October 31, 2024 • 24 mins
Moderated by Jennifer Garam, ovarian cancer survivor & advocate and health journalist, and featuring Dr. Melissa Frey, Gynecologic Oncologist at Weill Cornell Medicine
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Episode Transcript
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Speaker 1 (00:05):
Welcome to What To Know Down Below by Tina's Wish.
We're here to empower you withthe knowledge and tools you
need to advocate for your owngynecologic health. Knowledge
is power, and we encourageeveryone to join us in learning
more about what you need toknow down below.
Speaker 2 (00:28):
Hi everyone. I'm your host, Jennifer Garam , and
I am an ovarian cancer survivorand advocate and a health
journalist. I'm here with Dr.
Melissa Frey of Wild CornellMedicine for the next
installment of our three-partseries, A Guide to Gynecologic
Cancers. Today we will betalking about cervical cancer
and the importance of the HPVvaccine. You can find our other
(00:51):
episodes in this series focusedon uterine and vaginal and
vulva cancers, as well as ourprevious series on ovarian
cancer, wherever you get yourpodcasts. Hello, Dr. Frey .
Thank you for being here todayfor the second episode in our
series on gynecologic cancers.
As a refresher for ourlisteners, what is gynecologic
(01:13):
cancer in general and what iscervical cancer in particular?
Speaker 3 (01:18):
Gynecologic cancer refers to a cancer of one of
the organs in the femalereproductive system. The cervix
is the , um, sort of bottom ofthe uterus. Um, and cervical
cancer is very commonworldwide. Um, it is not as
common in the United States ,um, likely due to cervical
(01:42):
cancer screening, but we stillsee approximately 14,000 cases
a year in the United States.
Um, so it's something that westill see and I'm so glad we're
doing this , um, session on itbecause cervical cancer is
something that is highlypreventable, and that is with
both , um, vaccines and thenalso with cervical cancer
screening to catch somethingbefore it turns into cervical
(02:04):
cancer.
Speaker 2 (02:05):
Great . And then just to kind of talk about HPV,
because that has an associationwith cervical cancer, so can
you explain what HPV is, howcommon it is, and how that
relates to cervical cancer?
Speaker 3 (02:20):
HPV is a virus. It is extremely common. Um, it is
, um, usually transmitted , um,via sexual activity, but I, you
know, I often tell people that,you know, the majority of
people who are sexually activeare probably exposed to HPV at
some point in their lifetime,so the virus is quite common.
(02:42):
But if, if one becomes infectedwith the virus and one's own
immune system cannot clear HPV,then this can cause changes in
the cells of the cervix that ifleft untreated and undiagnosed
can eventually progress tocervical cancer. But this is a
very, very slow progression. Weoften say that it takes over a
decade from exposure to HPV todevelopment of cervical cancer,
(03:05):
so there's lots of time toidentify and prevent the
cancer.
Speaker 2 (03:09):
How would you know if you have HPV ?
Speaker 3 (03:12):
So, HPV is usually identified on cervical cancer
screening. So currently werecommend that women beginning
at age 21, get pap tests. Andusually this pap is repeated
every three years if it'snormal. And then beginning at
age 30, we often add HPV to thePAP test. And so HPV is
(03:34):
diagnosed on this type ofcervical cancer screening .
Speaker 2 (03:38):
Would a PAP test catch it too without that
additional screening?
Speaker 3 (03:44):
The, the PAP test is, is what most women think of
it is usually a combination ofwhat's , um, cytology or
looking at the cells of thecervix , um, and looking at
HPV. And so you could speakwith your doctor about which
tests they're doing, but ingeneral, for women age 21 to
29, we're doing pap alone andnot HPV, and then we're adding
(04:06):
HPV at age 30.
Speaker 2 (04:09):
Uh, I just wanna talk here for a second about
stigma and overcoming stigmabecause I feel like with any
sort of sexually transmitted ,um, uh, thing, like there's
gonna be a stigma, people mightfeel, take , feel responsible,
feel ashamed. Can you talkabout that? Because I feel like
we need to get rid of thestigma so that people will talk
more openly and they can raraise these concerns to their
(04:32):
doctor sooner and not feel likeit's something they did wrong.
I mean, it sounds like it's socommon to be exposed to it,
people shouldn't have any sortof stigma or shame around it.
Speaker 3 (04:41):
Absolutely. This is something that more people than
not are exposed to. If they'resexually active , um, we don't
routinely screen for it like wedo for other sexually
transmitted infections becauseit is so common and for the
majority of people , um, anexposure does not lead to an
infection because our ownimmune system is able to
eradicate it. And so I , thisis again, something that's
(05:03):
extremely common. We know thatnot only does HPV cause uh ,
cervical cancer, but it alsocauses , um, anal cancer. It
also can cause , um, oralpharyngeal or some of the head
and neck cancers. So this isextremely common. Um, and I
agree with you completely thatwe have to take away the stigma
,
Speaker 2 (05:20):
Um , because I feel like the stigma gets in the way
of people speaking up andsharing concerns. And so the
more that we talk about it, themore we can kind of diffuse
these, the stigma. Um, so thenmoving on to the HPV vaccine,
what is this? Is this a newerthing? Um, can can you explain
it? Can everyone get it? Why isit important?
Speaker 3 (05:41):
The HPV vaccine has been available for several
years. The vaccine that isavailable in the United States
is called Gardasil nine, andthis covers nine subtypes of
HPV . So it covers what'scalled HPV 16 and 18. So these
are the types of HPV that causeprobably about 70% of cervical
(06:03):
cancers across the world. Butthen it also covers several
other types of HPV that canalso cause , um, cervical and
some of the anal and othercancers that are HPV related .
