CERVICAL CANCER
Questions & Answers
What is an immune system?
What is a vaccine?
What is human papillomavirus
(HPV)?
What types of diseases
are caused by HPV?
What types of treatments
are available for the warts caused by HPV?
Is there
a cure for HPV?
How does
it cause cancer?
How long does it take
to develop cancer if the body is not able to fight
off the initial infection with the cancer-causing
HPV?
Which subtypes of HPV
cause genital warts, abnormal pap smears and cervical
cancer?
Can people be infected
with more than one type of HPV?
What are important
components of a public health approach to cervical
cancer awareness, prevention and early detection?
RISK FACTORS: Who can
get cervical cancer?
How do I protect myself
from getting HPV infection?
What usually happens once someone gets
infected with HPV?
What is cancer
screening?
What are the U.S.
recommendations for cervical cancer screening?
Do I still need to get screened for
cervical cancer if I received the vaccine?
How do I get checked (screened) for cervical
cancer?
How long
and how often should I get regular cervical cancer
screening?
What are the different
treatment options (and possible side effects) for
cervical cancer?
Once I am diagnosed
with cervical cancer, what additional tests will
be required?
What is
the cervical cancer vaccine (Gardasil)?
How long
does the vaccine protect women against the HPV?
Do I still
need to get screened for cervical cancer if I received
the vaccine?
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Q &
A section for practitioners (focusing on medical information) please
click here
Q1:
What is an immune system?
The human immune system is like
the body’s internal military defense system. There
are many parts to the immune system (different cells,
proteins and chemicals) and they work together in a
very complicated, but usually coordinated way to eliminate
foreign organisms or cells. Antibodies are things that
generally block entry of the bacteria or virus into
the human cell(s).
Q2:
What is a vaccine?
A vaccine generally contains either
living organisms or, more commonly, non-living parts
of the bacteria or viruses
A healthy human body makes antibodies
in response to the vaccine or in response to the natural
infection
Once someone is vaccinated, it
means that their body has produced “antibodies” that
usually block entry of the bacteria or virus into the
human cell(s).
Depending on the type of vaccine,
the protection or amount of “blocking effect” lasts
from 5 years to 15+ years. Science is continually giving
us more information about how long vaccines actually
last, so expect the recommendations for vaccinations
and booster shots to change as new evidence becomes
available.
Q3:
What is human papillomavirus (HPV)?
A virus is a type of organism that
needs to live inside of cells in order to survive.
Like humans and other organisms, viruses contain building
blocks and road maps that give instruction on how to
make more of itself and how to live (RNA or DNA). DNA
viruses become a part of the human cell and can “take
control” of the cell if certain factors exist. In a
small percentage of people, some DNA viruses can cause
cancer.
Human papillomavirus is a family
of DNA viruses that live in skin or mucosal tissues
(anogenital, mouth or airways). They generally cause
warts and there are over 100 sub-types of HPV.
The virus is covered by an outer
shell (capsid). This shell interacts with the human
skin or genital cells. If the immune system is not
able to defend against this outer shell, then the virus
will enter and begin making more of itself and start
to cause problems. The HPV vaccine is designed to
help the vaccinated person’s immune system block the
entry of this capsid/virus into their cells.
Q4:
What types of diseases are caused by HPV?
Papilloma essentially means warts.
HPV very commonly causes skin warts. Very ill people
can get warts in their lungs. Anogenital warts are
also caused by HPV (warts in the private parts). Some
of the HPV also causes cervical cancer. These are known
as “oncogenic” or “cancer-causing” HPV types.
Q5:
What types of treatments are available for the warts
caused by HPV?
Surgical (cutting it off)
Destruction with cold, heat, lasers
or other chemicals
Application of medicines that cause
the human immune system to fight the virus more effectively
(immune modulators)
Q6:
Is there a cure for HPV?
NO!
Once you have it, it stays in your
body. Even if the wart is destroyed, the virus remains
in the body and can come back when the immune system
is weakened and when a woman is pregnant.
Q7:
How does it cause cancer?
Persistent infection with the oncogenic
types of HPV leads to cancers of the cervix, anus,
vagina, vulva, penis, mouth and sinuses.
If the immune system is not able
to clear the infection, then the virus continues to
reproduce in the cells. Over time, abnormalities in
the cells occur (see abnormal pap smears). The immune
system has a harder time fighting abnormal cells. If
not treated, these cells become more abnormal and turn
into cancer. Once a cancer starts, the immune system
is not able to fight it off alone.
Q8:
How long does it take to develop cancer
if the body is not able to fight off the initial infection
with the cancer-causing HPV?
Generally, it takes 10-20 years
for a HPV-related cancer to develop
Fortunately, there are precancerous
stages that are easy to treat. These precancerous abnormalities
are what we look for in cervical cancer screening.
Q9:
Which subtypes of HPV cause genital warts, abnormal pap
smears and cervical cancer?
