January 29, 2025 • 45 mins
Listen to this replay of "Cervical Cancer Awareness" from Season 2 with guest Dr. Sharon Sutherland from the Cleveland Clinic. Speaking of Women's Health Podcast host Holly Thacker, MD focuses her questions on raising awareness about cervical cancer and the importance of regular screenings to prevent it.
January is Cervical Cancer Awareness month, so there's no better time to hear about how you can prevent cervical cancer with regular screenings.
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Episode Transcript
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Speaker 1 (00:01):
Welcome to the Speaking of Women's Health
podcast.
I'm your guest host for thisepisode, leigh Klecker.
I'm the producer of theSpeaking of Women's Health
podcast and I'm back in theSunflower House for a somewhat
new episode.
In season two, our wonderfulexecutive director and host, dr
(00:26):
Holly Thacker, interviewed DrSharon Sutherland all about
cervical cancer.
As January is Cervical CancerAwareness Month, dr Sutherland
is the director of the Centerfor Prevention of Cervical
Cancer at the Cleveland Clinic,of the Center for Prevention of
Cervical Cancer at the ClevelandClinic, and cervical cancer
(00:50):
prevention is so important and amessage that we want to
continue sharing this January inseason three.
But before we replay thatepisode, I want to share a few
pieces of information oncervical cancer, some new and
some just some friendlyreminders.
So Dr Thacker again, ourbrilliant Speaking of Women's
(01:11):
Health podcast host andexecutive director of Speaking
of Women's Health.
She recommends that women, evenif they are told they can go
five years between their PAPs,that many times insurance covers
it three years and people arebusy and five years can turn
into a longer time period andeven if you're not getting a PAP
(01:33):
smear of the cervix, one stillneeds to get regular gynecologic
exams because too many womencan fall through the cracks, and
this is a, by and large,preventable cancer death.
And the latest statistic oncervical cancer is about 13,820
(01:56):
new cases of invasive cervicalcancer will be diagnosed this
year and about 4,360 women willdie from cervical cancer.
It is the most frequentlydiagnosed cancer in women
between the ages of 35 and 44,with the average age being 50.
(02:18):
And many older women.
They don't realize that theyare still at risk of developing
cervical cancer as they age, andmore than 20% of cervical
cancers are found in women overage 65.
However, these cancers rarelyoccur in women who have been
getting regular tests to screenfor cervical cancer before they
(02:41):
were 65, which is why cervicalcancer screening is so important
and the message that we want torelay in this episode.
So back in May of 2024, the Foodand Drug Administration
expanded the approvals of twotests that detect cancer-causing
types of the humanpapillomavirus, or HPV, in the
(03:05):
cervix, and both tests they'reused as part of screening for
cervical cancer.
So under these expandedapprovals, people can now be
offered the option to collect avaginal sample themselves for
HPV testing if they cannot haveor do not want to have a pelvic
(03:25):
exam.
However, the collection, whichinvolves a swab or a brush.
It must be done in a healthcaresetting.
That would be a primary careoffice, urgent care, pharmacy,
mobile clinic.
And it starts for womenbeginning at age 30.
And it starts for womenbeginning at age 30.
(03:49):
So the tests included in theapprovals are OnClarity HPV and
that's made by Becton, dickinsonand Company and Cobuz HPV.
So until now, screening forcervical cancer in the US has
required a sample of cellscollected from the cervix during
a pelvic exam performed by ahealthcare professional.
So that would be your physician,your nurse practitioner, a
(04:12):
physician assistant.
But the availability of theself-collection option in
healthcare settings should helpwiden access to cervical cancer
screening.
So increased access to HPVtesting is a particular need for
certain populations among whichrates of cervical cancer
(04:35):
screening continue to be low,like healthcare deserts across
the country, where people stilldon't have access to a regular
healthcare clinician.
And access isn't the onlybarrier to cervical cancer
screening.
People may have personalpreferences, be it religious or
cultural beliefs, maybe ahistory of trauma or
(04:56):
disabilities or medicalconditions that would prevent
them from getting a pelvic examperformed by a healthcare
clinician, and many cliniciansthey believe that making this
home-based sample collection anoption will hopefully widen
access to screening even furtherin the future.
(05:17):
The gold standard for cervicalcancer screening is CO testing,
with both a HPV and a pap testby a doctor or advanced practice
provider, but the self-HPVtesting which is still being
studied is better than not doingany screening at all, so this
(05:37):
is a really good new option forthose who would qualify.
I want to thank you forlistening to this quick update
on cervical cancer screening,and up next is the cervical
cancer awareness podcast episodewith Dr Sutherland and Dr
Thacker from season two, and Ihope you enjoy listening to it,
(06:01):
either for the first time oragain.
And thanks for joining me inthe Sunflower House and I'll see
you next time.
Speaker 2 (06:12):
Welcome to the Speaking of Women's Health
podcast.
I'm your host, dr Holly Thacker, the Executive Director of
Speaking of Women's Health, andI'm back in the Sunflower House
for a brand new episode of ourSpeaking of Women's Health.
And I'm back in the SunflowerHouse for a brand new episode of
our Speaking of Women's Healthpodcast.
And this is our second seasonand it's January, which is
(06:34):
Cervical Cancer Awareness Month,and I started off the New
Year's season talking aboutstaying healthy and sticking to
health goals and lots of funnatural beauty hacks, and I
promised the audience I wouldtell you if I used any of the
beauty hacks.
And I did use that apple cidervinegar on my nails.
(06:54):
It did help dehydrate them fora good manicure.
So go back and listen to thatfirst one of the year if you
missed it.
But even though we like funthings as women and we care
about how we look and how wefeel and I do have an upcoming
podcast more on skincare andhair because I know those are
popular topics we're not goingto be around to enjoy those fun
(07:17):
feminine things if we don't takecare of ourselves.
And we're going to talk aboutsomething very serious, as
serious as cancer and one of themost exciting preventive tests
that came down in the field ofmedicine is the pap smear, and
cervical cancer screening hasbeen around so long and some of
(07:39):
the guidelines have changed.
It's kind of gotten complicatedfor physicians so you can
imagine what it's like for theaverage woman.
Guidelines have changed.
It's kind of gotten complicatedfor physicians so you can
imagine what it's like for theaverage woman and I think that
that's kind of fallen off a lotof patients and women's
important concerns Very muchdifferent than it was 20 or 30
years ago when I started in thefield.
(08:00):
And women specifically theywanted their yearly exam and
their PAP and their pelvic.
And women specifically theywanted their yearly exam and
their pap and their pelvic.
So it is my great pleasure toinvite our guest, dr Sharon
Sutherland, a partner, a friend,a colleague.
She's a staff physician at theCleveland Clinic for over 20
years, even though she onlylooks 20.
And she was trained in OBGYNand she's a surgeon.
(08:25):
She has a very calm, measured,unflappable, focused approach
and that's a wonderfulconstellation of characteristics
that you want in a physicianand surgeon.
And she's focused her career,most recently after delivering,
you know, I'm sure, thousands ofbabies, she's now really
(08:49):
focused on patient care qualitycervical cancer screening and
ultrasound pelvic ultrasound andwe hope to get into some of
these topics.
She does see patients at themain campus, and she also spends
some time in the Center forSpecialized Women's Health,
where we love to see her, andshe trains some of our
(09:09):
Specialized Women's Healthfellows.
Her main clinical focus rightnow, though, is on diagnosis and
treatment of pre-cancers of thecervix as well as abnormal
bleeding, and those are twoareas that, in midlife women's
health even though they'reimportant before and after
really are big focuses, and shehas been named the director for
(09:33):
the Center for the Prevention ofCervical Cancer, which is a
group of 14 specialists who aredriving excellence in care and
treatment of patients withprecancerous cervical lesions,
because you certainly want todeal with those before they turn
into cancer.
She's also taken on another bigrole.
You know she's the typicalmultitasking, high-energy woman.
(09:56):
She is now in charge ofgynecologic ultrasound, and she
is the director of gynecologicimaging for OBGYN Institute, and
I feel kind of a kinshipbecause neither one of us are
radiologists, but just like Iread bone densities I'm not a
radiologist, but that's aradiology reading imaging test I
(10:19):
really feel like the clinicalbackground helps me be a better
radiologist with bone health,and I imagine she may have some
comments about that in terms ofbeing a gynecologist and a
radiologist in terms ofultrasound in the pelvis.
She completed medical school andresidency at Ohio State and a
master's of public health atColumbia University, and she and
(10:44):
her husband are big Clevelandfans, cleveland Browns fans, osu
fans and we won't talk aboutthe recent football championship
.
And there's one.
Oh my goodness, her lecturethat she gave to our entire
Institute on cervical cancer wasso good and I was so
embarrassed because I wasgetting out of the shower and I
(11:05):
had a towel on my head andaccidentally turned on the Zoom
camera.
Oh my goodness, all you couldsee was my towel and, oh, I was
like so embarrassed.
So sometimes it's good to keepthe camera off, but it's great
that we have the camera on.
So welcome, dr Sutherland.
Speaker 3 (11:24):
Thank you so much, Dr Thacker.
Speaker 2 (11:25):
This is a pleasure and this is such an important
topic, tell us about cervicalcancer.
It seems like we've made somany strides but now it feels
like to me that we'rebacktracking and we are still
seeing women in 2024 withcervical cancer invasive, that
they may die from.