And it also covers HPV six and11, which actually are the
cause of more than 90% of analgenital warts. And so this
vaccine actually kind ofprevents against likely several
(06:25):
cancers and against genitalwarts. And so this vaccine is,
is a tremendous tool in cancerprevention. So who can get the
HPV vaccine? Well, the answeris really everyone. So
currently the vaccine isapproved for men and women
between the ages of nine and45. It has been recommended for
(06:46):
all men and women between ages11 and 12 , um, catchup
vaccination. So if you miss theopportunity to get vaccinated
between 11 and 12 isrecommended up to age 26. And
then for people who are age 27to 45, this vaccine is
available, but it's usuallyrecommended this is a decision
with your physician. Insuranceoften does not cover the
(07:09):
vaccine for individuals who aregreater than 26, but this is
still an option.
Speaker 2 (07:14):
Okay. Are there any risk factors to receiving the
HPV vaccine?
Speaker 3 (07:20):
Um, for the most part, this is, is really a safe
vaccine. Um, this is not avaccine that we offer to people
who are pregnant, but apartfrom that , um, there are
really very, very fewcontraindications. And so I
think the majority of peopleshould discuss this and should
get HPE vaccination.
Speaker 2 (07:36):
Um, and can you just explain what contraindication
means?
Speaker 3 (07:38):
Oh, sorry.
Contraindication means a reasonthat you couldn't get it. Okay
. But this is a very safevaccine that, that most people
should be getting. I will saythat our vaccine rates are not
nearly as high as they , wewould like them to be. Um,
probably only about 60% ofwomen in this country are
actually getting their firstdose, and we know that number
is even less for men. And sowe're really hoping and trying
to do whatever we can toimprove vaccination rates. Um,
(08:01):
and so I would emphasize again,this is a very safe vaccine
that can prevent cancer.
Speaker 2 (08:05):
And you said first dose, is there more than one
dose for this vaccine?
Speaker 3 (08:09):
Yes. So the recommendation is for people
who get the vaccine betweenages nine and 14, you can have
just two doses, and that'susually given sort of today.
And then again in six to 12months, if someone is 15 or
older when they start thevaccine series, then we give
three doses and that , so thatwould be today and in one to
two months, and then si andthen six months. And then for
(08:31):
anyone who's immunocompromised,so anyone who has is on
long-term steroids or who hasHIV, then we recommend three
doses, even if they start thevaccine at the younger age.
Speaker 2 (08:43):
Uh , and then you said up until age 45
individuals can receive thisvaccine. Why is that the cutoff
in , why should people not, isthere any exception or really
people over 45 shouldn't getthis vaccine or are there
exceptions to that?
Speaker 3 (08:57):
So the vaccine is, is technically the approval
goes up to 45. Um, therecertainly are physicians who
offer this to patients , um, atolder ages. Um, and you know, I
think that's based on anindividual discussion between
patient and physician becausereally the, the approval is at
45. And so most of the data wehave on the effectiveness of VA
(09:18):
vaccine really is in that agegroup. And, and we also know
that this is a vaccine youwanna get before exposure to
HPV. And so that's why wereally are, are pushing for
vaccines at the 11 to 12 yearsof age range because we want to
get the vaccine prior toexposure because that's when it
has maximum effect.
Speaker 2 (09:38):
Um, and then you touched on this, the VA is the
vaccine covered by insurance?
You said it, it typically is upuntil a certain age and then
after that it might not be.
Speaker 3 (09:46):
In general, we see it's covered up until age 26.
Um, for many people it is fornot covered between age 26 and
45, although it is approved forthat age group.
Speaker 2 (09:57):
Okay. And would you say that's kind of, could be
subject to individual insuranceplans? Absolutely . Like people
should look into it if they'reinterested mm-hmm
. Um , so when you say thatindividuals should get their
first dose 11 to 12, and thereare a lot of ages that we just
spoke about from certain ageranges, so just if people want
clarity and they want to gothrough all these different age
(10:18):
ranges and all these differentthings that need to happen at
different ages at at the age of1112, are they talking to a
pediatrician or at what ageshould , uh, a young person
start to see a , a gynecologistor their gynecologists that are
specializing in younger, youknow, adolescents?
Speaker 3 (10:35):
So this is something that should be offered by
pediatricians. So it's often adiscussion between the
pediatrician, the parent , um,and the child. There are
pediatric gynecologists, butthis is really for sort of the
rare case where someone has agynecologic disorder in
childhood. I would say that forthe majority of of of things
that come up for a child, thisis really within the realm of
(10:57):
pediatrics. And so we are, youknow, really hopeful that
pediatricians are offering thisvaccine to their patients and
to the families that they see.
Speaker 2 (11:05):
Great. So it sounds like if you were a parent, you
have a child around approaching11 or 12 and the pediatrician
has not brought it up to you,you would would say to bring it
up to the pediatrician and andand ask about it and talk, have
that conversation?
Speaker 3 (11:18):
Absolutely. And this is , um, a male or a female
child. Um, and the decision to,you know, initiate the HPV
vaccine does not mean that aparent thinks their child is
about to become sexuallyactive. And I think that is
sort of part of the nuance ofthis and part of the stigma of
the vaccine. This just meansthat there's a vaccine that can
prevent cancer and it is mosteffective if given before onset
(11:40):
of sexual activity. And so todo it at 11 or 12 is a safe and
recommended time . And so thatwhenever , um, if ever someone
decides to be sexually active ,that vaccine has already been
given and someone already hasprotection .
Speaker 2 (11:53):
Great. And then you had mentioned this is for male
and female and also, so this isa vaccine that is for people
regardless of gender,regardless of sexual identity
across the board?
Speaker 3 (12:06):
Absolutely.
Speaker 2 (12:07):
Okay. Um, and then also just want to touch on the
fact that the HPV vaccine couldhelp prevent cervical cancer
and some of those otherconditions that you mentioned,
but is not going to be , um,prevent pregnancy. It's not
gonna prevent other sexuallytransmitted diseases. It's not
a replacement for any of that.
