opening in the center of the cervix) or in the lining of the uterus. The cells do not appear normal, but doctors are uncertain about what the cell changes mean.

Follow-up tests/treatments may include:

  • Colposcopy and biopsy and/or endocervical curettage

AIS Endocervical adenocarcinoma in situ . Precancerous cells are found in the glandular tissue.

Follow-up tests/treatments may include:

  • Colposcopy and biopsy and/or endocervical curettage

LSIL Low-grade squamous intraepithelial lesion. Low-grade means there are early changes in the size and shape of cells. "Lesion" refers to an area of abnormal tissue. Intraepithelial is the layer of cells that forms the surface of the cervix. LSILs are considered mild abnormalities caused by HPV infection.

Follow-up tests/treatments may include:

  • Colposcopy and biopsy

HSIL High-grade squamous intraepithelial lesion. High-grade means that there are more marked changes in the size and shape of the abnormal (precancerous) cells. This means the cells look very different from normal cells. HSILs are more severe abnormalities and have a higher likelihood of progressing to invasive cancer.

Follow-up tests/treatments may include:

  • Colposcopy and biopsy and/or endocervical curettage
  • Further treatment with LEEP, cryotherapy, laser therapy, conization, or hysterectomy
    

Key Point 2

HPV is a virus that is associated with cervical cancer. If you do not have HPV, you will not have cervical cancer.

 Even if you do have HPV, it is important to know what kind you have, because only a few viruses cause cancer. Most women with cancer-associated HPVs will not get cervical cancer.

HPV, or human papillomavirus , is one of the most widespread sexually transmitted diseases in the United States. It's also the infection responsible for causing nearly all cases of cervical cancer.

HPV is not a single virus. As many as 100 different types have been isolated by scientists. About 30 HPV strains can infect the genital areas and may cause genital warts. Among the genital strains,13 types of HPV pose a high risk of triggering cell changes on the cervix that can progress into cervical cancer. Approximately 70% of all cervical cancers are associated with two of the high-risk types of HPV (HPV 16 and 18).

Because HPV usually causes no symptoms, you can have it and not even know it. Some studies suggest that the majority of sexually active men and women in the U.S. have been infected with at least one type of HPV in their lifetimes. As common as HPV is, it is important to note that:

  • If you do not have HPV, you will not get cervical cancer.
  • Not all types of HPV cause cervical cancer.
  • Having HPV does not necessarily mean you will get cervical cancer. In most women, the body's immune system renders the virus harmless.
  • Even if you do have a high-risk strain of HPV, early detection and treatment can eliminate the threat before the virus causes harm.
  • Women who have never been sexually active are unlikely to get HPV and have a very low risk for developing cervical cancer.

Sexual behavior is the most critical risk factor for getting HPV. So, if you are sexually active, be aware that:

  • HPV spreads through skin-to-skin contact, not by bodily fluids.
  • Using condoms cannot entirely protect you against HPV.
  • Women with multiple sex partners have a much greater risk of being infected than women who are monogamous.
  • Anyone with a suppressed immune system is at greater risk of being infected with HPV.
  • HPV can be contracted from one partner and go dormant for extended periods of time. It can then become active enough to be transmitted to another sexual partner, even a spouse.
  • In a small number of women, the virus can live dormant for years and eventually convert cells on the cervix into cancer cells.

Testing for HPV

There is a test - just as quick, simple, and painless as the Pap test - which  can determine whether you have any of the high-risk types of HPV before there are any conclusive visible changes to the cervical cells. It is called the HPV-DNA test, and it was approved by the Food and Drug Administration (FDA) in 2000 to determine whether women with abnormal Pap tests needed further examination or testing.

In 2003, the FDA approved the expanded use of the test. It can now be done routinely, in conjunction with a Pap smear, to screen women over the age of 30 for HPV infection. Results of the Pap and HPV-DNA tests, together with a complete medical history and evaluation of other risk factors, can help physicians determine what sort of follow-up treatment may be necessary.

Like the Pap test, the HPV-DNA test is performed by collecting cells from the cervix (usually at the same time a Pap test sample is taken) and then sending them to a laboratory for analysis.

The HPV-DNA test is not approved by the FDA as a substitute for regular Pap screening, nor is it intended to screen women under 30 who have normal Pap tests.

    

Key Point 3

It is important to continue to reassess your gynecological health. Even when vaccines are made available for prevention and treatment of HPV, annual physical exams and cytology will remain critical for a woman's ongoing health care.

Biotechnology firms, pharmaceutical companies, and academic researchers are continuing their work to develop vaccines against the types of HPV that cause cervical cancer. Some are designing vaccines to prevent initial HPV infections which, if successful, hold the promise of eliminating cervical cancer entirely. Others are focusing on vaccines to control the progress of cancer or prevent its recurrence in women who already have cervical dysplasia or cancer.

While a number of these vaccines are in clinical trials, developers still face many challenges, and it may be years before an effective and affordable vaccine will be available for widespread use.

In the meantime, regular pelvic exams, including cervical cancer screening, are your best protection against the disease. While you should consult with your doctor to find out how often you should be screened, recently revised guidelines for cervical cancer screening from the American College of Obstetricians and Gynecologists (ACOG) provide the following specific recommendations.

First screenWomen up to age 30Women age 30 and older
About three years after first sexual intercourse or by age 21, whichever comes first.Annual cervical cytology (Pap) testing. 

Three screening options:

  1. Women who have had three negative results on annual Pap tests can be re-screened with cytology alone every two to three years. 
  2. Annual cervical cytology testing.
  3. Cytology with the addition of an HPV-DNA test. If both the cervical cytology and the DNA test are negative, re-screening should occur no sooner than three years.

*Women of any age who are immunocompromised, are infected with HIV, or were exposed in utero to DES should be screened annually.

Source: American College of Obstetricians and Gynecologists

 

The ACOG also noted in its guidelines that most women who have had a hysterectomy with removal of the cervix for benign reasons may discontinue routine Pap testing. However, women who have had the procedure and also have a history of abnormal cell growth should be screened annually until they have had three consecutive, negative Pap tests, at which time they can discontinue routine screening.

Other generally accepted screening guidelines call for:

  • Post-menopausal women to continue to have regular Pap tests.
  • Women 65 to 70 who have had at least three normal Pap tests and no abnormal Pap tests in the last 10 years may decide, after talking with their physicians, to stop having Pap tests.

Medline Plus

Medline Description: 

Conduct an off-site search for Cervical Cancer and HPV information from MedlinePlus.  These up-to-date search results are based on search terms specific to Second Opinion Key Points.

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