Dr Warner Huh (Host): Hello, everyone, and happy new year. This is Dr. Warner Huh again, the Chair of the Department of Obstetrics and Gynecology here at the University of Alabama, Birmingham. And I'd like to welcome you to this new monthly episode of Women's Health with Dr. Huh.

So today, we're going to talk about something that is clearly dear to my heart. And for the listeners out there, you may not know that I've spent almost my entire academic career on this topic. And so, my guest today is someone that's also dear to my heart because she and I share the same vision. But today, we're going to talk about cervical cancer prevention and this new program called Operation Wipeout.

And so, with me today is Dr. Isabel Scarinci, who is a professor in the Department of OB-GYN and the Vice Chair of Global and Rural Health in our department. She's a psychologist by training, has been at UAB for many, many years, and has contributed enormously both at the national and global level as it relates to cervical cancer prevention, which includes things like screening and HPV vaccination. So, welcome to the podcast, Dr. Scarinci.

Dr Isabel Scarinci: Oh, happy to be here.

Host: So, as I mentioned earlier, you and I probably collectively have spent almost over 40 plus years on this topic of understanding how we can reduce the incidence and the mortality of cervical cancer, or more importantly, improve the lives of women and reduce the suffering related to cervical cancer. So, you and I have had many, many conversations and have done a lot of great work together. But let's just talk about cervical cancer prevention at a high level because I think some of our listeners may not understand the components of this, including what we call primary prevention, which is vaccination against HPV, and then secondary prevention, which is really screening.

I think most women who are listening to this understand what a Pap smear is. They may not understand what the history of the Pap smear is. And some, women, and I think you and I agree on this now, may not even know why the Pap smear is being done. but can you just talk a little bit about, how much of a difference both screening and HPV vaccination has made against cervical cancer, both in the U.S. and internationally?

Dr Isabel Scarinci: You and I have gone back a long way, and I think the work we have done and others is really the interdisciplinary work that where we need the GYN oncologist, we need the public health practitioners, and we need the clinical psychologist that can contribute to how we engage women and children. We'll be talking more about that in those behaviors of vaccination and screening. And I think for us who have dedicated a career to eliminate this cancer, I think we're getting there, because we can confidently say that this is a cancer that we've pretty much figured out A to Z and now is in the hands of the civil society and women and families to access the tools we have. I don't think we can say that for any other cancer.

Host: I totally agree and to kind of add some additional context to that for our listeners, you know, the pap smear, which I think most women is synonymous with gynecologic care in the United States when it was introduced after World War II, has reduced the rates of cervical cancer in this country by at least 75%. And, you know, there was a time where cervical cancer was much more common than breast cancer. So, there's no question that we've had this incredible impact. And then, the HPV vaccination was FDA approved in 2006. I can't believe it's already that long ago. And we have countries like Australia who are making very broad predictions, probably accurate ones, where they will largely eliminate cervical cancer from their country because of HPV vaccination and changes in screening practice. And I really want to highlight something you just said, which is we cannot make this claim for any other cancer out there right now. And nothing would make me happier when I retire, where medical students read about cervical cancer as a distant entity in a textbook, kind of similar to let's say smallpox or similar to polio, right? I mean, to me, it's incredible to be a part of this campaign where we can literally try to work to eliminate cervical cancer and hopefully its precursors. So, I don't know if you have anything further to add to that.

Dr Isabel Scarinci: No, I think it's important for the listeners to kind of see why we say that we have figured out A to Z. You're right. If you think of Pap in 30 years between the '50s and '80s, you know, went down over 70%. But then, scientists, about 30 years ago, another 30 years, found that HPV, human papillomavirus, is the cause of most cervical cancers. That opened the doors for us to talk about elimination, because we need now to vaccinate children and adolescents to prevent them from getting this virus. And women get screened, so they can also prevent pre-cancer and cancer.

