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Cervical Cancer: What To Know



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- Hi everyone, and welcome

to our Michigan Medicine live event.

I'm Ed Bottomley with the Michigan Medicine

department of communication, and today,

gynecologic oncologist Dr. Jean Hansen,

along with internationally-known physician researcher

in cervical cancer prevention, Dr. Diane Harper,

will be answering your questions regarding prevention,

screening, and treatment options for cervical cancer.

So first off, let's meet our experts.

Welcome to both of you, if you could start off

with just an introduction of short background

on each of you, if you could go first?

- Thank you, Ed.

I was an engineer by training

before I decided to go to medical school,

and then saw both of my parents die of cancer,

and so I have become extraordinarily interested

in cancer prevention, and how we address risk factors,

how we improve screening, how we look at helping people

live the fullest life they can possibly live.

- Thank you, Dr. Harper, Dr. Hansen?

- So, I am a gynecologic oncologist

here at University of Michigan.

I did my fellowship training in gynecologic oncology

at MD Anderson Cancer Center in Houston

and I recently came back home

to start my practice here at U of M.

- Fantastic, well, it's a pleasure to have both of you here.

Just a reminder to our audience, you can submit questions

at any time, even now, for our panelists to answer.

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and we'll also be posting it

onto the Michigan Medicine YouTube channel soon after that.

So let's move on to our questions.

Our first question for Dr. Harper,

how is cervical cancer diagnosed?

- Cervical cancer is usually diagnosed

with some kind of screening mechanism.

Cervical cancer by itself doesn't make you itch

and it doesn't make you hurt.

The only real symptom it would have at the cancer stage

would be if after you have sex, you notice bleeding.

That's unusual, and you need to come in

and get checked for that, but generally,

it's a preventive cancer that we can get,

because we ask women to come in and get screened.

- Okay, and the next question is a perfect follow-on

from that, what screening tests are available

for cervical cancer, when should I be screened,

and how often?

- There have been a lot of changes in the last 10 years

about screening, and there have been a lot

of different guidelines that have come out.

The most recent guidelines say

that we have three different ways

that you can be screened for cervical cancer.

The first thing I wanna say

is that you need to be 21 years of age,

so this is a privilege to be screened,

and you have to be 21.

Younger than that, it doesn't make sense,

so 21 is when we start.

At this time, we stop at 65, but there's some research

that says since we're living longer,

we might not have to stop at 65,

but for now, 65's the ending age.

So when you start, at 21,

you get the traditional kind of Pap smear,

the kind of Pap smear that we've had for 60 years.

It comes in, the woman comes in,

she has to have a speculum exam,

the physician goes in, they grab cells,

they send those cells off to the lab

and look at the cells and see if they're normal or abnormal.

We do that every three years for women

up until the age of 29, and then once they turn 30,

we have lots of options, so between 30 and 65,

she can get an HPV test alone,

she can get a Pap smear test alone,

or she can get both of those combined together.

The advantages of doing the HPV test alone

is that if that's negative and you test negative

for that virus, you can go another five years

very safely before you're screened again.

If you continue to use the Pap test,

like you used in your 20s,

then you can safely go every three years with the Pap test,

until you need to be screened again.

If you put the Pap smear and the HPV test together,

you spend a lot of extra money,

and don't gain a lot of extra information,

but that allows you to go for five years.

So those are the mechanisms we have for screening.

- The next question, you mentioned HPV.

Could you explain the guidelines

around HPV a little bit more?

- So just, I'm gonna take a little bit

of a step back from that, even.

HPV stands for human papilloma virus.

That is a great big family of viruses.

They have, think of them of having oodles of cousins,

right, lots of different cousins out there,

and each of those cousins cause

a different kind of HPV infection.

14 of those cousins cause what we call cancer,

cause high-risk types.

They can lead into a cancer, so when we look for HPV,

we're actually testing for a virus that you could get,

and we're looking to see, has that virus done any damage

to those cells that are on your cervix?

And that's what the key point is,

is looking and understanding what is HPV?

