Jaime Lewis (Host): According to the American Cancer Society, cervical cancer was once one of the most common causes of cancer death for American women. However, thanks to increased screening and prevention methods, the cervical cancer death rate has dropped significantly over the past 40 years. Here to discuss cervical cancer prevention, screening and treatment is Dr. Diana English, a gynecologic oncologist at Holy Cross Health in Fort Lauderdale. She'll talk about symptoms, screening guidelines, and the latest developments in cervical cancer care.

This is Thrive with Holy Cross Health, a production of Holy Cross Health. I'm Jamie Lewis. Dr. English, thank you so much for being here today.

Diana English, MD: My pleasure. Thank you so much for having me.

Host: Well, let's start with symptoms. What are the most common symptoms of cervical cancer that patients and families should be aware of?

Diana English, MD: Yeah. So, the most common symptoms include pelvic pain or cramping that's happening outside of your period and worsening. So in general, anything that's worsening should be checked out, any symptom that's worsening. Probably just as common or maybe even more common is abnormal bleeding, particularly post-coital bleeding. So, bleeding with or after sexual activity should be something that prompts a very quick assessment by a GYN or a GYN-oncologist. Abnormal vaginal discharge is also another common symptom of cervical cancer. These symptoms may happen in somewhat the more earlier stages of the cancer.

In more advanced stages, symptoms may include back pain or pain radiating down the leg. Sometimes there's a nerve that starts to get affected or impinged by the disease spread to the pelvic sidewall. And so, patients may complain of more of a sciatica-type pain. And so, those are more common symptoms later in the stage of the disease. And other late symptoms depend on if there's metastasis outside of the area of the pelvis, so for example, the lungs or other organs. Then, there could be, of course, more symptoms.

Host: I am jumping probably way too far ahead, but I'd like to know, because I think people are aware of the HPV vaccine that's been in the news a lot for the last, I mean, decade. How effective is the HPV vaccine in reducing the risk of cervical cancer? And at what age would somebody most benefit from having it?

Diana English, MD: Jamie, thank you so much for bringing up the HPV vaccine and asking that question. It is extremely effective at reducing HPV infections and HPV-related cancers, in particular cervical cancer by over 90%, really effective. Ideally, patients should get the vaccine in their youth, somewhere between nine and 12 years of age, but it is covered even when we're older.

So initially, it was covered up to age 26 years, and now it's covered up to age 45 years. It's certainly more effective if you receive the vaccine before you have sexual contact or sexual activity. And even more so before you have many sexual partners or have had, many sexual exposures. So, the younger you are to get it, the better off you will do to prevent getting high-risk HPV infections, and the sequela of that, which includes cervical cancer can include certain types of anal cancer, penile cancer, but it is quite effective. When you're younger, if you're younger than 15 years of age and you get it six months apart, you only need two vaccines, like two shots. If you're older, your immune system is, let's say, not as robust, you typically need three shots. So, you get the first shot in about two months or so, later the second shot, and then the third shot. So the younger you are, you need fewer shots. Definitely, it's better to get it before you're sexually active, but it's is covered now up to age 45 for those people who haven't had many sexual partners and may still benefit from getting coverage or protection from the most common types of high-risk HPV, which is what the vaccine is covering or protecting you from, and the high risk HPV is the main cause of cervical cancer. So, we literally have a vaccine that can prevent cancer. So, it seems to stand that it makes a lot of sense for people to get it as children. And certainly, if you haven't gotten it as a child, try and get it now. Try and get it later, especially if you haven't had many sexual experiences or many sexual partners.

Host: Right. And I know HPV is very, very common, far more common than you would assume. And so, when it comes to the vaccine, it makes a lot of sense not to overmoralize it, I suppose. And just to assume, I mean, what are the rates of HPV infection?

Diana English, MD: Yeah. So, most people that are sexually active, over 80% of adults that are sexually active have some type of HPV. What we're trying to protect against is the high risk type of HPV. So, the low risk types of HPV are more often the causes of warts, genital warts. The higher risk types of HPV, those are the types that cause cancer and those are the types of the vaccines preventing you from getting.

And sometimes people would say that they're not necessarily pro-vaccines. But in this particular case, I think in many cases, this vaccine has been shown to be extremely effective at preventing one from getting high risk HPV, and as such, the sequela, the cancers that come with high-risk HPV. So, it does make a lot of sense. It's extremely safe. Extremely safe. And so, I would certainly recommend most parents, most adults, again, as adults, if we haven't had many sexual partners, it does make sense to still get a vaccine.

Host: How does HPV, the kind that you are talking about, the high risk HPV, how does that develop into cervical cancer? What are the different stages of cervical cancer and how does that impact treatment?

Diana English, MD: So, great question. It usually takes several years after having contracted high-risk HPV to end up with actual cervical cancer, and that's why we do Pap smear screening to pick things up at a pre-invasive or an early phase so that we can do something about it to prevent actual cancer developing.