(12:28):
Um,
Speaker 3 (12:30):
Absolutely. The HPD vaccine should not take the
place of birth control. Um, itshould not take the place of
condom use , um, which we knowis, you know, one of the best
methods to prevent the , um,spread of sexually transmitted
diseases. So there are severalother sexually transmitted
diseases, chlamydia, gonorrhea,syphilis, HI, so those are,
those are not prevented withthe HP vaccine. Um, and so
(12:53):
someone should still thinkabout contraception and
prevention of STDs.
Speaker 2 (12:57):
Okay. And then is HPV also associated with
vaginal and vulgar cancers?
Speaker 3 (13:06):
Yes. So HPV can also cause vaginal and vulvar
cancers. The only difference is, is that there are other
causes of vaginal vulvar andvulvar cancer, and it's for
cervical cancer sort ofinterestingly, almost a hundred
percent of cases are caused byHPV. There are rare cases that
are not, but really the , themajority of cervical cancer is
(13:26):
driven by the HPV virus. Andthat really brings us back to
the importance of vaccinationand the importance of screening
with , um, PAP tests and HPVtests because this is a disease
that should be preventable orwe should be able to catch it
as a pre-cancer and prevent itfrom, from turning into a
cancer.
Speaker 2 (13:45):
Um, you said that most cervical cancer , um, is a
result of HPV, but in rarecases it could be something
else. What are some of thoseother risk factors , um, that
could, could , could put peopleat risk for developing cervical
cancer in addition to HPV ?
Speaker 3 (14:01):
So I would say there are other risk factors for ,
um, cervical cancer, but theyusually sort of are , um,
working with HPV. And so weknow that someone who has
multiple lifetime sexualpartners or an early age at
first intercourse , um, has anincreased risk for cervical
cancer. But this is reallylargely driven by exposure to
(14:23):
HPV through intercourse. Wealso know that tobacco use or
smoking is a very importantcontributor to cervical cancer,
but this is also related to HPV. We know that , um, people who
, um, use tobacco have a hardertime clearing the HPV virus and
so it actually prevents ourimmune system from clearing the
virus. So there are other riskfactors for cervical cancer,
(14:44):
but they're really aligned withHPV infection.
Speaker 2 (14:48):
And can someone still develop cervical cancer
even if they've had thevaccine, the HPV vaccine?
Speaker 3 (14:54):
Yes. Um, the HPV vaccine does not cover all HPV
subtypes, and so it ispossible, and also if someone
is exposed to HPV prior to thevaccine, then the vaccine will
not prevent them fromdeveloping cervical cancer.
Speaker 2 (15:11):
So it sounds like it could help mitigate that risk,
but just because you've had thevaccine, you shouldn't assume
you're in the clear and not payattention to your gynecologic
health anymore.
Speaker 3 (15:23):
Absolutely, and I I recently read a statistic that
if we could vaccinate all12-year-old girls in the United
States who would preventhundreds of thousands of HPV
infections annually , um, andthousands of cervical cancers
annually. And so this is reallysomething that I think we all
have to work together toimprove rates of HPV
vaccination.
Speaker 2 (15:45):
And what are some of the typical symptoms or warning
signs that someone might havecervical cancer? And are there
always symptoms or are therecases when it could be
asymptomatic?
Speaker 3 (15:56):
Cervical cancer can very often be asymptomatic. And
so , um, often we're findingthis on a PAP test or with an
HPV test. Um , and usually thatmeans this is at a very early
stage, which is, is what wehope from screening that if we
find something that's at anearly stage, sometimes people
can report irregular or heavyvaginal bleeding or bleeding
(16:18):
after intercourse. So ifsomeone is experiencing any of
these , uh, symptoms orcomplaints, that's something to
check in with your physicianabout. Um, some people note
abnormal vaginal discharge andthen if someone has advanced
disease, so disease that isspread outside the cervix,
that's when people can starthaving , um, back pain or
pelvic pain or changes in their, um, eating habits or changes
(16:40):
in their bowel habits or their, uh, urinary habits . So , um,
I would say that symptoms canreally , uh, there's a range of
symptoms that one canexperience from asymptomatic to
a lot of , uh, a lot ofsymptoms.
Speaker 2 (16:54):
Um, and then if you've received the HPV
vaccine, it sounds like youstill need a routine pap smear,
is that correct ?
Speaker 3 (17:02):
Absolutely. Um, the receipt of the vaccine does not
change recommendations forcervical cancer screening. And
so while I think we're talkinga lot about the vaccine here, I
would also stress theimportance of cervical cancer
screening because if we catchcervical cancer or pre-cancer
in early stage is verytreatable. Um, and so seeing a
gynecologist regularly for ,um, cervical cancer screening
(17:23):
is critical.
Speaker 2 (17:25):
Is there any , um, hereditary element like with
the other gynecologic cancerswith cervical or is does that
not apply in this instance?
Speaker 3 (17:34):
There are very rare hereditary syndromes that can
increase the risk for cervicalcancer. Um, but this is
exceedingly rare. So if someonehas a lot of cervical cancer in
their family, that's certainlysomething to uh , mention to a
physician. And if someone has,you know, know cervical cancer
combined with especially breastcancers and colon cancers, that
is something to mention to aphysician. But this is not ,
(17:56):
um, like a , an ovarian canceror a uterine cancer where we
can commonly see these cancersgroup in families due to a
shared genetic predisposition.
This is , uh, really would bequite rare to have a genetic
syndrome , um, lead to cervicalcancer.
Speaker 2 (18:11):
Okay. Uh, I wanna talk a little about pap smears
because this is another thing.
I feel like there's a lot ofdifferent information out there
of how often you should get it,when you should start, when you
should get them more often. SoI just wanna go through , um,
you know, the ages of the papsmear, I think you said 21 for
the first one. Um, and then howfrequently should someone have
(18:33):
a pap smear and what wouldchange that frequency age , um,
concerning findings, anythinglike that?
