- 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.
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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
- 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.
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.
- 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
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
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.