April 16, 2021 by John Fernandez
Q&A on Cervical Cancer: Experts Offer Latest on Screenings, Prevention and Treatments
In 1991 — the year the Cold War ended and the World Wide Web launched — cervical cancer was a leading cause of cancer death for women. Last year, it didn’t even rank in the top ten.
“The development of the pap smear is one of the biggest success stories of medicine and preventative medicine over the last 50 years because we’ve been able to find and detect cancers very early, and also precancerous changes, and treat them before they’ve even become cancer,” says Thomas Morrisey, M.D., director of gynecologic oncology at Lynn Cancer Institute, part of Baptist Health South Florida.
Despite these medical advances, it’s estimated that about 4,000 American women will die of cervical cancer this year. As part of Cervical Cancer Awareness Month, Dr. Morrisey and Dr. Contreras appeared on Baptist Health’s Resource Live program hosted by Emmy®-winning journalist and TV host, Laurie Jennings. Their discussion about the importance of screening and prevention, as well as the latest treatments and research, is summarized in the Q&A below.
Laurie Jennings: “Dr. Contreras, who is most at risk of getting cervical cancer?”
“Risk factors include women who start intercourse at an earlier age, those that have multiple sexual partners. That has to do with the contraction of HPV, or human papillomavirus. We know that more than 90% of these cervical cancers are caused by HPV. We also think of risk factors like in-utero exposures. So, when a woman is pregnant, previously they would receive medications like DES that causes a rare type of cervical cancer. Smoking can also increase your risk.”
Laurie Jennings: “I’ve heard cervical cancer called the silent killer. Why is that?”
“In presentation, it doesn’t become symptomatic until it becomes very large. So, we can catch it at a very early stage, at an asymptomatic state, by pap smears and by exams. Vaginal discharge and bleeding after exercise and intercourse, those are common signs of cervical cancer. But, usually, they don’t show up until the disease is not at an early stage.”
“Also, as women present with more advanced disease, we think about changes in bowel or bladder movement, leg pain, back pain, and then vaginal discharge that can have a foul smell. And lastly, you also think about pain with intercourse. Pain with sexual intercourse should also be a red flag to seek further medical attention.”
Laurie Jennings: “You mentioned HPV, and we know we have the vaccine now. Is the vaccine the most important thing you can do to prevent cervical cancer?”
“Absolutely. It’s amazing that we have a vaccine that can prevent cancer, and it’s not just cervical cancer, other types of cancers can be prevented through the vaccination. We know that head and neck cancers can be caused by HPV. So, it’s important for women, but it’s also important for men because it can prevent cancers in men.
“Now, the CDC recommends that young kids, around 11, 12 years of age start receiving this vaccination, because it’s important to vaccinate kids before they become sexually active. And the thought behind vaccinating boys is not only to prevent cancers in them, but when they’re sexually active down the line, we can prevent transmission of HPV to women. It’s a very important tool. It initially came about in around 2006, but now the vaccine has improved to cover more strains of HPV, so really it’s a great option for young kids.”
Laurie Jennings: “How much of the population has HPV at this point?”
“We think about in the 80% range, it depends on what study you look at. So, it’s a lot more common than we think.”
Laurie Jennings: “Like all cancers, you want to detect it early. What kind of screenings are out there now?”
“First, pap smears, where we take a swab and take some of the cells from the outside and inside of the cervix and look under the microscope, and we’re able to detect early changes on the pathway to cancer, and treat those before they became cancerous.
“We now add an HPV test to the pap smear, and that gives us even more sensitivity and enables the ability to detect people who we need to worry about that are at risk for developing cervical cancer and treat it ahead of time.”
Laurie Jennings: “What are the current recommendations about the timing of getting pap smears and HPV tests?”
“There’s been some debate from the different organizations who recommend what the best thing to do is, and they’re conflicting a little bit right now. Basically, it’s recommended that pap smears don’t start until age 21, because it’s very rare for anything to develop before that. And so the first pelvic exam with pap smear is recommended by the American College of OB GYN at age 21. The American Cancer Society actually recommends the first pap smear to be done at age 25. After that point, we recommend doing pap smears alone every three years until people are 30.
“At age 30, it’s recommended to do a pap smear and an HPV test once every five years, by most of the governing bodies, some still say once every three years.”
Laurie Jennings: “What about women beyond childbearing years who are maybe in their late forties or fifties, even sixties, and they’ve had a lot of clear pap smears. Do you still want them once a year getting that pap smear?”
“We continue doing pap smears and screening until age 65. But in someone who has always had normal pap smears, why should they still get them? Even if you’re exposed at a very young age, it can stay latent for a very long time and then develop the pre-cancerous changes 20, 30 years later. So, it’s important to stay on top of things and make sure that you have a pap smear and a HPV test every five years.”
Laurie Jennings: “What kind of treatments are out there?”
“It varies based on the size of the tumor and whether or not it’s spread to any surrounding organs, or the surrounding lymph nodes. With early-stage disease, the usual primary treatment is surgery and then we review the pathologies of the tumor that was removed to determine if women may benefit from further chemotherapy or radiation.
“In women diagnosed with more advanced disease, the standard of care is chemotherapy with radiation therapy. Now, the radiation therapy for women that have locally advanced cervical cancer consists of both external beam radiation, and internal radiation, which is also called brachytherapy.”
Laurie Jennings: “You specialize in brachytherapy. Is that a new treatment for cervical cancer?”
“It was discovered at the close of the 1800s, and it was in 1905 that it was first used to treat cervical cancer. When we think about radiation for cervical cancer, brachytherapy is the most important component.
“We place an applicator right next to the tumor itself, and in that applicator, we place a radioactive source and this allows us to give a really high dose of radiation to the tumor while we spare all of the surrounding normal structures, like the bladder and rectum. So, it’s a really old treatment, but we do it in a much, much more modern way now.”
Laurie Jennings: “Is brachytherapy available here in South Florida?”
“Miami Cancer Institute has a fabulous facility with all the state-of-the-art equipment and treatment. We have very new methods of giving the radiation treatment, which is much safer, much more accurate, and much, much more precise in terms of sparing the tissue around the tumor. So, we have those facilities available in Miami, and also in Boca Raton.”
Laurie Jennings: “A recent study was published about the racial disparities in the use of brachytherapy. Do you think, Dr, Contreras, that improving access to this therapy among black women would improve the overall survival rate?”
“Absolutely. So racial disparities is something that’s affecting not just women with cervical cancer, but we see that women that are minorities that are diagnosed with breast cancer are more likely to die from their disease, and unfortunately it’s the things we’re seeing across the board. The study you’re quoting is a study where they looked at several hundred women, and ultimately what they found is that black women were less likely to receive brachytherapy, And as a result, they were more likely to die of their disease.
“Unfortunately, because it is a specialized treatment, not every cancer center has access to this type of therapy, so that’s one of the barriers. I think it’s important when someone sees their physician, or you’re talking about treatment options, that you ask these questions. And even if it’s not available locally, this is something that we can deliver after the patient completes external beam at another facility.”
Laurie Jennings: “Are there other advancements that have been made in treating cervical cancer, and in research?”
“There’s some exciting research going on in patients who’ve had cervical cancer that’s been caught in an advanced stage, or comes back and is metastatic to other areas. There are new medicines that are targeted therapies, much like many of the commercials that people see on TV for medicines, like Keytruda and Opdivo, that are very targeted for specific gene problems that certain tumors may have, and cervical cancers something that’s very amenable to this. So, we’re trying lots of new combinations of medicines, which are very promising for that, including doing some clinical trials at Miami Cancer Institute.”