Dr Neerja Bhatla, gynecologist and obstetrician at AIIMS, joined IBNLive readers for an interaction on fighting cervical cancer.
Q. HPV is a predisposing factor.. use of barrier contraceptive or even better avoiding illegitimate sex would be a better way of prevention? Asked by: Sathyaki
A. Barrier contraceptives do not prevent, only reduce the risk, as this is a ubiquitous virus present over a large area of the skin and internal organs.
Q. What is cervical cancer? Is it related to spine? Asked by: meena
A. Cervical cancer is cancer of the mouth of the uterus - the uterine cervix. It is the most common cancer among women in India. It is not related to the spine.
Q. How is cervical cancer diagnosed? Asked by: Kamya
A. Cervical cancer can be diagnosed in the precancer stage by screening with the Pap smear, HPV test or even simple visual inspection tests that use acetic acid and iodine. The final diagnosis is made on biopsy, which is a simple clinic procedure that does not cause significant discomfort or problem.
Q. Does sex without condoms lead to cervical cancer? Asked by: Diya
A. Condoms can reduce the risk of transmission of the HPV virus and can help in healing of simple precancer lesions but do not reduce the risk completely. However, condoms do protect against other infections and should be used anyway
Q. Is my wife at risk of cervical cancer? we've been married for 3 years. Asked by: Sagar
A. All women remain at risk of acquiring this very common infection throughout life.
Q. How do I get cervical cancer? Is it possible to be prevented? Asked by: Aditi
A. Cervical cancer is caused by persistent infection with high risk types of human papillomavirus, the presence of co-factors such as early age of onset of sexual activity, multiple pregnancies, multiple partners of self or spouse, smoking, prolonged oral contraceptive use, other sexually transmitted infections like herpes simplex, chlamydia, gonorrhea, etc. It can be prevented by screening and treatment of precancer lesions with Pap test or HPV test. It can also be prevented by taking the HPV vaccine which protects against two virus types that cause 70% of cases of cervical cancer.
Q. Can the HPV vaccine be taken if one is not a virgin? Asked by: Alisha
A. The HPV vaccine is best taken while a virgin, and best at younger age 10-14 years. Although it can be taken later, but the efficacy is reduced if one has already acquired infection with one of the vaccine types.
Q. Why are my friends in the UK given the HPV vaccine that prevents cervical cancer, but we can't access it here? Asked by: Shruti
A. It is available in India.
Q. How will I know I have cervical cancer? Asked by: Zoya
A. All cancers are asymptomatic in the early stage. Thus women should get screened regularly every 3-5 years after the age of 30 to detect the precancer stage which is easy to treat. Some symptoms should raise concern about cervical cancer. These include postcoital bleeding (after intercourse), inter-menstrual bleeding, persistent vaginal discharge for more than 6 months, or if your doctor finds the cervix looks unhealthy. Pain is a feature of inflammation and is seen in cancer only when it is in an advanced stage.
Q. Which cancers are caused by HPV? What are the various types of cervical cancer caused by HPV? Asked by: Tara
A. Cervical cancer is the most important, but other important cancers include head and neck cancers, anal cancers, penile, vulval and vaginal cancers. Both squamous and adenocarcinomas of the cervix are caused by HPV.
Q. What is Pap smear? Asked by: Kamya
A. Pap smear is a simple test in which the doctor or nurse can examine the cervix and use a brush to scrape some cells and send them to the pathologist for testing. In this way, cervical cancer can be detected in its precancerous stage, as early as 10 years before development of cancer. The Pap smear needs to be repeated every 3 years. The newer HPV test is more sensitive, it is also collected in the same way and can be repeated every 5-8 years.
Q. There are controversies about the cervical cancer vaccine causing deaths? should I give it to my daughter? Asked by: shiela ramani
A. There have been deaths reported among girls who had received the HPV vaccine, but none of them have been found to be related to the vaccine. The vaccine can be given to girls who are otherwise healthy, not suffering from allergies, convulsions, or any serious medical problems.
Q. What is the right age for this vaccine to be administered? Asked by: shiela ramani
A. The best age to take the vaccine is at the age 10-14 years, but can be given at any age up to onset of sexual activity for its full benefit.
Q. Incidence may be high among women with multiple partners? Asked by: Sathyaki
A. The risk of acquiring high risk HPV infection is increased when there are multiple partners and even if the partner has multiple partners. However, all women are at risk of this infection.
