HPV vaccine prevents cervical cancer

Host Amber Smith: Upstate Medical University in Syracuse, New York invites you to be The Informed Patient with the podcast that features experts from Central New York's only academic medical center. I'm your host, Amber Smith. The human papilloma virus, or HPV, is the most frequent sexually transmitted infection in the United States. Some types of this virus cause genital warts. Other types cause head and neck or throat cancers and genitourinary cancers, including cervical cancer. My guest today is gynecologic oncologist, Allison Roy, who is an assistant professor at Upstate. Welcome back to The Informed Patient, Dr. Roy.

Allison Roy, MD: Thank you. It's great to be here again.

Host Amber Smith: I know that the HPV vaccine protects against genitourinary cancers. And from what I understand, the vaccine is recommended for 9- to 12-year old boys and girls. But it's a relatively new vaccine, so I imagine there are a lot of adults who were not vaccinated when they were children. Among the patients that you see with cervical cancer, are they mostly women who were not vaccinated as children?

Allison Roy, MD: Yes. I would say the vast majority of my patients with cervical cancer are patients that weren't vaccinated. Additionally, they may also not be up to date with regular screening.

Host Amber Smith: So, do you recommend your adult patients get the HPV vaccine if they did not get it when they were younger?

Allison Roy, MD: As you mentioned before, the HPV vaccine is recommended for everyone ages nine through 26, although it's recommended between 9 and 12. And the reason for that is because you want to have the vaccine prior to any kind of sexual exposure where you may be at risk for HIV. The decision to vaccinate beyond age 26, really depends on risk factors. And it's an individualized decision between the patient and their physician.

Host Amber Smith: So someone, say, between 27 and 45, how would you go about assessing their risk factors? What should they consider?

Allison Roy, MD: Most patients between 27 and 45 will have been exposed to HPV at some point. And it's important to understand that the vaccine itself doesn't cure HPV or treat HPV that one already has. However, the HPV vaccine does cover multiple different strains or types of HPV virus. And you may not have been exposed to all of those types. Therefore there's still some benefit from getting the vaccine at an older age. And so when I talk to patients about getting it as an adult, I think about who's at risk for more HPV transmission. So, patients who have multiple sexual partners or maybe have new sexual partners, or if they work in a profession like gynecology or dermatology, where they may be occupationally exposed to HPV, actually through treatment procedures. Another important factor that is a consideration is cost. And so unfortunately, although the vaccine is FDA approved from 27 to 45, a lot of insurance companies don't yet cover it. And so that can also be a factor in terms of patients getting vaccine.

Host Amber Smith: I didn't realize that. So it could be expensive to pay out of pocket?

Allison Roy, MD: It can be expensive to pay out of pocket for the vaccine, and insurance companies are starting to come around and cover it, but it's not quite there yet.

Host Amber Smith: So, what about people who are over age 45? Are they not considered to be at high risk for cervical cancer or throat cancer?

Allison Roy, MD: So risk for HPV-related cancers doesn't just suddenly disappear after age 45, but when you're considering the vaccine benefit, it starts to decrease a little bit in that age group, again, because of prior HPV exposure. Or patients that are potentially in more monogamous or committed relationships where they don't necessarily have multiple sexual partners or new partners, although we do know that people in those age groups still do. But it's just in terms of kind of risk-benefit. Right now, the vaccine isn't approved for that age group. It may be in the future.

Host Amber Smith: So someone, say a woman in her twenties or thirties, if she has developed genital warts, or cervical cancer for that matter, is it too late for her to be vaccinated?

Allison Roy, MD: It's not too late for her to be vaccinated. And as I kind of previously alluded to, while the vaccine doesn't treat or cure HPV that one has already been exposed to, it does cover multiple different types of HPV. And so the vaccine could still help protect them against the types that they haven't been exposed to.

Host Amber Smith: If you have a patient who has developed genital warts, is she at greater risk for developing cervical cancer?

Allison Roy, MD: Not necessarily, although risk of exposure to one type of HPV probably means that they're engaging in behaviors that are a little bit higher risk for exposure to other types of HPV. But in general, the HPV strains that cause genital warts don't typically cause cancer. They're more of a low-grade strain. But again, because you have that potential for exposure, you know, your risk is a little bit higher based just off of that.

Host Amber Smith: This is Upstate's The Informed Patient podcast. I'm your host, Amber Smith talking with gynecologic oncologist, Dr. Allison Roy. She's an assistant professor at Upstate, and we're discussing cervical cancer, which can be largely prevented by the HPV vaccine.

Aside from the HPV vaccine, what else has done to protect women from cervical cancer?

Allison Roy, MD: An important part of cervical cancer is actually that we do have screening for it. And so routine pap smears are also performed, in addition to HPV vaccination to help prevent against cervical cancer.

Host Amber Smith: Can you walk me through what happens if a woman's Pap smear or Pap test, or the cervical exam is abnormal?

Allison Roy, MD: Pap tests are a screening tool. And so typically if a Pap test comes back abnormal, you're going to do a more specific test. And usually this is something called a colposcopy, which may or may not, depending on what's found, include biopsies of the cervix. And a colposcopy is similar to a Pap in that it's an exam where you're up in stirrups and you have a speculum and you actually are looking at the cervix with a microscope, as opposed to just with the naked eye to help identify abnormal cells.

Host Amber Smith: Are you able to visualize the cancer cells that way, with the naked eye?