Speaker 3 (11:44):
Well, people don't realize, but 100 years ago
cervical cancer was one of thenumber one causes of death of
women, especially in their earlylife, between the ages of 20
and 40.
In fact, my owngreat-grandmother died of
cervical cancer in her 40s, soit was a very, very common
disease.
We did have development of thePAP test, as you mentioned, and
(12:05):
then more recently testing forhigh-risk HPV.
So now it's down as far as thelist of cervical, you know, as
far as cancers for women, it'snot at the head of the pack
anymore.
Speaker 2 (12:18):
but we definitely have opportunity.
My mother's mother died of agynecologic cancer which they
said was cervical.
So it was either cervicalpotentially I mean, I don't have
the pathology and she was inher 40s and it was devastating.
And I just think that a lot ofyounger women and just busy
women, if they don't have thatpersonal experience, they're
(12:40):
just thinking about breastcancer, maybe they're thinking
about ovarian cancer.
If they have abnormal bleeding,they worry about uterine cancer
.
But cervical cancer really weshould be ahead of and there
really shouldn't be hardlyanyone, any woman, dying of
cervical cancer, right?
Because what's the cure rate ifyou find it really early?
Speaker 3 (13:01):
Yeah, that's absolutely true.
As far as our current rates, wehave about 14,000 new cases of
cervical cancer every year inthe US.
When we think about the averageage, average age is 50.
We see some people as young asin the early 20s to mid-20s, and
then we're seeing an increasein women as they get older, and
(13:22):
part of it has to do with thereduction in cervical cancer
screening in women over 65.
Speaker 2 (13:27):
And you know that the alert on our medical record
goes away at 65, and we can turnthat back on.
But I have a lot of women whosay, oh well, I was told I'm
over 65.
I don't need that anymore.
Oh, I don't have a cervix so Idon't need exams.
The gynecologist told me not tocome back and I can understand
(13:47):
why.
Maybe you don't need to see abusy surgical cancer doctor or a
gynecologist that'sspecializing in things.
But we have a whole cadre ofvery well-trained women's health
nurse practitioners for annualexams or at least every two-year
exams.
So tell us why are you morethan just a cervix and what's
(14:08):
involved and what's thedifference between exams and
PAPs and HPVs, et cetera.
We'll be back after a quickbreak.
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Speaker 3 (15:00):
So, just in general, when we talk about cure rate,
like you mentioned, it'sprobably one of the only cancers
that we can truly prevent.
So if all of our women weregetting the proper screening
with the PAP and the HPV, basedon their risk factors, at the
right time, we would reallypotentially see zero cervical
cancers.
If we do diagnose them early,the cure rate is very high
(15:23):
greater than 90%.
So it's the kind of thing thatwe don't want to be fearful of.
For some people, they feargetting a pap because they're
worried what if it's abnormal?
What if I have to do somethingto follow up?
But it's exactly the reverse weshould be fearful of what
happens if I don't get a pap.
Speaker 2 (15:38):
Absolutely, absolutely.
And the other trend I've seenis busy physicians and busy APPs
have so much on their plate andthat's one reason I encourage
women to make more appointmentsrather than less.
It's easier to cancelappointments and to come focused
with things and not expect, youknow, 10 problems and a
preventive visit to all be doneat once.
(15:58):
But if they have a normal PAPand a negative HPV, a lot of
women are told not to come backfor five years and women aren't
putting that in their calendarsnecessarily, and some women,
five years is not appropriate.
We have a lot of transplantpatients, people who are
immunocompromised HIV.
Do you want to talk about someof those special categories?
(16:19):
I think, minority women, womenthat maybe are disadvantaged and
haven't had regular healthscreenings?
If you can, comment on thosespecial groups?
Speaker 3 (16:31):
Yeah, so one of the areas that we're looking at is,
just like you mentioned, tryingto look at that patient's
individual risk.
Women who are HIV positive, Ithink, have about four times the
risk of developing cervicalcancer.
Same with transplant, whetherit's a bone marrow transplant or
a solid organ transplant.
So those patients go throughscreening prior to getting
(16:53):
transplant, but then it's veryimportant every single year, as
long as they're healthy enough,to have a Pap and HPV test.
The other evolving area are alot of these immunosuppressive
drugs.
They're really improvingquality of life for people with
colitis, maybe with severepsoriasis, things like arthritis
.
However, they carry with them amajor risk of immunosuppression
(17:16):
and, in this case, risk ofcervical cancer.
So we recommend that ourphysicians look through that
list in our APPs of their meds,because sometimes they're
relatively healthy but they'reon this medication that flags
that, hey, this gal should havea pap every year and when
cervical cancer is not diagnosedearly.
Speaker 2 (17:39):
tell us about what some of the symptoms and some of
the problems that women candeal with.
I've seen some young womenreally suffering with horrible
complications.
Speaker 3 (17:50):
So when we think about the cancer, it typically
develops at the tip of thecervix, and so that's where, in
the very early stages, it can beprevented or cured with a minor
surgery to the cervix In thefirst stage.
If we catch it early enough,sometimes we can do a
hysterectomy and completelyremove the tumor.
This is the type of tumor thatspreads locally, so rather than
(18:12):
the cells going all through yourbody, usually the first thing
that'll happen is it'll invadeinto the upper vagina, into the
bladder, into the rectum, intothe pelvic bones.
So it's a very destructivetumor.
Women will present with pelvicpain, they'll present with
abnormal bleeding, and thetreatments at that point require
(18:34):
chemotherapy and radiation.
Sadly, only two out of threewho are diagnosed with cervical
cancer will survive five years,and the main reason is that more
than half of our cervicalcancers are diagnosed when
they're already beyond thecervix.
Speaker 2 (18:50):
Yeah, and that really just shouldn't be the case.
My niece, who's in college?
She's 18.
She's at the University ofAlabama, roll Tide.
When I saw her at the holidaysshe asked me Aunt Holly, when
should I get my first pap smear?
I went to the health center andthey said I don't need one.
But I just want to know.
(19:11):
I want to stay healthy.
Speaker 3 (19:14):
So when we think about screening there are
different guidelines.
In some places they recommendstarting at 25, but
unfortunately we know that's toolate for some patients.
So in general at the ClevelandClinic we recommend starting at
the age of 21, doing a PAP everytwo to three years up until the
age of 30.
And then at the age of 30,adding HPV screening along with
(19:37):
the pap.
And for most women that can bein that four to five year range.
But for those higher risk womenwe need to be doing those tests
more often.
Speaker 2 (19:47):
Well, I know our nurse practitioner, dana Leslie,
who I've had on this podcastand I plan to have again this
season who I personally see formy gynecologic exams and PAPs.
She many times will do it everythree to three and a half years
because if she's seeing theperson and then they don't come
back and so too many people justget lost to follow up and you
(20:09):
know it's hard to completelyknow if between now and the next
time you see a person, ifthey're going to be put on
rheumatoid arthritis medicinesor their nutritional status is
going to go down or you knowsomething else is going on.
And a lot of women I find don'talways even keep records of
their last pap and HPV and so orthey don't know what they had
done to their cervix, like oh,it was abnormal, but then it's
(20:30):
okay.
Can you talk a little bit aboutcolposcopy, that paps are
really not diagnostic and youneed to do colposcopy if you're
not sure?
And then what some of thesurgical procedures are if the
PAP is abnormal?
Speaker 3 (20:45):
So the colposcopy is one of the early advances in
cervical cancer screening.
First we had the PAP and atthat time the PAP was really
just to diagnose the actualcancers.
But then they started torealize maybe there are some
changes in the cells that candiagnose it early.
So we have protocols that wefollow and, based on the PAP
(21:05):
profile and the rate ofhigh-risk HPV for that
particular patient, we all do acolposcopy.
That is like a PAP.
We look at the cervix with amicroscope, we apply different
medicines to the cervix.
We look at the cervix with amicroscope, we apply different
medicines to the cervix and thenany areas that look like they
could be precancerous we taketiny pinch biopsies.
A lot of women are fearful ofpain but often feel very little.
(21:27):
I relate it to somebody tuggingyour hair.
All of us have had a littlehair pull at the beautician and
we're good with that.
So you know it's the type ofthing that the colposcopy for
most women is not severelypainful.
We will see an upgrade ofresults.
So, for example, some patientswill present with a low-grade
(21:50):
pap but then have about a 15 to20 percent chance that they
actually have a higher-gradelesion that the pap missed.
So that's why the colposcopy isso important.
Abnormal paps don't hurt us,and being positive for high-risk
HPV doesn't hurt us.
What we're really looking foris that high-grade pre-cancer,
because that is the trigger totreat.
Speaker 2 (22:13):
And there's no special preparation that a woman
needs to do for colposcopy.
If she's having a heavy period,does she have to reschedule?
Can she just come into theoffice like for a pap smear that
takes just a little bit longerand then plan to go back to work
?
We'll be back after a quickbreak.
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Speaker 3 (23:16):
For most women they don't need any preparation.
In general, if you're havinglight bleeding, like at the
beginning or the end of theperiod, it doesn't interfere.
But if you are on one of thoseheavy flow days where you're
changing protection every couplehours, we would recommend that
you reschedule, Althoughsometimes cervix cancers present
with abnormal bleeding.
So if we have patients that arehaving abnormal bleeding, it's
(23:38):
very important that we actuallyexamine the cervix, because
sometimes we find that thecervix is actually the problem
From the standpoint of otherpreparation.
