Robert Edwards, MD, Chair of the Department of Ob/Gyn and Reproductive Sciences at UPMC Magee Women’s Hospital at the UPMC Hillman Cancer Center, talks about an increase in advanced cervical cancer.
Interview conducted by Ivanhoe Broadcast News in September 2022.
Over the last decade the numbers pertaining to cervical cancer have been dropping. Can you tell me a little bit about what you’re seeing now?
EDWARDS: Yes. Preventive efforts in cervical cancer as a disease process have actually been ongoing since the 1950s with the widespread advent of the Papanicolaou smear, otherwise known as the Pap smear. In the 1980s, we participated in some of the early studies looking at the immunity of the precipitating virus that causes cervical cancer, which is human papillomavirus. Human papillomavirus is present all over the body. But in women, it only gets colonized to the cervix through sexual activity. So that makes it a sexually transmitted disease. It’s really what we call sexual commensal. Meaning if you’ve had sex, you certainly are at risk. If you’ve had sex with multiple partners, you’re at increased risk. It isn’t a disease in the way that we track like we would through the health department or something like that. Most women, if they’re sexually active, will have evidence of cervix involvement with human papillomavirus around the age of twenty-one. Hence, we start pap smear screening now at the age of 21 – not in the teens the way we used to. The reason for that is we were over diagnosing too many cervical dysplasia that weren’t going to turn into cancer. We were over-treating young women and impairing their fertility. So that’s why the screening has been backed off for women in their twenties and thirties. So now if you have normal pap smears, three consecutive normal paps, it’s only done every three years. That really has very little to do with the recent increase in Stage IV cervical cancer, which is being reported. The second preventive strategy, which I was heavily involved in, was the development of the human papillomavirus prophylactic vaccine. Two companies, Merck and GSK, did a large number of studies. I participated in several of them, looking at systemic immunization to prevent colonization of the cervix with human papillomavirus. It only works if it happens to occur before woman’s sexual debut because once she’s colonized, she is colonized. It doesn’t prevent or treat cervical colonization that’s already occurred. What we have going on now is we have these two preventive strategies, both of which are effective. One was approved by the FDA in 2005 and the Papanicolaou smear has been around for forty to fifty years now. What we have is for the general population, as more women get vaccinated and women who have access to health care in their teenage years and their parents are informed, will get the vaccine prevention. We think in another 10 years pap smears will get less and less commonly done because a larger percentage of the population will be vaccinated. What we’re seeing with advanced cervical cancer, much like we saw with COVID, is that the people who are getting the advanced disease are the people that suffer from health disparity. That is, they don’t have access to health care, or the health care is too expensive for them to access. In the case of cervix cancer, it tends to be poor women, Caucasian, more than Black women, and they tend to occur in the rural areas around in Pennsylvania – rural areas around the major urban centers. For Black women, it’s the urban populations that aren’t getting any sort of health care because of the expense or access issues.
What kind of an increase are we seeing in those advanced cases?
EDWARDS: Depending on the study, between two and four percent. And the reason that’s difficult to understand is because those women have about a 17 percent overall survival at five years. This is because Stage IV cervix cancer, while it can be treated with radiation, the actual surgical treatment of cervix cancer is not something that can be done in a woman who’s advanced that far.
When you hear a two to four percent increase, how concerning is that from where you sit?
EDWARDS: That’s several hundred to up to perhaps 500 women a year dying from cervix cancer. There’s about 16,000 women who get cervical cancer each year. That number has been going down, as you stated. The incidence of advanced cervical cancer and incurable recurrent cervix cancer is actually going up. The other point to make clear is that when you have advanced cervix cancer, your treatment options are reduced and the risk for high dose radiation, which is what is required to treat that. Several of my patients now have very serious side effects from the radiation. They may be cured of their cancer, but they’re suffering greatly from the side effects from having to use higher doses of radiation to clear the cancer.
What are some of those side effects?
