Cervical Cancer: Prevention, Screening & Treatment – Part 2

Intro: We’re talking wellness at MemorialCare Health System. It’s time for Weekly Dose of Wellness. Here’s Deborah Howell.

Deborah Howell (Host): Hello, and welcome to the show. I'm Deborah Howell, and today's guest is Dr. Ramez Eskander, gynecologic oncologist from the University of California Irvine and the MemorialCare Medical Center. Cervical cancer is one of the most common cancers in women worldwide. We can learn about the causes and risk factors of cervical cancer, screening methods to detect it early, and vaccines that can possibly prevent it from developing at all. Dr. Ramez Eskander is here to talk about robotic-assisted surgical treatment options and the benefits of this minimally invasive approach for patients. And hello and welcome, Dr. Eskander.

Ramez Eskander, MD: Thank you for having me, Deborah.

Deborah Howell (Host): Our pleasure. What is cervical cancer, sir?

Ramez Eskander, MD: Cervical cancer... well, the word cervix is Latin for the neck of the uterus. And the cervix is the portion of the uterus that connects to the vagina. And it's on average about two to four centimeters in length, and cervical cancer is carcinoma or cancer that affects that portion of the uterus.

Deborah Howell (Host): I see. That's a... boy, that's it in a nutshell, isn't it? And what are the signs and symptoms?

Ramez Eskander, MD: Uh, traditionally, cervical cancer presents with bleeding, and that bleeding usually happens after intercourse or between normal menstrual cycles. Additionally, some women can present with pelvic pain, pressure, pain with intercourse, amongst other symptoms such as foul-smelling discharge.

Deborah Howell (Host): Okay, alright. So... so if any of those things are happening, get yourself to the doctor, ladies.

Ramez Eskander, MD: Absolutely. Certainly, routine exams are critical.

Deborah Howell (Host): Yes, yes. And what are the risk factors and causes?

Ramez Eskander, MD: The causes of cervical cancer, and this is one of the most interesting things in the specialty of gynecologic oncology, is cervical cancer is the only malignancy of the gynecologic cancers where we know what causes it. And the cause is the human papillomavirus. And that is a double-stranded DNA virus, and it infects the cells that line the cervical tissue. And unfortunately, in some women who are infected with the HPV virus, that virus integrates into the DNA and leads to changes that ultimately result in malignancy or malignant transformation. Now interestingly, in the majority of women, HPV infections occur and the body clears them. But in a subset of women, they are unable to clear this virus, and when the virus sits around and causes these genetic changes over time, there is cancer or progression to cancer.

Deborah Howell (Host): I see. So that would intend me to ask my next question: can cervical cancer then be prevented?

Ramez Eskander, MD: Absolutely. We do believe and we do know that the vast majority, over 95 percent of cervical cancers are directly caused by HPV. And with our understanding of HPV as the etiologic agent of cervical cancers, there was a tremendous interest in vaccines and vaccinations. To date, we actually have three vaccines. There is the Gardasil vaccine, and there is the Cervarix vaccine, and there's a new 9-valent... so I'll clarify what that means. The Gardasil vaccine protects against four HPV types, HPV 6, 11, 16, and 18. Importantly, HPV 16 and 18 are what we call high-risk HPV types, and those account for the majority of cervical cancers. HPV 6 and 11 are associated with genital warts, benign changes. The Cervarix vaccine covers HPV 16 and 18. The 9-valent vaccine, which was newly developed, actually covers HPV 16 and 18, and seven additional high-risk HPV strains. And the beauty is, if you vaccinate before men and women, and that's very important because this vaccine is intended for both women and men. If you vaccinate before HPV exposure, and that's the critical point. If you vaccinate before exposure, you can have tremendous protection against high-risk HPV-related cancers.

Deborah Howell (Host): Now would you be taking more than one of these vaccines?

Ramez Eskander, MD: No, you can get any one of them. The Cervarix vaccine is manufactured by one drug company, the Gardasil vaccine is manufactured by another, and the 9-valent is actually manufactured by the same company that manufactures Gardasil. The 9-valent you can consider as a replacement and evolution of the initial Gardasil vaccine because you have greater coverage now.

