Intro: Expert Insights is an ongoing medical education podcast. The Carle Division of Continuing Education designates that each episode of this enduring material is worth a maximum of 0.25 AMA PRA Category 1 credit. To collect credit, please click on the link and complete the episode's post-test.

This podcast forum is brought to you to share expertise and insights within our integrated delivery system to help us improve the health of the people we serve and achieve world class accessible care. This is Expert Insights.

Rania Habib, MD, DDS (Host): The CDC estimates that there are 11,500 new cervical cancers diagnosed every year. But the good news is that the rates of cervical cancer are decreasing in the U.S. In this episode of Expert Insights, we will learn all about cervical cancer, the importance of early screening, and the role of human papillomavirus.

This is Expert Insights with the Carle Foundation Hospital. I'm your host, Dr. Rania Habib. Joining me today is Dr. Beverly London, a Gynecologist with the Carle Foundation Hospital. She is here to discuss cervical cancer, updated screening guidelines, and provide human papillomavirus awareness. Thank you, Dr. London. We're so excited to have you on the show today. Welcome.

Beverly London, MD: Thank you. I'm so happy to be here. I think this is such an important topic to, for everyone to be updated and educated about.

Host: Absolutely. Now let's start with a very simple question. For listeners who still might be a bit confused about female anatomy, what is the cervix?

Beverly London, MD: The cervix is actually the entrance to the uterus, or the womb, so you can't get into the uterus without going through the cervix first.

Host: Okay. So we know that cancer can affect all portions of the uterus, but this episode specifically focuses on cervical cancer. How common is cervical cancer, and what are the most common signs and symptoms that a patient might experience?

Beverly London, MD: So, cervical cancer in the United States affects close to 12,000 women, and about 4,000 women will die from cervical cancer each year. Outside of this country, it's the fourth most common cancer worldwide. So it is a significant cause of cancer deaths outside of this country. And we estimate about 700,000 women per year outside of the United States get cervical cancer and about half of those women will die, especially in areas like Central America, Sub Saharan Africa.

And the result of this is that women die from their cervical cancer outside of this country and then they leave all of these children without moms because of those deaths. So it has a double impact when you talk about its impact outside the United States.

Host: Mmhmm. And what are some of the most common signs and symptoms that a patient might experience?

Mm

Beverly London, MD: So the bad part about cervical cancer is the majority of women have no symptoms at all. So that's what can be scary about it, but what's good is that we have the PAP screen. But some women will present with irregular bleeding, some women will have bleeding or pain with sex, some will have issues with urination or pain with urination, and some women will have change in their bowel movements.

So it can really vary. I can think of the most famous person that had cervical cancer was Evita Peron, who had cervical cancer in the 40s, and that's the time when they were just developing the PAP screen to screen for cervical cancer.

Host: So it sounds like the major issue with diagnosing cervical cancer is that patients really don't have very specific signs and symptoms. So how is cervical cancer diagnosed?

Beverly London, MD: We diagnose it with a PAP smear, which is just where we take a swab of cells from the cervix to get a sample. And it's a quick procedure, sometimes we'll use a speculum to visualize the cervix, but the pap can be done without a speculum, just with swabs in the vaginal area. We do have our transgender patients that sometimes it's too uncomfortable for them to have a PAP with where we use a speculum, they can swab themselves to get enough cells and get testing for the HPV virus in order to do their PAP.

Host: Now we know that early cancer screening plays a large role in improving outcomes. Could you review the updated cervical cancer screening guidelines?

Beverly London, MD: So the guidelines have changed a little bit in the last few years, so based on a lot of research that has been done. But in general, we start PAPs at age 21, and after age 65, if that patient has no history of abnormal PAPs, they can stop their PAP screen. So between age 21 to 30, every woman should have a PAP screen every three years.

Between age 30 and age 65, they can space out their PAP between 3 and 5 years. So no longer do you need to do a PAP every single year, but you still need your well woman exam to go over other things on a yearly basis, but the PAPs we usually do every 3 to every 5 years.

Host: Now, what about the people who have an abnormal pap smear and could you go into a little detail about what an abnormal pap smear actually means?