So we know that it's related to cancers,

we know that for cervix cancer, it causes 100% of them,

we know that HPV infects the penis

and gives you about 90% of penile cancers.

It infects the vagina and the vulva

and gives you about half of those cancers that come with it,

and it causes head and neck cancer,

and head and neck cancers, depending on where it is,

can be anywhere from 10% to up to 90%

of those head and neck cancers,

so there are many different kinds of places in the body

that this virus can infect,

and many different percentages

that it can be at fault for causing the cancers.

- Thank you for that explanation.

The next question, what can cause an abnormal Pap test

besides HPV?

- So, in the laboratory,

and when the clinician takes your Pap smear testing,

they may not get all of the cells that they need to,

in order for that to be able to be read

as what we call a satisfactory smear.

So, in other words, there's at least two different kinds

of cells we need to see, and so, potentially,

a smear that would be unsatisfactory

would be one that didn't get all sampled.

Now, that's a little different than abnormal,

so, 'cause it doesn't really say

that there's something wrong, it just says,

we couldn't see the cells we needed to see

to do the screen right, but it is one

that would cause the woman potentially

to be called back in, depending on what was seen.

So, the other things that cause the cells

to be considered abnormal that's not HPV

is just the way the cells look,

the way the cells happen upon each other.

One of the big advances,

when I first started my medical practice,

we did Pap smears and we put them on a glass slide

and we sprayed them with hair spray, okay?

And so, when the pathologist had to look at it,

he had to look at, like, 100 different cell layers

to try to find all the cells in that gloppy mess

I put on that glass slide, and so now,

we have something called liquid cytology,

which is, we take it and we put it

in a little thing of liquid,

and then the liquid goes through

and they strain it and they filter it

and it takes all the cruddy stuff away

and just allows you to get the cells on it

so when they look at it under the microscope,

they can look and see the cells well.

That has helped us reduce the number of abnormals a lot

because some of the abnormals we would get

would be cells folded over on each other.

The art of cytology is an art of reading

and appreciating art, okay?

It's all based on a subjective viewing

of how big a nucleus is, how big it is

in comparison to something else,

is it folded over, is it not folded over?

So by going to this liquid cytology,

we're able to help eliminate most of that,

so at this point, in this day,

if you have an abnormal Pap smear,

it's usually because it's HPV-associated.

- All right, and the next question, you've touched on this,

if I have an abnormal Pap, do I have cervical cancer?

- No, and that is the most important thing

for people to know.

First of all, if you have a positive HPV test,

you do not have cervical cancer.

If you have an abnormal Pap test,

you most likely do not have cervical cancer,

but the key point for both of those are,

those are early signals that something

could be progressing towards that,

and we have to know where you are in that progression

towards cancer so we can stop it

before it gets to being cancer.

So that's what it's really important for people to realize,

is don't panic when it's abnormal,

but pay attention, and let's come in and find out

where you are on that progression,

and let's get you stopped.

- Thank you for that very important,

very important information there.

This question, I haven't been ignoring you, Dr. Hansen.

This question could possibly be for both of you.

What is a colposcopy,

and how will I know if I need one?

- So, a colposcopy is essentially

a microscope that looks at the cervix

and helps us identify abnormal cells.

The way that we know you need a colposcopy

is based on the type of abnormal Pap smear you have,

so, there's sort of a range of types

of Pap smear results you can get

from kind of low-grade changes

to very kind of high-grade abnormal changes,

but basically, the Pap smear is a screening test,

and so that tells us, if you have an abnormal Pap smear,

that you need to come in and get a colposcopy

and what that means for the patient

is that they will come in,

they will get a pelvic exam and a speculum exam,

we actually put a vinegar solution on the cervix,

and that helps abnormal sort of HPV-infected cells

light up or become more obvious to us,

and then we put a microscope near the cervix

that helps us really identify those abnormal areas,

and then in that, if we identify any abnormal areas,

we biopsy those, and that's a biopsy that's done

while the patient's awake.

It's typically very well tolerated

by patients in the office,

and that biopsy will tell us whether there's abnormal,

abnormal cells or not, or abnormal tissue or not,

and whether, kind of where on the spectrum the patient is

in terms of cancer or pre-cancer.