Host: You're exactly right. The impact of the vaccine has been enormous. So, there was no question that when the vaccine was approved by the FDA and the clinical trials, how effective it was in protecting against HPV infection, which like you said, and I want to underscore this for our listeners, persistent HPV infection is the precursor or the risk factor for developing cervical pre-cancer and cancer. That is undeniable now and we know that. So if you can prevent HPV acquisition and persistence, you will then break the cycle in terms of the risk of developing cervical cancer down the road. But the important thing is that we've got to vaccinate.

And as I mentioned, the vaccine has been around since 2006. We're on the sort of the second generation of the vaccine. And I think the things that I think people really struggle with is things like safety. I think we've demonstrated that this is an extraordinarily safe vaccine. But for our listeners yet again, it's an incredibly effective vaccine and one that I know that will change the lives of millions of women over the next 50 years if they're actually vaccinated.

So, some of our listeners may not be aware of sort of the newer changes that are related to cervical cancer screening. I think that there are probably tons of listeners out there who still think that women need to get a Pap every single year. And I think we have drifted away from that quite a bit. But you and I have been very involved in this concept. Now, it's more than a concept. It's actually a true screening paradigm called primary HPV screening. So, first off, can you tell the listeners, A, what that is, and B, why is that important for women, let's say, in 2024?

Dr Isabel Scarinci: So, now that we know that it's a virus that causes cervical cancer, and you need to be infected with the virus, and then that virus needs to persist and then develop to pre-cancer and cancer. So, the Pap test look for changes in the cells. But now, the HPV testing look for presence of the virus, so that then women who are positive for the high-risk HPV can followup more closely with their provider. So, that's what primary HPV testing is, is that we can detect the presence of the high-risk virus even before it causes any changes and gives the opportunity for women to follow up more closely. The odd good news for us women is that then we can increase the intervals. We don't need to go as often if we are HPV negative and we have that assurance that we are okay and don't need to go every year, that I'm sure no women enjoyed that exam.

Host: So, this is the thing about screening that I think is really important for listeners and women to know, is that the power of prediction of a negative HPV test is so profound. We know that the risk of developing cervical cancer over an extended time frame with a negative HPV test is incredibly small. And remember, when most women get screened, they screen with a negative test. So, being able to tell a woman, yeah, your HIV test is negative, the profound reassurance that we have to tell a woman that they're likely going to be very okay for at least probably the next five plus years is extremely high.

But the other thing, and I think, I know you agree with this, is for our listeners, and I just want to make sure that they're aware of this, is that even though the Pap has done an incredible job of reducing rates of cervical cancer, it's no longer that effective as a screening test by itself. And, you know, there's this thing called sensitivity, and it's really a measure of test performance, but what it tells us is really the reflection of the false negative rate. So if you get a test, how often is that result falsely negative? And that sensitivity is actually quite low for Pap.

And so, for our listeners and patients out there, if you're still getting just the Pap alone, you probably need to ask your provider why. Because I'm going to tell you right now, you're probably not getting the best contemporary screening test, and I think it's really important. The good news, at least here in the state of Alabama and the United States, the majority of providers are using HPV testing, but they're doing it in combination with PAP testing, which is fine. But if you're out there and you're only getting a PAP, you need to ask your provider why, because, really, they need to add HPV testing.

So, I'm going to ask you something that really builds up on this concept of using just HPV testing as a screening test, which is something called self-sampling. And I'll be honest with you, Isabel, you're like literally one of the very few experts in the world, in the US, on this topic. Can you just tell the listeners and the audience, A, what self-sampling is, B, why it's important, and this is the hard one, when you think we might see that come into mainstream use, basically?

Dr Isabel Scarinci: Yeah, that's what is amazing about science. Once we discovered that HPV is the cause, then we have the HPV testing, as you mentioned, that's the most effective, screening for cervical cancer. Then, another technology became available, that is the opportunity for women to collect their own sampling for HPV testing. Our group here at UAB, in collaboration with the National Cancer Institute, was one of the first groups to research this approach in the US almost 20 years ago. So, we have been doing that work along with others for 20 years and has shown to be effective in many studies around the world. Women do it as well as a medical provider. They can do it at home, and the results are the same as if a medical provider collected the sample. So, that is an amazing opportunity for women who have busy schedules or are reluctant to come in.

