Transcription:
Importance of Gynecologic Screenings

Melanie Cole (Host):  Welcome to Back to Health, your source for the latest in health, wellness and medical care, keeping you informed so you can make informed healthcare choices for yourself and your whole family. Back to Health features conversations about trending health topics and medical breakthroughs from our team of world-renowned physicians at Weill Cornell Medicine. I’m Melanie Cole and today we’re discussing the importance of gynecologic screenings. Joining me is Dr. Evelyn Cantillo. She a Gynecologic Oncologist, an Assistant Professor or Obstetrics and Gynecology at Weill Cornell Medicine and an Assistant Attending Obstetrician Gynecologist at New York Presbyterian Weill Cornell Medical Center. Dr. Cantillo, it’s a pleasure to have you join us today. Please start by telling us the importance of gynecologic screenings for women and what types of cancers are considered gynecologic cancers?

Evelyn Cantillo, MD, MPH (Guest):  So, in terms of gynecologic cancers, or cancers that affect the woman’s reproductive system, there’s cervical cancer, uterine cancer, ovarian cancer, vaginal cancer and vulvar cancer. Unfortunately, we do not have great screening for either uterine which is also known as endometrial cancer, ovarian cancer or actually vaginal or vulvar cancer. But we do have very good screening and have made really big strides with cervical cancer screening. So, cervical cancer is actually the third most common gynecologic cancer diagnosis and cause of death among gynecologic cancers in the United States. In the Unites States, approximately 14,000 new cases of invasive cervical cancer and 4300 cancer related deaths occur. It’s estimated to occur in this next year. In some parts of the world, that are considered resource poor, cervical cancer is actually the leading cause of cancer related mortality among women.

Over the past 50 years, there has been a 75% decrease in the occurrence and death from cervical cancer due to screening programs.

Host:  Wow, those are some pretty important statistics. Dr. Cantillo, so at what age and how often should women start getting gynecologic screenings?

Dr. Cantillo:  I’d like to maybe separate the gynecologic screenings from initiating gynecologic care. Because they are two separate things. And gynecologic care can be initiated very early on even before we start doing actual screening let’s say for cervical cancer. I think that the beauty of gynecologic care is that you can go on this journey with a woman throughout the course of her life from before she is actually having periods and then is having periods and maybe is starting to become sexually active to reproductive age to being postmenopausal. So, you can actually start gynecologic care early in the teenage years even though that overlaps a little bit with some of the pediatric care that some of these patients have.

In terms of gynecologic screenings, I’m really talking about PAP smears, the recommendation is to start PAP smears at the age of 21 years old. And that’s in women who are what we call immunocompetent so someone who doesn’t have an immune system problem that’s not suppressed, not taking medications for immune suppression which is sometimes seen in some diseases where they are on steroids for a long amount of time or in someone who has HIV. So, in someone who doesn’t have any of those conditions and is considered immunocompetent, they should be starting gynecologic cervical cancer screening at the age of 21.

Host:  What are some of the most common symptoms? I think this is such an important question Dr. Cantillo, women always want to know what are some of the common symptoms that we might experience? How do we know? What would send us to our doctor? If we’re going for our yearly, but if we have symptoms and some of them are so nonspecific, some of them are normal symptoms women just have anyway. So, tell us about some symptoms that would send us to our doctor, some red flags.

Dr. Cantillo:  Like you mentioned, unfortunately, we do not have great screening for some of these cancers. Especially for ovarian cancer. I’d say I’d like to highlight that one a little bit more just because when we do diagnose it, it tends to be at a more advanced stage and that’s because the symptoms are very vague and includes bloating, early satiety, which is getting full with smaller amounts of food than normal, and just general malaise, not feeling well. However, as you can hear those are very nonspecific and so, one thing I always encourage women to do is just listen to their bodies. There’s a difference between bloating that’s intermittent or might happen in relation to food and that could be caused by diet versus something that is consistent, something that is persistent. And so it’s not related to anything and you’re just feeling that way over an extended period of time.

In terms of endometrial cancer, while we don’t have great screening for it; actually it presents – symptom or a sign and that tends to be postmenopausal bleeding. So, women who are postmenopausal and that’s defined as not having a menses or a period for greater than one year are considered postmenopausal. Postmenopausal bleeding is never normal, and I think I can’t stress that enough. A lot of women do not know that. But postmenopausal bleeding is never normal, and it always requires a workup and that’s either going to the gynecologist or going to a primary care physician, whoever you can get in to see first because they can start some of the testing we would need like an ultrasound or even a biopsy in that situation.

In terms of endometrial cancer, women that are actually obese, tend to be at greater risk because that is a risk factor for endometrial cancer as well as women who may have what we call unopposed estrogen, so maybe go for long periods of time without getting a period like three or four months without getting a period and then kind of cycle like that, that is also a risk factor. There are some genetic kind of relationships for endometrial cancer like hereditary syndromes that I could talk about that a little bit later.

