By Kay Taylor, MD and Director of PINCC
Taken from Dr Taylor's UC Berkeley presentation
PINCC is a non-profit volunteer medical service organization dedicated to preventing cervical cancer for women without access to care internationally.
Cervical Cancer Deaths
Cervical cancer kills over 280,000 women every year worldwide: needlessly! That’s over 800 women every day!
It is the #1 and #2 cancer killer of women in developing countries. With early detection and treatment, cervical cancer is almost completely preventable! Cervical cancer has been greatly reduced in industrialized countries since 1959, when Dr. Papanicolau popularized the Pap smear. The death rate was as high in the USA as it was in Africa in 1950.
Death Rate per 100,000 women now:
USA and Europe: 2.2 Latin America 31
Africa: 40 India: 17
The Cause: HPV (Human Papilloma Virus), a double-stranded DNA virus.
- Most common sexually transmitted disease worldwide;
- 50-80% of people will get it sometime in their lives.
- There are 30-40 genital strains, 11 of which are carcinogenic
The most common is HPV 16; in the USA, HPV 18 is second. These two cause 70% of cancers. In other countries, HPV 18 is less common than other strains. This means that even if a woman has been immunized, she will need to be screened to eliminate the possibility of infection with another strain. The rest are non-cancer-causing viruses, which cause genital warts both externally on the genitals and in the vagina, and on the mouth, penis and anus.
How HPV spreads:
- Genitals- penis, testicles, anal area, vulva, vagina, cervix
- Manual: Hand contact with genitals, self and partner
- Oral: mouth/tongue to genitals, mouth to mouth
What can HPV do?
Non-carcinogenic strains cause
- Genital, anal and oral warts
- Infants: laryngeal condylomata, oral papillomatosis
Carcinogenic strains cause:
- >99.8% of cervical cancer
- 90% of anal cancer
- 40-50% of oropharyngeal cancer (mouth and throat)
- 40% of vulvar and vaginal cancer
- 40% of penile cancer
Burden of HPV disease in the USA:
9,800 deaths in 2010.
Cervical cancer: 12,200 cases 4,210 deaths
Vulvar cancer: 2,480 cases 680 deaths
Penile cancer: 500 cases 124 deaths
Women: 4,448 cases 980 deaths
Men 14,616 cases 3,152 deaths
Women: 2,934 cases 396 deaths
Men: 1,800 cases 252 deaths
How HPV causes cancer:
Infects cells at transformation zones: Cervix, oropharynx, anus invades basal epithelial cells by microtrauma, e.g. sexual intercourse. It replicates without cell death, so no cytokine immune response. It becomes a persistent infection; clones of infected cells proliferate, then eventually invade.
Our best defense: A healthy immune system.
- 80% of HPV infections are cleared spontaneously by women under 25 years old.
- Persistent HPV infections, especially after age are at higher risk for cancer development
- HPV high-risk testing can identify infections, but are only 80% accurate.
Practical HPV Management:
- Limit number of sexual partners
- Use condoms (male and female): this is only partially effective
- Avoid high-risk cofactors that weaken the immune system: Tobacco, excess alcohol, trans fatty acids
- Assume you’ll get infected – and Get Checked Regularly! Regular gyn exams and Pap smear yearly, until 3 negative results, and no new sexual partners; then Pap can be done every 2-3 years
- Available to girls/women and boys/men ages 12-26
- Some cross-reactivity with other strains
- Not effective if you already have the carcinogenic strain
- Vaccines against more strains are being developed
Why you should get checked: Cervical cancer is preventable!
