The story below is from our March/April 2019 issue. For the full issue Subscribe today, view our FREE interactive digital edition or download our FREE iOS app!
Perhaps the most startling fact about cervical cancer is how it’s almost always preventable.
Meg U Photography
Elizabeth Milne wants people to know how life-altering cervical cancer can be.
Roanoke resident and graphic designer Elizabeth Milne wants people to know how life-altering cervical cancer can be. A cancer survivor, Milne was diagnosed in 2014 with endocervical adenocarcinoma, the earliest stage of cervical cancer, with an abnormal Pap smear. That test, along with appropriate follow up evaluations and treatment, may have saved her life.
Although Milne has been treated and she is considered cured, HPV is never too far from her mind and she is fearful that she may have a recurrence. The virus can lay dormant and cause no symptoms, so she second-guesses any changes in her body. When she does receive a Pap smear, she is uneasy until the test results are known.
Milne was devastated by her diagnosis. Even in the earliest stages of cervical cancer, the HPV virus can take a toll on the body physically. Many patients are also deeply affected emotionally.
“I only told my sisters and my boyfriend at the time,” she says. Only after she was treated with an outpatient procedure to remove cancerous cells from her cervix was she able to tell her mother. “I didn’t want her to worry. I’m not even sure if my dad knows about it to this day.”
Now 35, Milne is able to share her experience among friends, and eventually publicly at a local Junior League meeting.
“I think people are embarrassed because it’s associated with a sexual disease.”
At the time of her treatment, Milne went to all of her appointments alone. She even drove herself to and from her biopsy. “For me, the biopsy was not painful. However, there was some mild cramping a day or two later. The cramping actually had more of an emotional toll on me, as it reminded me that there was something wrong with my otherwise healthy body.”
Caught early on, Milne’s disease was well-managed, but there is still an emotional toll. With every new romantic relationship, she feels the stress of discussing her HPV diagnosis and it stays in the front of her mind.
Men and women can contract certain types of cancers caused by a virus that is as common as a cold. Human Papillomavirus (HPV) is the cause of nearly all cervical cancers and is mostly preventable. According to the CDC, most sexually active people will be exposed to one of over 100 types of HPV in their lifetime, some forms are deadlier than others. Common warts and genital warts are also caused by HPV and are spread by skin to skin contact.
Dr. Janet Osborne, Chief of gynecologic oncology at Carilion Clinic, wants patients to know that most invasive cervical cancers can be avoided, and is passionate about getting the word out.
“It is truly heartbreaking every time myself or one of my partners sees a woman with advanced cervical cancer; cure rates are low and it’s almost always preventable. In my first year practicing medicine in Roanoke, I saw more women with advanced cervical cancer than in the preceding 11 years in practice in Wisconsin,” says Osborne.
Data from the Centers for Disease Control and Prevention (CDC) back up her observations. Virginia ranks in the top half of the country for cervical cancer deaths. CDC data collected from 2011-2015 indicated that 63,645 women were diagnosed with cervical cancer, with 20,673 deaths.
“Patients are just not showing up to get care. It’s not uncommon for women to stop getting Pap smears after their last child is born,” says Osborne. She is optimistic about the 2019 Medicaid expansion in Virginia. Many people don’t get preventative screenings due to lack of insurance or being under-insured.
“When a patient presents with advanced cervical cancer symptoms [weight loss, fatigue, back pain, leg pain or swelling, leakage of urine from the vagina and bone pain that does not go away], many can no longer be cured with surgery, such as a hysterectomy, and now require chemotherapy and radiation,” Osborne says.
“This is why cervical cancer awareness is life-saving. In such late-stage disease, chemotherapy and radiation may extend life, but there may be significant side effects of treatment and curing the cancer is difficult. Most people could have avoided the entire ordeal.”
Vaccines and Screening
“Cancer is a scary word and there is a lot of fear with that. Pap smears aren’t perfect, but the screenings do work. Milne’s testing and treatment was the right way,” Osborne says.
Milne didn’t have the opportunity to receive an HPV vaccine. When Milne was the best age to receive the vaccine, it was between 1983 and 1984. Long before the first FDA-approved vaccine, Gardisil was marketed in 2006 to cover four strains of the HPV virus. The guidelines for treatment and the vaccine have changed significantly since then.