However, it's not yet approved by the FDA in the United States, so it's not yet available to the public until this approval is obtained, which for someone who has been doing this work for 20 years and have seen the results for our work and others is disappointing. And I hope it will be approved soon, because the World Health Organization already endorsed self-sampling and recommends self-sampling as an option for women who are not coming into the clinics. So, can I tell you when it's going to be approved? I don't know,

Host: I know intentionally I was putting you on the spot because I know obviously the answer to this question, but many of our audience doesn't, and I want to make sure they understand this. And I hope the audience understands the utility, the value, and the power of having a test where a woman can actually get their screening test at home, built on HPV testing that we know is a powerful risk predictor for developing cervical cancer. And I think in this country, our problem still is that we're not screening enough women. We're not screening and treating enough women and not much has changed in the last 30 years. So, the intent here is really to screen more women and give them access to that screening so that for people who have an abnormal test, then we can then take those resources and bring them in. But if women are not getting screened at all, then we're not making that real difference that we need to make.

So, I'm hoping that one day in the near future that self-sampling will be approved by the FDA and that you and I will be doing a separate podcast on this whole topic. But I think it's a game-changer. It's a game-changer certainly for the women and the citizens of the state of Alabama where healthcare access and provision can be limited, and so it's really important. I don't know if you have anything further you want to add to that.

Dr Isabel Scarinci: And very much needed, because if you look at the data for our own state, Alabama, cervical cancer mortality is the same today as 1999. So, women who are getting screened come in, they're getting screened, but there is a group out there that are not being screened and we need to find alternatives for these women.

Host: I couldn't agree with you more. So, I'm actually now excited to go to my next question, which is this thing called Operation Wipeout. And literally, we could spend a full hour talking about Operation Wipeout, but could you tell the audience what this is, maybe a little bit about the history behind it, what you've learned so far, the goals, and what you're most excited about?

Dr Isabel Scarinci: Well, you and I have worked together on this for a long time, and I think Operation Wipeout is a dream coming true. We can do the research. We can train our residents, our fellows, to provide the best care they can. But we need to get these tools, HPV vaccination, screening, and appropriate followup out there. And this has been a frustration of mine that we haven't done a great job to get those tools there. They're free, because most the health insurance cover HPV vaccination and screening. And if not, we have federal programs who pay for that. So out of that, we have mobilized organizations here in Alabama and people to do something about it.

And in collaboration with Rotary Club of Birmingham TogetHER for Health, Alabama Department of Public Health that has been a champion in this effort, Quality of Life Health Services, American Cancer Society, we came together, and did a summit where we brought providers from all over the state to listen to them. We didn't have a single talk, we really want to listen to the solutions, because it is unacceptable that Alabama has one of the highest incidence and mortality. And we need to go beyond our role as researcher or practitioner and find the solution for that problem.

It was an amazing experience as you were so much part of it, as you saw, has been one of, if not the most rewarding, experience in my entire career. And this is the group from all over the state, providers in rural Alabama, most of our counties are rural. They came up with an elimination plan, which to me is amazing. And then, our state health officer has been very much behind this and launched this plan last May. And now, we are the first and only state in the United States to have an elimination plan that is not led by one organization, but all of us working together. And many things that we have done in less than a year has been really amazing and more partners are coming together. So, this shows that it's not so much about putting money on the table, but really engaging the right people toward a mission, because everybody now has a role in cervical cancer prevention control. If you're a mother, you need to vaccinate your kids. If you're a business owner, you can let your employees off time for women to get screened or vaccinate their kids. So now, it's really in the hands of civil society and that's what Operation Wipeout is about. We have a written plan. It's evidence-based and that's where we as academicians come in, because we can show what is evidence-based and what's not and then have these other organizations to implement that plan and really move toward elimination. So for the first time, we can really talk about elimination of a cancer in Alabama. And I couldn't be happier.