Q. Can you prevent cervical cancer? Asked by: Zoya
A. Yes, cervical cancer can be prevented by regular screening programs. Ideally, these should be started 3 years after the onset of sexual activity, but definitely by the age of 30 years. Done regularly, these tests help in detection of precancerous lesions, these can be treated very simply on an outpatient basis. The philosophy of screening is that cervical cancer has a long precancerous phase of 15-20 years during which time it can be detected. This is known as cervical intraepithelial neoplasia (CIN) and it can be removed by simple procedures like cryotherapy or LEEP, so that cervical cancer is prevented. Sometimes, screening programs detect asymptomatic cancers in the early stages. This also helps to have timely treatment with full recovery, although these treatments are naturally more severe.
Q. Who is at risk of acquiring cervical cancer? Asked by: Anubha
A. Every woman is at risk of acquiring cervical cancer once she is sexually active, so every woman should be screened after the age of 30, max 35 years.
Q. Should I have my daughter vaccinated with the HPV vaccine? Should I be vaccinated too? Asked by: seema
A. Yes, girls should be vaccinated with the HPV vaccine. Mothers can consider the option up to age 45 years, but their benefit is less than it is for young girls. Screening is essential even after vaccination, as the vaccine does not cover all the types that can cause cervical cancer, only 70-80 per cent of them.
Q. Why do we not hear about cervical cancer more often like breast cancer? The Government should do a campaign on this. Asked by: shiela ramani
A. Somehow there is great reservation among women to talk about anything regards the reproductive tract. But there is indeed a great need to spread the awareness. In fact, there is going to be a conference in May 2013 that is precisely looking at a greater call to action. Global and women's health leaders, advocates, academics, and policymakers will share strategies to implement successful programs, raise awareness, and shift policy at the national, regional and global level. To register and for more information about the meeting agenda, visit: http://www.cervicalcancerforum.org/.
Q. I have heard that something called VIA is also pretty specific when it comes to screening. So, instead of pap can I go for VIA, its cheap? Asked by: Mithoo
A. VIA is as sensitive as Pap, specially in women who have not reached the menopause, so certainly you can go for it. But remember that it is less specific, so when you get a VIA, you are more likely to get a false positive result, and that means a greater chance that you will need to go for colposcopy. Colposcopy is the procedure recommended for any woman who has a positive screening test, whether on Pap, HPV or VIA test. The cervix is examined under magnification and biopsy taken from any area that is abnormal. This is the final diagnosis. IF found to be CIN1, treatment may not be necessary, but CIN2/3 will be advised to get a cryotherapy or LEEP or cone biopsy treatment.
Q. Most of my friends have never heard of cervical cancer but I heard that more women get it than breast cancer. Is it true? Asked by: Ritu
A. Yes it is true that it is the most common cancer among women in India, number 3 worldwide after breast and colon cancer. In the metro cities of India, breast cancer is now the number one. So you should get screened for cervical cancer once over age 30, and should do a monthly breast self-examination too
Q. How does cervical cancer screened? What is the best way? Asked by: shiela ramani
A. The best way is really now found to be the HPV test. If combined with the Pap smear it has a very powerful negative predictive value and if both these tests are negative there is no need to repeat for the next perhaps 8 years. The HPV test is done only after age 30 years, many normal women could be positive before that, but most would clear it out naturally, as happens with a common cold virus. If persistent after age 30 years, we need to think of other tests like Pap and colposcopy to see if it has done any harm. All women with HPV infection will not develop cancer.
Q. Can I get cervical cancer after marriage? If so, can I get my husband screened for any STD? Asked by: Nilima
A. Yes, almost 80 per cent of women will acquire this infection once they are sexually active. It is difficult to get the male partner screened for HPV, since it is a quiet infection that may not produce much symptoms and is present over a large area of the genital tract and skin. Of course, if there are any visible lesions they should be screened.
Q. How do women prevent themselves from the disease? Asked by: shiela ramani
A. In most developed countries, women get themselves screened regularly, at least once in 5 years, for cervical cancer. Once over the age of 30 years, this should be a regular practice.
Q. How come we hear more about breast cancer than cervical cancer in our country? Asked by: shiela ramani
A. Somehow there is indeed more awareness and discussion about breast cancer than cervical cancer not only in India, but everywhere in the world. We need to change that. We need to tell everyone we know, our mothers, sisters, daughters, friends, to go for screening for both these important cancers.
Q. How will I know I have cervical cancer? Asked by: Shilpi
A. Only if you get checked up by a gynaecologist and get regular screening with the HPV test or Pap. Or at least a VIA test. Remember, ultrasound, CT scans, etc are not good tests for early cervical cancer or precancer. By the time an ultrasound can detect a cervical cancer it is too big, may even be too late. On the other hand, ultrasound sometimes detects benign Nabothian cysts. So go for the right test.