Speaker 3 (18:40):
So assuming that , um, all the paps are , uh,
normal and that a person isotherwise healthy, so does not
have HIV or other immunocompromising conditions, then
the standard recommendationwould be beginning at age 21
through age 29, getting a PAPtest every three years when
someone turns 30, there are acouple options. You could
(19:03):
continue doing the pap testevery three years. You could do
HPV testing alone every fiveyears, or you can do what we
call co testing . And this iswhen you do the PAP test with
the HPV test . And I would sayco testing is probably what's
done most commonly. We actually, um, the guidelines actually
say that after age 65, ifsomeone has had adequate and
(19:26):
normal prior screening, we canstop doing pap tests. So again,
that would be the kind ofgeneral guidelines for someone
who is otherwise healthy withno abnormal paps. If someone
has an abnormal PAP test or ifsomeone has HPV, then that
changes. And there are reallyindividualized algorithms based
on exactly what one has thatguide. How, how often and when
(19:48):
we repeat the PAP and the HPV ,
Speaker 2 (19:51):
Um, I'm just curious, why does it stop at 65
and are there any exceptions tothat?
Speaker 3 (19:56):
So this was , um, kind of work done looking at ,
um, the incidents of cervicalcancer and also looking at sort
of the , the positivepredictive value of having a
lifetime of normal PAP tests.
Um, and so, so the guidelinessay we can stop after age 65,
but that would only be forsomeone who, you know, doesn't
(20:17):
have a medical condition thatmakes us concerned they're at
increased risk for cervicalcancer and people who've had
prior normal screening. So forpeople who wears any concern,
they may continue screeningafter age 65 because it's,
it's, it is possible to get acervical cancer after age 65.
We know, we know that.
Speaker 2 (20:34):
I have a question too. If you have had your
reproductive tract removedbecause of cancer, so say you
don't have a cervix, but do youstill need to be looked at or
screened or , or examined orcan you not get, get cervical
cancer if you don't have acervix?
Speaker 3 (20:50):
So for, for someone who's had their uterus and
cervix removed, who's, who'snot had a history of abnormal
paps or high grade paps, thenthey actually don't need to
continue cervical cancerscreening. They don't need to
continue PAP tests. I stillwould recommend seeing a
gynecologist regularly because, um, there are still cancers
(21:11):
of the vulva, the vagina andother organs that are possible.
And so I wouldn't say to stophaving gynecologic visits, but
you don't have to do a PAP testif you've had a hysterectomy
and no history of abnormal paptests.
Speaker 2 (21:24):
Okay . Um , yeah, it sounds like with the paps, if
you have any sort of irregularfinding, you just really need
to talk to your doctor abouttheir specific recommendations
for you and make sure that youare getting the optimal
screening based on yourcircumstances. Absolutely. And
if someone's pap smear cameback normal, but they're
experiencing symptoms that arenot normal for them, should
(21:46):
they still bring this up withtheir doctor?
Speaker 3 (21:48):
Absolutely. Um, because, you know, there could
be something else that'scausing the symptoms and so
it's very important not to relyon a negative PAP test. Um, and
I think this is sort of a , amisconception that comes up a
lot is that , um, people thinkthat if their pap is negative,
they've sort of been screenedfor all the gynecologic
cancers. And so I would saythat the pap only screens for
(22:09):
cervical cancer and if someoneis having symptoms, that always
needs to be evaluated even ifthe pap was completely normal.
Speaker 2 (22:17):
That is such an excellent point to bring up.
Even though we're talking aboutcervical cancer in this
episode, I think people don'trealize that pap smear just
screens for cervical cancer andthey assume it kind of screens
for , um, reproductive canceracross the board. And people
are surprised to find thatovarian cancer, for instance,
does not have an earlydetection test and a pap smear
(22:39):
does not screen for that. So Ithink it's really important to
note any change from your norm.
I mean, there's othergynecologic cancers and you
should always be payingattention to your body and
bringing up any concerns withyour doctor as soon as possible
rather than, you know, monthsdown the road.
Speaker 3 (22:56):
Absolutely. And, and I would say that, you know ,
ovarian cancer and uterinecancer are much more common
than cervical cancer in theUnited States. And so the
absence of a cervical cancer oncervical cancer screening does
not rule out the presence of anovarian or uterine cancer. So
I'm glad you brought that up.
Okay .
Speaker 2 (23:13):
Do you have any final words of advice for our
listeners when it comes tocervical cancer or HPV?
Speaker 3 (23:21):
I think I would just emphasize again, the importance
of vaccination and theimportance of cervical cancer
screening because those are ,um, two tools that we could
really use to eradicatecervical cancer in this country
because we should, you know, weshould not be having 14,000
cases a year and 4,000 deaths ayear for a disease that is
preventable.
Speaker 2 (23:41):
Great . Thank you so much . And I also just wanna ,
um, add the importance of justadvocating for yourself and
asking questions. Like yousaid, we've gone through so
many different recommendationsfor the vaccine, for the pap
smear different ages, and toreally inform yourself and
know, and , and if you don'tknow, ask your doctor and talk
to 'em and get this informationfrom them because you might not
have it readily available. AndI think it's so important to
(24:03):
have these conversations andreally be informed about what's
going on in your own body andwhat you need to be doing to
take care of your health. Sothank you so much. Um, Dr. Frey
, thank you so much for sharingyour expertise and a huge thank
you to everyone listening. Wehope this information helps you
feel empowered and to takecontrol of your own health. Be
sure to tune in for the finalepisode of our three part
(24:24):
series as we discuss vaginaland vulva cancers.
Speaker 1 (24:34):
For more information about gynecologic health, visit
tina's wish.org/what to know .