- Slow development from infection to invasion: average 20 years
- Cervical cancer is the most preventable cancer in the world:
- Pre-cancerous cell changes occur early, in <5 years
- Long latency of early stages, detectable by tests:
- Pap smear, colposcopy and biopsy
- Local in-office treatment is 90% effective, with few side effects
Pap smear: not very sensitive (65%); but if positive, it’s very specific (95%)
3 yearly Paps have >85% sensitivity for dysplasia
HPV high-risk screening: 80% accurate
Colposcopy with biopsy: 90+ % accurate
Treatment for positive results:
Cryotherapy: freezing cervical skin to 5 mm. deep, through squamous layer
- 90-95% successful for low-grade, visible lesions
- Minor side effects: initial cramping, discharge for 2 weeks
- Complications: Possible infection, if gonorrhea or chlamydia present, that could lead to infertility. Possible vaginal ulceration, needing 4-6 weeks healing
LEEP: Loop Electrical Excision Procedure
- Can be done in the office under local anesthesia
- Removes epithelium and subcutaneous tissue
- Allows histological confirmation of pre-invasion
- 90% effective, even for severe dysplasia
- Can reach tissue in cervical canal
- Side Effects: Mild bleeding and discharge for 2 weeks and cramping for several days
- Nothing in vagina for 6 weeks while healing
- Complications: Infection if chlamydia/ gonorrhea present, post-procedure hemorrhage within a week, cervical incompetence and pregnancy loss if too large a cut is made into the muscle
The HPV Vaccine: a cure for cervical cancer?
Not yet, but hopeful
- Only effective prior to infection
- Only protects against 70% of carcinogenic HPV strains
- Length of protection is unknown
- 3-injection series must be completed
HPV Vaccine Facts:
2 Vaccines approved by FDA and available:
Gardasil: Quadrivalent: HPV 6 and 11 (warts) and HPV 16 and 18 (carcinogenic)
Cervarix: Bivalent : HPV 16 and18
Both have shown >99% seroconversion immune response after 3 doses
- Now 5-7 years with decreased but present antibodies
- No tests of direct viral challenge to confirm immunity
- Too early to know if will give long-term immunity
Why the Rest of the World is so far behind in prevention
1. Viral spread at young ages: up to 40% of girls in Africa and some areas of Latin America have been sexually abused before age 16.
2. Prostitution of girls and women: more than 1 million are forced into prostitution, abused and trafficked world wide every year. These victims are at high risk for both HIV and HPV infection, at younger ages.
3. Coinfection with HIV/ AIDS causes more rapid development of HPV lesions to cancer. Even though cervical cancer is listed as an AIDS-defining disease, the majority of HIV/ AIDS programs in developing countries do not have cervical screening programs.
4. Poverty is a two-edged sword. Where screening is available, it is usually too expensive in private medical sector for most women, and too scarce in public health centers. Poor diets, other diseases etc. which accompany poverty also weaken the immune system
5. Lack of doctors and other health workers, medical resources, training, and equipment limit the ability of public health care sites to address this problem. Global public health funding focuses on reproductive health: contraception, maternal and child health, and infectious diseases such as malaria and TB. Cervical cancer affects women mostly over age 35, so not included in the above programs.
How PINCC helps: bringing care to women in need around the world
- We work with clinics and hospitals serving poor, HIV+, and rural women in countries with inadequate health care resources.
- Our volunteer teams train their doctors and nurses in an affordable, single-visit, see-and-treat method of cervical screening and treatment.
- We return every 6 months to continue training, donating equipment and increasing skills until the center is self-sufficient.
- We collaborate with Departments of Health of the countries where we work to establish training centers and spread the network of care sites.
- We have trained hundreds of doctors and nurses.
Is PINCC cost Effective?
PINCC can screen and treat a woman for $15! Because of volunteers paying their own way to give services, and low administrative costs, most donations are spent on direct program costs. Our sustainable programs will treat thousands of women for years to come, continuing to save the lives of women who had no access to care.
Women’s health is a social justice issue! All women, regardless of age, income, race, or creed deserve adequate health care. We are working to bring the available, affordable technology to stop cervical cancer to those in need, around the world.
Your support gives us wings!
Click here to find out how you can help!