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What's New In Cervical Cancer

In a recent Facebook webchat, Dr. Ursula Matulonis, medical director of Gynecologic Oncology in Dana-Farber’s Susan F. Smith Center for Women’s Cancers, and Dr. Colleen Feltmate , director of minimally invasive surgery in Gynecologic Oncology at Brigham and Women’s Hospital, discussed what is new in Cervical Cancer. You can access the webchat at: http://blog.dana-farber.org/insight/2017/01/what-you-should-know-about-cervical-cancer-webchat/?utm_source=newsletter&utm_medium=email&utm_content=What%20you%20should%20know%20about%20cervical%20cancer&utm_campaign=spotlight
Here are my notes: 

About 13,000 women are diagnosed with cervical cancer each year in the US
 
Screening for cervical cancer:
·      Is a bit of controversial
·      Can be confusing even for doctors.
·      Should include screening for Human Papilloma Virus (HPV), especially for age 
           30 and over            
·      All agree women should see gynecologist by the time become sexually active
·      Now using HPV and pap test in combination for screening women over 30 yo.
 
Where do you find out about screening?
ASCCP (American Society for Colposcopy and Cervical Pathology web site (http://www.asccp.org/asccp-guidelines) guides doctors and patients with practical algorithms
 
Risk factors for cervical cancer:
·      HPV-sexually transmitted through direct contact.
·      Increased sexual partners—increases risk of HPV
·      Smoking
·      Immunosuppression—don’t clear the virus well
·      Skipping pap smears/no access to medical care for pap smears—one of biggest factors is not having pap smear for five or more years
 
Vaccination for HPV:
·      As young as 9-11 up to age 26
·      Important to get before exposure (sex activity)
·      Boys and girls should be vaccinated
·      Anal, throat, and oral cancer—risk for women and also risk for men
·      Three shot series—some immunity to HPV if do partial series, but need to complete all for it to work best [when I was looking for more information, I found the CDC is now recommending two doses, 6-12 months apart.  If a child received the second dose within 6 months of the first, then a third dose should be given.  Here’s the link with info: https://www.cdc.gov/hpv/parents/vaccine.html ]
 
Many women will have precancerous changes on their pap smear—it is a screening test, meant to pick up any abnormalities
·      If abnormal pap, next step is colposcopy (procedure that uses a binocular-like          tool to get a closer look at the cervix). 
·      Depending on result of colposcopy, may biopsy to test if pre or cancer
·      Often if cervical cancer is picked up early can do limited excision
·      If your pap smear shows precancerous changes, you can get medical care with general gynecologist
·      Sometimes gyn will refer to oncologic gynecologist
 
Cervical cancer
Almost 100% cervical cancer is driven by HPV
Two types of cervical cancer: squamous cell carcinomas—begin in the flat cells of the cervix; and Adenocarcinomas – begin in the glandular cells of the cervix.  Some argue adenocarcinoma can be more virulent and come back more often.  Others argue they are the same.
Another type is combination of both, but this type is very rare
HPV types 16 & 18 cause the vast majority of cervical cancers.  Initial HPV vaccine covered these types only. Now the vaccine protects against 7 types-covers about 99% cervical cancer causing HPV. [Again, this is a bit off from the CDC info: “All three licensed HPV vaccines protect against types 16 and 18, which cause the majority of cervical cancers across racial/ethnic groups (67% of the cervical cancers among whites, 68% among blacks, and 64% among Hispanics). The 9-valent HPV vaccine protects against seven HPV types that cause about 80% of cervical cancer among all racial/ethnic groups in the United States.”  From https://www.cdc.gov/hpv/parents/questions-answers.html ]
 
When cervical cancer is first diagnosed:
Staging of Cancer- Imaging techniques may be ordered—CT/MRI/PET scans
Is having children a concern?—may change approach of treatment
Is the cancer a visible or a microscopic lesion?
 
Minimally invasive surgery—has come along way
 
Stage 1—in past did a radical abdominal hysterectomy—removed uterus, cervix, much of vagina.  Had a lot of surgical complications, long recovery and no longer able to have children.  Now if don’t want children will do a laparoscopic hysterectomy—less bleeding, less pain and less late side effects.  Patients can even go home the next day.  And in younger women, doctors are doing less surgery so that many can still have children. [Radical trachelectomy—removes cervix, top 1-2cm of vagina and surrounding tissue, but leaves uterus].  Research continues to look at ways to map the cancer so only take out the cancer, and leave behind healthy tissue.
 
In later stages, cancer may be in the lymph nodes and pelvis. If surgery isn’t curative—chemo and radiation may be needed
 
Quality of life:
Side effects of treatment—trouble with intercourse due to changes in tissue—Multidisciplinary approach is most beneficial (used at Dana Farber):
Includes biofeedback techniques, sometimes local estrogen creams, dilators, and counseling. 
 
Racial disparity a big concern with cervical cancer. Rate of cervical cancer in African Americans is almost double that of Caucasians--probably due to limited access to medical care among African Americans.
 
Audience Questions:
Is there any age when a woman can stop cervical cancer screening?
If a woman has had normal pap smears, has no evidence of HPV infection, and has had the same sex partner, probably can stop screening after age 65.  However, women and men are living longer and longer, and often having new partners later in life.  In this case, screening is still necessary after age 65 [According to the American Cancer Society, more than 15% of cervical cancers are diagnosed in women over 65.https://www.cancer.org/cancer/cervical-cancer/about/key-statistics.html ].
 
When should someone seek a second opinion?
Consider it before any major intervention or surgery
If anything a doctor does or says doesn’t feel right to you
It is always reasonable to decide between medical practitioners—no reasonable doctor should feel slighted when patient gets a second opinion
 
Where is the field going?
Looking into molecular mechanisms driving cervical disease
Immunotherapy may play a larger role in the future
A trial is now being conducted at Dana Farber looking at using a vaccine to treat HPV-16 in patients with HPV 16 anal and oral cancer [https://clinicaltrials.gov/ct2/show/NCT02865135?term=HPV+and+anal+cancer&rank=2 ]
Another trial is looking at using a HPV vaccine in patients who are at high risk for cancer recurrence.
 




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