About Cancer

Even though the test itself usually leads to no harm, what you do not know about Pap smears and over-reliance on reassuring results can be severely detrimental to your health. This, in fact, can kill you. The reasons for this seemingly shocking statement and other crucial things that a smart woman should know regarding cancer prevention are the subject of this article!!

Let us take a very brief little historical detour to understand why. The Papanicolaou test, shortened to Pap, is a test which scrapes cells from the uterine cervix using a small spatula and brush. These scraped cells are then reviewed under a microscope to look for abnormal or pre-cancerous cells. The Pap test has been around for approximately 50 years and was a great advance in cervical cancer prevention. Even today, since nearly 50% of cervical cancers in the US occur in women who have never been screened, and 60% of cases develop in women who have not been screened in at least 5 years, an argument has been made that widespread periodic screening of ALL women would further reduce the overall incidence of cervical cancer, and eventually eliminate it. It is certainly true that any kind of screening is better than no screening at all.

However, unfortunately, even when Pap screening is readily available, this may not alter the results. In just one example, screening had been performed in 63% of women younger than 45 who died of cervical cancer in Scotland from 1982 to 1991. Other reports note that up to 20% of women with severe pre-cancer or invasive cervical cancer had a normal Pap smear within the preceding year. Thus it appears that standard Pap screening may not be sufficient to prevent cervical cancer. Many women present with symptoms, and up to half have been recently screened with at least standard Pap screening.

The bottom line is that despite its major contribution to cervical cancer prevention, we now know that the conventional Pap smear has dangerous limitations. Using biopsies as the best available gold standard, the ability of the Pap smear to pick up pre-cancer and very early cancer may be as low as 20% - 30%. In other words, up to 80% of pre-cancerous changes can be missed if you rely on the Pap smear alone. Used alone, it is simply a yesterday or last century technology.

By the way, if you are experiencing any symptoms like abnormal bleeding between periods or bleeding after intercourse, please call your doctor right away. You need an evaluation and possible biopsies, not Pap tests or any other screening tests. Screening is defined as looking for disease in the absence of symptoms. If you already have symptoms, it is past that point. While abnormal bleeding is usually due to many possible benign non-cancerous reasons, you owe it to yourself to be fully evaluated.

It is extremely important to detect cervical abnormalities when they are still pre-cancerous. When abnormal cells are scraped from the cervix by a Pap test and detected under the microscope, it usually means that there is dysplasia or a pre-cancerous area present on the cervix. In some cases it can also be an early cervical cancer. Cervical cancer rarely develops directly from a normal area. Instead it develops over time, usually years. Cells become more and more abnormal and finally invade or start growing deeper into normal cervical tissue. When these cells invade, they are no longer pre-cancerous and an invasive cancer is now present.

When found before becoming invasive or cancerous, these lesions are not a threat to life and are usually curable with minimally invasive therapies. In other words, hysterectomy and more drastic treatments like radiation and chemotherapy are avoided.

Critical Statement: We now know that there is a sexually transmitted virus, called the HPV or human papilloma-virus, which is largely responsible for virtually all cervical cancers, AND we have a simple painless TEST FOR IT! It is not perfect but is pretty accurate.

HPV is actually quite common and most (up to 75% or three out of four ) women who have been sexually active have likely been infected at some time in their life.

There are two categories of HPV: low risk and high risk. There are multiple subtypes of each category, but the important thing to remember is that a persistent infection with high risk HPV puts you at higher risk of developing a pre-cancerous condition or cancer of the cervix. The relatively good news is that low risk HPV very rarely leads to cancer, although it can still cause you problems like cervical, vaginal or vulvar warts which can be hard to treat and are sexually transmitted. The better good news is that most HPV infections are transient. In other words, they go away on their own, usually within 9 months to a year. However, since this is a sexually transmitted virus, you can be re-infected by contact with an infected partner or a promiscuous lifestyle. So, especially if you are enjoying active sexuality, all of this is extremely important.

The bad news is that a persistent infection with high risk HPV is the single most important factor is predicting that you may develop cervical cancer. Keep in mind that not everyone with persistent HPV infection develops cervical cancer. In fact, most women do NOT develop pre-cancer or cancer. However, your risk is increased and should put up a major red flag to carefully follow-up with your doctor. If you have actually been diagnosed and treated for pre-cancer or cancer of the cervix in the past, this is relative proof that you have had a persistent HPV infection and are therefore more likely to experience a recurrent infection and/or disease.

The second piece of bad news is that there is no currently approved treatment for high risk HPV infections. However, since they usually go away spontaneously this bad news is not so bad for most women. In addition a commercially available vaccine has just been made available. The ideal time for immunization is BEFORE sexual activity begins: so between ages 8 and 13 is ideal. However, although there is incomplete agreement on this, women upto age 26 may benefit from the vaccine.

Women who are infected with HIV or are immunologically suppressed due to other diseases or medications are less likely to have their HPV infection spontaneously go away. Therefore, they are at a higher risk of coming down with pre-cancer or cancer of the cervix.

The HPV virus is sexually transmitted as noted. Contact with the genitals in some fashion must occur. However, given the variable length of time it takes for the infection to clear spontaneously, an infection does not mean that your partner has been unfaithful. The virus can live on inanimate objects for a short time, so contact with sex toys or other forms of indirect sexual contact transmission is possible.

