Transcription:
Special Edition - Cervical Cancer Awareness Month

Melanie Cole (Host): On this special episode of Women's Health Wednesday, we're sharing our previous episode on Cervical Health Awareness, published on Jan 2021 and featuring Dr. Evelyn Cantillo. Our Women's Health Wednesday Series features in-depth conversations with Weill Cornell Medicine's top physicians on issues surrounding women's health throughout the life course. Listen here for the information and insights that will help you make the most informed and best healthcare choices for you.

I'm Melanie Cole and I invite you to listen as we discuss cervical health. Joining me, is Dr. Evelyn Cantillo. She's an Assistant Professor of 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 back with us again today. Please tell us a little bit about cervical cancer. How common is it?

Evelyn Cantillo, MD, MPH (Guest): It's a pleasure to be back and happy New Year. So cervical cancer is the third most common gynecologic cancer diagnosis in the United States and cause of death among gynecologic cancers. In the United States, approximately 14,000 new cases of cervical cancer are diagnosed and there are a little over 4,000 cancer related deaths that occur each 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.

Host: Wow. That's quite a statistic. So, before get into screening and such, is there anything women can do to keep a healthy cervix? Is there anything that we can do as far as lifestyle or I mean, people look at all of these different there's washes, there's all these things. Is there anything we can do?

Dr. Cantillo: I think gynecologists will always say the vagina is a self cleansing, has its own self cleansing mechanisms. So, there are no washes or anything to do. I think the best thing to keep a healthy cervix are to maintain routine gynecologic visits. So, visits with a gynecologist as well as using barrier contraception, such as condoms.

Host: That's great advice. So, now tell us about HPV and its relation to cervical cancer, because we're hearing more and more about that. I know I got both of my teen children vaccinated for this. Tell us a little bit about it.

Dr. Cantillo: So, HPV is a common virus that's passed through skin to skin contact. It infects the skin and actually any moist membranes like the cervix or throat. It is sexually transmitted. And it actually gets classified into either a low risk or high risk. When we think about low risk HPV, in relation to the cervix or gynecologically, let's say that we're thinking about genital warts, while the high-risk HPV are the ones that are virtually associated with all cases of cervical cancer. Within the high-risk category, there are two HPV strains that account for about 70% of all the cervical cancers associated with HPV.

Host: Well, then tell us a little bit about the current guidelines for pap smears and cervical cancer screening. As a woman in my fifties, I mean, we got our pap smears, every year back then, but not now so much. So, tell us a little bit about what's going on in this direction.

Dr. Cantillo: I know it's a little scary when recommendations start changing after you've been doing things in a particular way for so long. But right now, our major medical societies that guide pap smear guidelines recommend that the age to start pap smears in immunocompetent women; so women whose immune system is not suppressed either because of medication or illnesses such as HIV; the age to start pap smears is 21 years old. So, there are different guidelines that do exist. The Society of Gynecologic Oncology, the American College of Obstetrics and Gynecology, and our Association of Colposcopists which basically sets a lot of these guidelines forward, allow consideration of HPV testing starting at the age of 25. HPV testing is not recommended in women younger than 25, because it can lead to unnecessary procedures in an HPV infection that is most likely to clear. Starting at age 30, the recommendation is that from age 30 to 65, one of the following methods is acceptable. So, the first option would be co - testing, which includes doing a pap smear and HPV testing every five years.

And that's actually the preferred recommendation. The second one would be doing a pap smear every three years. And lastly, you can consider just primary HPV testing every three years for women over 25. And so that would be just doing HPV testing without the pap smear.

Host: Well, then let's talk a little bit about the vaccine itself. How has Gardasil and the HPV vaccine changed the recommendations? And while you're telling us that Dr. Cantillo, tell us who should be getting this vaccine, and if they didn't receive the vaccination or didn't finish the series, speak about the vaccine. Give us a little summary of, of what's out there now.

Dr. Cantillo: Sure. So I think I'll start by saying that vaccination status, whether you've received the vaccine or not, does not change recommendations for pap smears. They are completely the same. I think in terms of discussing the HPV vaccine, the one that's available in the United States is called Gardasil-9 and the number nine reflects the number of HPV strains that are included in the vaccine. So, they include nine of the high-risk HPV strains that are associated with cervical cancer and covers about 90% of the HPV strains associated with cervical cancer. A routine HPV vaccination is recommended at 11 or 12 years old. It can be administered starting at nine years of age. For adolescents and adults aged 13 to 26, who haven't had the vaccine before, or who have not completed the vaccine series; catch up vaccination is recommended. So, ideally you want to do it at 11 or 12. If you haven't done it at that age; anytime between 13 and 26, you are eligible to receive the vaccine.

In the United States, the HPV vaccine is actually approved through the age of 45. The decision vaccinate people in this age group, so, essentially 27 to 45, is made in conjunction with your doctor. Clinicians and patients should be aware of that HPV vaccination of individuals that are older than 27 may not be covered by insurance providers or other payors.