Genital warts: HPV 6 and 11 cause
about 90%
Low-grade pap smear abnormalities
(LSIL): 16, 18, 45, 31 cause over 50% of the low grade
lesions. Types 6 and 11 cause about 12%
High-grade pap smear abnormalities
(HSIL): 16, 18, 45, 31 cause about 65% of the high
grade lesions
Cervical cancers: HPV 16 ≈ 50%
; HPV 18 ≈ 20% ; HPV 45 ≈ 5% ; HPV 31 ≈ 5%. There are
at least 11 other “high-risk” types of HPV known to
cause cancer.
Q10:
Can people be infected with more than one type of HPV?
YES
A healthy person will make antibodies
only against that specific type of HPV, but those antibodies
usually do not last more than 3 years
In some populations, over 50% of
people are infected with more than one HPV type.
Q11:
What are important components of a public health approach
to cervical cancer awareness, prevention and early
detection?
Effective public
awareness and education
Patient willingness
and ability to come in for screening
Enough health providers
trained to do education, counseling and screening
Trained health providers
based in the communities as opposed to one centralized
location
Private areas, appropriate
supplies and equipment to perform the cervical cancer
screening
Resources to perform
or analyze the screening test (personnel, facilities,
mailing/shipping/contractual costs (if not analyzed
locally))
Information tracking
system to ensure that test results are recorded, shared
with the appropriate health provider, that the patient
can be contacted if an abnormality is found and/or
reminded to come in for her next check-up
A plan to maintain
and sustain the equipment, supplies and health workforce
so that there is enough to do screening according to
the most appropriate recommendations for your jurisdiction.
Q12:
RISK FACTORS: Who can
get cervical cancer?
People infected with the oncogenic
virus types who are not able to clear the infection
AND who are not able to get screening or treatment
of precancer lesions. Even with tests that can tell
us what type of HPV virus, we cannot predict if a person’s
body will develop the cancer
About 89% of worldwide cervical
cancer cases occur in developing countries with inadequate
screening and treatment programs
More cervical cancer tends to occur
between age 15-25 years old OR in the 50-70 year olds
In unscreened populations, cervical
cancer tends to be diagnosed earlier and at more advanced
stages
The following are other risk factors
and behaviors which make it more likely to develop
cervical cancer:
Multiple sexual partners
Persistent infection with multiple types of HPV
Chlamydia infections
Tobacco use
Multiple births
Long-term use of oral contraceptives
HIV infection
Other cancers (weakened immune system)
Family history of cervical cancer
Q13:
How do I protect myself from getting HPV infection?
Condom used during sex can be helpful,
but only if the warts are on the part covered by the
condom.
A spermicide/special detergent
(SDS) combination could be helpful in preventing transmission
of HPV
Spermicides alone do not protect
against any form of sexually transmitted infection.
The HPV vaccine presently available
protects against 4 of the most common subtypes of HPV.
However, there are at least 13 other subtypes that
cause cervical cancer (that are not in the Gardasil)
and over 100 other subtypes that cause warts.
Q14
What usually happens once someone gets infected with
HPV?
About 75-90 percent
of HPV infections will clear within a year of initial
infection.
If someone has persistent
infection with a high-risk HPV type for more than 2
years, they have a higher cancer of progressing to
cervical cancer. For someone persistently infected
with HPV-16 after 3-5 years, they have a 40% chance
of developing a precancer lesion.
Precancer is more
likely in women infected with more than one type
Early precancer changes
can often be detected within 5 years from infection.
If someone has an
untreated precancer, they have a 20-30% chance of developing
cervical cancer within 5-10 years.
Q15
What is cancer screening?
Screening is a public health intervention
used on a population at risk, or target population.
Screening is not undertaken to diagnose a disease,
but to identify individuals with a high probability
of having or of developing a disease. Women targeted
for screening for cervical cancer may actually feel
perfectly healthy and may see no reason to visit a
health facility. For screening to be effective, accurate,
easy to apply, simple, inexpensive, culturally acceptable,
and safe, the disease screened must be common and should
have a detectable preclinical stage, for which effective
treatment should be available; a large proportion of
people at risk should participate in screening, investigations
and treatment; the local health services infrastructure
should be sufficiently developed to provide the diagnostic,
treatment and follow-up services.
Screening programmes will only
be successful if the following elements are present:
high coverage 6 (80%) of the
population at risk of the disease;
appropriate follow-up and management
for those who are positive on screening.
Efforts to increase coverage
will be wasted if those who test positive are not
followed up correctly;
Effective links between programme
components (e.g. from screening to diagnosis and
treatment);
High quality of coverage, screening
tests, diagnosis, treatment, and follow-up;
Adequate resource
Q16
What are the U.S. recommendations for cervical cancer
screening?
The following
is a summary of various US organizations, because
different organizations recommend different intervals.
In general, cervical cancer screening should be done
in any woman who has been sexually active for three
or more years or is 21 years of age. The cervical
cancer screening should be performed annually until
around age 30, then can be spaced out to every 2-3
years if the female is in a monogamous/low risk relationship.
