American Forum Op-Ed

AMERICAN FORUM

By Jennifer S. Smith, Ph.D., M.P.H.

Kristen Forbes of Noblesville, Indiana, had recently graduated from college when she was diagnosed with invasive cervical cancer at age 22. After a yearlong, painful battle, she succumbed to the disease, leaving behind a bright future and grieving family members and friends.

Like most of the 4,000 women in the United States who die of cervical cancer each year, Kristen’s death was preventable. We now have the medical know-how and the tools to stamp out this major cancer once and for all. What we need now, as our country honors National Cervical Cancer Awareness Month this January, is the will among members of the public health community – government officials and policymakers, medical professionals, insurers, women and others – to make it happen.

Cervical cancer used to be the leading cause of death for women in the U.S. With widespread use of Pap test screening in the last 50 years, cervical cancer rates have declined significantly, but have leveled to about 12,000 cases each year. This disease should be relatively easy to prevent. We know it’s caused by the human papillomavirus, or HPV, a common sexually transmitted infection. Most HPV infections go away on their own, but persistent HPV infections can lead to cell changes that can progress to cervical cancer. Fortunately, with proper treatment, the disease can usually be stopped before cancer develops.

The HPV vaccine is now available and prevents infection from the two types of HPV that are responsible for 70 percent of all cervical cancers. We have an established screening tool – the Pap test – that identifies cell changes that can signal cervical disease or cancer. We also have newer technology – the HPV test – to help identify women who are at increased risk.

So how can we make sure no more women die of cervical cancer?

First, we need to increase HPV vaccination rates. The HPV vaccine is recommended for routine administration in girls ages 11 and 12, with a “catch up” provision for those up to age 26. Studies show, though, that less than one in two young adolescent girls has received it.

We also need to increase screening rates. At least half of all cervical cancer deaths are due to a lack of screening. Yet about 25 percent of women in the U.S. have not been screened in the past three years. Importantly, women who have been vaccinated still need to be screened to protect against HPV types not targeted by the vaccine.

Also, while the Pap test has led to a dramatic decrease in cervical cancer in the U.S., about one third of cervical cancer deaths are caused by screening errors with the Pap test, a problem that more sensitive HPV DNA testing could address. The HPV test is available, in conjunction with a Pap test, for women ages 30 and older.

Most importantly, we need to make cervical cancer prevention a top national health priority. Public health officials and policymakers should support--and fund--programs to educate women about this disease and enable them to access prevention and treatment services. Medical professionals should educate their patients and provide these services, and insurers should pay for them. Women must take charge of their health and get screened and ensure that their adolescent daughters get vaccinated. All of these groups’ efforts must be coordinated for maximum efficiency and impact.

The elimination of cervical cancer is an eminently achievable goal. To achieve this vision, a new program – Cervical Cancer-Free America (www.cervicalcancerfreeamerica.org) – is driving state and local prevention programs, and ensuring that successful strategies are shared among the states. The initiative is led by the University of North Carolina at Chapel Hill’s Gillings School of Global Public Health.

Since the initiative’s launch last year, six states – Alabama, California, Indiana, Kentucky, North Carolina and Texas – have already joined the effort to become “cervical cancer-free.” Major universities and other public health experts are leading the charge in each state, supported by government and other leaders.

The movement to eradicate cervical cancer is gaining momentum in our country. But there is more work to be done. Let’s join hands and work together to ensure that no more women like Kristen Forbes lose their lives to this preventable disease.
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Smith is director of Cervical Cancer-Free America.
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Copyright (C) 2011 by the American Forum. 1/11

By Susan Wysocki and Susan Scanlan

It’s not surprising that women are confused about the recently changed recommendations for cancer screening and prevention. New guidelines from the American College of Obstetricians and Gynecologists (ACOG) – the leading medical group that provides health care for women – say women should wait longer to begin cervical-cancer screening and that they should be screened less frequently. On the heels of similar changes to breast-cancer screening guidelines, it’s understandable that many women might see this as a step backward.

On the contrary, the new cervical-cancer screening recommendations reflect advances in our understanding of this disease and in tools now available to prevent it. More importantly, they present an opportunity to educate women about the significant opportunity we have to further prevent – if not eliminate – cervical cancer.

New ACOG screening guidelines recommend women should begin getting Pap tests at age 21 (as opposed to within three years of becoming sexually active) and that, from ages 21 to 29, most women should have Pap tests every two years instead of annually. Additionally, screening for women 30 and older with a history of normal Pap test results now moves to every three years.

To understand the rationale for these changes, it’s important to first know how the disease develops. Cervical cancer is caused by “high-risk” types of the human papillomavirus (HPV), a common sexually transmitted infection. Most women will have HPV at some point in their lives, but their immune systems will typically clear the virus without symptoms or treatment. HPV infections that persist over time – typically many years – can cause cell changes that can potentially lead to cervical cancer. Because cervical cancer is slow-growing, it generally allows ample time for screening to detect problems that can be treated before the cancer can develop. The majority who die of cervical cancer in the U.S. have either never been screened or have not been screened in many years.

A Pap test is the traditional means of screening for cervical cancer. It involves examining cervical cells under a microscope to detect abnormalities that can then be treated, if necessary. Since its use became widespread 60 years ago, the Pap test has helped to significantly reduce cervical cancer rates. So, if the Pap test has been such a success, why change the guidelines? First, newer research shows that cervical cancer is extremely rare in women under 21. Cervical abnormalities among sexually active girls in this age group are common, but they typically go away on their own. Newer studies, however, show that treatment for these abnormalities that would most likely resolve themselves can cause later pregnancy complications, such as premature birth. This is one instance in which treatment can cause more harm than good. By delaying the start of screening, we can hopefully avoid unnecessary treatment.

The rationale for less-frequent screening is similar. Evidence shows that screening with a Pap test every year does not offer any additional benefit over screening every two or three years. Waiting longer between screenings can help avoid unnecessary treatment of abnormalities that likely will go away on their own.

Also, new technological advances offer women 30 and older – the group most at risk for cervical cancer – more protection against this disease. For these women, an HPV test is now available and uses molecular technology to determine whether HPV is present. An HPV infection that continues for years is what leads to increased risk of developing cervical cancer. If an HPV infection is found, a woman can be monitored more closely by her clinician. A negative HPV test in tandem with a normal Pap test can give a clinician and her patient increased reassurance that the woman is not at risk of developing cervical cancer for at least the next three years. The HPV test also is used for women of all ages to help clarify inconclusive Pap test results. The HPV test is not used routinely in women under 30 because HPV is so common in this age group that a positive HPV test could lead to unnecessary treatment.

While screening is critical to preventing cervical cancer, two HPV vaccines – the first-ever vaccines to fight a cancer – are now FDA-approved and offer significant potential to help reduce cervical cancer rates.

Remember, these new screening recommendations are simply guidelines and that clinicians, in conjunction with patients, need to determine the most appropriate cervical-cancer prevention approach for each woman. These new guidelines provide an opportunity for more conversation on this issue between women and their health-care providers. After all, few things are better for women’s health than educated and empowered patients.
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Wysocki is president and CEO of the National Association of Nurse Practitioners in Women’s Health. Scanlan is chair of the National Council of Women’s Organizations.
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Copyright (C) 2009 by the American Forum. 12/09