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Cervical cancer: most threatening, most preventable by Cindy Abole Public Relations Of the many types of cancers that affect women, cervical cancer can be the most threatening, but also the most preventable. About 50 years ago, cervical cancer killed more women in the United States than any other form of cancer including breast and lung. In some areas across the country, cervical cancer deaths have progressively declined, thanks to the effectiveness of screening programs and key diagnostic tools like the Pap smear. But in South Carolina, the message isn’t quite hitting home. Today, the Palmetto State is ranked sixth nationally in cervical cancer deaths. The real tragedy is that more than 100 South Carolina women, almost twice the national average, will die this year unless more efforts can be done to promote the effectiveness of continual screenings and improve educational outreach for women of all ages.  Dr. William T. Creasman “We don’t know the cause of its high incidence or prevalence,” said William T. Creasman, M.D., professor and chairman of the Department of Obstetrics and Gynecology. “But communication and patient education seem to be the biggest factors. There are misconceptions and misinformation out there as to the benefits of early detection through Pap tests.” Cervical cancer is a slow-growing cancer that affects the lining of the cervix or lower part of a woman’s womb. It is the result of cellular changes in the cervix that can turn normal cells to precancerous cells over time. But not all precancerous conditions will progress into cancer. Why one woman develops cancer and another doesn’t is unknown. Its cause may depend upon her genetical makeup and exposure to risk factors which include smoking, early sexual activity, abnormal Paps and long-term contraceptive use. HPV and cervical cancer According to the American Medical Women’s Association, about 76 percent of women have never heard about Human Papillomavirus (HPV). Yet this virus has been associated with the at least 95 percent of cervical cancers. Behind chlamydia, HPV is the second most common sexually-transmitted disease affecting both men and women. Of the 100 strains of HPV that exist, most do not cause cervical cancer. About 30 types of HPV have the ability to infect the genital tract and can be passed from one person to another through skin-to-skin contact. HPV interacts with the body’s immune system. As a women ages, they may experience other concurrent illnesses, which may affect their immune systems and how they can fight off certain viruses and diseases. Many women with weakened immune systems may be unable to fight off certain HPVs, causing some virus strains to remain dormant and undetected for years. Later, as the virus is expressed, it may sometimes affect normal cells of the cervix to become pre-cancerous or cancerous cells. This year, the American Cancer Society estimates that 12,800 new cases of cervical cancer will be diagnosed across the country. Of that number, about 4,600 women will die from the disease. Cervical cancer in S.C.  In South Carolina, it has been estimated that about 90 percent of adult women have been screened at least once for cervical cancer, according to Creasman. The other 10 percent have never undergone a Pap test. Of the women who’ve undergone testing, few continue to receive Pap smears on an annual basis.    “The Pap smear is the only screening test that’s been clearly proven to save lives in the United States,” said Roger Young, associate professor, Department of Obstetrics and Gynecology. “Statistics are no more clear cut than with results from Pap smears.” Benefits of annual screenings But are the problems related to cervical cancer deaths in South Carolina related to access of care?  Creasman doesn’t think so. Although there may be access problems in some rural areas, Creasman believes that ignorance and poor patient education, especially to the lack of early detection through continual screening, is the underlying problem. South Carolina cancer statistics show that cervical cancer is even deadlier for African American women than white women. The South Carolina Cancer Registry, a program funded by DHEC and the Centers for Disease Control and Prevention, reports that black women are about twice as likely to be diagnosed with late-stage cervical cancer, lessening their chances for effective treatments and survival. Creasman also believes that patients, especially women in their late 30s to 50s, aren’t asking for Pap tests during their yearly exams. For example, patients may tell their primary care physician they’ve received their Pap or plan to be tested but may not follow through when it comes to screening. “In reality, it is these women who haven’t had a Pap test in the past five years, that we need to worry about it,” he said.  According to Creasman, physicians deal with three types of patient groups: Those who’ve had continual yearly Pap testing, patients who’ve been tested, but do not receive Pap smears on an annual basis and those individuals who have never been tested before.  