So, high risk HPV affects different cells in our body. It certainly loves the lower genital tract, so it can affect the cervix, the vagina, the vulva, the anus, probably are the most common areas. Certainly, as you know, it can affect the throat as well, but it loves a certain type of epithelium, and the lower genital tract is definitely one of the high risk areas for high risk HPV causing problems. So, it causes changes in the cells. That are pre-cancerous or what we call dysplastic changes that we can often pick up when we do Pap smears. And so, if we pick up these early changes, then we have different strategies to manage these changes that are pre-cancerous and prevent actual cancer developing.

The earliest stage of cancers, you know, cancer stage from stage I through stage IV, the earliest stage would be limited to the cervix. That's stage I. And it depends on the size and we have different kind of subphases or substages of stage I. And then, stage II is when it has started to spread to the upper vagina. And there are different parts of stage II, where it starts to spread outside of the cervix into what we call the parametria. And then stage three, it spread to the lower vagina or all the way outside of the cervix to the pelvic side wall. And then, stage IV, the most advanced stage, it has actually spread outside of the pelvic organs. And now, it's maybe in the lung or the liver or somewhere else.

Host: And what are the treatment protocols for, let's say, early stage cervical cancer?

Diana English, MD: So for early stage cervical cancer, the earliest stage, it can be managed with a simple procedure, even a cone biopsy if it's extremely early or more commonly a simple hysterectomy. Depending on certain characteristics of the cancer, we may need to do a radical hysterectomy, which involves removing the upper vagina, removing some of the tissues beside the cervix, which is called the parametria. And then, of course, sampling lymph nodes. So, we remove the uterus, cervix, the upper vagina tissues, beside the cervix called the parametria, and sample lymph nodes. There can be lymph node spread that occurs. And so, we always want to make sure we don't miss that when we're doing a staging surgery.

And in a more advanced stage of the disease, if it's not a stage I, then stage II and higher are often treated with a combination of chemotherapy and radiation. And more recently, we've started to look into the use of immunotherapy in conjunction with chemotherapy and radiation to see if we can get even better results.

Host: What kinds of genetic factors are at play when it comes to this kind of cancer? I feel like what I understand, just kind of anecdotally, is that it does not behave exactly the same as other cancers, that it is not genetic. Do I have that right?

Diana English, MD: You do have that, right? Yes, it's not genetics. So, the biggest risk factor is high-risk HPV, like having high-risk HPV. Other risk factors include things that affect your immune system. So, there's this delicate interplay between the HPV virus and your immune system. Our immune system is always trying to suppress the virus, prevent it from causing these precancerous changes that with time could lead to cancer, usually have several years, but if your immune system is weaker, so if you're a smoker, if you're immunosuppressed, if you have HIV, other things that weaken your immune system, then you're much more likely to have that progression after having high-risk HPV, having that progression from early kind of dysplastic changes to cancer.

Host: Okay. And how recoverable is a patient after having had cervical cancer? Is it the kind of thing that they can bounce back from?

Diana English, MD: Yeah. So, that's a great question. So, most women with cervical cancer nowadays, it's picked up early, especially if they're following up with their GYNs, getting regular Pap smears, we are able to pick things up really early. In the more advanced stages, the treatment tends to be more intense. In the earlier stages, the option primarily would be surgery, but certainly there's still the option of chemoradiation. Chemoradiation tends to be a bit tougher in some aspects on a patient. Certainly, if it's a younger woman, her sexual function is more likely to be affected than if she had only had surgery.

So for younger women, the quicker we can pick things up and we can do surgery. And if we can avoid radiation, they'll probably have a better sexual function than if they had to receive chemotherapy and radiation. But even the patients that have to receive chemotherapy and radiation, depending on the stage, stage II, stage III patients, over 70% of them will be cured. And so, you're looking at life after cancer treatment and what does that look like? Certainly, sexual function from the standpoint of having radiation affect the vagina, but then also the effects sometimes on the hormones, the ovaries have been affected, so sometimes there are hormones, they don't have the normal hormones in terms of the amount it's circulating in their body anymore because the ovarian function has been affected.

And so, being in a facility where they can get good supportive care, ideally at the time of the cancer diagnosis, considering having a palliative care physician or team, start to talk with that patient about the emotional and psychological effects, and then also managing any sexual dysfunction, any hormonal changes that might be happening that are hitting the patients hard, different menopausal symptoms that may happen. So, getting good supportive care in conjunction with the cancer care. So in addition to you getting your typical chemotherapy, radiation, or immunotherapy for the cancer, getting good supportive care is probably the best thing to ensure that patients have the best overall experience, the best quality of life. Again, most of these patients will be cured, so we want them to maintain their quality of life and have a good outlook that, or survivorship beyond cancer continues to be one that is filled with more good days than bad days. Good quality of life.

Host: That seems like a very good note to end on. Thank you so much, Dr. English, for all your expertise.

Diana English, MD: My pleasure. Thank you for having me again.

Host: That was Dr. Diana English, gynecologic oncologist at Holy Cross Health in Fort Lauderdale. To schedule an appointment, visit holycross.com/drenglish. And thank you for listening to Thrive with Holy Cross Health.