That's tinas wish.org/wH-A-T-T-O-K-N-O-W . And like,
follow or subscribe whereveryou listen to your favorite
podcasts.
Welcome to What To Know Down Below by Tina's Wish.
We're here to empower you withthe knowledge and tools you
need to advocate for your owngynecologic health. Knowledge
is power, and we encourageeveryone to join us in learning
more about what you need toknow down below.
Speaker 2 (00:28):
Hi everyone. I'm your host, Jennifer Garam , and
I am an ovarian cancer survivorand advocate and a health
journalist. I'm here with Dr.
Melissa Frey of Wild CornellMedicine for the next
installment of our three-partseries, A Guide to Gynecologic
Cancers. Today we will betalking about cervical cancer
and the importance of the HPVvaccine. You can find our other
(00:51):
episodes in this series focusedon uterine and vaginal and
vulva cancers, as well as ourprevious series on ovarian
cancer, wherever you get yourpodcasts. Hello, Dr. Frey .
Thank you for being here todayfor the second episode in our
series on gynecologic cancers.
As a refresher for ourlisteners, what is gynecologic
(01:13):
cancer in general and what iscervical cancer in particular?
Speaker 3 (01:18):
Gynecologic cancer refers to a cancer of one of
the organs in the femalereproductive system. The cervix
is the , um, sort of bottom ofthe uterus. Um, and cervical
cancer is very commonworldwide. Um, it is not as
common in the United States ,um, likely due to cervical
(01:42):
cancer screening, but we stillsee approximately 14,000 cases
a year in the United States.
Um, so it's something that westill see and I'm so glad we're
doing this , um, session on itbecause cervical cancer is
something that is highlypreventable, and that is with
both , um, vaccines and thenalso with cervical cancer
screening to catch somethingbefore it turns into cervical
(02:04):
cancer.
Speaker 2 (02:05):
Great . And then just to kind of talk about HPV,
because that has an associationwith cervical cancer, so can
you explain what HPV is, howcommon it is, and how that
relates to cervical cancer?
Speaker 3 (02:20):
HPV is a virus. It is extremely common. Um, it is
, um, usually transmitted , um,via sexual activity, but I, you
know, I often tell people that,you know, the majority of
people who are sexually activeare probably exposed to HPV at
some point in their lifetime,so the virus is quite common.
(02:42):
But if, if one becomes infectedwith the virus and one's own
immune system cannot clear HPV,then this can cause changes in
the cells of the cervix that ifleft untreated and undiagnosed
can eventually progress tocervical cancer. But this is a
very, very slow progression. Weoften say that it takes over a
decade from exposure to HPV todevelopment of cervical cancer,
(03:05):
so there's lots of time toidentify and prevent the
cancer.
Speaker 2 (03:09):
How would you know if you have HPV ?
Speaker 3 (03:12):
So, HPV is usually identified on cervical cancer
screening. So currently werecommend that women beginning
at age 21, get pap tests. Andusually this pap is repeated
every three years if it'snormal. And then beginning at
age 30, we often add HPV to thePAP test. And so HPV is
(03:34):
diagnosed on this type ofcervical cancer screening .
Speaker 2 (03:38):
Would a PAP test catch it too without that
additional screening?
Speaker 3 (03:44):
The, the PAP test is, is what most women think of
it is usually a combination ofwhat's , um, cytology or
looking at the cells of thecervix , um, and looking at
HPV. And so you could speakwith your doctor about which
tests they're doing, but ingeneral, for women age 21 to
29, we're doing pap alone andnot HPV, and then we're adding
(04:06):
HPV at age 30.
Speaker 2 (04:09):
Uh, I just wanna talk here for a second about
stigma and overcoming stigmabecause I feel like with any
sort of sexually transmitted ,um, uh, thing, like there's
gonna be a stigma, people mightfeel, take , feel responsible,
feel ashamed. Can you talkabout that? Because I feel like
we need to get rid of thestigma so that people will talk
more openly and they can raraise these concerns to their
(04:32):
doctor sooner and not feel likeit's something they did wrong.
I mean, it sounds like it's socommon to be exposed to it,
people shouldn't have any sortof stigma or shame around it.
Speaker 3 (04:41):
Absolutely. This is something that more people than
not are exposed to. If they'resexually active , um, we don't
routinely screen for it like wedo for other sexually
transmitted infections becauseit is so common and for the
majority of people , um, anexposure does not lead to an
infection because our ownimmune system is able to
eradicate it. And so I , thisis again, something that's
(05:03):
extremely common. We know thatnot only does HPV cause uh ,
cervical cancer, but it alsocauses , um, anal cancer. It
also can cause , um, oralpharyngeal or some of the head
and neck cancers. So this isextremely common. Um, and I
agree with you completely thatwe have to take away the stigma
,
Speaker 2 (05:20):
Um , because I feel like the stigma gets in the way
of people speaking up andsharing concerns. And so the
more that we talk about it, themore we can kind of diffuse
these, the stigma. Um, so thenmoving on to the HPV vaccine,
what is this? Is this a newerthing? Um, can can you explain
it? Can everyone get it? Why isit important?
Speaker 3 (05:41):
The HPV vaccine has been available for several
years. The vaccine that isavailable in the United States
is called Gardasil nine, andthis covers nine subtypes of
HPV . So it covers what'scalled HPV 16 and 18. So these
are the types of HPV that causeprobably about 70% of cervical
(06:03):
cancers across the world. Butthen it also covers several
other types of HPV that canalso cause , um, cervical and
some of the anal and othercancers that are HPV related .