Dr. David Soper “Women who have regular Pap tests don’t get cervical cancer,” said David E. Soper, M.D., director of gynecology, Department of Obstetrics and Gynecology. “They can be diagnosed with premalignant lesions long before cervical cancer develops. Annual Pap smears offer about 95 percent detection.”  According to the National Cancer Institute (NCI) guidelines, women are advised to begin testing for cervical cancer by the age of 18 or whenever they become sexually active. The NCI also recommends that women continue with annual screenings throughout their lifetime. In addition, women who’ve had three normal consecutive Pap smears can be tested less frequently.  Studies indicate that women undergo interval testing every 21 months. So if they are scheduled by their physician for screening after two to three years, they are more likely to return between five to 10 years. That’s why Creasman advocates annual testing. The South Carolina Cancer Registry reports that about 40 percent of all newly diagnosed cervical cancer cases affect more women between the ages of 45 - 49. Other findings show that screening success is higher among women ages 18 - 44. This may be attributed to a woman’s perceptions for less gynecological care once they have passed their child-bearing years. Creasman agrees that most patients will schedule their annual Pap tests and pelvic exams at 15/18/24-month intervals.  “That’s the surprise for women who’ve not come in for a Pap smear within the past five years and have never previously had a bad test,” said Roger Young, M.D., Ph.D., associate professor of obstetrics and gynecology. “Then, all of a sudden, they’re diagnosed with bad cervical dysplasia or early cervical cancer.” Besides patient education and costs, the prevalence of false-positive results from Pap tests  particularly with atypical cells, can be a key factor that can hurt cervical screening programs. Its results can produce adverse affects that may affect the cost of additional testing and other invasive procedures. This is especially true in rural areas where its harder for women to afford and receive long-term medical care. “False-positives can cause a lot of anxiety, heartache and misery, not only for the patients but for friends and relatives,” Young said. “That’s perhaps the number one reason why women don’t go through with it. They know someone else’s story and think if they get a bad Pap result they would be evaluated and nothing more would come of it.” Today, more medical pathology labs are looking at newer testing methodologies to improve screening detection of cellular abnormalities. Of the 50 million Pap smears conducted in the United States, only 8 percent will be classified as abnormal. It takes an annual screening of about 75,000 women to detect one single case of cervical cancer. Use of newer methods like the thin-layer Pap, a newer test that produces a well-preserved sample of cervical cells, can help improve screenings and allow time for follow-up care and treatment. Along with the importance of continual screenings is interpreting its results. MUSC's Department of Pathology and Laboratory Services supports more than 100 MUSC related gynecologists and physicians in the tri-county area. The cytopathologists and lab technicians evaluates an estimated 26,000 Pap slides per year. The labs must meet stringent guidelines and enforces a number of quality assurance mechanisms as specified by the FDA. MUSC's labs are certified buy the College of American Pathologists and the American Society of Cytopathology. In an effort to improve cost-effective Pap smear surveillance, MUSC's Department of Pathology and the Department of Obstetrics and Gynecology has initiated a split-sample study to monitor the diagnostic sensitivity and cost effectiveness of both the conventional and thin-layer Pap techniques, a subject that has been long-debated among physicians and pathologists. “Our labs are considered above standard,” Rana S. Hoda, M.D., associate professor director of cytopathology section, Department of Pathology and Laboratory Medicine. Most academic institutions are required to meet higher accreditation standards than other private labs.  Following the results of an abnormal Pap, the physician examines the results and may  evaluate the patient with a colposcopy, a magnified inspection of the cervix and perform a biopsy.  Promoting health education Like many public health programs, there are limited funds spent on cervical cancer education and screening. In contrast, educating the public about other public health challenges like the Human Immunodeficiency Virus (HIV) has had more success because of federal and state funding. The need to promote safe sex practices and education regarding the virus that produces the Acquired Immunodeficiency Syndrome (AIDS) is considered more of a public health need because of its effects upon a broader population base versus women and cervical cancer. “Anytime you see a patient is an opportunity to educate,” Creasman said. “How well it’s done or whether it’s done at all is a different matter. A lot of it can be dictated by time constraints because of managed care or other reasons.” MUSC-related research and outreach  At MUSC, physicians and