- Thank you for that, anything to add, Dr. Harper?

- I'd just like to say,

because I come from a primary care standpoint,

I like to say we like to make sure that women understand

that nothing goes inside their vagina

other than the speculum.

The colposcope stays on the outside of them,

and that we use bright light and magnification,

exactly what Dr. Hansen said, bright light and magnification

along with that vinegar solution,

in order to be able to let the cervix tell us its story.

- Good stuff, thank you.

The next question, what are preventive measures

for cervical cancer?

- So, we know that there are risk behaviors

that are associated with cervical cancer.

Number one is smoking, so stop.

Stop smoking.

We can help you with lots of different ways,

but smoking makes the infection stay and progress

and it is a risk factor for cervical cancer.

The other risk factor for cervical cancer

is the number of sexual partners that you have.

It is also the number of sexual partners

that your partner has,

so that even if you have never had sex with anyone,

the partner you choose to have sex with

may have had 20 partners.

That gives you all 20 of their partners' risk,

so it's incredibly important for people

as they're starting relationships

to really be open and honest with each other

about how many partners have you had?

What kind of risk am I getting into?

Are you gonna be there to support me

when my Pap is abnormal?

Those are important things to know.

We also know that some kinds of contraceptives

help or alleviate some HPV infections.

We know that using a progestin-based IUD

so in other words, Mirena, Skyla, those kinds of IUDs,

have been helpful at not letting

that HPV infection progress any further in the spectrum.

It doesn't prevent it, it's not a preventive medicine,

but it's something that's helpful that they can use,

and by far and away, the biggest thing

is that the way in which HPV infections are spread

is a skin-to-skin contact, it's not blood.

It's not saliva, it's not semen, it's not eye tears.

It's skin-to-skin contact,

that's the only way it can be spread,

so how do you disrupt that?

You use condoms.

You use condoms, you use female condoms,

you use male condoms.

I would say that I may not have mentioned

when we talked earlier, but the other condom part

that is useful is when you're having anal sex,

because that is also incredibly helpful

to prevent the tissue-to-tissue contact

that allows transmission of HPV contact.

- Thank you for that.

Now we're gonna move on to some questions

I believe, for you, Dr. Hansen.

How common is cervical cancer?

- So cervical cancers are kind of our third

most common gynecologic cancer,

so it's, in this country, it's one of the,

sort of less common gynecologic cancers.

The most common are uterine cancer and ovarian cancer,

so it's kind of behind that,

and I think it's important to realize

that cervical cancer is mostly a cancer

found in developing countries.

The majority, 75% or more

of the cervical cancer cases worldwide

are not in developed nations like the US or Western Europe,

they're in other countries,

and that's where we really need to work hard

with prevention and strategies to alleviate those cases.

- Are there different types of cervical cancer?

- Yeah, there's several, we categorize it

by how it looks under the microscope or the histology,

so the most common by far is called squamous cell carcinoma

and that makes up about 75% of cervical cancer cases.

Those are typically, if not 100%, related to HPV exposure.

The next kind of category we see are adenocarcinomas

or adenosquamous carcinomas.

Those are, tend to develop a little bit

kind of farther up into the cervical canal

and may not be detected as well on screening tests

like a Pap smear, as a squamous cell carcinoma would be,

and then the remainder, the next, other five to 10%

of cases are kind of more rare histologies,

small cell, neuroendocrine,

kind of more aggressive histologies

that are not, tend to not be HPV-related.

- Now, with regards to cervical cancer,

what is the prognosis for cervical cancer?

- It really depends on the stage,

so the stage is assigned by the size of the tumor

and the location of the tumor, and so,

the earliest stage cancers are confined to the cervix

and really are not even visible to the naked eye.

They're microscopic, and as they grow,

your stage becomes higher,

and so, the prognosis for cervical cancer

that is microscopic or really just detected on biopsy

that we can't see, the five year survival

for those types of cancers are above 95%, so very very good.

