Are you getting appropriate cervical cancer screening? Dr. Judith Reichman explains simple tests that can aid prevention

Last year, 10,000 women in the United States were diagnosed with cervical cancer and almost 4,000 died from this largely preventable disease.  “Today” medical contributor Dr. Judith Reichman was invited onto the show to help you make sure you are getting appropriate cervical cancer screening.

A bipartisan association called Women in Government just announced that in some states women are not getting appropriate cervical cancer screenings.  Best grades for screening were given to Delaware, Massachusetts, Illinois, Maryland and North Carolina. The worst grades went to Tennessee and Texas.

Let’s do a quick review: What causes cervical cancer?  Is it really a sexually transmitted disease?
Yes.  We know that 99.7 percent of cervical cancers are caused by sexually transmitted viruses called the human patillomavirus, or HPV.  There are more than 30 types of genital HPV viruses. Those classified as high-risk HPVs are more likely to result in cervical cancer abnormalities or high-grade lesions (HSIL) that lead to cervical cancer.  Low-risk HPVs usually result in cervical changes that are less likely to be precancerous - such as low-grade lesions, or LSIL - although they cause venereal warts in about 1 percent of those infected.

HPV is very contagious during intercourse, and unfortunately, condoms won’t completely protect you; the virus can spread through skin-to-skin contact. As a result, HPV is found in more than 70 percent of sexually active young adults!  And because there are virtually no symptoms, most people are unaware that they have it.

Fortunately, most HPV infections do not lead to a pre-cancer or cancer of the cervix.  Most infections are temporary, especially in younger women, and cervical cancer in women under the age of 19 is rare.  In adolescence and young adulthood, 70 percent of high-risk HPV types and 90 percent of low-risk HPVs weaken or disappear after three years.

If a persistent high-risk HPV infection does enter the cervical cells, the process can take three years before the infection takes over and causes cell mutations. This means that if we wait three years from the onset of intercourse (when a woman can become infected) to begin cervical cancer screening, it is unlikely that we will fail to detect any cervical cancers.

How does a woman know she has an HPV infection?  Should she routinely be checked for this type of virus?
I have to emphasize that lack of symptoms does NOT mean that a woman (or her partner) is virus-free.  In sexually active younger women, there is a good chance that an HPV viral test will indeed be positive. 

On a personal note, I can tell you from clinical experience that receiving a diagnosis of high-risk HPV can produce a feeling of overwhelming anxiety in the patient and her loved ones, as well as in the treating physician. Questions such as: “When did I get this?  Who gave it to me?  Does this mean that I can give it to all my future partners?  Will it affect my babies?” are common and can’t be answered with any certainty, although transmission during pregnancy is highly unlikely.

There is also no ready cure available for HPV.  The only response that I and other physician can give seems inadequate in the face of a patient’s fear and distress: that this virus, like most viruses, will most likely subside and disappear.

What doctors and medical researchers do know is that the persistence of high-risk HPV is worrisome.  And the older a woman is when she gets it, or the longer she has it, the more at risk she becomes for cervical cancer.

Will a Pap smear indicate if HPV is present?
The Pap smear detects changes in the cervical cells that occur as a result of persistent viral infections. Liquid Pap smears - in which the cells are placed in a solution and filtered so that they can be separated and stained-can also be used for “reflexive HPV testing.” This means that if the results show mildly suspicious changes in the cells, the leftover fluid can be checked for HPV viruses.  If high-risk viruses are present, the doctor is notified and further testing with colposcopy (a special microscope that allows a physician to better view the cervix) and biopsy may be recommended.

If all “bad” Pap smears are due to HPV infection, should women just get HPV testing and forego Pap smears?

Right now this is not the standard of care, especially for young women who are not in stable, long-term relationships.  Young, single, sexually active women will have too many positive results, and when they do they should definitely follow up with a Pap smear.

However, if a woman over 30 in a stable relationship is HPV-negative, has a normal Pap smear and is considered “low-risk,” (i.e. she and her partner are monogamous, she has never had an abnormal pap, she doesn’t smoke or take steroids, and she was not exposed to the synthetic estrogen supplement DES during her mother’s pregnancy), then the two negative tests virtually guarantee that nothing has been overlooked. She doesn’t need to repeat cervical cancer screening for three years.

If we know HPVs cause cervical cancer, will vaccines against HPV prevent it?
Currently, several vaccines against two of the most high-risk types of HPV are being investigated.  Preliminary results show that these vaccines prevent persistent viral infection and subsequent pre-cancerous changes.  One of them may even be submitted for FDA approval by the end of 2005.

So what should women do to ensure that they get an A+ in their cervical cancer screening?
Here is the schedule that is currently recommended:

 
• Screenings for younger women:  Start three years after the onset of intercourse and no later than age 21.  
• Between 21 and 30: Repeat every year (conventional non-liquid Pap smear) or every one-to-two years (liquid-based Pap test).  
• Over 30:  Repeat Pap every two-to-three years if you are “low risk” and have had three normal, consecutive Pap smears.  HPV screening is optional.  
• After 70:  Stop Pap smears if you’ve had three normal Pap tests and no abnormal results in the last 10 years.  
• After hysterectomy:  No need for Pap smear if hysterectomy was done for benign disease and the cervix was removed.

It is important to note that since Pap smears were introduced more than 50 years ago, cervical cancer mortality rates in the United States have decreased by 75 percent.  Half of the cervical cancers in the U.S. occur in women who have never been screened, and another 10 percent occur in women who have not been screened in the past 10 years.  We must not discard a test that saves lives.

Dr. Reichman’s Bottom Line: For those women who want to check on their cervical health between Pap smears, HPV testing may be appropriate.  Perhaps in the future, HPV testing will become the standard method used to determine who should get a Pap smear and how often.

Dr. Judith Reichman, the “Today” show’s medical contributor on women’s health, has practiced obstetrics and gynecology for more than 20 years. You will find many answers to your questions in her latest book, “Slow Your Clock Down: The Complete Guide to a Healthy, Younger You,” published by William Morrow, a division of HarperCollins.