As we get older and our hormonelevels drop, sometimes the
cervix will become stenotic.
What that means is I relate itto like a flower that is going
(23:59):
in reverse.
So if we think of our cervixlike a flower that blooms, it
blooms when we have hormones andthen it goes back into the bud
stage and closes up very tightlyin menopause.
So sometimes we'll givemedicines to soften the cervix
and make it more likely that wecan get adequate samples.
Speaker 2 (24:15):
Yeah, that is so important.
I usually will give vaginalDHEA because it's not estrogen.
So even if there is somethingwrong inside the uterus that's
estrogen sensitive, it's notgoing to hurt.
And then the cytotec ormisoprostol, which we use to
prevent stomach acids, helps todilate the cervix.
I always joke you could drive atruck through my cervix.
(24:38):
I had three big boys, whichmade it very easy when I've had
to have hysteroscopies orprocedures to look up inside of
the uterus, which I will wantyou to talk about the procedure
of office hysteroscopy, which alot of gynecologists don't
necessarily do, but you do andyou have that expertise.
And you have been listening tothe Speaking of Women's Health
podcast.
(24:58):
I'm your host, Dr Holly Thacker, and we are talking to
gynecologist surgeon andcervical cancer expert, Dr
Sharon Sutherland.
So you were talking about howbleeding can be a sign of
cervical cancer, and that's onething I talk to all of our
trainees about.
A lot of times they'll justorder a pelvic ultrasound, which
(25:19):
is very important and may behelpful for other reasons, but
I'm like you need to repeat thepap.
I don't care that their pap wasnormal three years ago.
If they're having abnormalbleeding, it's a diagnostic pap.
So talk to us about screeningpaps, about this trend of some
doctors only going with HPV,which I'm certainly not for.
I think you want the cells aswell as that, Because I've seen
(25:41):
women that don't haveHPV-related cervical cancer,
some with like gastric mucosatypes, and I don't know if
there's some geneticpredispositions, potentially,
even though most of it is HPV.
Speaker 3 (25:52):
So you're absolutely right.
When we look at the totality ofcancers, 5% will actually test
negative for HPV.
In fact, sometimes I have foundexactly that I've diagnosed the
cancer.
The pap will show invasivecervical cancer, but the HPV
test would be negative.
(26:13):
This is the concern aboutactually moving to 100% HPV
testing.
In other words, that wouldrequire all women to do an HPV
test first and then to returnfor a PAP if the HPV was
abnormal.
I think the biggest concern isthat it's hard enough for women
just to come for the PAP, letalone two visits.
(26:33):
Yes, hpv is also very, verycommon.
We think about 80% of women areexposed by the time they're 50.
So you know who knows what thefuture holds.
There are some excitingresearch areas now.
For example, women doing a homeswab for HPV.
So when we have groups of womenwho sometimes find it very
(26:54):
difficult to get into medicalcare sometimes it's in a rural
area, sometimes they may have ahard time with their work
schedules, that type of thingthat would unleash that ability
to maybe improve screening forthose women.
But they would still have to beactivated to come in and get
the follow-up testing.
Speaker 2 (27:12):
And certainly we want to take away any kind of stigma
about having HPV, because ifyou're sexually active, which
most people have been in theirlife, that's how we have to
reproduce our species.
You can have one sexual partnerand have HPV, so it's sexually
associated, but it's notnecessarily like we consider a
sexually transmitted infectionper se.
We just assume that mosteveryone has it, and I do think,
(27:36):
though, that women need tounderstand that.
Having multiple sexual partners, smoking cigarettes, bad
nutrition, not eating enoughfruits and vegetables and some
of the anti-cancer DIMsubstances having low vitamin Ds
which you know, like almost allmy patients in Northeast Ohio
have I wonder if you havecomments, other comments in that
regard comments.
Speaker 3 (28:01):
Other comments in that regard.
I think you're very on spotthere that HPV in a healthy
patient will sometimes justcause a temporary infection.
That patient may have atemporary slight change in their
pap, but the natural historyfor most women is that their
body will overcome it, the HPVwill go dormant and their PAPs
will go back to normal.
Now we have to remember thatsometimes later in life some new
insult comes.
(28:21):
So, for example, now we havebreast cancer, we're getting
chemotherapy for breast cancerthat sometimes can wake up that
HPV virus that went dormantyears ago.
From the standpoint of what wecan do, the best thing, like you
mentioned, is good nutrition.
I think the other thing that alot of women cheat on is sleep.
Women do not get enough sleepand that's so important, you
(28:45):
know, to our healing.
So all those things youmentioned, I think are also, you
know, very important.
Speaker 2 (28:51):
And HPV is everywhere .
There's all different types.
Some types 16 and 18 are worsethan others.
I have had women who havenormal PAPs but they have
persistent positive HPV and Ireally like your service that
you have that we can put in anabnormal PAP consult to see if
that patient should go on forcolposcopy, Because I know I
(29:11):
would want the next step to takea look at the cervix with
colposcopy if I had persistentHPV, since we know that is such
a significant risk for cervicalcancer, even though you can have
it and not have cancer.
Speaker 3 (29:25):
And that's where we're very lucky in GYN that we
do have PAPs, so that's veryhelpful when we think about the
prevention of cervical cancer.
Also, for some women they needvaginal PAPs.
So they've had a hysterectomybut perhaps they had a
high-grade precancerous lesionor they have a history
transplant or some other riskfactor.
So colposcopy and biopsying ofthe vagina can help us prevent
(29:50):
vaginal cancer.
It's treated with laservaporization, so to treat
vaginal cancer we kind of burnaway just a superficial layer of
the vaginal wall versus thecervix, where we do a surgery to
remove part of the cervix.
Hpv, though, is implicated inmany other cancers, and the
research is not nearly as matureas it is in gynecology.
(30:13):
The next rising area is an analcancer.
We're seeing a rise in analcancer, especially in women who
have had a high-grade dysplasiaof the cervix.
So if you've had that situation, you might talk to your doctor
about it.
We can actually do anal PAPsand anoscopy, where we look at
the anal area with a microscopeand do biopsies, and then, sadly
(30:37):
, the most common HPVV relatedcancer now is oropharyngeal, so
it's now overtaken the GYNcancers.
We don't have a pap test for thethroat, we don't have an HPV
test for the throat andunfortunately they aren't mature
enough to be able to diagnosethis as a precancerous lesion.
So more to come.
You know there's a lot ofresearch happening in those
(30:59):
areas.
Speaker 2 (31:00):
That's fascinating, I certainly.
It's one reason I ask all mypatients have you seen the
dentist?
You needed a good oral exam,teeth exam and oral exam twice a
year.
And I encourage everyone to notuse alcohol mouthwash, because
HPV and alcohol, even if you'renot swallowing it or drinking it
, if you're just exposing yourmucosa to it every day sometimes
(31:21):
there's lots of differentcofactors with cancer and there
may be some breast cancers toothat could be potentially HPV
related.
My son Stetson, who's beenmentioned lots of times on this
podcast and is in season two aswell, lots of times on this
podcast and it's going to be ais in season two as well.
The geneticist.
He developed terrible plantarwarts, which is from a different
(31:42):
, you know type of HPV virus andyou know most people have warts
on their fingers or their feet,and he needed extensive
scraping of his feet and I woulddo that every night like I'd be
in, like my pajamas, and then Iended up developing a breast
papilloma that needed surgeryand I said, oh, it's benign, why
do I need surgery?
(32:03):
Well, one in four times it canturn to cancer.
And the breast surgeon saidthis could be HPV related and I
thought, oh my God, I spent somuch time scraping, scraping and
probably being exposed to thatstrain of HPV every night trying
to fix his feet.
Luckily, he improved hisnutrition and sleep.
Sleep was really bad for him inhigh school and he cleared it
(32:26):
up, thank goodness.
But I thought that was reallyfascinating and there's so many
things in the environment thatwe're naturally exposed to, as
well as nutritional factors andgenetic factors, that can all
coalesce.
So tell us a little bit abouthysteroscopy, preparing for that
, why that's been such a huge,huge advance, at least in terms
(32:49):
of taking care of midlifewomen's health.
Speaker 3 (32:53):
So abnormal bleeding at midlife is very, very common.
For most women it is probablyhormone related and there's not
any kind of pathology.
Back 30 years ago if a womanhad abnormal bleeding and went
to the gynecologist, the doctorwould say well, you're done
having children, let's do ahysterectomy.
So if you look at your ownfamily tree, a lot of women will
(33:14):
have gone through hysterectomy.
But now rate of hysterectomy isfar lower.
The reason is because we haveways to do minimally invasive
procedures to diagnose problemsand treat them.
So when we think abouthysteroscopy, what that is is
where we put a camera throughthe cervix, we instill saline
(33:34):
and then what that'll do isexpand the cavity.
We look on the video screen andwe can literally look directly
at the lining of the uterus.
For some women it's very coolbecause you can see where your
fallopian tubes come out, whereyou're.
When you got pregnant, thatlittle embryo floated right down
that tube and and stuck youknow before your, your baby,
before you even knew that youwere pregnant.
(33:56):
But sometimes we'll find thatthere are polyps, Sometimes
there can be scar tissue, therecan be a regular thickening,
sometimes due to hormonalimbalance.
That could be precancerous, andsometimes not very often, but
sometimes we'll find a woman hasan endometrial cancer.
Speaker 2 (34:14):
Yeah, and so anytime someone is over 40 and they have
abnormal bleeding we have toevaluate it.