EDWARDS: Pain, dysfunction of the urogenital track, sexual discomfort, bleeding, bladder insufficiency and bladder dysfunction including urinary incontinence, rectal dysfunction, and fecal incontinence. They can also have severe radiation damage to the pelvis. Radiation as a rule is very safe, but when you have an advanced cancer that has a large volume of disease in the pelvis, you have to use really high doses. That is the issue.
With this increase of women who don’t have that access to care, what are the solutions?
EDWARDS: The solutions are straightforward and staring us in the face. If we promote and educate our populations about the advent of human papilloma virus vaccine, if we make those vaccines available without financial risk to adolescent women in the community, and if parents understand that HPV vaccination is not about promoting sexual activity, it’s about preventing cancer. If we do those three things and we do them effectively, we’ll have a big impact on this because it’s a lot less expensive to give a preventive vaccine than it is to screen a population repetitively over time. When patients have economic burdens from these repetitive screening which they do, particularly Medicaid populations, they tend not to be compliant. When they’re not compliant, the other factor I’ll point out is many of our rural populations have increased risk of tobacco use. Smoking and human papillomavirus together double your risk of cervix cancer.
What is the age range of women who are seeing these advanced cervical cancers?
EDWARDS: Unfortunately, it’s the women who are no longer getting regular gynecologic care. That is women in their early 50s. The median age for advanced disease is about 53. It’s 10 years earlier than any other gynecologic cancer. It tends to occur in women who are not regularly seeing a physician. They’re not old enough to have other medical conditions. They’re too old to need contraception. They really don’t have any other reason to come to the doctor. If they’re not getting screened, they’re too old to get the vaccination. That’s who is falling through the cracks.
Are there options for women who are in that underserved population or in the poor rural areas to get a pap smear at a lower cost? Or are there places they can look for help to get those screening tests if they choose?
EDWARDS: Most hospitals, particularly rural hospitals, offer some sort of screening program. Now, I will also point out the other issue that’s going on is rural hospitals are under assault economically right now and are closing, particularly obstetric units, are closing across the country in rural locations because they’re not financially sustainable. We’re seeing this in Pennsylvania in particular. There are only two hospitals, between Erie and the center of the state, there are only two hospitals that offer OB care above I-80. They’re both struggling. They’re both UPMC hospitals, so I happen to know their status. When hospitals stop having obstetric care and stop having health care providers that take care of the reproductive issues of women, that screening rate goes way down and it’s going in the opposite direction from where we need it to go. Vaccination is the way out of this and preventing disease that is preventable if the vaccination occurs before a woman is 15.
Any signs or symptoms of cervical cancer?
EDWARDS: Cervix cancer tends to present with bleeding. The bleeding can often be confused with irregular bleeding women see before they go through menopause. That can be difficult. There’s also a peculiar discharge when it’s advanced as with Stage IV disease, they can get a pronounced discharge. That will often bring a patient in. But you’d like to have patients come in before they’re Stage IV. Any irregular bleeding that’s out of the norm, particularly in a woman who’s gone through menopause and now starts bleeding, particularly bleeding after intercourse, is a sentinel sign that she may be developing a cervical abnormality like cervical cancer.
Is there anything I didn’t ask you that you would want to make sure that people know?
EDWARDS: I think cervix cancer is a symptom of a bigger problem we have with access to health care in our rural and underserved populations. It really is going to take some sort of investment in resources to give these women better access. Because right now, a lot of their cancer rates are approaching what we see in third-world countries. This is really a policy issue, particularly for women that need to be addressed at the national level as well as state local levels.
END OF INTERVIEW
This information is intended for additional research purposes only. It is not to be used as a prescription or advice from Ivanhoe Broadcast News, Inc. or any medical professional interviewed. Ivanhoe Broadcast News, Inc. assumes no responsibility for the depth or accuracy of physician statements. Procedures or medicines apply to different people and medical factors; always consult your physician on medical matters.
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