And it also covers HPV six and11, which actually are the
cause of more than 90% of analgenital warts. And so this
vaccine actually kind ofprevents against likely several
(06:25):
cancers and against genitalwarts. And so this vaccine is,
is a tremendous tool in cancerprevention. So who can get the
HPV vaccine? Well, the answeris really everyone. So
currently the vaccine isapproved for men and women
between the ages of nine and45. It has been recommended for
(06:46):
all men and women between ages11 and 12 , um, catchup
vaccination. So if you miss theopportunity to get vaccinated
between 11 and 12 isrecommended up to age 26. And
then for people who are age 27to 45, this vaccine is
available, but it's usuallyrecommended this is a decision
with your physician. Insuranceoften does not cover the
(07:09):
vaccine for individuals who aregreater than 26, but this is
still an option.
Speaker 2 (07:14):
Okay. Are there any risk factors to receiving the
HPV vaccine?
Speaker 3 (07:20):
Um, for the most part, this is, is really a safe
vaccine. Um, this is not avaccine that we offer to people
who are pregnant, but apartfrom that , um, there are
really very, very fewcontraindications. And so I
think the majority of peopleshould discuss this and should
get HPE vaccination.
Speaker 2 (07:36):
Um, and can you just explain what contraindication
means?
Speaker 3 (07:38):
Oh, sorry.
Contraindication means a reasonthat you couldn't get it. Okay
. But this is a very safevaccine that, that most people
should be getting. I will saythat our vaccine rates are not
nearly as high as they , wewould like them to be. Um,
probably only about 60% ofwomen in this country are
actually getting their firstdose, and we know that number
is even less for men. And sowe're really hoping and trying
to do whatever we can toimprove vaccination rates. Um,
(08:01):
and so I would emphasize again,this is a very safe vaccine
that can prevent cancer.
Speaker 2 (08:05):
And you said first dose, is there more than one
dose for this vaccine?
Speaker 3 (08:09):
Yes. So the recommendation is for people
who get the vaccine betweenages nine and 14, you can have
just two doses, and that'susually given sort of today.
And then again in six to 12months, if someone is 15 or
older when they start thevaccine series, then we give
three doses and that , so thatwould be today and in one to
two months, and then si andthen six months. And then for
(08:31):
anyone who's immunocompromised,so anyone who has is on
long-term steroids or who hasHIV, then we recommend three
doses, even if they start thevaccine at the younger age.
Speaker 2 (08:43):
Uh , and then you said up until age 45
individuals can receive thisvaccine. Why is that the cutoff
in , why should people not, isthere any exception or really
people over 45 shouldn't getthis vaccine or are there
exceptions to that?
Speaker 3 (08:57):
So the vaccine is, is technically the approval
goes up to 45. Um, therecertainly are physicians who
offer this to patients , um, atolder ages. Um, and you know, I
think that's based on anindividual discussion between
patient and physician becausereally the, the approval is at
45. And so most of the data wehave on the effectiveness of VA
(09:18):
vaccine really is in that agegroup. And, and we also know
that this is a vaccine youwanna get before exposure to
HPV. And so that's why wereally are, are pushing for
vaccines at the 11 to 12 yearsof age range because we want to
get the vaccine prior toexposure because that's when it
has maximum effect.
Speaker 2 (09:38):
Um, and then you touched on this, the VA is the
vaccine covered by insurance?
You said it, it typically is upuntil a certain age and then
after that it might not be.
Speaker 3 (09:46):
In general, we see it's covered up until age 26.
Um, for many people it is fornot covered between age 26 and
45, although it is approved forthat age group.
Speaker 2 (09:57):
Okay. And would you say that's kind of, could be
subject to individual insuranceplans? Absolutely . Like people
should look into it if they'reinterested mm-hmm
. Um , so when you say thatindividuals should get their
first dose 11 to 12, and thereare a lot of ages that we just
spoke about from certain ageranges, so just if people want
clarity and they want to gothrough all these different age
(10:18):
ranges and all these differentthings that need to happen at
different ages at at the age of1112, are they talking to a
pediatrician or at what ageshould , uh, a young person
start to see a , a gynecologistor their gynecologists that are
specializing in younger, youknow, adolescents?
Speaker 3 (10:35):
So this is something that should be offered by
pediatricians. So it's often adiscussion between the
pediatrician, the parent , um,and the child. There are
pediatric gynecologists, butthis is really for sort of the
rare case where someone has agynecologic disorder in
childhood. I would say that forthe majority of of of things
that come up for a child, thisis really within the realm of
(10:57):
pediatrics. And so we are, youknow, really hopeful that
pediatricians are offering thisvaccine to their patients and
to the families that they see.
Speaker 2 (11:05):
Great. So it sounds like if you were a parent, you
have a child around approaching11 or 12 and the pediatrician
has not brought it up to you,you would would say to bring it
up to the pediatrician and andand ask about it and talk, have
that conversation?
Speaker 3 (11:18):
Absolutely. And this is , um, a male or a female
child. Um, and the decision to,you know, initiate the HPV
vaccine does not mean that aparent thinks their child is
about to become sexuallyactive. And I think that is
sort of part of the nuance ofthis and part of the stigma of
the vaccine. This just meansthat there's a vaccine that can
prevent cancer and it is mosteffective if given before onset
(11:40):
of sexual activity. And so todo it at 11 or 12 is a safe and
recommended time . And so thatwhenever , um, if ever someone
decides to be sexually active ,that vaccine has already been
given and someone already hasprotection .
Speaker 2 (11:53):
Great. And then you had mentioned this is for male
and female and also, so this isa vaccine that is for people
regardless of gender,regardless of sexual identity
across the board?
Speaker 3 (12:06):
Absolutely.
Speaker 2 (12:07):
Okay. Um, and then also just want to touch on the
fact that the HPV vaccine couldhelp prevent cervical cancer
and some of those otherconditions that you mentioned,
but is not going to be , um,prevent pregnancy. It's not
gonna prevent other sexuallytransmitted diseases. It's not
a replacement for any of that.
