What to Know Down Below™
Welcome to What to Know Down Below™ by Tina’s Wish! We’re here to empower you with the knowledge and tools you need to advocate for your own gynecologic health.
Knowledge is power, and we encourage everyone to join us in learning more about what you need to know, down below!
What to Know Down Below™
Cervical Cancer & the Power of Prevention
Moderated by Jennifer Garam, ovarian cancer survivor & advocate and health journalist, and featuring Dr. Melissa Frey, Gynecologic Oncologist at Weill Cornell Medicine
Welcome to What To Know Down Below by Tina's Wish. We're here to empower you with the knowledge and tools you need to advocate for your own gynecologic health. Knowledge is power, and we encourage everyone to join us in learning more about what you need to know down below.
Speaker 2:Hi everyone. I'm your host, Jennifer Garam , and I am an ovarian cancer survivor and advocate and a health journalist. I'm here with Dr. Melissa Frey of Wild Cornell Medicine for the next installment of our three-part series, A Guide to Gynecologic Cancers. Today we will be talking about cervical cancer and the importance of the HPV vaccine. You can find our other episodes in this series focused on uterine and vaginal and vulva cancers, as well as our previous series on ovarian cancer, wherever you get your podcasts. Hello, Dr. Frey . Thank you for being here today for the second episode in our series on gynecologic cancers. As a refresher for our listeners, what is gynecologic cancer in general and what is cervical cancer in particular?
Speaker 3:Gynecologic cancer refers to a cancer of one of the organs in the female reproductive system. The cervix is the , um, sort of bottom of the uterus. Um, and cervical cancer is very common worldwide. Um, it is not as common in the United States , um, likely due to cervical cancer screening, but we still see approximately 14,000 cases a year in the United States. Um, so it's something that we still see and I'm so glad we're doing this , um, session on it because cervical cancer is something that is highly preventable, and that is with both , um, vaccines and then also with cervical cancer screening to catch something before it turns into cervical cancer.
Speaker 2:Great . And then just to kind of talk about HPV, because that has an association with cervical cancer, so can you explain what HPV is, how common it is, and how that relates to cervical cancer?
Speaker 3:HPV is a virus. It is extremely common. Um, it is , um, usually transmitted , um, via sexual activity, but I, you know, I often tell people that, you know, the majority of people who are sexually active are probably exposed to HPV at some point in their lifetime, so the virus is quite common. But if, if one becomes infected with the virus and one's own immune system cannot clear HPV, then this can cause changes in the cells of the cervix that if left untreated and undiagnosed can eventually progress to cervical cancer. But this is a very, very slow progression. We often say that it takes over a decade from exposure to HPV to development of cervical cancer, so there's lots of time to identify and prevent the cancer.
Speaker 2:How would you know if you have HPV ?
Speaker 3:So, HPV is usually identified on cervical cancer screening. So currently we recommend that women beginning at age 21, get pap tests. And usually this pap is repeated every three years if it's normal. And then beginning at age 30, we often add HPV to the PAP test. And so HPV is diagnosed on this type of cervical cancer screening .
Speaker 2:Would a PAP test catch it too without that additional screening?
Speaker 3:The, the PAP test is, is what most women think of it is usually a combination of what's , um, cytology or looking at the cells of the cervix , um, and looking at HPV. And so you could speak with your doctor about which tests they're doing, but in general, for women age 21 to 29, we're doing pap alone and not HPV, and then we're adding HPV at age 30.
Speaker 2:Uh, I just wanna talk here for a second about stigma and overcoming stigma because I feel like with any sort of sexually transmitted , um, uh, thing, like there's gonna be a stigma, people might feel, take , feel responsible, feel ashamed. Can you talk about that? Because I feel like we need to get rid of the stigma so that people will talk more openly and they can ra raise these concerns to their doctor sooner and not feel like it's something they did wrong. I mean, it sounds like it's so common to be exposed to it, people shouldn't have any sort of stigma or shame around it.
