In the past an abnormal Pap smear was a frightening diagnosis that often led to treatments in cases where the abnormalities might have cleared up naturally. Now that doctors have more tools at their disposal such as testing for high-risk Human Papillomavirus (HPV), women are often advised to take a “wait and see” approach by having repeat testing to see if dysplasia has resolved.
While it is positive that women aren’t risking scarring, infertility, stress, the expense, and the need to take time off work for a medical procedure that isn’t necessary, the flip side is that some women are so unconcerned that they fail to make follow-up Pap smear appointments.
The problem is also visibility. While most women know multiple other women with breast cancer, it is rare to know a woman with cervical cancer – particularly someone who has died from it.
“In the early 1900s, cervical cancer was the number one cause of cancer deaths of women,” said Kristin Zorn, MD, director of the Division of Gynecologic Oncology at the University of Arkansas for Medical Sciences (UAMS). “Because of advancements in treatment, it is much less common to have a woman die of cervix cancer than in the past. The issue has fallen off the radar screen because people don’t know many women who have died of cervical cancer. It is not as visible to people. It is not hitting them where they live. That is why we need to raise awareness of the people who are still being affected by it.”
Doctors are less likely to issue stern warnings to a woman regarding the need for follow-up appointments.
“In a way, better knowledge of detection and treatment of cervical cancer has been a victim of its own success,” Zorn said. “I think there is confusion, and some of this is the fault of us in the medical community. A big part of the success with Pap smears was for them to be repeated over time so we could see if it was clearing up or getting worse. To encourage patients to keep follow-up appointments, doctors might put the fear of God in them. Now doctors are less likely to do that. And it can backfire.”
Doctors explain to patients that they have low grade dysplasia, and not cervical cancer and pre-cervical cancer. Women are told not to worry too much, that is might clear up on its own.
“We know a lot more about HPV now,” Zorn said. “We know many people infected with HPV will recover and they won’t have to be treated. The woman’s immune system will kick in, and get control. Before, we jumped in and treated a lot of women who, now in retrospect, could have waited and their body would have healed on its own. Now if we do a HPV test at the same time and find the worrisome types of HPV are not present, a patient can be followed rather than having biopsies or other treatment of the cervix. When there are abnormal cells and high risk HPV present, women are more at risk for severe dysplasia or true cervical cancer.”
At times procedures such as biopsies or cervix cryosurgery can lead to two issues: scarring that impairs fertility because sperm can’t travel up to the uterus, or the cervix is weakened so that it dilates too early in pregnancy, which can result in pre-term birth or even miscarriage.
“It is smart to prevent unnecessary treatments in terms of decreasing healthcare costs and sparing women time, expense, and possible side effects,” Zorn said. “But now we are seeing more women who fail to get follow-up appointments. The women who tend to get in trouble are those who haven’t seen a gynecologist in ten to 15 years. They had their children, and once that was done, they had their tubes tied. So they don’t go to the OB\GYN to get birth control pills. That is usually how we get women in for Pap smears.”
Zorn said even if you are a healthcare provider who doesn’t do Pap smears yourself, in addition to asking patients if they are current with mammograms and colonoscopy, ask her about the last time she has had a Pap smear.
“Remind them of this importance even if you are not going to be the one to do the test,” Zorn said. “Sometimes women are going to their primary care doctor, but they don’t get back to a gynecologist until they already have a cancer.”
Doctors can also provide advice about how to enhance the immune system to help clear up mild dysplasia.
“The number one risk factor impacting the immune system in cervical disease is smoking,” Zorn said. “It is hard to clear up dysplasia when you are smoking or even exposed to secondhand smoke. That is the number one piece of advice I give. That is getting easier with so many places not allowing smoking, but Arkansas still has higher rates of smoking than the national average.”
Second is good nutrition: lots of fruits, vegetables and whole grains. Limit fatty foods, and limit alcohol consumption.
“That is the same diet recommended by diabetes and heart doctors,” Zorn said. “But that is hard for Americans to hear, because it is not the lifestyle we want to lead.”
Providers may get a lot of questions about vitamin supplements, but said there is no clear evidence that makes much difference in this arena.
“We as human beings are designed to get nutrition from the foods we eat, digesting foods and gradually absorbing the contents,” she said. “Supplements as pills and powders are probably never going to be the same as eating a healthy diet. I can’t recommend any particular supplement as being proven to improve overall health or cancer risk. Avoiding cigarettes and focusing on a generally healthy lifestyle is the best advice I can give.”
Zorn is known for her research in ovarian cancer with numerous publications on ovarian cancer on topics ranging from prevention strategies to patients’ responses to chemotherapy. She is a recipient of the National Institutes of Health Women’s Reproductive Health Research Award. She is also a member of a Centers for Disease Control program that is working to improve HPV vaccination rates in adolescents and young adults.
For more go online to: www.cancer.gov/cancertopics/types/cervical/pap-hpv-testing-fact-sheet
www.sgo.org/hpv/