As you get into larger tumors that are still on the cervix

but visible to the naked eye,

the survival's somewhere between 80 and 90%,

and then as you get to tumors that are spread

outside the cervix or even spread

to other parts of the body,

your survival goes down dramatically,

so for somebody who has a cervical cancer that's,

for example, in the lungs at the time of diagnosis,

their five year survival is somewhere around 10 to 15%,

so I think that speaks to the prevention angle

where it's really, really important for us

to detect these cancers, A, before they develop,

and if there is a cancer present,

to identify it at an early stage, because we know

that the stage really, really impacts longterm survival.

- And just as a follow-on, we are seeing more people

with the early stages that are curable because of screening,

but the important message for those women

is that yes, they're survivors and they're cured,

but they have to stay in the screening pool,

because we don't know that they're not going

to ever develop another abnormality or another cancer,

so it's, and if they should develop another cancer,

it's also curable, so those are good things to keep going

as they move forward.

- Thank you, thank you both for that.

What's the, you might have touched on this already,

but what is the average age for cervical cancer?

- The average age is about 48 years old,

so it's a cancer that is,

typically happens in younger women.

There's very small proportions of patients

that are over the age of 75 or 80 that get cervical cancer,

and that's why we currently, the guidelines are

to stop screening at age 65,

with the exception of some certain situations, so, yeah.

- What we see with the natural history of HPV

is that of those people whose HPV infection doesn't go away,

which is about 5% of the people that are infected,

it takes on average about 15 years

from infection until they would develop cancer,

and so if you think that they're exposed

in their early 20s or late teens,

then about 35 is that first peak

of the cervical cancers that you see,

and then you think of the middle-aged women

who either themselves are having affairs

or whose marriages have broken up

or whose partners are bringing in new HPV,

then they have this next timeframe

in which they develop cervical cancer,

so while the average age is around 48,

we see this little peak around the 35, 40 age,

and then we see this other peak around the 55, 60 age

that corresponds very nicely with when people

are getting reinfected again.

- Thank you for that, very interesting.

This question just came in, are there different,

are there any different,

are there different ethnic types of women

that are more likely to get cervical cancer?

I think I said that one right.

- You know, the differences in the cervical cancer

kind of incidence in different populations

tends to be related to socioeconomic status.

In patients that,

in populations that have less access to care,

barriers, whether they're language

or transportation barriers to accessing care

and accessing screening, those are the populations

that we see more frequent HPV infection and more cancer,

and I think that that's also related to why we're seeing,

why we see more cervical cancer cases in developing nations,

'cause they don't have this infrastructure

of screening that we have here.

- I think it's important for people to realize

that this is an equal opportunity infection,

and that it doesn't matter who you are or where you are

in this world, what color your skin is,

what food you eat, what religion you practice,

that this is an equal opportunity infection,

and it entirely depends upon your sexual partners,

entirely depends upon whether or not you smoke,

and that we have seen in the five continents literature,

we've seen this in population after population

after population, and the key to that is that,

prevention is so important,

and now that we have HPV vaccines,

and now that we know only two doses is needed

for kids up to 15 years of age,

potentially we can get to one dose,

we could really make an impact

in the number of women who get cervical cancer,

so I think that's important for looking at racial,

ethnic disparities, yes it is higher in Hispanics

and in African American women, than it is in white women,

in the people who get cervical cancer,

but that's only because we haven't been able

to tell our story and reach out to them

and help them feel comfortable coming in

and being a part of a screening program.

- I feel like there are a lot

of very important takeaways today,

so towards the end, I'll circle back,

and make sure anyone who's tuning in,

we can get some of these important messages out again,

so thank you both.

The next question, can I still get pregnant

if I have cervical cancer?

- Yeah, I think, so there's a couple of different ways

to answer this.

This may mean, if you've been treated for cervical cancer,

can you still get pregnant in the future?

So, in some situations, if you have a cervical cancer

that's confined to the cervix and is a certain size,

we have, there is a procedure called a trachelectomy

that we can do that essentially removes the cervix

and the surrounding tissue, as well as the tumor,

and we are able to sort of reattach the uterus

to the top of the vagina and create

sort of a normal functioning uterus.