As with anything else, there is a benefit and a risk associated with HPV testing. The main benefit is one of reassurance. If the HPV is negative, the risk of dysplasia or cancer is extremely low. The second major benefit is one of convenience, since the screening interval can be safely increased to three years instead of annual visits. However, just to be complete, there are other reasons to go to a doctor on an annual basis for well woman care. The main risks of HPV testing are related to anxiety and psychological stress of knowing about an HPV infection and wondering about how one got that infection since it is predominately a sexually transmitted virus.

Critical Statement: Caution! If you have an early pre-cancer, it can go away by itself under doctor supervision. Over-treatment is possible and can lead to scars, pain and infertility. Certainly, treatment of an HPV infection alone (i.e. no abnormal cells detected) by surgical means (including cutting, burning and freezing) is not effective and can lead to more harm than good. Discuss the risks and benefits of treatment with your doctor. If you are not satisfied with the answers, get a second opinion!

Critical Statement: Condoms do NOT prevent male-female sexual transmission of HPV. The reason for this is that the virus can be living on the scrotum of your male sexual partner. Also, the anti-spermicidal agent Nonoxynol-9 has NO effect against HPV.

Critical Statement: As far as other gynecologic cancers are concerned, the Pap was never designed or promoted to screen for these. Period. End of story!! Do not let anyone tell you otherwise. The HPV test is also only meant to be a cervical screening tool. Screening technologies for ovarian and uterine cancers are under development, but are currently woefully inadequate.

So, what cervical screening test(s) should you ask for?

The following information is based upon American Cancer Society recommendations, but also includes my evaluation of the medical literature and practice experience. In all cases, this means that these recommendations are as aggressive as is reasonable to get the optimal prevention result. The truth is that what YOU need is somewhat individualized and depends on age and personal medical history. There is no single cookie-cutter answer for every woman and you should discuss the details with your physician.

You can get screened MORE often than the recommendations offered below, but there is no added benefit based on very extensive medical studies. And, there can be some harm. Why? Because screening is NOT for cervical cancer. Rather it is for PRE-cancer. Because of this, there are usually years of time built-in for the abnormalities to change from pre-cancer to cancer, or not. Remember, some of these pre-cancerous changes will go away on their own. So, over-screening and over-treatment can lead to more harm than good. This is vastly different than recommendations for breast cancer screening, where the goal of the yearly mammogram is to detect early cancer, not pre-cancer. In this situation, the earlier the detection and the faster the treatment, the better the results. Breast cancer will NOT go away on its own. So, you see there is a big difference, depending upon what you are screening for or trying to prevent.

If you are under the age of 30:

• You should have your first screening examination approximately 3 years after first sexual contact, regardless of whether or not vaginal penetration has occurred, or by the age of 21
• You should get a Pap smear every 3 years while you are under 30
• If your Pap smear result uncovers atypical cells of undetermined significance, otherwise known as ASC-US, testing should be done for high risk human papilloma-virus (HPV) should be performed

If you are between the ages of 30 and 65:

• BOTH a Pap smear and HPV test should be obtained every 3 years

If you are over the age of 65:

• Routine screening is no longer recommended IF you have had adequate and recent screening with Pap and/or HPV testing

If you have had a complete or total Hysterectomy (meaning the cervix has been removed):

• If the hysterectomy was performed for benign reasons, vaginal screening is not recommended
• If the hysterectomy was performed for precancerous cervical findings, three additional consecutive Pap screening tests should be done before discontinuing further screening.
• If the hysterectomy was performed for cervical cancer, the timing and frequency of follow-up examinations and vaginal screening is individualized and should be decided upon in concert with your gynecologic oncologist.

If you have been treated for pre-cancerous lesions and your cervix was not removed:

• Pap and HPV test should be done 6 months after treatment and both repeated after 2 years. If normal after these two screenings, routine age-dependent screening as discussed above can be resumed.

If you have HIV or you are otherwise immunologically suppressed from disease or medications:

• Yearly screening with Pap and HPV should be performed.

What happens after an abnormal Pap or HPV test?

If the Pap is ASC-US and the HPV is negative:

• Repeat both after one year
• If normal at this point, you can resume routine age dependent screening as discussed above.

If the Pap is normal but the HPV is positive:

• Repeat yearly for two years
• If both as normal after these two screenings, you can resume routine age dependent screening as discussed above.

An additional visual test called Colposcopy, and possible biopsies, is/are recommended if:

• Pap smear shows cells that are worse than ASC-US
• Pap smear shows ASC-US and the HPV is also positive
• The HPV test is repeatedly positive and the Pap has been, and continues to be, normal. There is some controversy in this situation, with some experts advising visual magnified evaluation earlier than others. In many cases, nothing is found, but the additional reassurance of a visual test and possible biopsies may be beneficial. In these situations, it is best to discuss all the risks and benefits extensively with your doctor.

Summary recommendations:

1. Get screened
2. Get screened using a combination of Pap and HPV testing using the guidelines above
3. Report any abnormal discharge or bleeding symptoms to your doctor early, and insist that an explanation be determined
4. Do not think that the Pap, HPV test and routine pelvic exams reliably prevent any other cancers

All of the above information is meant to aid you in making informed choices regarding screening, prevention and your health. It is NOT meant to replace your existing doctor-patient relationship, since every individual specific health situation is different. If you do not have a trusted doctor with whom you can discuss these matters, GET ONE!! Your continued health depends upon it!