Speaker 3:Absolutely. This is something that more people than not are exposed to. If they're sexually active , um, we don't routinely screen for it like we do for other sexually transmitted infections because it is so common and for the majority of people , um, an exposure does not lead to an infection because our own immune system is able to eradicate it. And so I , this is again, something that's extremely common. We know that not only does HPV cause uh , cervical cancer, but it also causes , um, anal cancer. It also can cause , um, oral pharyngeal or some of the head and neck cancers. So this is extremely common. Um, and I agree with you completely that we have to take away the stigma ,
Speaker 2:Um , because I feel like the stigma gets in the way of people speaking up and sharing concerns. And so the more that we talk about it, the more we can kind of diffuse these, the stigma. Um, so then moving on to the HPV vaccine, what is this? Is this a newer thing? Um, can can you explain it? Can everyone get it? Why is it important?
Speaker 3:The HPV vaccine has been available for several years. The vaccine that is available in the United States is called Gardasil nine, and this covers nine subtypes of HPV . So it covers what's called HPV 16 and 18. So these are the types of HPV that cause probably about 70% of cervical cancers across the world. But then it also covers several other types of HPV that can also cause , um, cervical and some of the anal and other cancers that are HPV related . And it also covers HPV six and 11, which actually are the cause of more than 90% of anal genital warts. And so this vaccine actually kind of prevents against likely several cancers and against genital warts. And so this vaccine is, is a tremendous tool in cancer prevention. So who can get the HPV vaccine? Well, the answer is really everyone. So currently the vaccine is approved for men and women between the ages of nine and 45. It has been recommended for all men and women between ages 11 and 12 , um, catchup vaccination. So if you miss the opportunity to get vaccinated between 11 and 12 is recommended up to age 26. And then for people who are age 27 to 45, this vaccine is available, but it's usually recommended this is a decision with your physician. Insurance often does not cover the vaccine for individuals who are greater than 26, but this is still an option.
Speaker 2:Okay. Are there any risk factors to receiving the HPV vaccine?
Speaker 3:Um, for the most part, this is, is really a safe vaccine. Um, this is not a vaccine that we offer to people who are pregnant, but apart from that , um, there are really very, very few contraindications. And so I think the majority of people should discuss this and should get HPE vaccination.
Speaker 2:Um, and can you just explain what contraindication means?
Speaker 3:Oh, sorry. Contraindication means a reason that you couldn't get it. Okay . But this is a very safe vaccine that, that most people should be getting. I will say that our vaccine rates are not nearly as high as they , we would like them to be. Um, probably only about 60% of women in this country are actually getting their first dose, and we know that number is even less for men. And so we're really hoping and trying to do whatever we can to improve vaccination rates. Um, and so I would emphasize again, this is a very safe vaccine that can prevent cancer.
Speaker 2:And you said first dose, is there more than one dose for this vaccine?
Speaker 3:Yes. So the recommendation is for people who get the vaccine between ages nine and 14, you can have just two doses, and that's usually given sort of today. And then again in six to 12 months, if someone is 15 or older when they start the vaccine series, then we give three doses and that , so that would be today and in one to two months, and then si and then six months. And then for anyone who's immunocompromised, so anyone who has is on long-term steroids or who has HIV, then we recommend three doses, even if they start the vaccine at the younger age.
Speaker 2:Uh , and then you said up until age 45 individuals can receive this vaccine. Why is that the cutoff in , why should people not, is there any exception or really people over 45 shouldn't get this vaccine or are there exceptions to that?
Speaker 3:So the vaccine is, is technically the approval goes up to 45. Um, there certainly are physicians who offer this to patients , um, at older ages. Um, and you know, I think that's based on an individual discussion between patient and physician because really the, the approval is at 45. And so most of the data we have on the effectiveness of VA vaccine really is in that age group. And, and we also know that this is a vaccine you wanna get before exposure to HPV. And so that's why we really are, are pushing for vaccines at the 11 to 12 years of age range because we want to get the vaccine prior to exposure because that's when it has maximum effect.
Speaker 2:Um, and then you touched on this, the VA is the vaccine covered by insurance? You said it, it typically is up until a certain age and then after that it might not be.