If you haven't been, I mean,what my general rule of thumb is
unless they're like super highrisk or previously had cancer or
Lynch syndrome or some geneticpredisposition is that if you've
been evaluated in the last yearwe'll maybe readjust your
hormones and check.
But if it's been more than ayear and a lot of clinicians are
(34:38):
just ordering ultrasounds andif the lining is thin, they're
not necessarily pursuing tissuediagnosis.
But I think sometimes you canmiss some cases.
Speaker 3 (34:48):
I think that's true especially in older women.
There are certain subtypes ofendometrial cancer that are less
common.
Unfortunately, they have aworse prognosis.
In other words they're moreaggressive.
So clear cell, serous type ofcancer.
So in general I recommendbiopsy for everybody 45 and over
who has either bleeding inbetween periods, very heavy
(35:12):
periods, or in general any womanwith postmenopausal bleeding.
It's not normal.
Once we're in menopause, we'renot supposed to bleed, so
something is going on and thebiopsy can be a way to sample
that lining, either reassure usthat there isn't a cancer or, if
it's there, to find it early sowe can treat it.
Speaker 2 (35:33):
And some women who have bleeding in their late
fifties and they say, oh, it'smy regular period.
We do a biopsy and it'ssecretory and they're still
ovulating.
But you don't necessarily knowthat.
And there are somepostmenopausal women, of course,
that I prescribe and weprescribe hormone therapy to
that we cycle so that we knowwhen they bleed, because
unfortunately the uterus is madeto bleed.
But I think if the ultrasoundand the biopsy aren't revealing,
(35:56):
I think the next step oflooking in the office with that
(36:21):
lighted camera three millimeters, you know doesn't take too much
time for most women, unlesswomen to be strong and be
healthy and be in charge.
I did want to touch a bit abouttrying to reach out, because
you've done so much for thecommunity, for rural women, for
inner cities, for disadvantagedwomen, and rates of cervical
cancer in certain groups,including black women, is
increasing and I know one of ourfellows who we've also had on
(36:42):
this podcast, Dr Madeline Cohn,is very interested in doing some
quality improvement andpopulation research and looking
at different characteristics.
So I wondered if you couldcomment about some of your
outreach activities and whythat's important and different
populations that might not begetting good gynecologic medical
(37:04):
care regularly that they need.
Speaker 3 (37:07):
So that really brings up a good point.
Sometimes it is around access,Sometimes it's really around
patient activation.
So one example is HPVvaccination.
Many people know that that cancut children's rates of
developing cervical cancer by90%.
So if you have young people inyour life, either male or female
(37:29):
, to recommend, you know, talkmaybe with their parents to say
you know, this is a vaccinethat's really proven to help
reduce these rates of severedysplasia of the cervix.
Speaker 2 (37:39):
And venereal warts too, depending on which of the
vaccines that you get.
Speaker 3 (37:45):
Oh, that's so true.
And these other cancers, forexample, anal dysplasia and the
oropharyngeal cancers.
There's probably going to beinformation that says you know
that the HPV vaccinations arevery effective.
However, when we look at rates,it's very interesting.
Urban women have higher ratesof HPV vaccination, and most
likely because they are morelikely to have a clinic within
(38:07):
walking distance.
Sometimes they may have morereliable insurance, even if it
is a government program.
They're in that loop wherethey're getting their regular
care.
Women in rural areas are lesslikely to get HPV vaccination
and in fact, what we're seeingis that urban versus rural,
we're seeing higher rates ofcervical cancer, probably not
(38:29):
only because of HPV vaccinationbut also access to providers for
PAPs.
However, on the racial side, ifwe should look at men and women
, you probably know in generalthat for a lot of our African
American women, they have worsehealth outcomes.
Cervical cancer is no different.
When we diagnose cervicalcancer in a black woman, more
(38:52):
likely that it's advanced andmore difficult to treat.
So it's one of those thingswhere just because care is there
doesn't mean that people willalways come in and get the care
they need.
Speaker 2 (39:02):
Certainly, especially if there's, you know, being
suspicious of the medicalprofession, especially, you know
, based on past historicalevents.
How much of that do you thinkis lack of screening or genetic
predispositions?
I also am always one interestedabout vitamin d, because we see
(39:23):
maybe less breast cancer inblack women but more aggressive
breast cancer and we certainlysee lower vitamin d levels the
farther north you go and thedarker the skin is.
And I wonder, has anyone lookedat vitamin d in cervical cancer
?
I know they have in prostatecancer and breast cancer.
Speaker 3 (39:38):
I'm not aware of any studies around vitamin D, but
from the standpoint of the risk,I think it is the lack of
screening.
And when we think aboutcoordination of care, there are
those three big areasvaccination, screening and then
following up for women who'vebeen known to be abnormal in
their PAP or their HPV.
So we're so excited with thecenter that we have a
(40:00):
coordinator now.
Her name is Nicole Jackson.
And what we do is every singleweek we look through the list of
every patient in the clinicsystem who's either had an
abnormal PAP or a high-risk HPV,and then Nicole will do that
one-to-one outreach.
So if that patient hasn'tfollowed up, they haven't
scheduled a colposcopy.
If it's indicated, she'll reachout and say hey, you know,
(40:22):
we're here.
How can I explain to you whatthis test is?
Why is this important?
Because you know it's just ashame if we have somebody who
could prevent a cervical cancerif she just came in and she
chooses not to.
Speaker 2 (40:38):
Now this is just so wonderful.
Do you know if there's other,because we have listeners from
81 countries all over the place?
Are there other medical centerswho are doing this to be a lot
more proactive with the resultsand the screening we have?
Speaker 3 (40:53):
Well, I think as a medical center, a lot of times
we aren't really in the bestposition to do that outreach to
the community.
So I have looked at some of thecenters around the country and
what they're doing, but when wethink about our biggest
opportunity is for medicalcenters to partner with
community health agencies.
So we have federally qualifiedhealth centers.
(41:14):
We sometimes don't have acounty health department, and so
that's a point of care for alot of people, and so how can we
actually travel out into thosecommunities, because it's
difficult for patients sometimesto come into a medical center.
So, you know, I think there'smore to come.
I think that idea of home HPVtesting, for example, that could
(41:35):
be a game changer.
But then there has to be thatfollow-up care, if we're able to
make it, you know, to thatpoint so that patients know like
, hey, this is nothing to bescared of, I'm positive, I just
have to go and get checked.
Speaker 2 (41:48):
Exactly, exactly.
Well, this has just been sowonderful.
January is cervical cancerprevention month, but every
month of the year is importantto think about your health, to
be strong and be healthy and bein charge and take control.
Keep copies of your records,bring them in.
If you think that you need anexam or a PAP and your clinician
(42:09):
is not interested, then you canpotentially find another one.
I think it's so important toget that sleep, get that good
nutrition, eat cruciferousvegetables that are rich in DIM,
which seem to have anti-HPVeffects, and any new gynecologic
symptom or abnormal bleeding orabnormal discharge certainly
(42:29):
needs to be evaluated.
So any other final partingcomments, dr Sutherland?
Speaker 3 (42:36):
Well, I am so grateful for all that you do in
your facility and in this groupto really activate women.
I think sometimes you know wehave so many priorities and it's
so easy for women to put theirhealth, you know, at the end of
the list.
I'll do it someday.
And that's where we have torealize that we don't want
(42:57):
anybody taking care of us.
So if we're going to take careof everybody else, just like the
oxygen mask in the plane, yougot to put yours on first.
So women have to be able tostart putting themselves first
and say you know what?
I have to make time for this.
So I appreciate what you'redoing to encourage people to do
that.
Speaker 2 (43:13):
Oh, and there was one other point that I wanted to
make that I learned in yourlecture the lecture that I was
so embarrassed by, andthankfully the audio recording,
but not the visual recording ofme zooming in wasn't there that
you talked about that if you'renot pregnant and you have an
abnormal pap and you're goingfor colposcopy, that the
ordering physician should orderan ECC.
(43:36):
And why is that important?
Because I thought that was avery important pearl that I was
not aware of.
And we have a lot of physicianswho listen to this podcast as
well.
Speaker 3 (43:45):
Yeah, so when we think about the cervix, there's
the ectocervix.
In other words, when we look atthe cervix with a speculum, we
can look directly at it.
However, it's the liningbetween the opening of the
cervix and the lining of theuterus, what we call the
endocervical canal.
10% of the high-gradeprecancers are exclusively found
(44:05):
in that area.
Those are more difficult todiagnose and they're also more
difficult to treat because it'san ascending tumor.
So, in other words, sometimes,if you think of it like taking a
scoop for an ice cream scooper,you have to go deeper to be
able to get all of thosehigh-grade precancer cells to
prevent it from turning intocancer.
(44:26):
So yeah, the ECC is a veryimportant part of colposcopy.
Speaker 2 (44:30):
So women out there who've had abnormal PAPs and had
colposcopies, ask your women'shealth clinician did you get the
ECC and when should you getyour next pap and HPV?
So thank you so much for ourlisteners.
If you've enjoyed this episodeand you want to help support the
podcast, share it with others.
(44:51):
It's free.
You can give us a five-starrating.
If you don't get our regularall of our podcasts you can
subscribe.
Anywhere you listen to podcastsApple Podcasts, spotify, tune
in.
And thanks again and I lookforward to seeing you next time
(45:12):
in the Sunflower House.
