Your Health

The incidence of sexually transmitted diseases in the United States is widespread. The human papillomavirus (HPV), which causes genital warts, is one of the most common sexually transmitted diseases, although it is the least publicized.  About 20 million Americans have the HPV virus and about 5.5 million people are infected yearly, according to the Centers for Disease Control and Prevention. These statistics are profoundly serious for women because HPV is one of the leading causes of cervical cancer.

HPV affects an estimated 50% to 80% of sexually active women at least once in their lifetimes.^1,2 More than 50 known types of HPV can affect the genital area. Of these 50 types, six account for almost 80% of cervical cancer cases.³ A  single HPV type (type 16) is responsible for about 50% of the cancers.⁴

Cervical cancer occurs in the cervix, a part of the uterus, when cells begin to grow abnormally. The cervix connects the uterus to the vagina, which leads to the outside of a woman’s body. These wayward cells can be detected early by regular screenings. Cervical cancer screening saves lives but many women do not have regular cancer screenings.  Basically all cancers of the cervix, including nonsquamous tumors (adenocarcinomas), are related to chronic HPV infections. Vaccines are in development (and could be available as early as 2005) that will reduce the incidence of this disease, although it will take many years to vaccinate the population and actually see a reduction in cervical cancer rates. In a recent study, a vaccine based on HPV 16 virus-like particles (VLPs) was tested in a placebo-controlled trial with young women in the United States. The vaccine was found to prevent 100% of HPV 16 infections and HPV 16-associated cervical intraepithelial neoplasia.⁴

PREVENTION AND EARLY DETECTION

The most reliable way to avoid transmission of STDs is to abstain from sexual intercourse, ie, oral, vaginal, or anal sex, or to be in a long-term, mutually monogamous relationship with an uninfected partner. Other methods include using the male or female condom. More than 30 types of HPV can infect the genital tract. In addition to the external genitalia (penis, vulva, scrotum, perineum, and perianal skin), genital warts can occur on the uterine cervix and in the vagina, urethra, anus, and mouth. HPV types also have been associated with abnormal vaginal, anal, and cervical cell production and squamous cell carcinoma.⁵

The American College of Obstetricians and Gynecologists (ACOG) states that cervical cancer screenings (Papanicolaou smear screening or Pap test combined with HPV DNA testing) should start by the time a woman is 21 years old or after becoming sexually active.⁶ All women 30 years old or younger should get cervical cytology (cancer) screening at least every 2 years. Women 30 and older who have had three normal Pap tests in a row do not need to get screened yearly and should be screened for cervical cancer about every 2-3 years.⁷ According to American Cancer Society (ACS), women age 70 and older who have had three or more normal Pap test results consecutively and no abnormal test in the past 10 years may stop getting Pap tests. The ACOG recommends that women over 70 should still get Pap tests every 2 to 3 years. A physician can tailor a plan for each individual. As an alternative, the newer liquid-based Pap test can be used every year or every 2 years and is more accurate.⁸ Liquid-based cytology refers to a new way to process Pap test results. Instead of smearing the sample on a glass microscope slide, the cervical cells are placed in liquid in a small bottle. Some of the liquid is placed on a slide and then examined under a microscope.

If you had a hysterectomy to treat cervical cancer or if you had a hysterectomy leaving your cervix intact, you should continue having regular Pap tests. If you had a hysterectomy to treat precancerous changes in your cervix, you should continue with regular tests for at least a few years after the surgery.  If you had a total hysterectomy (the entire uterus, including the cervix was removed) for a reason other than cancer or precancer, you may not need to have the Pap or HPV test any more. Always check with your physician.

DIAGNOSIS AND TREATMENT

Cervical cancer or early cervical precancers often have no signs or symptoms, therefore regular Pap tests are vital. Symptoms may include: unusual discharge from the vagina, blood spots or light bleeding in between menstruation, or bleeding or pain during intercourse. Early diagnosis can result in successful treatment.

Treatment depends more on the severity of the disease (staging) than the cell type (grading). In the United States the majority of cervical carcinoma patients are diagnosed with early stage disease, meaning they can be treated with surgery or radiation (RT) alone.⁹ Surgical treatments include: cervical conization; vaginal or abdominal hysterectomy; radical abdominal hysterectomy, including lymph node removal; or the new radical trachelectomy, where the upper uterus is preserved for future pregnancy. Advanced cases may require internal or external radiation, or chemotherapy.

ADVOCACY

In 1999, an organization—the Alliance for Cervical Cancer Prevention —was formed to clarify, promote, and implement strategies for preventing cervical cancer in developing countries. Alliance projects are concentrated in regions where cervical cancer incidence and mortality are highest, including sub-Saharan Africa, Latin America, and South Asia. More than 20 Alliance-funded research and demonstration projects have been implemented in 17 countries. The numbers of cervical cancer deaths around the world underscore the demand for such programs.  This preventable disease kills an estimated 274,000 women every year, affecting the poorest and most vulnerable women and sending a ripple effect through families and communities that rely heavily on women’s critical roles as providers and caregivers.¹⁰

A California bill, SB 315, authored by Democratic Senator Liz Figueroa, calls on state health programs such as Medi-Cal to test women for HPV. The bill recommends the state seek funding from foundations and other nongovernmental sources to add HPV screening to women’s annual checkups.  Fourteen states have passed bills geared to reducing cervical cancer.¹¹

SUMMARY

Prevention and early diagnosis can reduce morbidity and mortality of cervical cancer. If diagnosed, a woman should seek aggressive treatment. In addition, it is important to seek support. There are many resources available to help deal with the physical, sexual, or emotional issues.

REFERENCES

1. Koutsky L. Epidemiology of genital human papillomavirus infection. Am J Med. 1997;102:3-8.
2. Crum CP, Abbott DW, Quade BJ. Cervical cancer screening: from the papanicolaou smear to the vaccine era. J Clin Oncol. 2003;21:224-230.
3. Galloway DA. Papillomavirus vaccines in clinical trials. Lancet Infect Dis. 2003;3:469-475.
4. Gravitt PE, Shah KV. A virus-based vaccine may prevent cervical cancer. Curr Infect Dis Rep. 2005;7:125-131.
5. Sexually transmitted diseases treatment guidelines 2002. Centers for Disease Control and Prevention. MMWR Recomm Rep. 2002;51:1-77.
6. Jin XW, Zanotti K, Yen-Lieberman B. New cervical cancer screening strategy: combined Pap and HPV testing. Cleve Clin J Med. 2005;72:141-148
7. Sirovich BE, Woloshin S, Schwartz LM. Screening for cervical cancer: will women accept less? Am J Med. 2005;118:151-158.
8. Bernstein SJ, Sanchez-Ramos L, Ndubishi B. Liquid-based cervical cytologic smear study and conventional Papanicolaou smears: a meta analysis of prospective studies comparing cytologic diagnosis and sample adequacy. Am J Obstet Gynecol. 2001;185:308-317.
9. Lanciano RM, Won M, Coia LR, Hanks GE. Pretreatment and treatment factors associated with improved outcome in squamous cell carcinoma of the uterine cervix: a final report of the 1973 and 1978 patterns of care studies. Int J Radiat Oncol Biol Phys. 1991;20:667-676.
10. Parkin DM, Bray F, Ferlay J, Pisani P. Estimating the world cancer burden: Globocan 2000. Int J Cancer. 2001;94: 153-156.
11. Vesely R. Figueroa proposal targets cervical cancer. Available at: www.nccc-online.org/news_022405.php . Accessed March 13, 2005.