Speaker 3:In general, we see it's covered up until age 26. Um, for many people it is for not covered between age 26 and 45, although it is approved for that age group.
Speaker 2:Okay. And would you say that's kind of, could be subject to individual insurance plans? Absolutely . Like people should look into it if they're interested mm-hmm <affirmative> . Um , so when you say that individuals should get their first dose 11 to 12, and there are a lot of ages that we just spoke about from certain age ranges, so just if people want clarity and they want to go through all these different age ranges and all these different things that need to happen at different ages at at the age of 1112, are they talking to a pediatrician or at what age should , uh, a young person start to see a , a gynecologist or their gynecologists that are specializing in younger, you know, adolescents?
Speaker 3:So this is something that should be offered by pediatricians. So it's often a discussion between the pediatrician, the parent , um, and the child. There are pediatric gynecologists, but this is really for sort of the rare case where someone has a gynecologic disorder in childhood. I would say that for the majority of of of things that come up for a child, this is really within the realm of pediatrics. And so we are, you know, really hopeful that pediatricians are offering this vaccine to their patients and to the families that they see.
Speaker 2:Great. So it sounds like if you were a parent, you have a child around approaching 11 or 12 and the pediatrician has not brought it up to you, you would would say to bring it up to the pediatrician and and and ask about it and talk, have that conversation?
Speaker 3:Absolutely. And this is , um, a male or a female child. Um, and the decision to, you know, initiate the HPV vaccine does not mean that a parent thinks their child is about to become sexually active. And I think that is sort of part of the nuance of this and part of the stigma of the vaccine. This just means that there's a vaccine that can prevent cancer and it is most effective if given before onset of sexual activity. And so to do it at 11 or 12 is a safe and recommended time . And so that whenever , um, if ever someone decides to be sexually active , that vaccine has already been given and someone already has protection .
Speaker 2:Great. And then you had mentioned this is for male and female and also, so this is a vaccine that is for people regardless of gender, regardless of sexual identity across the board?
Speaker 3:Absolutely.
Speaker 2:Okay. Um, and then also just want to touch on the fact that the HPV vaccine could help prevent cervical cancer and some of those other conditions that you mentioned, but is not going to be , um, prevent pregnancy. It's not gonna prevent other sexually transmitted diseases. It's not a replacement for any of that. Um,
Speaker 3:Absolutely. The HPD vaccine should not take the place of birth control. Um, it should not take the place of condom use , um, which we know is, you know, one of the best methods to prevent the , um, spread of sexually transmitted diseases. So there are several other sexually transmitted diseases, chlamydia, gonorrhea, syphilis, HI, so those are, those are not prevented with the HP vaccine. Um, and so someone should still think about contraception and prevention of STDs.
Speaker 2:Okay. And then is HPV also associated with vaginal and vulgar cancers?
Speaker 3:Yes. So HPV can also cause vaginal and vulvar cancers. The only difference is , is that there are other causes of vaginal vulvar and vulvar cancer, and it's for cervical cancer sort of interestingly, almost a hundred percent of cases are caused by HPV. There are rare cases that are not, but really the , the majority of cervical cancer is driven by the HPV virus. And that really brings us back to the importance of vaccination and the importance of screening with , um, PAP tests and HPV tests because this is a disease that should be preventable or we should be able to catch it as a pre-cancer and prevent it from, from turning into a cancer.
Speaker 2:Um, you said that most cervical cancer , um, is a result of HPV, but in rare cases it could be something else. What are some of those other risk factors , um, that could, could , could put people at risk for developing cervical cancer in addition to HPV ?
Speaker 3:So I would say there are other risk factors for , um, cervical cancer, but they usually sort of are , um, working with HPV. And so we know that someone who has multiple lifetime sexual partners or an early age at first intercourse , um, has an increased risk for cervical cancer. But this is really largely driven by exposure to HPV through intercourse. We also know that tobacco use or smoking is a very important contributor to cervical cancer, but this is also related to HPV . We know that , um, people who , um, use tobacco have a harder time clearing the HPV virus and so it actually prevents our immune system from clearing the virus. So there are other risk factors for cervical cancer, but they're really aligned with HPV infection.
