The cancer that screening and vaccine can prevent

February 2016 Vol 16 (1)

The number of women who die from cervical cancer in New Zealand has dropped dramatically by 60 per cent since 1990. The human papillomavirus (HPV) vaccine, available free to all young women under 20, may in the future see even fewer women lost to this most preventable and most high profile of the gynaecological cancers.

 

Jill Lamb Colposcopy

The high profile in New Zealand grew out the 1987 Metro article ‘An unfortunate experiment at National Women’s Hospital’ by Sandra Coney and Phillida Bunkle, involving under-treatment of women with severe pre-cancerous (CIN3) changes of the cervix. The article prompted the 1987–88 Cartwright Inquiry, named after the presiding judge, Judge Dame Silvia Cartwright, and in turn the setting up in 1990 of the National Cervical Screening Programme, in which more than 95 per cent of eligible women are now enrolled. It is now well known that having a regular smear test reduces a woman’s risk of developing cervical cancer by 90 per cent.

Jill Lamb has worked in women’s health for more than three decades and in colposcopy for two,  so has seen the full impact of the Cartwright Inquiry. In 2009 she became New Zealand’s first registered nurse colposcopist, joining already authorised women’s health nurse practitioner Georgina McPherson in being the first non-doctors to use colposcopy to diagnose whether women with moderate to high-grade abnormal cervical smears have pre-cancers, cancers or non-cancers.

Changes over the decades in which Lamb has worked in the field have meant a refining of the screening programme as more research evidence becomes available about HPV infections, abnormal smear tests and cervical cancer.

“We used to do a lot more treatments for low-grade abnormalities but we now realise that they usually clear by themselves and the women are monitored instead.” With thousands of women each year getting low-grade abnormal smears (CIN1), this has prevented many going through the anxiety of unnecessary colposcopies.

HPV awareness and vaccine

Lamb thinks some generational differences have also emerged since New Zealand introduced a national, free, HPV immunisation programme in 2008 for young women under 20, aimed at reducing HPV infection and cervical cancer. The Gardasil vaccine targets four high-risk HPV types that are responsible for 70 per cent of cervical cancer and 90 per cent of genital warts.

“Young woman are very comfortable – if they’ve had the vaccine – with realising that HPV can cause cervical cancer and they are trying to prevent it by being vaccinated against the most common virus types causing the cancer,” says Lamb,  “while many women now in their 40s, 50s and 60s didn’t even realise that an abnormal smear test was caused by a virus.”

An important part of her job is raising awareness of the HPV vaccine in every patient she meets, telling them that a free vaccine is available for their daughters, sisters, nieces and grand-daughters and that across the Tasman it is also now offered free to boys. “A lot of people who have had colposcopy are very keen to get their children vaccinated… a lot of them don’t want their daughters going through unnecessary vaginal examinations and treatments if they can avoid it.”

Lamb also spends much of her time putting people’s fears to rest by telling them that testing positive for a high-grade HPV virus is more normal than not; and in most cases it clears naturally.

She says many women who present for colposcopy with medium to high-grade abnormal smears are already very anxious. “They arrive thinking they have cervical cancer because of the word ‘abnormal’ and then you mention they have a virus…

“So I try and normalise them and tell them that having HPV is a very normal part of being a human being. We share the planet with viruses, parasites and bacteria and it’s what we do. What we don’t want people to get is cervical cancer.”

While most people with high-grade HPV will clear the virus naturally within 6–24 months, around 11 per cent of people will have high-risk virus throughout their lives – this doesn’t mean they will get cancer but they will need to be carefully monitored and referred to colposcopy.

Of those women who do go on to develop high-grade (CIN3) pre-cancerous abnormal cells, about a third (33 per cent) would also go on to develop cervical cancer if the abnormalities were not removed.

“We can remove the abnormality but we cannot remove the virus,” says Lamb. This is one of the reasons why Lamb is also a strong smokefree advocate, as smokers, and the immuno-compromised, can struggle to clear the HPV virus from their systems.

New HPV screening on horizon

HPV awareness is growing with the advent of the vaccine and will need to grow even more, as the National Cervical Screening Programme has been consulting on moving from the current cytology screening for abnormal cells to HPV screening for high-risk HPV types, which is thought to be a more reliable screening tool. Women would notice little change to the actual cervical screening, with the major difference being at the laboratory end and the likelihood of screening dropping from three-yearly to five-yearly for those with normal test results.

The hope is that immunisation, combined with regular screening, will see cervical cancer numbers continuing to fall. At present Lamb says she sees between 40–50 women a week in her colposcopy clinics and probably only sees, on average, one woman every two months with actual cervical cancer. May that number keep on falling.

See also related gynaecological cancer articles: Gynaecological cancers: silent no longer and  We need to talk more about vulvas

HPV and cervical cancer

  • It is estimated that at some point in their lives about 80 per cent of sexually active women will become infected by one of the about 40 types of human papillomavirus (HPV) that affect the genital area.
  • Most HPV infections have no symptoms and clear on their own, but if infection by one of the 
  • 15–20 ‘high-risk’ HPV types is persistent, this can lead to abnormal pre-cancerous cells developing.
  • If the abnormal cells are not detected, via a regular smear test every three years, and treated, they may progress to invasive cervical cancer.
  • Having regular smear tests can reduce a woman’s risk of developing cervical cancer by 90 per cent.
  • An HPV vaccine that is now available for free for young women aged 12–20 targets several high-risk HPV types known to cause around 70 per cent of cervical cancer.
  • In 2012 there were 166 new cases of cervical cancer diagnosed and 56 women died of cervical cancer.
  • HPV can also cause cancer of the vulva, vagina, penis, anus, some head and neck cancers, and genital warts.
  • Genital warts are caused by ‘low-risk’ HPV types and are not associated with cervical cancer.