(12:28):
Um,
Speaker 3 (12:30):
Absolutely. The HPD vaccine should not take the
place of birth control. Um, itshould not take the place of
condom use , um, which we knowis, you know, one of the best
methods to prevent the , um,spread of sexually transmitted
diseases. So there are severalother sexually transmitted
diseases, chlamydia, gonorrhea,syphilis, HI, so those are,
those are not prevented withthe HP vaccine. Um, and so
(12:53):
someone should still thinkabout contraception and
prevention of STDs.
Speaker 2 (12:57):
Okay. And then is HPV also associated with
vaginal and vulgar cancers?
Speaker 3 (13:06):
Yes. So HPV can also cause vaginal and vulvar
cancers. The only difference is, is that there are other
causes of vaginal vulvar andvulvar cancer, and it's for
cervical cancer sort ofinterestingly, almost a hundred
percent of cases are caused byHPV. There are rare cases that
are not, but really the , themajority of cervical cancer is
(13:26):
driven by the HPV virus. Andthat really brings us back to
the importance of vaccinationand the importance of screening
with , um, PAP tests and HPVtests because this is a disease
that should be preventable orwe should be able to catch it
as a pre-cancer and prevent itfrom, from turning into a
cancer.
Speaker 2 (13:45):
Um, you said that most cervical cancer , um, is a
result of HPV, but in rarecases it could be something
else. What are some of thoseother risk factors , um, that
could, could , could put peopleat risk for developing cervical
cancer in addition to HPV ?
Speaker 3 (14:01):
So I would say there are other risk factors for ,
um, cervical cancer, but theyusually sort of are , um,
working with HPV. And so weknow that someone who has
multiple lifetime sexualpartners or an early age at
first intercourse , um, has anincreased risk for cervical
cancer. But this is reallylargely driven by exposure to
(14:23):
HPV through intercourse. Wealso know that tobacco use or
smoking is a very importantcontributor to cervical cancer,
but this is also related to HPV. We know that , um, people who
, um, use tobacco have a hardertime clearing the HPV virus and
so it actually prevents ourimmune system from clearing the
virus. So there are other riskfactors for cervical cancer,
(14:44):
but they're really aligned withHPV infection.
Speaker 2 (14:48):
And can someone still develop cervical cancer
even if they've had thevaccine, the HPV vaccine?
Speaker 3 (14:54):
Yes. Um, the HPV vaccine does not cover all HPV
subtypes, and so it ispossible, and also if someone
is exposed to HPV prior to thevaccine, then the vaccine will
not prevent them fromdeveloping cervical cancer.
Speaker 2 (15:11):
So it sounds like it could help mitigate that risk,
but just because you've had thevaccine, you shouldn't assume
you're in the clear and not payattention to your gynecologic
health anymore.
Speaker 3 (15:23):
Absolutely, and I I recently read a statistic that
if we could vaccinate all12-year-old girls in the United
States who would preventhundreds of thousands of HPV
infections annually , um, andthousands of cervical cancers
annually. And so this is reallysomething that I think we all
have to work together toimprove rates of HPV
vaccination.
Speaker 2 (15:45):
And what are some of the typical symptoms or warning
signs that someone might havecervical cancer? And are there
always symptoms or are therecases when it could be
asymptomatic?
Speaker 3 (15:56):
Cervical cancer can very often be asymptomatic. And
so , um, often we're findingthis on a PAP test or with an
HPV test. Um , and usually thatmeans this is at a very early
stage, which is, is what wehope from screening that if we
find something that's at anearly stage, sometimes people
can report irregular or heavyvaginal bleeding or bleeding
(16:18):
after intercourse. So ifsomeone is experiencing any of
these , uh, symptoms orcomplaints, that's something to
check in with your physicianabout. Um, some people note
abnormal vaginal discharge andthen if someone has advanced
disease, so disease that isspread outside the cervix,
that's when people can starthaving , um, back pain or
pelvic pain or changes in their, um, eating habits or changes
(16:40):
in their bowel habits or their, uh, urinary habits . So , um,
I would say that symptoms canreally , uh, there's a range of
symptoms that one canexperience from asymptomatic to
a lot of , uh, a lot ofsymptoms.
Speaker 2 (16:54):
Um, and then if you've received the HPV
vaccine, it sounds like youstill need a routine pap smear,
is that correct ?
Speaker 3 (17:02):
Absolutely. Um, the receipt of the vaccine does not
change recommendations forcervical cancer screening. And
so while I think we're talkinga lot about the vaccine here, I
would also stress theimportance of cervical cancer
screening because if we catchcervical cancer or pre-cancer
in early stage is verytreatable. Um, and so seeing a
gynecologist regularly for ,um, cervical cancer screening
(17:23):
is critical.
Speaker 2 (17:25):
Is there any , um, hereditary element like with
the other gynecologic cancerswith cervical or is does that
not apply in this instance?
Speaker 3 (17:34):
There are very rare hereditary syndromes that can
increase the risk for cervicalcancer. Um, but this is
exceedingly rare. So if someonehas a lot of cervical cancer in
their family, that's certainlysomething to uh , mention to a
physician. And if someone has,you know, know cervical cancer
combined with especially breastcancers and colon cancers, that
is something to mention to aphysician. But this is not ,
(17:56):
um, like a , an ovarian canceror a uterine cancer where we
can commonly see these cancersgroup in families due to a
shared genetic predisposition.
This is , uh, really would bequite rare to have a genetic
syndrome , um, lead to cervicalcancer.
Speaker 2 (18:11):
Okay. Uh, I wanna talk a little about pap smears
because this is another thing.
I feel like there's a lot ofdifferent information out there
of how often you should get it,when you should start, when you
should get them more often. SoI just wanna go through , um,
you know, the ages of the papsmear, I think you said 21 for
the first one. Um, and then howfrequently should someone have
(18:33):
a pap smear and what wouldchange that frequency age , um,
concerning findings, anythinglike that?