Welcome to the Speaking of Women's Health
podcast.
I'm your guest host for thisepisode, leigh Klecker.
I'm the producer of theSpeaking of Women's Health
podcast and I'm back in theSunflower House for a somewhat
new episode.
In season two, our wonderfulexecutive director and host, dr
(00:26):
Holly Thacker, interviewed DrSharon Sutherland all about
cervical cancer.
As January is Cervical CancerAwareness Month, dr Sutherland
is the director of the Centerfor Prevention of Cervical
Cancer at the Cleveland Clinic,of the Center for Prevention of
Cervical Cancer at the ClevelandClinic, and cervical cancer
(00:50):
prevention is so important and amessage that we want to
continue sharing this January inseason three.
But before we replay thatepisode, I want to share a few
pieces of information oncervical cancer, some new and
some just some friendlyreminders.
So Dr Thacker again, ourbrilliant Speaking of Women's
(01:11):
Health podcast host andexecutive director of Speaking
of Women's Health.
She recommends that women, evenif they are told they can go
five years between their PAPs,that many times insurance covers
it three years and people arebusy and five years can turn
into a longer time period andeven if you're not getting a PAP
(01:33):
smear of the cervix, one stillneeds to get regular gynecologic
exams because too many womencan fall through the cracks, and
this is a, by and large,preventable cancer death.
And the latest statistic oncervical cancer is about 13,820
(01:56):
new cases of invasive cervicalcancer will be diagnosed this
year and about 4,360 women willdie from cervical cancer.
It is the most frequentlydiagnosed cancer in women
between the ages of 35 and 44,with the average age being 50.
(02:18):
And many older women.
They don't realize that theyare still at risk of developing
cervical cancer as they age, andmore than 20% of cervical
cancers are found in women overage 65.
However, these cancers rarelyoccur in women who have been
getting regular tests to screenfor cervical cancer before they
(02:41):
were 65, which is why cervicalcancer screening is so important
and the message that we want torelay in this episode.
So back in May of 2024, the Foodand Drug Administration
expanded the approvals of twotests that detect cancer-causing
types of the humanpapillomavirus, or HPV, in the
(03:05):
cervix, and both tests they'reused as part of screening for
cervical cancer.
So under these expandedapprovals, people can now be
offered the option to collect avaginal sample themselves for
HPV testing if they cannot haveor do not want to have a pelvic
(03:25):
exam.
However, the collection, whichinvolves a swab or a brush.
It must be done in a healthcaresetting.
That would be a primary careoffice, urgent care, pharmacy,
mobile clinic.
And it starts for womenbeginning at age 30.
And it starts for womenbeginning at age 30.
(03:49):
So the tests included in theapprovals are OnClarity HPV and
that's made by Becton, dickinsonand Company and Cobuz HPV.
So until now, screening forcervical cancer in the US has
required a sample of cellscollected from the cervix during
a pelvic exam performed by ahealthcare professional.
So that would be your physician,your nurse practitioner, a
(04:12):
physician assistant.
But the availability of theself-collection option in
healthcare settings should helpwiden access to cervical cancer
screening.
So increased access to HPVtesting is a particular need for
certain populations among whichrates of cervical cancer
(04:35):
screening continue to be low,like healthcare deserts across
the country, where people stilldon't have access to a regular
healthcare clinician.
And access isn't the onlybarrier to cervical cancer
screening.
People may have personalpreferences, be it religious or
cultural beliefs, maybe ahistory of trauma or
(04:56):
disabilities or medicalconditions that would prevent
them from getting a pelvic examperformed by a healthcare
clinician, and many cliniciansthey believe that making this
home-based sample collection anoption will hopefully widen
access to screening even furtherin the future.
(05:17):
The gold standard for cervicalcancer screening is CO testing,
with both a HPV and a pap testby a doctor or advanced practice
provider, but the self-HPVtesting which is still being
studied is better than not doingany screening at all, so this
(05:37):
is a really good new option forthose who would qualify.
I want to thank you forlistening to this quick update
on cervical cancer screening,and up next is the cervical
cancer awareness podcast episodewith Dr Sutherland and Dr
Thacker from season two, and Ihope you enjoy listening to it,
(06:01):
either for the first time oragain.
And thanks for joining me inthe Sunflower House and I'll see
you next time.
Speaker 2 (06:12):
Welcome to the Speaking of Women's Health
podcast.
I'm your host, dr Holly Thacker, the Executive Director of
Speaking of Women's Health, andI'm back in the Sunflower House
for a brand new episode of ourSpeaking of Women's Health.
And I'm back in the SunflowerHouse for a brand new episode of
our Speaking of Women's Healthpodcast.
And this is our second seasonand it's January, which is
(06:34):
Cervical Cancer Awareness Month,and I started off the New
Year's season talking aboutstaying healthy and sticking to
health goals and lots of funnatural beauty hacks, and I
promised the audience I wouldtell you if I used any of the
beauty hacks.
And I did use that apple cidervinegar on my nails.
(06:54):
It did help dehydrate them fora good manicure.
So go back and listen to thatfirst one of the year if you
missed it.
But even though we like funthings as women and we care
about how we look and how wefeel and I do have an upcoming
podcast more on skincare andhair because I know those are
popular topics we're not goingto be around to enjoy those fun
(07:17):
feminine things if we don't takecare of ourselves.
And we're going to talk aboutsomething very serious, as
serious as cancer and one of themost exciting preventive tests
that came down in the field ofmedicine is the pap smear, and
cervical cancer screening hasbeen around so long and some of
(07:39):
the guidelines have changed.
It's kind of gotten complicatedfor physicians so you can
imagine what it's like for theaverage woman.
Guidelines have changed.
It's kind of gotten complicatedfor physicians so you can
imagine what it's like for theaverage woman and I think that
that's kind of fallen off a lotof patients and women's
important concerns Very muchdifferent than it was 20 or 30
years ago when I started in thefield.
(08:00):
And women specifically theywanted their yearly exam and
their PAP and their pelvic.
And women specifically theywanted their yearly exam and
their pap and their pelvic.
So it is my great pleasure toinvite our guest, dr Sharon
Sutherland, a partner, a friend,a colleague.
She's a staff physician at theCleveland Clinic for over 20
years, even though she onlylooks 20.
And she was trained in OBGYNand she's a surgeon.
(08:25):
She has a very calm, measured,unflappable, focused approach
and that's a wonderfulconstellation of characteristics
that you want in a physicianand surgeon.
And she's focused her career,most recently after delivering,
you know, I'm sure, thousands ofbabies, she's now really
(08:49):
focused on patient care qualitycervical cancer screening and
ultrasound pelvic ultrasound andwe hope to get into some of
these topics.
She does see patients at themain campus, and she also spends
some time in the Center forSpecialized Women's Health,
where we love to see her, andshe trains some of our
(09:09):
Specialized Women's Healthfellows.
Her main clinical focus rightnow, though, is on diagnosis and
treatment of pre-cancers of thecervix as well as abnormal
bleeding, and those are twoareas that, in midlife women's
health even though they'reimportant before and after
really are big focuses, and shehas been named the director for
(09:33):
the Center for the Prevention ofCervical Cancer, which is a
group of 14 specialists who aredriving excellence in care and
treatment of patients withprecancerous cervical lesions,
because you certainly want todeal with those before they turn
into cancer.
She's also taken on another bigrole.
You know she's the typicalmultitasking, high-energy woman.
(09:56):
She is now in charge ofgynecologic ultrasound, and she
is the director of gynecologicimaging for OBGYN Institute, and
I feel kind of a kinshipbecause neither one of us are
radiologists, but just like Iread bone densities I'm not a
radiologist, but that's aradiology reading imaging test I
(10:19):
really feel like the clinicalbackground helps me be a better
radiologist with bone health,and I imagine she may have some
comments about that in terms ofbeing a gynecologist and a
radiologist in terms ofultrasound in the pelvis.
She completed medical school andresidency at Ohio State and a
master's of public health atColumbia University, and she and
(10:44):
her husband are big Clevelandfans, cleveland Browns fans, osu
fans and we won't talk aboutthe recent football championship
.
And there's one.
Oh my goodness, her lecturethat she gave to our entire
Institute on cervical cancer wasso good and I was so
embarrassed because I wasgetting out of the shower and I
(11:05):
had a towel on my head andaccidentally turned on the Zoom
camera.
Oh my goodness, all you couldsee was my towel and, oh, I was
like so embarrassed.
So sometimes it's good to keepthe camera off, but it's great
that we have the camera on.
So welcome, dr Sutherland.
Speaker 3 (11:24):
Thank you so much, Dr Thacker.
Speaker 2 (11:25):
This is a pleasure and this is such an important
topic, tell us about cervicalcancer.
It seems like we've made somany strides but now it feels
like to me that we'rebacktracking and we are still
seeing women in 2024 withcervical cancer invasive, that
they may die from.
Speaker 3 (11:44):
Well, people don't realize, but 100 years ago
cervical cancer was one of thenumber one causes of death of
women, especially in their earlylife, between the ages of 20
and 40.
In fact, my owngreat-grandmother died of
cervical cancer in her 40s, soit was a very, very common
disease.
We did have development of thePAP test, as you mentioned, and
(12:05):
then more recently testing forhigh-risk HPV.
So now it's down as far as thelist of cervical, you know, as
far as cancers for women, it'snot at the head of the pack
anymore.