Speaker 2:And can someone still develop cervical cancer even if they've had the vaccine, the HPV vaccine?
Speaker 3:Yes. Um, the HPV vaccine does not cover all HPV subtypes, and so it is possible, and also if someone is exposed to HPV prior to the vaccine, then the vaccine will not prevent them from developing cervical cancer.
Speaker 2:So it sounds like it could help mitigate that risk, but just because you've had the vaccine, you shouldn't assume you're in the clear and not pay attention to your gynecologic health anymore.
Speaker 3:Absolutely, and I I recently read a statistic that if we could vaccinate all 12-year-old girls in the United States who would prevent hundreds of thousands of HPV infections annually , um, and thousands of cervical cancers annually. And so this is really something that I think we all have to work together to improve rates of HPV vaccination.
Speaker 2:And what are some of the typical symptoms or warning signs that someone might have cervical cancer? And are there always symptoms or are there cases when it could be asymptomatic?
Speaker 3:Cervical cancer can very often be asymptomatic. And so , um, often we're finding this on a PAP test or with an HPV test. Um , and usually that means this is at a very early stage, which is, is what we hope from screening that if we find something that's at an early stage, sometimes people can report irregular or heavy vaginal bleeding or bleeding after intercourse. So if someone is experiencing any of these , uh, symptoms or complaints, that's something to check in with your physician about. Um, some people note abnormal vaginal discharge and then if someone has advanced disease, so disease that is spread outside the cervix, that's when people can start having , um, back pain or pelvic pain or changes in their , um, eating habits or changes in their bowel habits or their , uh, urinary habits . So , um, I would say that symptoms can really , uh, there's a range of symptoms that one can experience from asymptomatic to a lot of , uh, a lot of symptoms.
Speaker 2:Um, and then if you've received the HPV vaccine, it sounds like you still need a routine pap smear, is that correct ?
Speaker 3:Absolutely. Um, the receipt of the vaccine does not change recommendations for cervical cancer screening. And so while I think we're talking a lot about the vaccine here, I would also stress the importance of cervical cancer screening because if we catch cervical cancer or pre-cancer in early stage is very treatable. Um, and so seeing a gynecologist regularly for , um, cervical cancer screening is critical.
Speaker 2:Is there any , um, hereditary element like with the other gynecologic cancers with cervical or is does that not apply in this instance?
Speaker 3:There are very rare hereditary syndromes that can increase the risk for cervical cancer. Um, but this is exceedingly rare. So if someone has a lot of cervical cancer in their family, that's certainly something to uh , mention to a physician. And if someone has, you know, know cervical cancer combined with especially breast cancers and colon cancers, that is something to mention to a physician. But this is not , um, like a , an ovarian cancer or a uterine cancer where we can commonly see these cancers group in families due to a shared genetic predisposition. This is , uh, really would be quite rare to have a genetic syndrome , um, lead to cervical cancer.
Speaker 2:Okay. Uh, I wanna talk a little about pap smears because this is another thing. I feel like there's a lot of different information out there of how often you should get it, when you should start, when you should get them more often. So I just wanna go through , um, you know, the ages of the pap smear, I think you said 21 for the first one. Um, and then how frequently should someone have a pap smear and what would change that frequency age , um, concerning findings, anything like that?
Speaker 3:So assuming that , um, all the paps are , uh, normal and that a person is otherwise healthy, so does not have HIV or other immuno compromising conditions, then the standard recommendation would be beginning at age 21 through age 29, getting a PAP test every three years when someone turns 30, there are a couple options. You could continue doing the pap test every three years. You could do HPV testing alone every five years, or you can do what we call co testing . And this is when you do the PAP test with the HPV test . And I would say co testing is probably what's done most commonly. We actually , um, the guidelines actually say that after age 65, if someone has had adequate and normal prior screening, we can stop doing pap tests. So again, that would be the kind of general guidelines for someone who is otherwise healthy with no abnormal paps. If someone has an abnormal PAP test or if someone has HPV, then that changes. And there are really individualized algorithms based on exactly what one has that guide. How, how often and when we repeat the PAP and the HPV ,
Speaker 2:Um, I'm just curious, why does it stop at 65 and are there any exceptions to that?