Speaker 3 (18:40):
So assuming that , um, all the paps are , uh,
normal and that a person isotherwise healthy, so does not
have HIV or other immunocompromising conditions, then
the standard recommendationwould be beginning at age 21
through age 29, getting a PAPtest every three years when
someone turns 30, there are acouple options. You could
(19:03):
continue doing the pap testevery three years. You could do
HPV testing alone every fiveyears, or you can do what we
call co testing . And this iswhen you do the PAP test with
the HPV test . And I would sayco testing is probably what's
done most commonly. We actually, um, the guidelines actually
say that after age 65, ifsomeone has had adequate and
(19:26):
normal prior screening, we canstop doing pap tests. So again,
that would be the kind ofgeneral guidelines for someone
who is otherwise healthy withno abnormal paps. If someone
has an abnormal PAP test or ifsomeone has HPV, then that
changes. And there are reallyindividualized algorithms based
on exactly what one has thatguide. How, how often and when
(19:48):
we repeat the PAP and the HPV ,
Speaker 2 (19:51):
Um, I'm just curious, why does it stop at 65
and are there any exceptions tothat?
Speaker 3 (19:56):
So this was , um, kind of work done looking at ,
um, the incidents of cervicalcancer and also looking at sort
of the , the positivepredictive value of having a
lifetime of normal PAP tests.
Um, and so, so the guidelinessay we can stop after age 65,
but that would only be forsomeone who, you know, doesn't
(20:17):
have a medical condition thatmakes us concerned they're at
increased risk for cervicalcancer and people who've had
prior normal screening. So forpeople who wears any concern,
they may continue screeningafter age 65 because it's,
it's, it is possible to get acervical cancer after age 65.
We know, we know that.
Speaker 2 (20:34):
I have a question too. If you have had your
reproductive tract removedbecause of cancer, so say you
don't have a cervix, but do youstill need to be looked at or
screened or , or examined orcan you not get, get cervical
cancer if you don't have acervix?
Speaker 3 (20:50):
So for, for someone who's had their uterus and
cervix removed, who's, who'snot had a history of abnormal
paps or high grade paps, thenthey actually don't need to
continue cervical cancerscreening. They don't need to
continue PAP tests. I stillwould recommend seeing a
gynecologist regularly because, um, there are still cancers
(21:11):
of the vulva, the vagina andother organs that are possible.
And so I wouldn't say to stophaving gynecologic visits, but
you don't have to do a PAP testif you've had a hysterectomy
and no history of abnormal paptests.
Speaker 2 (21:24):
Okay . Um , yeah, it sounds like with the paps, if
you have any sort of irregularfinding, you just really need
to talk to your doctor abouttheir specific recommendations
for you and make sure that youare getting the optimal
screening based on yourcircumstances. Absolutely. And
if someone's pap smear cameback normal, but they're
experiencing symptoms that arenot normal for them, should
(21:46):
they still bring this up withtheir doctor?
Speaker 3 (21:48):
Absolutely. Um, because, you know, there could
be something else that'scausing the symptoms and so
it's very important not to relyon a negative PAP test. Um, and
I think this is sort of a , amisconception that comes up a
lot is that , um, people thinkthat if their pap is negative,
they've sort of been screenedfor all the gynecologic
cancers. And so I would saythat the pap only screens for
(22:09):
cervical cancer and if someoneis having symptoms, that always
needs to be evaluated even ifthe pap was completely normal.
Speaker 2 (22:17):
That is such an excellent point to bring up.
Even though we're talking aboutcervical cancer in this
episode, I think people don'trealize that pap smear just
screens for cervical cancer andthey assume it kind of screens
for , um, reproductive canceracross the board. And people
are surprised to find thatovarian cancer, for instance,
does not have an earlydetection test and a pap smear
(22:39):
does not screen for that. So Ithink it's really important to
note any change from your norm.
I mean, there's othergynecologic cancers and you
should always be payingattention to your body and
bringing up any concerns withyour doctor as soon as possible
rather than, you know, monthsdown the road.
Speaker 3 (22:56):
Absolutely. And, and I would say that, you know ,
ovarian cancer and uterinecancer are much more common
than cervical cancer in theUnited States. And so the
absence of a cervical cancer oncervical cancer screening does
not rule out the presence of anovarian or uterine cancer. So
I'm glad you brought that up.
Okay .
Speaker 2 (23:13):
Do you have any final words of advice for our
listeners when it comes tocervical cancer or HPV?
Speaker 3 (23:21):
I think I would just emphasize again, the importance
of vaccination and theimportance of cervical cancer
screening because those are ,um, two tools that we could
really use to eradicatecervical cancer in this country
because we should, you know, weshould not be having 14,000
cases a year and 4,000 deaths ayear for a disease that is
preventable.
Speaker 2 (23:41):
Great . Thank you so much . And I also just wanna ,
um, add the importance of justadvocating for yourself and
asking questions. Like yousaid, we've gone through so
many different recommendationsfor the vaccine, for the pap
smear different ages, and toreally inform yourself and
know, and , and if you don'tknow, ask your doctor and talk
to 'em and get this informationfrom them because you might not
have it readily available. AndI think it's so important to
(24:03):
have these conversations andreally be informed about what's
going on in your own body andwhat you need to be doing to
take care of your health. Sothank you so much. Um, Dr. Frey
, thank you so much for sharingyour expertise and a huge thank
you to everyone listening. Wehope this information helps you
feel empowered and to takecontrol of your own health. Be
sure to tune in for the finalepisode of our three part
(24:24):
series as we discuss vaginaland vulva cancers.
Speaker 1 (24:34):
For more information about gynecologic health, visit
tina's wish.org/what to know .
That's tinas wish.org/wH-A-T-T-O-K-N-O-W . And like,
follow or subscribe whereveryou listen to your favorite
podcasts.
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