Speaker 2 (12:18):
but we definitely have opportunity.
My mother's mother died of agynecologic cancer which they
said was cervical.
So it was either cervicalpotentially I mean, I don't have
the pathology and she was inher 40s and it was devastating.
And I just think that a lot ofyounger women and just busy
women, if they don't have thatpersonal experience, they're
(12:40):
just thinking about breastcancer, maybe they're thinking
about ovarian cancer.
If they have abnormal bleeding,they worry about uterine cancer
.
But cervical cancer really weshould be ahead of and there
really shouldn't be hardlyanyone, any woman, dying of
cervical cancer, right?
Because what's the cure rate ifyou find it really early?
Speaker 3 (13:01):
Yeah, that's absolutely true.
As far as our current rates, wehave about 14,000 new cases of
cervical cancer every year inthe US.
When we think about the averageage, average age is 50.
We see some people as young asin the early 20s to mid-20s, and
then we're seeing an increasein women as they get older, and
(13:22):
part of it has to do with thereduction in cervical cancer
screening in women over 65.
Speaker 2 (13:27):
And you know that the alert on our medical record
goes away at 65, and we can turnthat back on.
But I have a lot of women whosay, oh well, I was told I'm
over 65.
I don't need that anymore.
Oh, I don't have a cervix so Idon't need exams.
The gynecologist told me not tocome back and I can understand
(13:47):
why.
Maybe you don't need to see abusy surgical cancer doctor or a
gynecologist that'sspecializing in things.
But we have a whole cadre ofvery well-trained women's health
nurse practitioners for annualexams or at least every two-year
exams.
So tell us why are you morethan just a cervix and what's
(14:08):
involved and what's thedifference between exams and
PAPs and HPVs, et cetera.
We'll be back after a quickbreak.
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Speaker 3 (15:00):
So, just in general, when we talk about cure rate,
like you mentioned, it'sprobably one of the only cancers
that we can truly prevent.
So if all of our women weregetting the proper screening
with the PAP and the HPV, basedon their risk factors, at the
right time, we would reallypotentially see zero cervical
cancers.
If we do diagnose them early,the cure rate is very high
(15:23):
greater than 90%.
So it's the kind of thing thatwe don't want to be fearful of.
For some people, they feargetting a pap because they're
worried what if it's abnormal?
What if I have to do somethingto follow up?
But it's exactly the reverse weshould be fearful of what
happens if I don't get a pap.
Speaker 2 (15:38):
Absolutely, absolutely.
And the other trend I've seenis busy physicians and busy APPs
have so much on their plate andthat's one reason I encourage
women to make more appointmentsrather than less.
It's easier to cancelappointments and to come focused
with things and not expect, youknow, 10 problems and a
preventive visit to all be doneat once.
(15:58):
But if they have a normal PAPand a negative HPV, a lot of
women are told not to come backfor five years and women aren't
putting that in their calendarsnecessarily, and some women,
five years is not appropriate.
We have a lot of transplantpatients, people who are
immunocompromised HIV.
Do you want to talk about someof those special categories?
(16:19):
I think, minority women, womenthat maybe are disadvantaged and
haven't had regular healthscreenings?
If you can, comment on thosespecial groups?
Speaker 3 (16:31):
Yeah, so one of the areas that we're looking at is,
just like you mentioned, tryingto look at that patient's
individual risk.
Women who are HIV positive, Ithink, have about four times the
risk of developing cervicalcancer.
Same with transplant, whetherit's a bone marrow transplant or
a solid organ transplant.
So those patients go throughscreening prior to getting
(16:53):
transplant, but then it's veryimportant every single year, as
long as they're healthy enough,to have a Pap and HPV test.
The other evolving area are alot of these immunosuppressive
drugs.
They're really improvingquality of life for people with
colitis, maybe with severepsoriasis, things like arthritis
.
However, they carry with them amajor risk of immunosuppression
(17:16):
and, in this case, risk ofcervical cancer.
So we recommend that ourphysicians look through that
list in our APPs of their meds,because sometimes they're
relatively healthy but they'reon this medication that flags
that, hey, this gal should havea pap every year and when
cervical cancer is not diagnosedearly.
Speaker 2 (17:39):
tell us about what some of the symptoms and some of
the problems that women candeal with.
I've seen some young womenreally suffering with horrible
complications.
Speaker 3 (17:50):
So when we think about the cancer, it typically
develops at the tip of thecervix, and so that's where, in
the very early stages, it can beprevented or cured with a minor
surgery to the cervix In thefirst stage.
If we catch it early enough,sometimes we can do a
hysterectomy and completelyremove the tumor.
This is the type of tumor thatspreads locally, so rather than
(18:12):
the cells going all through yourbody, usually the first thing
that'll happen is it'll invadeinto the upper vagina, into the
bladder, into the rectum, intothe pelvic bones.
So it's a very destructivetumor.
Women will present with pelvicpain, they'll present with
abnormal bleeding, and thetreatments at that point require
(18:34):
chemotherapy and radiation.
Sadly, only two out of threewho are diagnosed with cervical
cancer will survive five years,and the main reason is that more
than half of our cervicalcancers are diagnosed when
they're already beyond thecervix.
Speaker 2 (18:50):
Yeah, and that really just shouldn't be the case.
My niece, who's in college?
She's 18.
She's at the University ofAlabama, roll Tide.
When I saw her at the holidaysshe asked me Aunt Holly, when
should I get my first pap smear?
I went to the health center andthey said I don't need one.
But I just want to know.
(19:11):
I want to stay healthy.
Speaker 3 (19:14):
So when we think about screening there are
different guidelines.
In some places they recommendstarting at 25, but
unfortunately we know that's toolate for some patients.
So in general at the ClevelandClinic we recommend starting at
the age of 21, doing a PAP everytwo to three years up until the
age of 30.
And then at the age of 30,adding HPV screening along with
(19:37):
the pap.
And for most women that can bein that four to five year range.
But for those higher risk womenwe need to be doing those tests
more often.
Speaker 2 (19:47):
Well, I know our nurse practitioner, dana Leslie,
who I've had on this podcastand I plan to have again this
season who I personally see formy gynecologic exams and PAPs.
She many times will do it everythree to three and a half years
because if she's seeing theperson and then they don't come
back and so too many people justget lost to follow up and you
(20:09):
know it's hard to completelyknow if between now and the next
time you see a person, ifthey're going to be put on
rheumatoid arthritis medicinesor their nutritional status is
going to go down or you knowsomething else is going on.
And a lot of women I find don'talways even keep records of
their last pap and HPV and so orthey don't know what they had
done to their cervix, like oh,it was abnormal, but then it's
(20:30):
okay.
Can you talk a little bit aboutcolposcopy, that paps are
really not diagnostic and youneed to do colposcopy if you're
not sure?
And then what some of thesurgical procedures are if the
PAP is abnormal?
Speaker 3 (20:45):
So the colposcopy is one of the early advances in
cervical cancer screening.
First we had the PAP and atthat time the PAP was really
just to diagnose the actualcancers.
But then they started torealize maybe there are some
changes in the cells that candiagnose it early.
So we have protocols that wefollow and, based on the PAP
(21:05):
profile and the rate ofhigh-risk HPV for that
particular patient, we all do acolposcopy.
That is like a PAP.
We look at the cervix with amicroscope, we apply different
medicines to the cervix.
We look at the cervix with amicroscope, we apply different
medicines to the cervix and thenany areas that look like they
could be precancerous we taketiny pinch biopsies.
A lot of women are fearful ofpain but often feel very little.
(21:27):
I relate it to somebody tuggingyour hair.
All of us have had a littlehair pull at the beautician and
we're good with that.
So you know it's the type ofthing that the colposcopy for
most women is not severelypainful.
We will see an upgrade ofresults.
So, for example, some patientswill present with a low-grade
(21:50):
pap but then have about a 15 to20 percent chance that they
actually have a higher-gradelesion that the pap missed.
So that's why the colposcopy isso important.
Abnormal paps don't hurt us,and being positive for high-risk
HPV doesn't hurt us.
What we're really looking foris that high-grade pre-cancer,
because that is the trigger totreat.
Speaker 2 (22:13):
And there's no special preparation that a woman
needs to do for colposcopy.
If she's having a heavy period,does she have to reschedule?
Can she just come into theoffice like for a pap smear that
takes just a little bit longerand then plan to go back to work
?
We'll be back after a quickbreak.
Speaker 5 (22:34):
Throughout my own life and fitness journey, I have
had the privilege of meetingincredible people who've shared
valuable insights on mindset,health, fitness and spiritual
growth.
The profound impact of thisknowledge on my own life has
inspired me to share it with allof you.
I'm Erica Sweeney, host andfounder of my Fit Tribe Podcast.
Join me as we explore inspiringconversations with experts,
(22:58):
thought leaders and everydayheroes who offer their stories
and practical tips to help youon your own journey.
Our mission is to empower youto take charge of your health
and live your best life.
Speaker 3 (23:16):
For most women they don't need any preparation.
In general, if you're havinglight bleeding, like at the
beginning or the end of theperiod, it doesn't interfere.
But if you are on one of thoseheavy flow days where you're
changing protection every couplehours, we would recommend that
you reschedule, Althoughsometimes cervix cancers present
with abnormal bleeding.
So if we have patients that arehaving abnormal bleeding, it's
(23:38):
very important that we actuallyexamine the cervix, because
sometimes we find that thecervix is actually the problem
From the standpoint of otherpreparation.