Speaker 3:So this was , um, kind of work done looking at , um, the incidents of cervical cancer and also looking at sort of the , the positive predictive value of having a lifetime of normal PAP tests. Um, and so, so the guidelines say we can stop after age 65, but that would only be for someone who, you know, doesn't have a medical condition that makes us concerned they're at increased risk for cervical cancer and people who've had prior normal screening. So for people who wears any concern, they may continue screening after age 65 because it's, it's, it is possible to get a cervical cancer after age 65. We know, we know that.
Speaker 2:I have a question too. If you have had your reproductive tract removed because of cancer, so say you don't have a cervix, but do you still need to be looked at or screened or , or examined or can you not get, get cervical cancer if you don't have a cervix?
Speaker 3:So for, for someone who's had their uterus and cervix removed, who's, who's not had a history of abnormal paps or high grade paps, then they actually don't need to continue cervical cancer screening. They don't need to continue PAP tests. I still would recommend seeing a gynecologist regularly because , um, there are still cancers of the vulva, the vagina and other organs that are possible. And so I wouldn't say to stop having gynecologic visits, but you don't have to do a PAP test if you've had a hysterectomy and no history of abnormal pap tests.
Speaker 2:Okay . Um , yeah, it sounds like with the paps, if you have any sort of irregular finding, you just really need to talk to your doctor about their specific recommendations for you and make sure that you are getting the optimal screening based on your circumstances. Absolutely. And if someone's pap smear came back normal, but they're experiencing symptoms that are not normal for them, should they still bring this up with their doctor?
Speaker 3:Absolutely. Um, because, you know, there could be something else that's causing the symptoms and so it's very important not to rely on a negative PAP test. Um, and I think this is sort of a , a misconception that comes up a lot is that , um, people think that if their pap is negative, they've sort of been screened for all the gynecologic cancers. And so I would say that the pap only screens for cervical cancer and if someone is having symptoms, that always needs to be evaluated even if the pap was completely normal.
Speaker 2:That is such an excellent point to bring up. Even though we're talking about cervical cancer in this episode, I think people don't realize that pap smear just screens for cervical cancer and they assume it kind of screens for , um, reproductive cancer across the board. And people are surprised to find that ovarian cancer, for instance, does not have an early detection test and a pap smear does not screen for that. So I think it's really important to note any change from your norm. I mean, there's other gynecologic cancers and you should always be paying attention to your body and bringing up any concerns with your doctor as soon as possible rather than, you know, months down the road.
Speaker 3:Absolutely. And, and I would say that, you know , ovarian cancer and uterine cancer are much more common than cervical cancer in the United States. And so the absence of a cervical cancer on cervical cancer screening does not rule out the presence of an ovarian or uterine cancer. So I'm glad you brought that up. Okay .
Speaker 2:Do you have any final words of advice for our listeners when it comes to cervical cancer or HPV?
Speaker 3:I think I would just emphasize again, the importance of vaccination and the importance of cervical cancer screening because those are , um, two tools that we could really use to eradicate cervical cancer in this country because we should, you know, we should not be having 14,000 cases a year and 4,000 deaths a year for a disease that is preventable.
Speaker 2:Great . Thank you so much . And I also just wanna , um, add the importance of just advocating for yourself and asking questions. Like you said, we've gone through so many different recommendations for the vaccine, for the pap smear different ages, and to really inform yourself and know, and , and if you don't know, ask your doctor and talk to 'em and get this information from them because you might not have it readily available. And I think it's so important to have these conversations and really be informed about what's going on in your own body and what you need to be doing to take care of your health. So thank you so much. Um, Dr. Frey , thank you so much for sharing your expertise and a huge thank you to everyone listening. We hope this information helps you feel empowered and to take control of your own health. Be sure to tune in for the final episode of our three part series as we discuss vaginal and vulva cancers.
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