Allison Roy, MD: So it depends. Sometimes depending on the lesion, you can see something that looks abnormal. If it's very small and microscopic, the microscope can actually help us to see that a little bit better. We also use something called acetic acid, which is actually just a solution that you can put on top of the cervix that helps turn some of those abnormal cells a whitish color to allow us to see it better.

Host Amber Smith: Now I've heard the term cervical dysplasia. Is that related to cervical cancer?

Allison Roy, MD: So, cervical dysplasia is a general term for pre-cancer of the cervix. So these are abnormal cells, but they're not yet cancer. And there's three different grades of dysplasia, depending on how abnormal those cells look.

Host Amber Smith: You mentioned the colposcopy. Is that like a biopsy, or is it a type of biopsy, technically?

Allison Roy, MD: The colposcopy part of it is just the act of using that acetic acid solution and looking at the cervix with a microscope. Most often, when you have a colposcopy, if there's abnormal areas that are seen, biopsies will also be done.

Host Amber Smith: I see. And then once you get the results of those biopsies back, is that how you diagnose whether she has cervical cancer?

Allison Roy, MD: Cervical cancer is a diagnosis based off of the tissue. So based off of the biopsy sample that we get.

Host Amber Smith: What are a woman's options if she's diagnosed with cervical cancer?

Allison Roy, MD: So, it really depends on the stage at diagnosis. The stage of diagnosis is based on physical exam, as well as, typically, imaging that's done to kind of get a sense if the cancer spread anywhere else beyond the cervix. And so it's a combination of looking physically at the cervix and doing a physical exam, along with imaging to help decide what the treatment recommendation is going to be.

Host Amber Smith: Is surgery an option, or radiation, chemotherapy? Are they all options?

Allison Roy, MD: So again, depending on the stage. Surgery is an option in earlier stage cervical cancers. As we get into later stages, we actually move more toward treatment with a combination of radiation and chemotherapy, and not actually treating it with surgery at all.

Host Amber Smith: What are the survival rates like for cervical cancer?

Allison Roy, MD: Early stage cervical cancer, or cancers that are confined to the cervix, have a good overall survival rate. The statistics from the American Cancer Society give about a 90% survival at five years. And a lot of cancers are reported based on five-year survival, which is the amount of patients with that diagnosis that are still alive at five years from their diagnosis. So greater than 90% is great for early cervical cancer.

Unfortunately, once that disease starts to spread regionally, meaning within the pelvic area, that survival decreases to around 66%. And then when you start to have diagnosis of distant disease -- either a disease that spread to the abdomen, the chest, or actually locally invading into the bladder, into the rectum -- that drops down to about 15 to 20%.

Host Amber Smith: Do you know if the HPV vaccine has been in use long enough to have an impact and reduce the incidence of cervical cancer? Are we seeing less of it now?

Allison Roy, MD: Yes. There's actually been several studies that have shown a dramatic decrease in cervical cancer in young patients who have been vaccinated. There was a study that looked actually at a huge population of 1.7 million women that showed almost a 90% reduction in patients, cervical cancer frequency in those who were vaccinated before age 17. So these are huge decreases in numbers, based off of the vaccine.

Host Amber Smith: Does the woman who developed cervical cancer need to be concerned about throat cancer or other HPV-related cancers, as well as the cervical cancer?

Allison Roy, MD: Yeah. So cervical cancer and other HPV-related cancers are all kind of linked to that exposure risk to HPV. And so, unfortunately, someone who has a diagnosis of cervical cancer, or even someone who has a diagnosis of HPV, is potentially at risk for HPV in other sites. Unfortunately there's no standard screening for other HPV-related cancers the way there is for cervical cancer with the Pap smears. And I also have to add here just with HPV-related cancers, smoking is another major modifiable risk factor that is increased in all HPV-related cancers.

Host Amber Smith: At the beginning I said genitourinary cancers, and we've talked mostly about cervical cancer. Do you see many cases of vaginal or vulvar or anal cancers in women that are tied to HPV?

Allison Roy, MD: Vaginal and vulvar cancers are a little bit less common, but I certainly do see those in my patients. And most of them are tied to the HPV virus, a lot of vaginal/vulvar cancers. I don't see as many in terms of anal cancers, mostly because those end up going to my colorectal colleagues.

Host Amber Smith: So the vaginal or vulvar would not be diagnosed with a cervical test or a pap smear. How would those cancers be discovered?

Allison Roy, MD: Typically they're either based on a patient developing some sort of symptoms that comes to present, so things like itching, burning, maybe a bump that they feel, just general kind of irritation in the vaginal or vulvar area. Or they might be discovered just on a routine annual GYN (gynecologic) exam. You know, as providers, we're always looking at the external as well as the internal parts of the vulva, vagina, cervix, everything to look for any abnormal areas.

Host Amber Smith: So a woman who's listening to this interview, if she doesn't remember getting the HPV vaccine in childhood, should she talk with her gynecologist? Any gynecologist can help give a vaccination for HPV?

Allison Roy, MD: Absolutely. Yeah. Any OB/GYN (obstetrician/gynecologist) physician is able to talk about risk factors for the HPV vaccine and whether you should get it or not, depending on your individualized circumstances.

Host Amber Smith: Well, thank you so much for making time for this interview, Dr. Roy.

Allison Roy, MD: Thank you so much for having me. It's always a pleasure.

Host Amber Smith: My guest has been Dr. Allison Roy, a gynecologic oncologist at Upstate Medical University. The Informed Patient is a podcast covering health, science and medicine, brought to you by Upstate Medical University in Syracuse, New York. Find our archive of previous episodes at upstate.edu/informed. I'm your host, Amber Smith, thanking you for listening.