Deborah Howell (Host): Okay, that's good. I remember the big media campaign for Gardasil a couple of years ago, and then you didn't really hear too much about vaccinations, at least in the general media.

Ramez Eskander, MD: Unfortunately, this is an area of public health that garners a lot of interest. It's controversial because of the nature of this cancer, and unfortunately, we don't have great vaccination rates. So in the United States, we're only vaccinating about 30 to 40 percent of people who should be vaccinated with this therapy to prevent cancer.

Deborah Howell (Host): If you have a teenage girl, or a teenage boy?

Ramez Eskander, MD: Both, both. Ideally, the population that we would like vaccinated are females who are anywhere between 9 to 11 years of age, because you want to capture these individuals before they are exposed to HPV. If you're exposed to any of the high-risk HPV strains and you're vaccinated after exposure, it doesn't confer the benefit to protect you against infection and possible cancer. And that's why it's so critical to try to vaccinate young adolescent men and women before they're exposed to these strains.

Deborah Howell (Host): I hope so many people are listening right now because they need to hear that. And what types of screening are available to help detect HPV and find cervical cancer early?

Ramez Eskander, MD: That's another critical cornerstone to treatment, effective treatment, diagnosis and therapy, so that people don't suffer from this disease. Screening is critical. Even with vaccination, people should continue screening. And screening currently, we've had a tremendous evolution in screening. George Papanicolaou, the inventor of the Pap smear, many, many years ago, ultimately led to the adoption of Pap smear screening, which dropped cervical cancer mortality and was very effective. But as we've begun to understand the etiologic agent, HPV, and specifically high-risk HPV, we've begun to adopt screening strategies that incorporate HPV screening as part of traditional or routine care. So currently the American Society for Colposcopic and Cervical Pathology, which is the board that kind of guides, or one of them that guides cervical cancer screening, recommends that in women younger than 21, we don't do any screening. And sometimes that can surprise people, but the reality is cervical cancer is exceedingly rare, less than one in a million women, less than 21 will suffer from cervical cancer, and if you start screening at a young age, you may get false positives which will lead to interventions that can impact these young women's fertility in the future.

Deborah Howell (Host): I see.

Ramez Eskander, MD: Between age 21 and 29, cytology, which is Pap smear screening, should be done every three years. We don't necessarily believe HPV testing should be incorporated in that period because women will there's a high incidence of HPV infection, and the majority, as I mentioned earlier, will clear these infections on their own and won't develop persistent HPV infections, which is what you need to develop cervical cancer. Between ages 30 to about 65, we recommend cotesting, which is cytology (Pap smear) plus HPV testing. And if your HPV and your cytology are both normal, so you have no high-risk HPV infection, and the cells on the Pap smear look normal, then you can actually get tested at five-year intervals.

Deborah Howell (Host): I see.

Ramez Eskander, MD: Now, very recently and cutting edge, we're beginning to potentially move away from cytology altogether, and we're starting to look at just doing HPV testing.

Deborah Howell (Host): Really?

Ramez Eskander, MD: That's exactly right. So at age 25 or around age 25, you would present for an HPV screening test. And if you do not have any evidence of a high-risk HPV, you don't need additional cytology or testing. But if we do identify high-risk HPV, depending on which strain, and that goes back to the 16/18, 31/33, a litany of numbers, depending on which high-risk strain, you get triaged to either have a Pap smear or a colposcopic assessment, which is a very close look at the cervix under a microscope to see if there are any suspicious changes, and then interventions as required.

Deborah Howell (Host): Let me stop you there, Dr. Eskander, 'cause I can see right now I'm going to need to bring you back for another show to talk about the treatments because our time is up for today, but would you be so kind as to join us again soon?

Ramez Eskander, MD: My pleasure. Absolutely.

Deborah Howell (Host): It's been so, so wonderful and so informative to have you on the program today. We really appreciate your time.

Ramez Eskander, MD: Thank you, Deborah. It's my pleasure.

Deborah Howell (Host): To listen to the podcast or for more info, please visit memorialcare.org. That's memorialcare.org. I'm Deborah Howell. Join us again next time as we explore another Weekly Dose of Wellness brought to you by MemorialCare Health System. Have a fantastic day.