That's a procedure that's very specialized

that's done by gynecologic oncologists

and it's really done in very select patient populations,

patients who want to have children in the future,

who don't have a history of infertility,

who have certain histologies, for example,

squamous and adenocarcinoma only,

and who don't have very large tumors,

and so if they fit those criteria,

we are able to offer them that type of procedure.

In patients who are diagnosed

with an early stage cervical cancer

who are not planning on pregnancies in the future,

we typically offer a radical hysterectomy

which removes the uterus.

I think that that's where that question was going.

- On the prevention side, doing Pap smears

on every single lady who becomes pregnant is routine.

That is standard of care, and the reason is,

is that sometimes we'll be surprised

and women will be pregnant, and have cancer that's found.

- It's one of the most common cancers

diagnosed in pregnancy, so.

- Because they come in for their prenatal care

and we can actually screen them at that point,

which is really important, and so in that case,

there's a lot of discussion that goes on, but many times,

they can have a completely normal pregnancy

and usually, the baby is delivered by C-section,

I will actually defer to my colleague here,

that used to be C-section and radical hyst, but...

- It depends if it's a cancer

that's confined to the cervix and they're a candidate

for hysterectomy and we may get to that at some point,

kind of the different treatment options.

Then yes, a C-section with a radical hysterectomy

at the same time, is an option.

In some unfortunate cases,

patients will have advanced disease diagnosed in pregnancy

and then we recommend something different,

so, it really depends on the stage,

and again, that's the benefit of screening

and seeing these women for prenatal care,

is that you're able to diagnose these cancers

if they happen.

- Thank you for this.

The next question, as you predicted,

is a little bit of a follow-on.

If I've had a hysterectomy, can I get cervical cancer again

or another cancer?

- So, in women who have, so the majority

of hysterectomies are done for benign reasons,

so the most common reasons people get a hysterectomy

are abnormal bleeding, heavy bleeding,

fibroids, pelvic pain, so not cancer-related reasons.

In those women, if they have had negative

or normal Pap smears up until their hysterectomy,

they do not need any Pap smears afterwards

because the risk of having an HPV-related cancer

or pre-cancer is very, very rare.

In people who have abnormal Pap smears

leading up to that hysterectomy,

we ask that they continue to get screened

for 20 years after that initial abnormal Pap smear,

so they may have to come in and get Pap smears

of the vagina after their hysterectomy.

In some cases, women have a hysterectomy

where their cervix is not removed.

That's called a supracervical hysterectomy.

It's done for, in some cases.

In that situation, they need to continue screening

as if they had not had a hysterectomy

'cause they still have a cervix in place,

and after the cervix is removed,

if somebody has a history of HPV infection

or abnormal Pap smears, they're at risk

for developing dysplasia or kind of HPV-related changes

in the vagina and also in the vulva,

and if they are smokers, this risk is really magnified,

so we always encourage them to stop smoking.

- Next question, what's new in cervical cancer research?

Are there any clinical trials available?

- Yeah, I think the biggest thing

in the last several years, that's come up for treatment

of cervical cancer is immunotherapy.

So the immunotherapy takes advantage

of the sort of immunogenicity of cells,

so cervical cancer, specifically squamous cell cervical,

cervical cancers, they have,

the tumors are made up of cancer cells

and also kind of supporting cells

which we call the microenvironment,

and those cells in the microenvironment

tend to be very immunogenic and are very responsive

to immunotherapy, so there's a drug called pembrolizumab

which was FDA approved last year

for patients who have recurrent cervical cancer,

so cervical cancer that's been treated and has come back

or those who kind of have gotten chemotherapy

for their cancer and gotten, the tumors have grown on that,

so it's an option for people who have advanced

or recurrent cervical cancer,

not for people who have a microscopic cervical cancer

that can be treated with surgery,

so it's a very specific patient population

that that's useful in, but we are very optimistic

about how it will work.

There are some clinical trials here at Michigan Medicine

that are being done in patients with HPV-related cancers,

not just of the cervix, that use immunotherapy,

so those are, we're very excited about those.

- On the screening front,

we have some new things happening as well.