Sources: National Cervical Screening Programme http://bit.ly/1SScOFH 
Immunise Australia Program http://bit.ly/1TvuCWx


Jill spot

Symptoms of gynaecological cancers

NOTE:

Having the symptoms below doesn’t mean you have or will get cancer – but it is important to consult your GP or NP.

  • Bleeding following menopause is NOT normal
  • Bleeding after sexual intercourse is NOT normal
  • If, after visiting your GP or NP, the symptoms continue or worsen, it is important to return and inform them of this.

 Ovarian cancer

If you have the symptoms below and these symptoms persist on most days for two weeks or more, see your GP or NP.

Most frequent symptoms:

  • Persistent pelvic and abdominal pain
  • Increased abdominal size/persistent bloating – not bloating that comes and goes
  • Difficulty eating and feeling full quickly.

Sometimes you may experience these symptoms on their own or at the same time:

  • Change in bowel habits
  • Extreme tiredness
  • Urinary symptoms
  • Back pain.

N.B. See http://bit.ly/1KQrjCd for downloadable ovarian cancer symptom diary.

There is a genetic link to some ovarian cancers so if there are two or more cases of ovarian or breast cancer in your close family, seek advice from your doctor. For more information, visit the Gift of Knowledge website.

Uterine cancer 
(including endometrial cancer)

If you have any one of these symptoms, please see your GP or NP.

  • Abnormal bleeding
  • Bleeding after the menopause
  • Bleeding between periods
  • Heavier periods than normal.
  • Symptoms of gynaecological cancers
  • Abnormal discharge
  • More than normal or strong smelling.

Cervical cancer

If you have any one of these symptoms, please see your GP or NP.

  • As with uterine cancer (see above)
  • Painful sex
  • Bleeding after sex.

Vaginal and vulval cancer

If you have any one of these symptoms, please see your GP or NP.

  • Vulval itching, soreness
  • Obvious change in colour of the vulval skin
  • A noticeable lump.

Source: Symptoms reproduced with thanks from the New Zealand Gynaecological Cancer Foundation’s website: http://bit.ly/1Slll4p

Risk reduction

Some steps to reduce the risk of the following:

Cervical cancer

  • Practice safe sex (ie, use condoms to reduce exposure to HPV virus that can cause cervical cancer).
  • Encourage uptake of free HPV vaccination for young women up to 20 years old and consider vaccination of young men also. (Vaccination can also help protect against vaginal and vulval cancer.)
  • Have a three-yearly cervical smear test from the age of 20 to help prevent cervical cancer.
    (Note: a smear test will NOT detect or protect against other gynaecological cancers).

 All gynaecological cancers

  • Be smokefree.
  • Keep a healthy weight: being overweight can increase risk of some gynaecological cancers, particularly endometrial.

Source: Adapted from the New Zealand Gynaecological Cancer website http://bit.ly/1SSjgfY


Gynaecological cancer statistics

  • 1,063 women were diagnosed with gynaecological cancers in New Zealand in 2012. 
  • The most common diagnosis was uterine (513), ovarian (266) and cervical (166) cancers.
  • 394 women died of gynaecological cancers in New Zealand in 2012.
  • 175 died of ovarian cancer, 121 of uterine cancer and 56 of cervical cancer.
  • Ovarian is the fourth biggest killer of New Zealand women, with one woman dying every 48 hours from ovarian cancer (on average about 310 cases year and 200 deaths).
  • In comparison, in 2012 there were 3,025 women diagnosed with breast cancer and 617 deaths due to breast cancer.
  • In 2011 New Zealand’s five-year relative survival rates were: breast cancer (87%), cervical cancer (72%), ovarian cancer (39%) and uterine cancer (78.5%).
  • Gynaecological cancers make up approximately 10 per cent of all cancer cases and cancer deaths in New Zealand.

Sources:
Ministry of Health (2015) Cancer: New Registrations and Deaths for 2012
Ministry of Health (2015) Cancer Patient Survival (1994 to 2011)
New Zealand Gynaecological Cancer Foundation 

 

Further information

All gynaecological cancers

New Zealand Gynaecological Cancer Foundation
Aims to inform and educate community about gynaecological cancers with the aim of increasing survival rates. Has information on symptoms, statistics and personal stories and resources for health professionals. www.nzgcf.org.nz

Ovarian
Gift of Knowledge 
Registered charity focused on raising awareness and reducing incidence in 
New Zealand of genetic breast and ovarian cancer. www.giftofknowledge.co.nz

Ovarian Cancer Australia’s Symptom Diary
Downloadable tool that women can use to track and record four common ovarian cancer symptoms (pelvic abdominal pain, increased abdomen size/bloating, urinary frequency/urgency and feeling full after eating a small amount) over four weeks. http://bit.ly/1KQrjCd

Uterine cancer (including endometrial)
Cancer Research UK 
Blog published in November 2015 on links between obesity and some cancers, including the ‘oestrogen connection’ between obesity and increased risk of womb (endometrial) and breast cancers. http://bit.ly/1TvzJ98

Cervical
National Cervical Screening Programme. http://bit.ly/1SScOFH

HPV immunisation programme
Information on New Zealand’s Human Papillomavirus (HPV) immunisation programme for girls and young women up to 20 years old. http://bit.ly/1TvC83F

The New Zealand HPV Project
Information on genital HPV, its management and HPV vaccination, including of boys and young men. www.hpv.org.nz 

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