Beverly London, MD: So when a PAP is abnormal, either pathology sees that the cells look irregular, or they see that that patient has had exposure to the HPV virus. And we can particularly look at what type of the HPV virus they have because if they have 16 or type 18, those are higher risk versions of the virus.

The PAP actually tests for 13 different high risk types of the HPV virus. So we're picking up those abnormal distinctions on the PAP. But when it comes back abnormal, we do a test in the office called a colposcopy. And that's a simple test where we just take microscope and we look at the cervix with that microscope after we apply acetic acid, which is just vinegar.

That's the acetic acid makes changes on the cervix, so those cells that are abnormal on the cervix will turn white, which makes it easy to see and we know exactly where to take a sample of the cervix with the biopsy. We can use a instrument that's a metal instrument, but now PAP colposcopies have gotten so much better where we can just use a brush to get a sample from the cervix.

Host: So, how do the cancer screening guidelines change so the frequency of that PAP smear when someone has had either, you know, an abnormal PAP or the colposcopy, do they have to then have their PAP smear more frequently?

Beverly London, MD: Yes, absolutely. Anytime you have an abnormal PAP, we need to follow that patient more closely. Because it takes a long time to develop cervical cancer, usually 15 to 20 years in someone who doesn't have any weakness in their immune system, but an immunocompromised patient, they can develop cancer in 5 to 10 years. But whenever the PAP is abnormal, we need to do more close follow up.

Host: Now, you did mention immunosuppressed patients, and that's our next topic. Do the guidelines change for cervical cancer screening when the patient is immunosuppressed?

Beverly London, MD: Absolutely. So when I talk about immunosuppressed, I'm talking about those patients that have the HIV virus, but also patients that have had a stem cell transplant, an organ transplant, or they may be on medications that are making their immune system weaker. For instance, you might have a patient that has irritable bowel syndrome and that is on immunosuppressant medication, or a patient that has rheumatoid arthritis, or lupus, and they're on medications that suppress their immune system. Those, all of those immunosuppressed patients need to start their PAP screens earlier and can do lifelong PAP screening as long as they're on immunosuppressant medication. The guideline for starting at age 21 does not apply to immunosuppressed patients.

We start their PAPs a year after they become sexually active. So, if I have a patient that's 16 years old, she's sexually active, and she has HIV, I would start her PAPs at age 17, and I would do her PAPs lifelong. She's never going to stop PAP screening.

Host: Okay, that makes a lot of sense. We want to make sure that they're safe because their immune system doesn't have the same response like a normal, healthy patient.

Beverly London, MD: Right. And we don't want them to quickly develop cervical cancer that could have been prevented. It's been a big thing in the news recently. There was a blogger that has stage 4 cervical cancer. She had presented with bleeding, and they thought that her bleeding was related to fibroids and she didn't have updated PAP screening and now has advanced cervical cancer.

Host: Ah, it's devastating.

Beverly London, MD: Yeah, definitely a preventable disease, definitely a preventable cancer.

Host: Now, we've mentioned several times throughout the podcast already about human papillomavirus, which is also known as HPV. What role does HPV play in cervical cancer?

Beverly London, MD: HPV is a virus that infects the cells of many different parts of the body. So when we talk about HPV, it's considered the number one sexually transmitted infection across the country, but people think that you can only get HPV by having penetrative sex, but you can have just skin to skin contact sexually and pass the virus on from person to person.

So it's a virus that can cause cancer. And now we know HPV, we have HPV that can be in the throat, it can be in the anal canal, it can affect the vulva, the vaginal area, the penis in men, and it's number one cause of throat cancer now, where it used to be smoking was the number one cause of throat cancer. Now it's the HPV virus.

Host: That's incredible. And, you know, as a oral maxillofacial surgeon, we see a lot of those HPV positive patients getting throat cancer, like you said, and oral cancer. So the screening plays a very important role for the prevention of many cancers throughout the body. Now, which specific types, I know you mentioned it briefly, but if you can highlight that again, what specific types are linked to cervical cancer?

Beverly London, MD: So especially if that patient has exposure to HPV 16 or 18, they're at much higher risk of developing cervical cancer. HPV 6 and 11 causes genital warts, but doesn't cause cancer. But we're really trying to make sure we detect those patients that have had exposure to 16 or 18, and that's picked up on the PAP smear.