Since HPV is now a screening option,

there are already industries set up

to do self sampling with HPV, for women whose culture,

or they're in a abusive relationship,

they can't get in to be screened,

and so they can self-sample for HPV and know

whether or not they need to get in for further care.

We'd like to see that incorporated more

within the medical practice,

so it doesn't kind of go off by itself

so that we can help guide the way that comes forward,

but I think seeing self-sampling

is going to become something that's important.

The other advance that we're seeing on the screening side

is that we're moving more towards markers,

biological markers, that we can get,

that are independent of that traditional Pap smear,

so we're looking at different markers

of does the cell grow, doesn't it grow?

You know, what's already affected it in the environment?

So it could be potentially that one day,

we would do that self-sample screen,

we'd find out whether you had HPV,

we'd find out if you had biological markers on that,

and you could go straight from that

to no colposcopy and know what was going on,

so it would really streamline and simplify

the screening process,

and we're always looking for that point of care

where we can do it in the office

and not have to make people wait

two or three weeks for results,

so I think that the next 10 years

is gonna see a lot of changes in this field.

- Absolutely, I'm sure.

And you know what, we're talking about the next 10 years.

The next question, how has cervical cancer incidence

changed over time?

- When Pap smears were first invented,

or discovered, or made available to people,

the incidence of cervical cancer was somewhere

between 50 and 80 per 100,000 women,

and that was huge, that was a huge amount

of cervical cancer that was happening.

Now, the current CDC reports show

that in the United States, taking all races together,

they have about a 7.6 per 100,000 rate,

so we've dropped dramatically.

Now, when you look at underdeveloped countries,

in other parts of the world, their rates

are still at that 50 to 100 per 100,000 women.

When you look at the Nordic countries,

who have national databases,

Norway, Sweden, Finland, Denmark,

you see that they have been able

to get their cervical cancer rates down

to almost three per 100,000,

which was the maximum you could do

using Pap smear technology,

so now that our technologies are changing

and we're getting HPV involved in this, we really think

that we can lower that cancer rate even lower,

so at this point, we have come a long way from in the 19,

it was discovered in 1929, is when Dr. Papanicolaou

made his first speech at Battle Creek, Michigan.

1929, it took until 1960 for people to implement it,

and so, in that timeframe from 1960 to now,

we've made huge jumps in our ability to screen women,

to prevent this cancer, and we're gonna continue

to make jumps to try to get as many people in the population

down to these lower screening levels.

- Thank you for that.

The next question that we have,

if my daughter had the HPV vaccine,

does that protect her from getting cervical cancer?

- It protects her from getting HPV infection,

and if you don't get the infection, you can't get cancer,

so it's important that she had the vaccine.

The vaccine is very important

because it will prevent her from getting the infection.

What we don't know about the vaccines

is how long that protection will last,

and so it's incredibly important,

when her daughter becomes 21,

that she start the screening program.

- Thank you for that.

That's a pretty important statement you made there.

Can we circle back a little bit

and talk about some of those other preventive measures

that you feel that we should be sharing with everybody?

Some of the big takeaways that you feel,

in case anyone's tuned in just now.

Sorry. - Stop smoking!

That's the very first one.

That does so much harm and very little good,

so on anything, smoking is not a good thing to have.

- I think it's important to emphasize

that although we're talking about cervical cancer here,

not smoking will prevent other HPV-related cancers,

oropharyngeal cancers, which are just as serious,

although not our focus of discussion today.

- No, it's amazing, one day I want to create

a video that just takes all of our experts

from each of our Facebook Lives, saying, stop smoking

over and over again. - Stop smoking.

- Exactly, it is the most important thing you can do.

- Yep. - So, that is good.

If, the other one is be choosy about who you have

for a sexual partner.

Be choosy, talk to people.

Yes, love is wonderful, yes, we are human beings

and we are supposed to procreate,

we are supposed to have sex,

and we are supposed to have babies,

but be choosy about who you choose.

- And that was something you mentioned earlier,

that even if you'd had no sexual partners yourself,

it's about your chosen partner's sexual partners, right?