In terms of cervical cancer, like I said, we have great screening for it, however, a sign or symptom of cervical cancer could also be postmenopausal bleeding or something we call postcoital bleeding which is bleeding after intercourse. If that happens persistently that should be evaluated.

For vulvar cancer, also postmenopausal bleeding. Most of these conditions actually happen in women who are older, but they can also have pain or itching, and the vulva is just the skin on the outside, essentially before you go into the vagina. That’s called the vulva.

Host:  What an excellent explanation. That was so comprehensive Dr. Cantillo. So, then speak a little bit about the risk factors for these types of cancers and what role inherited trait plays in developing gynecologic cancers.

Dr. Cantillo:  So, like I was mentioning before, risk factors for endometrial cancer tend to be related to what we call unopposed estrogen. So, women who are obese essentially end up having effects of unopposed estrogen because the extra weight actually converts into a form of estrogen that can affect the uterine or endometrial lining. There are certain medications such as tamoxifen can increase – it’s a small increase but can increase the risk of endometrial cancer and tamoxifen is a medication that’s used for women with premenopausal breast cancer. And so, that is something that we just need to be aware of as well. Like I was mentioning before, women who may be have these episodes of not having periods for a few months at a time so like every three or four months they have menstrual cycles that could also be some unopposed estrogen that they are getting and that can increase their risk.

 Those are just some of the risk factors as well as having a family history. So, if you have a family history of colon and endometrial cancer, that could actually be indicative of something called Lynch syndrome which is a genetic hereditary syndrome where you have an increased risk of not just colon and endometrial cancer but also ovarian cancer. And the risk of endometrial cancer in this Lynch syndrome can be as high as up to 60% which is very high. And usually we are able to get an idea of family history and if there are enough people within what we say like a pedigree or your family history, you might warrant genetic counseling and testing. But that’s something that’s determined at the time of a visit when we’re getting medical history.

In terms of ovarian cancer, we know that somewhere between 15 to 25% of ovarian cancers are hereditary. People are mostly familiar with the BRCA or BRCA genes but this work in genetics continues to evolve. Studies suggest that a woman who has one first degree relative so a mother or a sister with ovarian cancer they have approximately a three to five percent risk of ovarian cancer over their lifetime which is even higher than what the general population risk is and that’s a little less than two percent.

Host:  Well you mentioned the BRCA gene. So why don’t you expand on that just a bit for us and if you test positive how does that affect a woman for potentially getting a gynecologic [00:09:21] Speak about the BRCA gene mutation.

Dr. Cantillo:  Absolutely. So, the BRCA mutation, there are actually two of them. There’s BRCA 1 and BRCA 2. And the BRCA gene mutation is associated with both hereditary breast and ovarian cancer and I’ll speak about the ovarian cancer risk here. So, for a patient with a BRCA 1 mutation, their risk of ovarian cancer is as high as 40 to 45%. And if you remember, I mentioned that general population without any kind of genetic predisposition, no family history, no risk factors at all, general population risk is a little less than two percent. So, we are talking like an exponential increase in the risk of ovarian cancer for patients with the BRCA 1 mutation. And for BRCA 2 it would be up to about 20%. Additionally, BRCA 2 carriers have increased risk of other cancers such as a certain type of melanoma or skin cancer, pancreatic cancer and prostate cancer in males.

Host:  Well while we’re on this subject then and we’re talking about BRCA gene mutations and these cancers, tell us about HPV. We’re hearing more and more about it. It’s relationship to cervical cancer. Tell us a little bit about HPV, the vaccination that we’ve heard about. Tell us about that.

Dr. Cantillo:  I’m so happy you asked about this. So, yes, HPV actually HPV is human papilloma virus and it’s a fairly common virus that is passed on through skin to skin contact. It infects the skin and any moist membrane like the cervix, or the throat for example and it is sexually transmitted. However, it is like I mentioned, common. HPV has two classifications. And one is low risk, and one is high risk. And that’s important because the high risk HPV types are the ones that are associated with cervical cancer.

So, I’ll focus on that a little bit more. In the high risk category, there’s HPV16 and that accounts for approximately 50, 5-0 percent of cases of cervical cancer. And HPV18 which accounts for another 20% of cervical cancer. So, these two high risk types of HPV actually account for about 70% of the cervical cancers that we know about. There are an additional five or six other HPV subtypes that account for another 20% of the cervical cancer that are reported.

In terms of low risk, those low risk HPV tends to be associated with genital warts.