researchers with the Department of Obstetrics and Gynecology are working to reduce cervical cancer deaths in South Carolina. A team of specialists and clinicians focus on developing translational  research for cervical dysplasia. Other studies involve pharmaceutical research, while other specialists focus on refining more pre-invasive therapies showing the positive effects of combined radiation and chemotherapy treatments for advanced staged cancer and other gynecological breakthroughs. The College of Nursing is actively working with the South Carolina Department of Health and Environmental Control to provide cervical screenings through Lowcountry family planning clinics. Its focus is to provide and establish cost effective follow-up care and services to urban and low-income women with abnormal Pap tests and initiate women’s health education.  “Patients clearly need to understand the importance of the annual Pap smear in preventing cervical cancer,” Soper said. “What they also need to understand is that it is related to a sexually-transmitted infection, HPV. The best way to prevent STDs and HPV-associated cervical cancer is to practice ‘safe sex,’ in addition to obtaining an annual Pap smear.” Cervical Cancer Facts: South Carolina has the 6th highest cervical cancer mortality rate of any state in the nation. Age: A woman’s risk increases with age. Race: African-American women are slightly more likely to develop and die from cervical cancer than Caucasian women. Lifestyle:  Women who have had first sexual intercourse at a young age, multiple sexual partners, or partners who have had multiple sexual partners. Women who smoke. Infection:  Human Papillomavirus (HPV) infection  has been associated with both preinvasive and invasive cervical cancer. HPV is passed from men to women during sexual intercourse. Prevention/Detection:  The Pap smear is the most effective way to prevent and detect cervical cancer. Women who are sexually active or who have reached age 18 should have a Pap test and pelvic exam annually. Cervical Cancer Symptoms Usually, there are no signs to detect a cervical precancer. But women can be aware of symptoms and cut down their risk factors that may cause cancer: Observe any unusual discharge (separate from monthly menstrual period) Observe any unusual bleeding or pain during intercourse To reduce your chance for HPV, practice safe sex Conduct yearly Pap tests, once a woman becomes sexually active Source: SC Central Cancer Registry/SCDHEC   Patient education key to preventing cancer by Cindy Abole Public Relations  Family nurse practitioner Susan Sims Barger isn't shy when she talks to female patients at the Department of Family Medicine about the “two minute-save-your-life” part of a women's exam. What most women don't realize is that the Pap test is one of few diagnostic medical tests available that have been proven to save lives. “As a woman, I can understand how difficult it can be for patients—the awkward position, uncomfortable feelings, even the personal fear of past experiences,” Barger said. “It's important to make the patient feel comfortable by explaining what goes on during a procedure and the usefulness of the test.”  During a Pap test, a clinician collects a small sample of cells from the cervix using a swab. The sample is then transferred onto a slide and read by lab technicians to detect cancerous or precancerous cell changes.  Within the past decade, medical experts have linked the Human Papillomavirus (HPV), a common virus that is sexually-transmitted, to nearly every case of cervical cancer.  Today, physicians are using the Pap smear and thin-layer Pap test, a newer version of the Pap smear that is now FDA-approved, to help detect more precise cellular changes in women who have had previous abnormal tests. The thin-layer test is now offered through MUSC's Division of Laboratory Services and several Medical University clinics.  “With thin-layer test, physicians have the ability to detect one more abnormal Pap smear for every 200 women screened,” said Rana S. Hoda, M.D., associate professor and director of cytopathology section, Department of Pathology and Laboratory Medicine. “It has the potential for improved quality of care and overall health care cost reduction for patients.” Within the Department of Family Medicine, physicians are trained to provide obstetrical care from conception, delivery and thereafter. Several staff physicians are able to handle women's conditions including mild dysplasia and more common sexually-transmitted diseases, according to Barry Hainer, M.D., director of clinical services, Department of Family Medicine.  “We're very keen to educating our patients,” Hainer said. “We discuss things and provide other preventive care services like Pap tests, mammograms and other tests. We also rely on our patients to tell us about their care. We make sure to ask patients questions so we don't duplicate services.” Medical residents, interns and clinical staffers are constantly trained in patient education to assure continual preventive care. Much of the continuing medical education (CME) training for residents focuses on patient education and effective communications.