Every year over a million women worldwide are diagnosed with a gynecological cancer. September is Worldwide Gynecological Awareness Month, which incorporates the awareness of the following five major cancers: cervical, ovarian, uterine, vaginal, and vulvar. Women in all parts of the world are at risk of gynecological cancers, but this risk is exacerbated in areas of the world where access to prevention and treatment is low. Over 80% of cervical cancer cases occur in the developing world, and lack of regular Pap smears and other interventional measures may contribute to this statistic
To cap off Worldwide Gynecological Awareness month, I spoke with Dr. George Sawaya, Professor of Obstetrics, Gynecology and Reproductive Sciences at the University of California San Francisco. His current research is in cervical cancer screening with particular interest in new technologies, cost-effectiveness and utility, novel approaches to population-based screening and risk communication. Dr Sawaya has also served on the cervical cancer guidelines committee for the American Cancer Society and the US Preventive Services Task Force.
Ruby Singhrao: Death from cervical cancer is high in many developing countries but lower in North America, Europe and Australia. What measures have been taken in these countries to reduce the risk of cervical cancer?
Dr George Sawaya: The United States has had widespread screening for cervical cancer using the Pap smear since the 1950’s. The risk of cervical cancer is driven by how much screening is available in the population, at least for now. We don’t know yet what the effect of HPV vaccination will be on cervical cancer, so currently the cornerstone of prevention is ] early detection of pre-cancerous lesions with treatment before they turn into cancer.
RS: So it seems that cervical cancer is one of the few gynecological cancers that can be prevented.
DR GS: Yes, cervical cancer is the poster child for gynecologic cancer prevention since it aims to detect and treat pre-cancerous lesions., Screening for colorectal cancer works in a similar way. Screening for breast cancer, on the other hand, aims to detect early cancers, so the benefit is mainly in preventing cancer deaths.
RS: Countries with a National Health Care system such as the UK, Canada and most European countries have comprehensive screening for cervical cancer that includes regular Pap smears and more recently routine vaccination of school girls with the HPV vaccine. In countries where there are not such equitable standards of care is there a higher risk of development of cervical cancer?
Dr GS: Certainly. Countries with the highest cervical cancer rates are countries where there is little to no screening.
RS: What are risk factors for developing cervical cancer?
Dr GS: The Nobel Prize was awarded two years ago for discoveries implicating viral infections of the cervix, namely human papilloma virus (HPV), in the development of cervical cancer. Therefore, the major risk factor is exposure to those viruses. It is a bit of a puzzle as most people are exposed to HPV but most don’t develop cervical cancer and this is not because most women get screened and have precancerous lesions that are treated. Most women get the virus and their bodies can mount an appropriate immune response to the virus. Based on estimates from the SEER program in the US, a woman’s lifetime risk of getting cervical cancer if she were not screened is around 3-4%. Her lifetime risk of being exposed to HPV, however, is 70-80%. That means that the vast majority of HPV infections do not lead to to cervical cancer.
RS: What are the risk factors for developing other types of gynecological cancers?
Dr GS: Among the 5 types of gynecologic cancer, 3 are the most common: cervical, uterine and ovarian.
For cervical cancer we believe the major risk factor is exposure to HPV. There are potentiating factors that increase a woman’s risk, like smoking. Immunocompromise is also a risk factor and having cervical cancer is an AIDS-defining illness for women who have HIV infection.
The main risk factor for uterine cancer is unopposed estrogen. We know this from studies of women who took estrogen but not progesterone. Also women who don’t ovulate are at increased risk of uterine cancer. Obesity is a risk factor for anovulation.
One of the risk factors for ovarian cancer seems to be uninterrupted ovulation. Since birth control pills suppress ovulation, taking birth control pills has been shown to be protective of ovarian cancer.
RS: Can women take active steps in their lives to reduce risk of gynecological cancer?
Dr GS: Getting Pap smears is really quite critical. Certainly for age-appropriate women and girls, HPV vaccination may also offer protection. We don’t know enough about vaccination to say whether it will affect screening in anyway. Others steps are just what you would do to maintain a healthy lifestyle: avoiding cigarette smoke and maintaining a healthy weight .
RS: Can women have children if they have had a gynecological cancer?
Dr GS: Women with gynecological cancers can work with a reproductive endocrinologist and their gynecologist to try to preserve their fertility.
Women with some early forms of cervical cancer, for example, can have uterine-sparing procedures that will allow them to become pregnant. Women with ovarian cancer can talk with their doctors about ovarian preservation if that cancer is diagnosed. These are quite specialized procedures, though.
Uterine cancer is perhaps the most difficult, as it is very difficult to carry a pregnancy in a uterus that is affected with cancer. There are some non-surgical hormonal treatments that people have used to preserve fertility.
Lastly, women can have embryos frozen that could later be implanted into surrogates. Women should speak with their doctors to learn more about their options
RS: For women in some cultures, the stigma of cervical cancer being linked to HPV, a sexually transmitted disease, is particularly onerous. They risk being accused of promiscuity and risk blame and family rejection. In any case these women need help and support. What would be your advice to a woman in this circumstance?
Dr GS: Well, it only takes having one partner with HPV to be exposed to HPV, so having cervical cancer does not equate with promiscuity.
RS: Does there then need to be more education within certain communities?
Dr GS: Of course. Education is certainly key to many public health messages.
RS: Do you think there should be culturally appropriate care for women who present with gyn cancers?
Dr GS: There should always be culturally appropriate care. That is what we strive for at UCSF and we have to because we have a multi-cultural society that we care for. I think as clinicians there may need to be better understanding as we see patients all the time and maybe we don’t think about someone from a social point of view.