Host:  Now what about the vaccination itself? Who should be getting it? What age? Is it boys and girls? Tell us a little bit about the vaccination and if someone is too old to have been vaccinated; then do they still get their regular PAP smears? Is the schedule changed a little bit? Tell us about the recommendation for PAP smears and the HPV vaccine.

Dr. Cantillo:  So, there are three different HPV vaccines but only one of them that’s used in the US at this point. So, I’ll focus on that one. In the United States we have the Gardasil-9 and the Gardasil-9 actually targets the HPVs that I just discussed so 16 and 18 which we know make up about 70% of the cervical cancers that we diagnose as well as all those additional ones that contribute the other 20%. In addition to that, it also includes two low risk HPVs that cause genital warts. So, it has a pretty comprehensive actually. Routine HPV vaccination is recommended at 11 to 12 years old. It can be administered starting at age 9 and is recommended in both boys and girls.

For adolescents and adults age 13 to 26 who haven’t previously been vaccinated or who haven’t completed their vaccine series; they can actually catch up. And I’ll explain what that is. The optimal time for HPV immunization or vaccination is prior to the initiation of sexual intercourse. That actually gives us an amount of response against a potential HPV infection that can occur through sexual intercourse. Individuals who initiate the vaccine series before 15, before the age of 15, the recommendation is for two doses of the HPV vaccine that should be given at zero and at six to twelve months. So, you get one at let’s say today, you get one vaccine and then either six to twelve months from today, you’d get the second one.

For individuals who are 15 years or older, the recommendation is for the three doses of HPV, the vaccine and that’s given let’s say today, so at time zero and then one to two months from now, so that would be the second one and then at six months from today. So, those would be the three shots. The minimum intervals between the first two doses is about four weeks. And then between the second and third doses about twelve weeks.

In immunocompromised patients, so patients who have suppressed immune systems for whatever reason; the recommendation is for the three dose HPV vaccine. And even if you’ve had the vaccine, you just continue with our routine kind of PAP smear guidelines that are laid out by the gynecologist. If you haven’t been vaccinated for HPV, the recommendations for PAP smears do not change. If you have been vaccinated, the recommendations still don’t change. So, you continue with routine gynecologic care.

Host:  Dr. Cantillo, women get cysts and fibroids and other growths. Are these a precursor for cancer? I mean I get them myself. It’s very worrisome. Tell us about some of those cysts and fibroids and things that we get.

Dr. Cantillo:  It is worrisome but actually fibroids are very common and the risk of a fibroid having what we call malignancy generation which is converting into cancer is less than one percent. So, that is an astronomically low risk. In terms of cysts, cysts are also very common. And not all cysts are the same. So, if there is a question of a cyst, we actually can use out ultrasounds and our imaging to help guide what our management should be.

Host:  And then tell us a little bit about women’s survivorship. As that continues to grow, where do you see the coordination of care between our gynecologic oncologists such as yourself, the patients own OB-GYN to allow for this continuum of care for women which is so important?

Dr. Cantillo:  It is a really important question. And sometimes patients have excellent relationships with either their gynecologist or their primary care physician who referred them to us and so, if there’s a way for us to coordinate our care with the general gynecologist or the primary care physicians, that is always something that’s encouraged. Also I really do recommend a patient continue with a primary care physician because they also take care of all the other things, cholesterol, thyroid, all the other things that keep us healthy. Our goal is to cure you of your cancer and make sure that you’re healthy, but we want to make sure that kind of expands into every field.

Host:  As we wrap up, and what an informative segment. Dr. Cantillo, what can a woman do if anything, to reduce her risk of gynecologic cancers and please reiterate for us the importance of those routine screenings we’ve been talking about.

Dr. Cantillo:  Women should establish care with a gynecologist they trust and feel empowered with. I think that’s very important. Women should listen to their bodies when something is wrong, and I truly believe that and should definitely follow recommended surveillance screenings whether that’s for the PAP smears for cervical cancer or mammograms for breasts and colonoscopy and everything else that keeps us healthy. I think it’s been a scary time with COVID, and people have been resistant to come to the hospital, however, I just want to make sure that people know that we are doing in patient visits and we have protocols set up so that there is enough space and enough time in between patients so that we are making sure that everyone is as safe as possible when they come in. But I would really encourage women to continue their screenings.

Host:  Thank you so much Dr. Cantillo for joining us today and sharing your incredible expertise. And Weill Cornell Medicine continues to see our patients in person as well as through video visits. And you can be confident of the safety of your appointments at Weill Cornell Medicine. That concludes today’s episode of Back to Health. We’d like to thank our listeners and invite our audience to download, subscribe, rate and review Back to Health on Apple Podcasts, Spotify, and Google Play Music. For more health tips, go to www.weillcornell.org and search podcasts. And parents, don’t forget to check out Kids Health Cast. I’m Melanie Cole.