So, then if we go back to the first age group, so, let's say you decide that you want to get your child vaccinated at the age of 11 or 12, then that's two doses of HPV vaccine and they should be given at time zero. So, let's say it's today. And

then, the next one would be six to 12 months from now. that recommendation is

for children basically up to the age of 15. If individuals start vaccination at 15 years or older, than three doses of HPV vaccine are recommended. And that would be, let's say one now, one in one to two months and the other one in six months,

Host: So doctor, if people have been vaccinated, do they still need to get regular pap smears or is testing for HPV sufficient
 to let us know what's going on

Dr. Cantillo: if people have been vaccinated, they still need to follow the same pap smear guidelines as someone who has not been vaccinated. The vaccine is protective against HPV strains. However, we always say it's not a hundred percent, right? Nothing is a hundred percent, which is why it's important to still follow up with your gynecologist or family care practice physician or whoever does gynecologic screenings to ensure that you are following the pap smear guidelines that have been set.

Host: Well, so then let's talk a little bit about cervical cancer. Are there symptoms? Is there something that we would notice? And because, we women have so many non-specific symptoms, when would we know to go to our doctor?

Dr. Cantillo: Yeah, that's a good question. Unfortunately by the time women are having symptoms from cervical cancer, it means that the disease is large enough that we can see it on exam. And so probably the most typical symptom in someone who is premenopausal or hasn't gone through menopause, would be post-coital bleeding, which is bleeding during intercourse and usually associated with some lower pelvic pain.

That's still seems pretty non-specific, which is why pap smears are so key because it is a test that, it's such an excellent screening test that we really can avoid catching the cancer later. In women that are post-menopausal, post-menopausal bleeding is never normal, whether it's because of cervical cancer or possibly something further up in the uterus. This always needs to be evaluated.

Host: Well, thank you so much for that very important answer. So, is there a connection between HPV and oral cancers?

Dr. Cantillo: So, like I mentioned before, HPV is not only passed through skin to skin contact, it effects any moist membranes. So, the cervix and the throat. What we know is that HPV associated malignancies account for about 70 to 80% of oral cancers in the United States. And it's primarily associated with one HPV strain in particular and that's HPV 16.

Host: So, as far as counseling patients, Dr. Cantillo and addressing their concerns, and I know I did this myself with my gynecologist, what advice do you have for patients that are asking for a pap smear to ease their fears? Even though maybe the year before or two years they'd had their pap smear, they've tested negative for HPV. I'm one of those women. I asked my doctor, well, why can't I have the pap smear anyway, just to ease my fears.

Dr. Cantillo: I know it's difficult to change something that you've been doing for a while. All of the data that we have now on our guidelines for screening are based in really good evidence. So, these are population studies on tens of thousands of people looking at what the risk is of developing a cervical cancer based on your prior pap smear results or HPV results. So, we use them both. And they are important to decide kind of how you get triaged appropriately. So, just know that it is based in a lot of data. And there is also something to be said for the harm in oversampling sometimes when we know that it will not change any outcomes.

Host: Dr. Cantillo, this information is so important for women to hear. Before we wrap up, what's new and exciting in the field of gynecologic oncology? Any game-changers you want to discuss or tell us about? And also while you're doing that, please wrap it up for us with your best advice for women about the HPV vaccine and cervical cancer and everything we've discussed today.

Dr. Cantillo:  So I think, in terms of new and exciting with regards to cervical cancer, I think we're always trying to be better about not just screening. And I think we do an excellent job of screening in the United States with regards to cervical cancer. Pap smears, completely transformed our ability to catch disease early and prevent unnecessary deaths. Once someone has this diagnosis of cancer, figuring out how to treat them is always something that we strive to be better at. And I'd say in the past year there's been some, exciting data about immunotherapy in certain types of cervical cancers that express that the certain type of protein. And we have medication that may demonstrate durable anti-tumor activity. And so, that's still being investigated, but that's pretty exciting, because we are always trying to be better. And so, I think, as we start wrapping all of this up, screening, screening, screening is really important. Having a good relationship with your gynecologist goes really far in allowing you to have some type of ownership over your health.

And the HPV vaccine is effective. We know that there's been with regards to screening programs, there's been a 75% decrease in the occurrence and deaths from cervical cancer over the past 50 years, from screening programs. That's incredible. The vaccination is helping us to decrease those numbers and hopefully, cervical cancer is not the only endpoint. There are pre-cancerous changes that can occur in the cervix that need to be treated. And if we can prevent these precancerous changes, we can hopefully spare some young women from having to undergo procedures on their cervix that could possibly affect their fertility later on. It is a large net that we cast with these screening and vaccination programs.

So, please get, if you have children, please get your children vaccinated at the recommended age. If you haven't been vaccinated or are between the ages of up the age of 26, please ask about the HPV vaccination. And the other really important thing is that we know that smoking, tobacco smoke is a risk factor for the persistence of HPV infection. So, if not just for your lungs, cause it definitely helps with overall health, but also to help with being able clear HPV infection, smoking cessation is definitely recommended.

Host: Thank you so much, Dr. Cantillo for this very informative episode 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 appointment 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 weillcornell.org and search podcasts. And parents don't forget to check out our Kids' Health Cast. I'm Melanie Cole.