- Yes, exactly, and that doesn't mean that you say,

well, you've already had 20, you're off my list, right?

It may very much, that may be your life partner,

but just know what the risk is going forward

and going into it, that's important.

It's important for him, too.

Remember, guys get HPV vaccine too,

guys get HPV-associated cancers,

so it's a two-way street in understanding

who do you wanna pick to have your partner,

to be your partner?

I think that's really important for people to understand.

Use condoms, use condoms, condoms will help.

They don't protect against all STIs,

they don't protect against all HPV infections,

but they cut down on it,

and so you wanna do everything you can

to keep yourself healthy, and let me tell you,

if you haven't been to the Trojan website lately,

there's a lot of amazing different condoms out there,

so you should really, like,

go check this out. - Nice plug.

- It really is, it's a good thing to look for.

And then the other thing is, if you really want

some kind of birth control and you have options,

and your body is able and you think you want an IUD,

a progestin IUD offers some protection.

We often call that LARC,

long-acting reversible contraception,

and that is become kind of the top,

number one international contraceptive method

we recommend everywhere,

and that helps prevent pregnancy when you don't want it.

It helps prevent HPV infection,

it helps do many things,

so I think those are the kind of top things

and then, additionally, think about,

I should give a plug to the HPV vaccine,

is now approved up to the age of 45,

so, you know, starting at the age of nine

up to the age of 45, that will prevent the infection.

We know that, we have absolutely solid data

that it will prevent the infection.

- Thank you, thank you.

Dr. Hansen, do you have any treatment takeaways,

any things that you think should be the,

if someone's just tuning in,

or if someone's coming to the end of this video

what they should take away from this?

- I think that the key, again, is prevention.

You know, we know that when these cancers are caught early

we have better treatment options,

less sort of aggressive treatment options,

and screening will help, will identify precancerous cells

or dysplasia, allow us to treat those

and prevent cancer in the future,

so I think that really, prevention is the key.

If you are in a situation

where you are diagnosed with cervical cancer,

it's important to be seen by a gynecological oncologist

because the surgery, you know,

surgery for early stage cervical cancer needs to be done

by a gynecologic oncologist and those,

and also, there's surveillance that needs to happen

after that surgery that's really important,

and so, it's important to get yourself

evaluated in that way.

Yeah.

- Thank you, thank you for that,

and we have another question that came in.

What about women who have gone through menopause?

Does this protect them from cervical cancer?

- Menopause does not protect people from cervical cancer.

Menopause reduces the amount of estrogen.

It makes the vaginal tissues more likely to tear,

it makes the cervix more likely to be what we call atrophic

and very easily disturbed, and remember,

I said this is a skin-to-skin infection,

so if you can fall down and skin your knee more easily,

then the bacteria can get in,

the virus can get in more easily,

so menopause does not protect you from HPV infections.

- Thank you for that.

You mentioned earlier, when we were talking

about resources, what resources do you know of

that are available for the low-income population

for getting a Pap test?

- The CDC runs a program that's called

the Breast and Cervical Cancer Prevention Program.

It has been going, I think since 1980,

and it specifically provides breast cancer screening

and cervical cancer screening for women 40 and older,

who have no other access for that, so in other words,

they don't have Medicaid, they don't have Medicare,

they don't have private insurance,

they have nothing to help them.

It is an amazing program, the number of people

who have been served by that has decreased

since the ACA has come through,

and provided people with more insurance,

but nonetheless, if you find yourself without insurance,

that you cannot get a Pap test for that,

the program will provide that for you free of charge

and the program will also provide you with help

to getting workups for when those screens are abnormal,

so you don't have to worry about saying,

okay, I'm gonna go in and get screened,

I think something might be wrong,

but then I don't have the money to follow up with it.

No, the program will help you do that.

But the purpose of the ACA was to get more people insured,

so more and more people should have insurance.

That was, all preventive services

was legislated by Congress,

so that that should be part of your ACA coverage,

and certainly, if you have private insurance,

you have to have preventive services covered as well.

So I think that gives us the three different ways

in which we can make sure that women have access to,

they have the ability to have that test paid for for them.