Host: You know, I think for many of us, whether it's in our personal lives or professional lives with our friends and families that we have these aha moments. And for me, I had my massive aha moment when we started to civilly engage all of our partners related to one concept, which is elimination of cervical cancer. And I think that's, what's exciting. And again, to just highlight what Dr. Scarinci said is that this is the only state-based campaign of its kind. And Dr. Scarinci is incredibly humble, and will not say this, so I'll say this on behalf, but this whole concept and this program has been picked up by the World Health Organization. It's been picked up by the CDC. It's been further recognized by the American Cancer Society. And we have other states who are coming to us and trying to emulate something that we've built here. So, I'm extremely proud. But we still have a lot of work to do. And that's why I wanted to start off this year 2024 with this podcast, to create incredible awareness related to the campaign and to Operation Wipeout and just cervical cancer prevention, because there's so much more that we can do. And again, I don't know if you have anything further to add to that, Isabel.

Dr Isabel Scarinci: Everybody has a role. You can reach out to us, Heather White, the Executive Director of TogetHER for Health, says it's a conga line. Just bring a gift, and we will welcome you. And I want to see the end of this disease in my lifetime.

On a personal note, I had polio. You mentioned polio earlier, and if you told my mother in 1963 when I had it that we would see the end of that disease in the world when we had an epidemic, she probably wouldn't believe you, and look where we are today. So for me, it is a personal commitment because to see the end of two diseases in my lifetime. Not many people can say that.

Host: I'm glad we're not doing this on video because if we did, people would see tears in my eyes just by that statement. But do you want to just comment just what UAB's general role and involvement has been in cervical cancer screening intervention as it relates to the state of Alabama, the U.S., and globally? I thought you might just want to briefly highlight the achievements of this institution when it comes to this topic.

Dr Isabel Scarinci: I think I'm so proud of being part of this institution because a lot of times for somebody who is, now you know my age, if I had polio in '63, I was eight months old. So, to see an academic center that is not only committed to research, that is our responsibility because we need to get the evidence-based strategies there and will continue to be. And we have done the research. Dr. Huh, you were involved in the development of the preventive vaccine and now the therapeutic vaccine. So, we need to continue that work.

It is our responsibility to train the residents and the medical students and the fellows to be the best they can, not only medically, but also from a health equity lens, and we are doing that. But the piece that always is missing in many academic centers that I think we are very innovative is this social responsibility. And I think Operation Wipeout and other efforts that we are doing represent what good does it do if we get the tools like HPV vaccination and screening and we don't get the tools to the ones who need the most.

That is something that we as an institution have given, and our department in particular, have given a lot of thought to that under your leadership. And I think we are doing it and we need to keep reminding ourselves. That is our job to get those tools there. We can't stop at just teaching and doing the clinical service, because what I found with Operation Wipeout that's I should have had that insight earlier, is that we give credibility to the effort because it comes from an academic center. So, everybody brings their credibility to the table and we don't do that a lot outside our medical walls here. So, that's what our department is doing and I'm very proud of. And I think we need to keep saying that publicly because by saying it, it makes us accountable and we will continue to do so.

Host: Thank you. And I appreciate those kind words, but I couldn't agree with you more. And you know, for me, in my long time at UAB, this is definitely one of the massive highlights. And it's just a lot of fun and really gratifying to engage the community around something like this. It warms my heart, but it brings a lot of validation to what we do every day. It really, really does. But I appreciate what you commented on.

Anyway, I want to thank Dr. Scarinci for giving us this amazing introduction to Operation Wipeout and its role in cervical cancer prevention in the state of Alabama. I'm hoping in the next year or two I can invite her back so she can give us an update in terms of where we are with Operation Wipeout.

But as always, please rate this podcast and we welcome any comments that you might have, particularly on topics that you all are interested in. And for more information on our women's health and OB-GYN services here at UAB and other clinical services that UAB provides, please check out uabmedicine.org. And until next time, thank you. Have a great day. Again, happy new year. And we'll see you next month. Take care. Peace out. Bye bye.