Cervical cancer screening can stop at age 65-70 if
the patient has had a normal pap smear within the
past 5-10 years. Additionally, cervical cancer does
not need to be done in a woman who has had a hysterectomy
for a problem other than cancer (fibroids, bleeding
after child birth, endometriosis, etc.)
Q17
Do I still need to get screened for cervical cancer if
I received the vaccine?
Absolutely.
The vaccine is not 100% effective in preventing cervical
cancer caused by the types in the vaccine. Additionally,
the protection may not last forever and it does not
protect against 30-50% of the other HPV types that
cause cervical cancer.
It is possible for a vaccinated
person to develop cervical cancer from another type
of HPV.Because of this and because the vaccine is not
perfect, educational programs, messages and public
expectations need to be managed accordingly.
Cervical cancer screening and treatment precancer lesions
is the only protection against the types of virus not
in the vaccine and against existing infection with
high-risk HPV types.
Q18
How do I get checked (screened) for cervical cancer?
Screening requires collection of
cervical cells. This generally means lying on an examination
table with the legs spread apart so that a trained
health provider can insert a speculum into the vagina.
This is important so that they can see the cervix and
collect the sample properly. There are other self-sampling
kits which are being researched. These can be done
in the privacy of your home.
Pap smears are used most commonly
in the U.S. and are required for CDC-funded Breast
and Cervical cancer screening programs. There are several
ways to do pap smears (conventional slide or liquid-based).
Each has its advantages. Liquid-based pap smears are
more costly to process, but can give more consistent
results regardless of the health provider’s skill.
Liquid-based pap smears might reduce the need to repeat
a pap because of an inadequate sample. Additionally,
HPV-typing can be done on liquid-based samples.
Q19
How long and how often should I get regular cervical
cancer screening?
In general, women should be screened
regularly (at least every 2-3 years) from 3 years after
the onset of sexual activity until age 65.
How does my doctor decide what
type of cervical cancer screening to offer?
The type of test depends on what
is available, what the insurance company will pay for
and/or what the standard of care is in that community.
Q20
What are the different treatment options (and possible
side effects) for cervical cancer?
Depending on the stage of cancer
and your other health conditions (such as severe heart
or kidney disease), the doctor may recommend one or
more of the following:
- Surgery (hysterectomy for stage
IA1; radical hysterectomy and pelvic lymph node dissection
for stage IA2-IIA; complete removal of most of the
pelvic organs, including the bladder and parts of
the rectum and colon for recurrent cervical cancer)
- Radiation therapy: beam or internal
radiation to stop the cancer cells from growing
- Chemotherapy: medications that
stop the cancer cells from growing
- Palliative treatment: aimed
at relieving symptoms, not aimed at curing the cancer
For precancer and early cancers
(Stage 0 or IA), surgery can be done by freezing (precancer
or preinvasive cancer only), laser (preinvasive cancer),
conization (precancer or early cancer).
Please refer to the American Cancer
Society information for more detailed information on
treatment options and side effects
Q21
Once I am diagnosed with cervical cancer, what additional
tests will be required?
Staging refers to the process of
finding out how far a cancer has spread. This is important
to direct appropriate treatment.
Cervical cancer staging is based
on how big and deep the cancer extends into the cervix
and surrounding tissues.
Depending on the clinical examination,
additional tests to look into the bladder and rectum
may be required. Sometimes a CT scan is required to
look for distant metastases.
Q22
What is the cervical cancer vaccine (Gardasil)?
Gardasil targets HPV 6, 11, 16
and 18
At best, it can protect against
90% of genital warts and 70% of cervical cancers
The best efficacy is in girls before
they start having sex
It must be given in 3 doses, ideally
over a 6 month period
It was primarily tested in girls
age 9 – 26, but has also shown to be effective in preventing
new infections in women up to age 45.
A recent study published in the
New England Journal of Medicine, August 21, 2008, questions
the cost-effectiveness of giving the vaccine to women
over 18 years of age.
If someone is already infected
with one of the virus types in the vaccine, the vaccine
will still help to protect against the other types.
The vaccine does not treat existing
HPV disease nor does it promote regression or healing
of existing HPV disease.
Q23
How long does the vaccine protect women against the HPV?
Available research shows a good
protection up to 5 years. Studies are being done now
to determine how effective the vaccine is at 10 years
after vaccination. Mathematical modeling suggests long-term
efficacy.
Q24
Do I still need to get screened for cervical cancer if
I received the vaccine?
Absolutely.
The vaccine is not 100% effective
in preventing cervical cancer caused by the types in
the vaccine. Additionally, the protection may not last
forever and it does not protect against 30-50% of the
other HPV types that cause cervical cancer.
It is possible for a vaccinated
person to develop cervical cancer from another type
of HPV.
- Because of this and because
the vaccine is not perfect, educational programs,
messages and public expectations need to be managed
accordingly.
Cervical cancer screening and treatment
precancer lesions is the only protection against the
types of virus not in the vaccine and against existing
infection with high-risk HPV types.
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