As we get older and our hormonelevels drop, sometimes the
cervix will become stenotic.
What that means is I relate itto like a flower that is going
(23:59):
in reverse.
So if we think of our cervixlike a flower that blooms, it
blooms when we have hormones andthen it goes back into the bud
stage and closes up very tightlyin menopause.
So sometimes we'll givemedicines to soften the cervix
and make it more likely that wecan get adequate samples.
Speaker 2 (24:15):
Yeah, that is so important.
I usually will give vaginalDHEA because it's not estrogen.
So even if there is somethingwrong inside the uterus that's
estrogen sensitive, it's notgoing to hurt.
And then the cytotec ormisoprostol, which we use to
prevent stomach acids, helps todilate the cervix.
I always joke you could drive atruck through my cervix.
(24:38):
I had three big boys, whichmade it very easy when I've had
to have hysteroscopies orprocedures to look up inside of
the uterus, which I will wantyou to talk about the procedure
of office hysteroscopy, which alot of gynecologists don't
necessarily do, but you do andyou have that expertise.
And you have been listening tothe Speaking of Women's Health
podcast.
(24:58):
I'm your host, Dr Holly Thacker, and we are talking to
gynecologist surgeon andcervical cancer expert, Dr
Sharon Sutherland.
So you were talking about howbleeding can be a sign of
cervical cancer, and that's onething I talk to all of our
trainees about.
A lot of times they'll justorder a pelvic ultrasound, which
(25:19):
is very important and may behelpful for other reasons, but
I'm like you need to repeat thepap.
I don't care that their pap wasnormal three years ago.
If they're having abnormalbleeding, it's a diagnostic pap.
So talk to us about screeningpaps, about this trend of some
doctors only going with HPV,which I'm certainly not for.
I think you want the cells aswell as that, Because I've seen
(25:41):
women that don't haveHPV-related cervical cancer,
some with like gastric mucosatypes, and I don't know if
there's some geneticpredispositions, potentially,
even though most of it is HPV.
Speaker 3 (25:52):
So you're absolutely right.
When we look at the totality ofcancers, 5% will actually test
negative for HPV.
In fact, sometimes I have foundexactly that I've diagnosed the
cancer.
The pap will show invasivecervical cancer, but the HPV
test would be negative.
(26:13):
This is the concern aboutactually moving to 100% HPV
testing.
In other words, that wouldrequire all women to do an HPV
test first and then to returnfor a PAP if the HPV was
abnormal.
I think the biggest concern isthat it's hard enough for women
just to come for the PAP, letalone two visits.
(26:33):
Yes, hpv is also very, verycommon.
We think about 80% of women areexposed by the time they're 50.
So you know who knows what thefuture holds.
There are some excitingresearch areas now.
For example, women doing a homeswab for HPV.
So when we have groups of womenwho sometimes find it very
(26:54):
difficult to get into medicalcare sometimes it's in a rural
area, sometimes they may have ahard time with their work
schedules, that type of thingthat would unleash that ability
to maybe improve screening forthose women.
But they would still have to beactivated to come in and get
the follow-up testing.
Speaker 2 (27:12):
And certainly we want to take away any kind of stigma
about having HPV, because ifyou're sexually active, which
most people have been in theirlife, that's how we have to
reproduce our species.
You can have one sexual partnerand have HPV, so it's sexually
associated, but it's notnecessarily like we consider a
sexually transmitted infectionper se.
We just assume that mosteveryone has it, and I do think,
(27:36):
though, that women need tounderstand that.
Having multiple sexual partners, smoking cigarettes, bad
nutrition, not eating enoughfruits and vegetables and some
of the anti-cancer DIMsubstances having low vitamin Ds
which you know, like almost allmy patients in Northeast Ohio
have I wonder if you havecomments, other comments in that
regard comments.
Speaker 3 (28:01):
Other comments in that regard.
I think you're very on spotthere that HPV in a healthy
patient will sometimes justcause a temporary infection.
That patient may have atemporary slight change in their
pap, but the natural historyfor most women is that their
body will overcome it, the HPVwill go dormant and their PAPs
will go back to normal.
Now we have to remember thatsometimes later in life some new
insult comes.
(28:21):
So, for example, now we havebreast cancer, we're getting
chemotherapy for breast cancerthat sometimes can wake up that
HPV virus that went dormantyears ago.
From the standpoint of what wecan do, the best thing, like you
mentioned, is good nutrition.
I think the other thing that alot of women cheat on is sleep.
Women do not get enough sleepand that's so important, you
(28:45):
know, to our healing.
So all those things youmentioned, I think are also, you
know, very important.
Speaker 2 (28:51):
And HPV is everywhere .
There's all different types.
Some types 16 and 18 are worsethan others.
I have had women who havenormal PAPs but they have
persistent positive HPV and Ireally like your service that
you have that we can put in anabnormal PAP consult to see if
that patient should go on forcolposcopy, Because I know I
(29:11):
would want the next step to takea look at the cervix with
colposcopy if I had persistentHPV, since we know that is such
a significant risk for cervicalcancer, even though you can have
it and not have cancer.
Speaker 3 (29:25):
And that's where we're very lucky in GYN that we
do have PAPs, so that's veryhelpful when we think about the
prevention of cervical cancer.
Also, for some women they needvaginal PAPs.
So they've had a hysterectomybut perhaps they had a
high-grade precancerous lesionor they have a history
transplant or some other riskfactor.
So colposcopy and biopsying ofthe vagina can help us prevent
(29:50):
vaginal cancer.
It's treated with laservaporization, so to treat
vaginal cancer we kind of burnaway just a superficial layer of
the vaginal wall versus thecervix, where we do a surgery to
remove part of the cervix.
Hpv, though, is implicated inmany other cancers, and the
research is not nearly as matureas it is in gynecology.
(30:13):
The next rising area is an analcancer.
We're seeing a rise in analcancer, especially in women who
have had a high-grade dysplasiaof the cervix.
So if you've had that situation, you might talk to your doctor
about it.
We can actually do anal PAPsand anoscopy, where we look at
the anal area with a microscopeand do biopsies, and then, sadly
(30:37):
, the most common HPVV relatedcancer now is oropharyngeal, so
it's now overtaken the GYNcancers.
We don't have a pap test for thethroat, we don't have an HPV
test for the throat andunfortunately they aren't mature
enough to be able to diagnosethis as a precancerous lesion.
So more to come.
You know there's a lot ofresearch happening in those
(30:59):
areas.
Speaker 2 (31:00):
That's fascinating, I certainly.
It's one reason I ask all mypatients have you seen the
dentist?
You needed a good oral exam,teeth exam and oral exam twice a
year.
And I encourage everyone to notuse alcohol mouthwash, because
HPV and alcohol, even if you'renot swallowing it or drinking it
, if you're just exposing yourmucosa to it every day sometimes
(31:21):
there's lots of differentcofactors with cancer and there
may be some breast cancers toothat could be potentially HPV
related.
My son Stetson, who's beenmentioned lots of times on this
podcast and is in season two aswell, lots of times on this
podcast and it's going to be ais in season two as well.
The geneticist.
He developed terrible plantarwarts, which is from a different
(31:42):
, you know type of HPV virus andyou know most people have warts
on their fingers or their feet,and he needed extensive
scraping of his feet and I woulddo that every night like I'd be
in, like my pajamas, and then Iended up developing a breast
papilloma that needed surgeryand I said, oh, it's benign, why
do I need surgery?
(32:03):
Well, one in four times it canturn to cancer.
And the breast surgeon saidthis could be HPV related and I
thought, oh my God, I spent somuch time scraping, scraping and
probably being exposed to thatstrain of HPV every night trying
to fix his feet.
Luckily, he improved hisnutrition and sleep.
Sleep was really bad for him inhigh school and he cleared it
(32:26):
up, thank goodness.
But I thought that was reallyfascinating and there's so many
things in the environment thatwe're naturally exposed to, as
well as nutritional factors andgenetic factors, that can all
coalesce.
So tell us a little bit abouthysteroscopy, preparing for that
, why that's been such a huge,huge advance, at least in terms
(32:49):
of taking care of midlifewomen's health.
Speaker 3 (32:53):
So abnormal bleeding at midlife is very, very common.
For most women it is probablyhormone related and there's not
any kind of pathology.
Back 30 years ago if a womanhad abnormal bleeding and went
to the gynecologist, the doctorwould say well, you're done
having children, let's do ahysterectomy.
So if you look at your ownfamily tree, a lot of women will
(33:14):
have gone through hysterectomy.
But now rate of hysterectomy isfar lower.
The reason is because we haveways to do minimally invasive
procedures to diagnose problemsand treat them.
So when we think abouthysteroscopy, what that is is
where we put a camera throughthe cervix, we instill saline
(33:34):
and then what that'll do isexpand the cavity.
We look on the video screen andwe can literally look directly
at the lining of the uterus.
For some women it's very coolbecause you can see where your
fallopian tubes come out, whereyou're.
When you got pregnant, thatlittle embryo floated right down
that tube and and stuck youknow before your, your baby,
before you even knew that youwere pregnant.
(33:56):
But sometimes we'll find thatthere are polyps, Sometimes
there can be scar tissue, therecan be a regular thickening,
sometimes due to hormonalimbalance.
That could be precancerous, andsometimes not very often, but
sometimes we'll find a woman hasan endometrial cancer.