Host: Okay, now we know that prevention of HPV is obviously preventative for all these different cancers and especially cervical cancer. So could you update us, Dr. London, on the guidance on which patients are best suited to have the HPV vaccination?

Beverly London, MD: Absolutely. So, during the pandemic, the CDC actually approved Gardasil vaccination for adults. So, we used to give the vaccine just between age 9 and age 26, but now the vaccine has been approved for adults up to age 45. So the patients that we should really talk to about getting vaccinated when they're older, if they've had an abnormal PAP, just this summer in July, the American College of Obstetrics and Gynecology started recommending getting the vaccine if you have a high grade pre cancerous cells of the cervix. So it's part of the treatment for pre cancerous cells of the cervix, not just preventative. So they've done studies where they found that it was effective even if you've had an abnormal pap to still get vaccinated. But patients that are immunosuppressed, they should be getting the vaccine.

If you have a new partner, you should think about getting the vaccine. If you're diagnosed with another sexually transmitted infection, let's say you get diagnosed with herpes or chlamydia, you should get the vaccine because it's going to prevent you from having exposure to another sexually transmitted infection.

Host: Now, for the patients who have already had an HPV infection, and I know this might seem like an odd question, but I'm sure our listeners are wondering, are they still eligible to receive the vaccine or is there no point to it?

Beverly London, MD: Absolutely, they should absolutely get it. The vaccine is covered under the Affordable Care Act, so all of the insurance plans are covering the vaccine. And even if you've been exposed to one type of the HPV virus, you haven't been exposed to all nine types that the virus protects against. So the virus protects against 16 and 18, which are the high risk types.

Also protects against 6 and 11, which can cause genital warts. And we know if you get vaccinated when you're in your teens, it can prevent almost 90 percent of the cancers caused by the HPV virus. So it prevents penile cancer, anal cancer, cervical cancer, vaginal vulvar cancer, and HPV of the throat. So six benefits in terms of cancer prevention.

Host: That is fantastic. Now, you've really shed some light, Dr. London, on the benefits of the HPV vaccination for adults and for all these different types of populations that are at high risk. But I'm sure our listeners are wondering, are there any major risks to the vaccination?

Beverly London, MD: The vaccine is the most studied vaccine before we studied the COVID vaccine. It's been around since 2004, so we're already on the second generation of the vaccine, and we're seeing a decrease in cervical cancer in younger patients as an effect of the vaccine. The side effects are, for most people, minimal.

Some people will get feel faint or get some redness or irritation at the injection site. A few people may get some nausea or headache. The majority of people tolerate it really well. So this vaccine has been around since 2004 and we're now seeing the benefits of it in terms of preventing cervical cancer.

Host: That is fantastic. Dr. London, you have provided us with a wealth of information that stems from anatomy and talking about cervical cancer and HPV. What is your final take home message for our listeners today?

Beverly London, MD: Yes, I'm going to tell you the tea, Dr. Habib. Get the vaccine. Get the vaccine. It's so beneficial. I've seen the benefits of the vaccine. I definitely recommend it every time I see a patient that comes in with an abnormal pap. Protects against six cancers, so you can't do better than that in terms of protecting yourself.

Host: Well, you have definitely piqued my interest. I know that my OBGYN has personally asked me about the vaccine and I've had some hesitation, but you've really shed some wonderful light on how this is preventing not only cervical cancer, but multiple types of cancer throughout our lifetime. So that's fantastic.

Beverly London, MD: Yeah, and definitely to those smokers out there, get the vaccine. It'll could prevent you from getting oral cancers.

Host: Absolutely. Well, thank you so much for joining us today, Dr. London. We appreciate your time and your expertise.

Beverly London, MD: Great. Thank you.

Host: Once again, that was Dr. Beverly London, a Gynecologist at the Carle Foundation Hospital. For more information, and to get connected with one of our providers, please visit carle.org. Or, for a list of Carle providers and to view Carle sponsored educational activities, head on over to our website at carleconnect.com.

I'm your host, Dr. Rania Habib, wishing you well. That wraps up this episode of Expert Insights with the Carle Foundation Hospital.