The Advisory Committee of Immunizations Practices (ACIP) at the CDC recommends that both girls and boys ages 11-12 receive the vaccine.
Vaccination prior to sexual activity is key, as HPV is spread by all types of sexual contact. While the vaccine has been shown to be more effective when administered at a younger age, the age range for treatment has expanded greatly.
As of 2017, Gardisil 9 is the only HPV vaccine available in the United States for use in males and females from ages 9 to 26. Men are vectors for HPV and may not experience any symptoms, yet unknowingly spread the disease. Depending on sexual activity, a broader group of people not previously targeted for HPV immunization may also benefit from Gardisil 9.
This newer version of the HPV vaccine now covers nine strains and is now recommended beyond children and young adults for use in men and woman ages 27 to 45, as well. Females ages 13 to 26 and males ages 22 to 26 already vaccinated with first-generation Gardisil, can be given a “catch-up” vaccination.
The newer version of the vaccine is also recommended for use in men and woman ages 27 to 45, specifically, men ages 22 to 26 should discuss vaccination with their health care provider if they have not been previously vaccinated, are immunocompromised or engage in sexual activity with other men. And patients like Milne, newly single, may also still benefit from this new vaccine.
Osborne suggests woman over the age of 26 who have had a change of marital status, or have had a low number of sexual partners and are now experiencing a change in sexual partners, discuss HPV vaccination with their health care provider.
Annual Pap screening (cytology) is no longer recommended for all women. Otherwise healthy women ages 21 to 65 should receive a Pap smear once every three years. Women over the age of 30, should receive a Pap screening as well as a high-risk HPV co-test every five years. The second test is completed during a Pap screening with the collection taken at the same time and should not require a second visit to the office.
“I had to return after three months for a follow up treatment post biopsy, then six months,” says Milne, “and now, I’m back to my annual PAP because everything has been healthy since then.”
Osborne stresses that with early detection, Pap screenings and vaccinations nearly all people avoid advanced cervical cancers.
Other HPV Cancers Rising
Nationally, cases of advanced cervical cancer are down 1.6 percent, according to the USPSTF. Approximately 43 percent of American adults (18-59) are infected with HPV, 79 million lives with 14 million new HPV infections annually. Use of condoms can help control the spread of HPV, but oropharyngeal (throat) and anal cancer and has been on the rise in the past 15 years.
Dr. Janet Osborne, Chief of gynecologic oncology at Carilion Clinic, explains that “two types of HPV, 6 and 11, are the most common strains and are not life-threating, but can be particularly embarrassing, account for nearly all of the cases of genital warts.”
The American Cancer Society’s estimates for cervical cancer in the US for 2019 are:
- About 13,170 new cases of invasive cervical cancer will be diagnosed.
- About 4,250 women will die from cervical cancer.
- 1,762,450 new cancer cases (all cancer) will arise in 2019 (approximately 4,830 new cases per day)
- 606,880 will result in death
- 1,660 new deaths per day
Other Facts:
- Cervical cancer was once one of the most common causes of cancer death for American women - that rate dropped due to increased screening measures.
- Ages most at risk for women are 35-44
- Rarely develops in women under 20
- Risk is still present as women age
- More than 15 percent of cases are found in women over 65
- In the US, Hispanic women are most likely to get cervical cancer, followed by African Americans, Asians and Pacific Islanders and whites.
- American Indians and Alaskan natives have the lowest risk in the country.
Types of Cervical Cancer
- Squamous cell carcinomas: 9 out of 10 cervical cancers develop from the cells in the exocervix
- Adenocarcinomas: most other cervical cancers develop from the gland cells
- Adenosquamous carcinomas or mixed carcinomas: least common, have features of both
Screenings
- Getting screened at age 21 to look for changes in cervical cells
- If you are 21-29 you should get a Pap test every 3 years
- If you are 30-64 you should get both a Pap test and HPV test together every 5 years
Factors that may increase the risk of developing cancer following a high-risk HPV infection:
- Smoking
- Having HIV or reduced immunity
- Taking birth control pills for extended periods of time (5+ years)
- Having given birth to three or more children
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