Q. We need a global platform to talk about cervical cancer. Asked by: Kabir
A. Many people are now getting involved in this move. Cervical cancer has been controlled in the West, but not eradicated even there. So there are efforts on now. The Cervical Cancer meeting at Malaysia in May 2013 is one such effort. Global and women's health leaders, advocates, academics, and policymakers will share strategies to implement successful programs, raise awareness, and shift policy at the national, regional and global level. To register and for more information about the meeting agenda, visit: http://www.cervicalcancerforum.org/.
Q. Why isn't the HPV vaccine freely available in the public sector? Asked by: Shruti
A. All vaccines are generally launched in the private sector first. With time, the benefits are clear, the costs are better. Many, many countries now have this vaccine in their national programs. It has been recommended by WHO and is a GAVI approved vaccine, too.
Q. Does oral sex cause cervical cancer? Can I virgin girl in her 30s get affected by cervical cancer? Asked by: Priya
A. Oral sex may be an important cause of oropharyngeal head and neck cancer. Cervical cancer has rarely been described in virgins.
Q. Which HPV vaccine (Gardasil or Cervarix) is better and suited for Indians? Asked by: shiela ramani
A. Both the vaccines have been found to have good efficacy in the reported studies.
Q. Where can i get more information on cervical cancer? what are all the ngos doing to help spread awareness? Asked by: Mithoo
A. There are a number of NGOs who deal with cancer and who are helping to conduct awareness programs as well as camps. There are a number of organisations also that focus on this task as professional bodies, dealing with both raising awareness about latest methods of diagnosis and treatment as well as increasing awareness about accessing these treatments among the lay people, as well as interacting with cancer survivors to benefit from their experience. Cervical cancer is on the priority list of all organisiations that deal with gynaecology, including FIGO, FOGSI, AGOI, AOGIN-India, ISCCP, etc.
Q. How many women get cervical cancer in India? Asked by: Aditi
A. It is estimated that there are about 130,000 new cases and about 72,000 deaths every year.
Q. Are there any side effects from the vaccine? Asked by: shiela ramani
A. The main side effects are injection site pain, slight fever, or skin rashes and reactions.
Q. I haven't been screened because I heard its painful is that so? Asked by: Priya
A. Not painful at all. It may be painful if someone is suffering from some infection, not otherwise.
Q. I heard Australia is now giving the cervical cancer vaccine to boys. Is that a good thing? Asked by: Tara
A. It gives protection against genital warts as well as anal cancers. It is also expected to provide some herd immunity to protect the girls, especially when coverage is less than 50 per cent.
Q. My doctor suggested I have the pap smear but I read about something called HPV testing? which is better? Asked by: seema
A. Yes, the HPV test seems to have a better sensitivity and better detection ability. With this test, the screening frequency can be decreased. So if you can do both HPV and Pap, that is best, repeat after 8 years if both are negative, go for colposcopy and biopsy if any positive.
Q. Where can I get the HPV vaccine? Asked by: Kiti
A. It is being provided by gynecologists and pediatricians.
Q. Are there any side effects from the vaccine? I don't like to get shots. Asked by: leila
A. Mainly pain at the injection site, fever sometimes, and skin reactions. Some young girls may feel dizzy, so good to lie down for 15 mins after taking the shot. No one reported having interruption of their regular activities from the pain. Three shots, mostly maximum reaction after the first shot.
Q. I've already gone through menopause. Should I still get a Pap test? Asked by: Sweetie
A. If you have been regularly getting Pap tests done and the last three were negative, then you can stop screening at age 65-70 years.
Q. If I give my daughter the vaccine, will she still need to go for screening someday? Asked by: Priya
A. Yes, screening is recommended as the vaccine protects against two types that cause 70-80% of cervical cancers. Presently the screening recommendations are unchanged, but in time, there may be less screening recommended for women whose risk is reduced by vaccination. Screening should start at age 30-35 years.
Q. How much does the treatment cost? Asked by: seema
A. Treatment of cancers is significantly more expensive than treatment of pre-cancers. Most importantly, there are a lot of side effects of cancer treatment, especially compared with precancer, and the likelihood of recovery still remains lower.
Q. How can I convince my sisters and friends they need to go for screening? Asked by: Aditi
A. They should see the global map on the website of the WHO Information centre http://apps.who.int/hpvcentre/statistics/dynamic/ico/country_pdf/ to see the difference in rates between countries with regular screening vs those without. It is true that cervical cancer rates are decreasing with increasing age at marriage, less children, better hygiene, etc., but for a significant reduction, regular screening and treatment of precancerous lesions is recommended.
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