Getting them to come in is another question.

- Yeah, yeah, indeed, indeed.

We have another treatment question that's come in.

Is surgery the only treatment option?

- So it depends on, it's the treatment for cervical cancer

is very dependent on the stage at which it's diagnosed,

so if it's a stage one cancer, which is either a microscopic

or larger tumor that's confined to the cervix,

generally, we treat those with surgery,

and that surgery is typically a radical hysterectomy

which involves removal of the uterus,

removal of the supporting tissues of the uterus,

and of the top of the vagina,

and the goal is to completely remove the tumor

with clean margins.

In cases where the tumor is larger,

involves the vagina or the supporting tissues of the uterus,

or even farther out to the pelvic side wall,

generally, those, we don't treat with surgery

because we're not able to remove it,

the tumor in its entirety in a safe way,

and so those patients will get a combination

of radiation and chemotherapy, rather than surgery,

and then in cases where the tumor has spread

to other parts of the body when it's diagnosed,

which of course we hope to prevent,

then those patients will get chemotherapy.

In some situations, there are very small cancers

that are confined to the cervix, that don't look,

kind of don't look aggressive under the microscope,

and those can actually be treated,

in patients who wanna have children in the future,

can be treated with just what we call a cone biopsy,

which is a large kind of excisional procedure

of the cervix that leaves most of the cervix in place.

Those patients just need to be followed very closely

after that procedure.

- And in terms of aftertreatment,

are there support services available after treatment?

- Yeah, you know, because this is a cancer

that happens in younger women,

and we're performing hysterectomies

or giving radiation therapy to younger women,

sometimes this is a common reason

that they would need support, so we do have,

through the cancer center support services,

support groups for patients who have undergone, essentially,

a surgical or radiation-related menopause at a young age,

and that's something that we can offer them

through the cancer center, and that's been really helpful.

The other thing is that it, after you finish your treatment

it's important to come back for regular visits.

Usually that will involve a pelvic exam.

The goal of that is to make sure

that the cancer hasn't come back,

and they get a Pap smear once a year

after we finish treatment, and we ask them about symptoms

and how they're doing and whether they have

any sort of signals that the cancer is coming back,

so we really really, if it does come back,

we wanna detect it early so they have more options.

- Okay, it looks like we've gone

through all of our questions.

I think there were a lot of really important touchpoints

that we pushed out today.

So, we're closing in on the end of our chat together.

I'm going to mention the Rogel cancer website,

the cancer answer line, we're also gonna post that

in the comments section as well.

Are there any final thoughts,

or anything you'd want to impart?

- My final thought is that everybody

should get their HPV vaccine.

I think that's probably what Dr. Harper will say as well.

Everybody, you know, now it's approved

from age nine to age 45 in both men and women,

and there's very very few true contraindications

to this vaccine, one is pregnancy,

but you can get it before or after pregnancy.

This is something that everybody should really be getting.

It's a huge, huge advance

in cervical cancer,

and really, everybody should be getting it,

I think. (laughs) - So, and my message

in addition to saying yes, the vaccine has done

an amazing job at preventing HPV,

is that when your daughter turns 21 years old,

one of your birthday presents to her

is to make her appointment for her first screening exam.

Get her started on a life of good behavior.

- And don't smoke. (laughing)

- That, too. - We've driven that point home

but yes, stop smoking. - Well, thank you both

for your time, I think it's been a really useful chat here.

Your time, your expertise,

the time of our audience that they've spent with us.

For more information on cervical cancer,

for the treatment options

at Michigan Medicine, you can visit

rogelcancercenter.org/gynecologic-cancers.

Now, that's a bit of a mouthful,

so we'll put that in the comments section, too.

You can also call the cancer answer line

at 800-865-1125.

That's 800-865-1125.

If you're interested in sharing this recording with others,

you'll find it on our Facebook page

after we've finished here,

and we'll also be putting it up

on the Michigan Medicine YouTube channel shortly thereafter.

So again, thank you Dr. Harper, Dr. Hansen,

for your time, thank you for joining us,

and everybody have a wonderful afternoon.