Speaker 2 (34:14):
Yeah, and so anytime someone is over 40 and they have
abnormal bleeding we have toevaluate it.
If you haven't been, I mean,what my general rule of thumb is
unless they're like super highrisk or previously had cancer or
Lynch syndrome or some geneticpredisposition is that if you've
been evaluated in the last yearwe'll maybe readjust your
hormones and check.
But if it's been more than ayear and a lot of clinicians are
(34:38):
just ordering ultrasounds andif the lining is thin, they're
not necessarily pursuing tissuediagnosis.
But I think sometimes you canmiss some cases.
Speaker 3 (34:48):
I think that's true especially in older women.
There are certain subtypes ofendometrial cancer that are less
common.
Unfortunately, they have aworse prognosis.
In other words they're moreaggressive.
So clear cell, serous type ofcancer.
So in general I recommendbiopsy for everybody 45 and over
who has either bleeding inbetween periods, very heavy
(35:12):
periods, or in general any womanwith postmenopausal bleeding.
It's not normal.
Once we're in menopause, we'renot supposed to bleed, so
something is going on and thebiopsy can be a way to sample
that lining, either reassure usthat there isn't a cancer or, if
it's there, to find it early sowe can treat it.
Speaker 2 (35:33):
And some women who have bleeding in their late
fifties and they say, oh, it'smy regular period.
We do a biopsy and it'ssecretory and they're still
ovulating.
But you don't necessarily knowthat.
And there are somepostmenopausal women, of course,
that I prescribe and weprescribe hormone therapy to
that we cycle so that we knowwhen they bleed, because
unfortunately the uterus is madeto bleed.
But I think if the ultrasoundand the biopsy aren't revealing,
(35:56):
I think the next step oflooking in the office with that
(36:21):
lighted camera three millimeters, you know doesn't take too much
time for most women, unlesswomen to be strong and be
healthy and be in charge.
I did want to touch a bit abouttrying to reach out, because
you've done so much for thecommunity, for rural women, for
inner cities, for disadvantagedwomen, and rates of cervical
cancer in certain groups,including black women, is
increasing and I know one of ourfellows who we've also had on
(36:42):
this podcast, Dr Madeline Cohn,is very interested in doing some
quality improvement andpopulation research and looking
at different characteristics.
So I wondered if you couldcomment about some of your
outreach activities and whythat's important and different
populations that might not begetting good gynecologic medical
(37:04):
care regularly that they need.
Speaker 3 (37:07):
So that really brings up a good point.
Sometimes it is around access,Sometimes it's really around
patient activation.
So one example is HPVvaccination.
Many people know that that cancut children's rates of
developing cervical cancer by90%.
So if you have young people inyour life, either male or female
(37:29):
, to recommend, you know, talkmaybe with their parents to say
you know, this is a vaccinethat's really proven to help
reduce these rates of severedysplasia of the cervix.
Speaker 2 (37:39):
And venereal warts too, depending on which of the
vaccines that you get.
Speaker 3 (37:45):
Oh, that's so true.
And these other cancers, forexample, anal dysplasia and the
oropharyngeal cancers.
There's probably going to beinformation that says you know
that the HPV vaccinations arevery effective.
However, when we look at rates,it's very interesting.
Urban women have higher ratesof HPV vaccination, and most
likely because they are morelikely to have a clinic within
(38:07):
walking distance.
Sometimes they may have morereliable insurance, even if it
is a government program.
They're in that loop wherethey're getting their regular
care.
Women in rural areas are lesslikely to get HPV vaccination
and in fact, what we're seeingis that urban versus rural,
we're seeing higher rates ofcervical cancer, probably not
(38:29):
only because of HPV vaccinationbut also access to providers for
PAPs.
However, on the racial side, ifwe should look at men and women
, you probably know in generalthat for a lot of our African
American women, they have worsehealth outcomes.
Cervical cancer is no different.
When we diagnose cervicalcancer in a black woman, more
(38:52):
likely that it's advanced andmore difficult to treat.
So it's one of those thingswhere just because care is there
doesn't mean that people willalways come in and get the care
they need.
Speaker 2 (39:02):
Certainly, especially if there's, you know, being
suspicious of the medicalprofession, especially, you know
, based on past historicalevents.
How much of that do you thinkis lack of screening or genetic
predispositions?
I also am always one interestedabout vitamin d, because we see
(39:23):
maybe less breast cancer inblack women but more aggressive
breast cancer and we certainlysee lower vitamin d levels the
farther north you go and thedarker the skin is.
And I wonder, has anyone lookedat vitamin d in cervical cancer
?
I know they have in prostatecancer and breast cancer.
Speaker 3 (39:38):
I'm not aware of any studies around vitamin D, but
from the standpoint of the risk,I think it is the lack of
screening.
And when we think aboutcoordination of care, there are
those three big areasvaccination, screening and then
following up for women who'vebeen known to be abnormal in
their PAP or their HPV.
So we're so excited with thecenter that we have a
(40:00):
coordinator now.
Her name is Nicole Jackson.
And what we do is every singleweek we look through the list of
every patient in the clinicsystem who's either had an
abnormal PAP or a high-risk HPV,and then Nicole will do that
one-to-one outreach.
So if that patient hasn'tfollowed up, they haven't
scheduled a colposcopy.
If it's indicated, she'll reachout and say hey, you know,
(40:22):
we're here.
How can I explain to you whatthis test is?
Why is this important?
Because you know it's just ashame if we have somebody who
could prevent a cervical cancerif she just came in and she
chooses not to.
Speaker 2 (40:38):
Now this is just so wonderful.
Do you know if there's other,because we have listeners from
81 countries all over the place?
Are there other medical centerswho are doing this to be a lot
more proactive with the resultsand the screening we have?
Speaker 3 (40:53):
Well, I think as a medical center, a lot of times
we aren't really in the bestposition to do that outreach to
the community.
So I have looked at some of thecenters around the country and
what they're doing, but when wethink about our biggest
opportunity is for medicalcenters to partner with
community health agencies.
So we have federally qualifiedhealth centers.
(41:14):
We sometimes don't have acounty health department, and so
that's a point of care for alot of people, and so how can we
actually travel out into thosecommunities, because it's
difficult for patients sometimesto come into a medical center.
So, you know, I think there'smore to come.
I think that idea of home HPVtesting, for example, that could
(41:35):
be a game changer.
But then there has to be thatfollow-up care, if we're able to
make it, you know, to thatpoint so that patients know like
, hey, this is nothing to bescared of, I'm positive, I just
have to go and get checked.
Speaker 2 (41:48):
Exactly, exactly.
Well, this has just been sowonderful.
January is cervical cancerprevention month, but every
month of the year is importantto think about your health, to
be strong and be healthy and bein charge and take control.
Keep copies of your records,bring them in.
If you think that you need anexam or a PAP and your clinician
(42:09):
is not interested, then you canpotentially find another one.
I think it's so important toget that sleep, get that good
nutrition, eat cruciferousvegetables that are rich in DIM,
which seem to have anti-HPVeffects, and any new gynecologic
symptom or abnormal bleeding orabnormal discharge certainly
(42:29):
needs to be evaluated.
So any other final partingcomments, dr Sutherland?
Speaker 3 (42:36):
Well, I am so grateful for all that you do in
your facility and in this groupto really activate women.
I think sometimes you know wehave so many priorities and it's
so easy for women to put theirhealth, you know, at the end of
the list.
I'll do it someday.
And that's where we have torealize that we don't want
(42:57):
anybody taking care of us.
So if we're going to take careof everybody else, just like the
oxygen mask in the plane, yougot to put yours on first.
So women have to be able tostart putting themselves first
and say you know what?
I have to make time for this.
So I appreciate what you'redoing to encourage people to do
that.
Speaker 2 (43:13):
Oh, and there was one other point that I wanted to
make that I learned in yourlecture the lecture that I was
so embarrassed by, andthankfully the audio recording,
but not the visual recording ofme zooming in wasn't there that
you talked about that if you'renot pregnant and you have an
abnormal pap and you're goingfor colposcopy, that the
ordering physician should orderan ECC.
(43:36):
And why is that important?
Because I thought that was avery important pearl that I was
not aware of.
And we have a lot of physicianswho listen to this podcast as
well.
Speaker 3 (43:45):
Yeah, so when we think about the cervix, there's
the ectocervix.
In other words, when we look atthe cervix with a speculum, we
can look directly at it.
However, it's the liningbetween the opening of the
cervix and the lining of theuterus, what we call the
endocervical canal.
10% of the high-gradeprecancers are exclusively found
(44:05):
in that area.
Those are more difficult todiagnose and they're also more
difficult to treat because it'san ascending tumor.
So, in other words, sometimes,if you think of it like taking a
scoop for an ice cream scooper,you have to go deeper to be
able to get all of thosehigh-grade precancer cells to
prevent it from turning intocancer.
(44:26):
So yeah, the ECC is a veryimportant part of colposcopy.
Speaker 2 (44:30):
So women out there who've had abnormal PAPs and had
colposcopies, ask your women'shealth clinician did you get the
ECC and when should you getyour next pap and HPV?
So thank you so much for ourlisteners.
If you've enjoyed this episodeand you want to help support the
podcast, share it with others.
(44:51):
It's free.
You can give us a five-starrating.
If you don't get our regularall of our podcasts you can
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And thanks again and I lookforward to seeing you next time
(45:12):
in the Sunflower House.
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