Wed, Feb 27, 2008
Mind Your Body, The Straits Times
Protect yourself against cervical cancer
At 29, most women feel they are standing on the threshold of their lives.
They are starting out in their careers, and perhaps thinking of marriage and having children. Or they have just become mothers. Health problems are usually far from their minds.
This was not the case for Ms Cheryl Ho. In 2003, when she was 29, she learnt that she had cervical cancer.
Ms Ho had married at 19 and was the mother of two boys.
She had no family history of the disease, and the only sign that something wasn't quite right was intermittent bleeding between her periods and during and after intercourse. This went on for six months before she finally went to see her gynaecologist.
She was told she had Stage Two cancer, which usually calls for surgical intervention.
Things you should know about cervical cancer
1 Cervical cancer is the second most common cancer worldwide among women over the age of 15. Breast cancer tops the list. In Singapore, it is the fifth most common cause of cancer deaths among women. About 200 women here are diagnosed with cervical cancer each year. The cancer begins in the cervix - the part of the uterus or womb that opens to the vagina - and can spread to other parts of the body if left untreated. It is not life-threatening if caught early.
2 Cervical cancer usually hits those in their 30s to 50s although there is no age limit to being diagnosed with it.
3 Cervical cancer is caused by the human papilloma virus, or HPV, which is easily transmitted through sexual intercourse or oral sex. Using condoms can cut the risk of transmission.
About 50 to 80 per cent of women will acquire a genital HPV infection in their lifetime. In most women, the virus clears up by itself. But in a small number of women, the virus survives for years. It can then convert some cells on the surface of the cervix into cancer cells. These changes happen very slowly.
4 There are over 100 types of HPV but only 15 types are known to cause cancer. HPV types 16 and 18 cause more than 70 per cent of all cervical cancers and are known as 'high-risk' types. 'Low-risk' HPV virus types don't cause cancer but can lead to genital warts.
When infected with HPV, the cells of the cervix only show signs of a viral infection at first. But over years, the virus can cause the cells to turn pre-cancerous. Doctors call this 'cervical intraepithelial neoplasia'. In time, it can turn into invasive cervical cancer. Women who smoke increase their chances of developing cervical cancer.
5 Men can also get HPV infections which turn into cancers of the penis and rectum, but these are far rarer than cancer of the cervix. The best way to prevent HPV is to have fewer sexual partners and to always use condoms.
6 There are usually no symptoms during the early stages of cervical cancer. In its later stages, symptoms could include bleeding in between periods or during and after sexual intercourse, pelvic pain and heavy or foul vaginal discharge.
7 A pap smear is the best way to detect early stages of cervical cancer. The doctor scrapes off some cells from the surface of the cervix and tests
them for abnormalities under a microscope. If your cells are abnormal, the doctors may suggest further tests to examine whether it is just an HPV infection or if it is pre-cancerous. Cells go through a series of changes before they turn into cancer. A pap smear can reveal these changes. This is why it is important to get regular pap smears.
8 Depending on the pre-cancerous changes to the cervix, treatment involves a simple surgery to remove the cancerous tissue or a wait-and-watch approach. If the cancer has spread, it may entail more radical surgery such as removal of the womb, with radiation and chemotherapy to destroy cancer cells.
9 In the case of very early, precancerous changes to the cervix, doctors may also recommend HPV DNA testing to determine if the HPV is a 'high-risk' or 'low-risk' type. If it is 'low-risk', no surgery may be necessary and they would recommend waiting for the virus to clear up on its own. If 'high-risk', they may recommend surgery in the form of a LEEP biopsy or laser vaporisation of pre-cancerous tissue.
10 Two vaccines, Cervarix and Gardasil, provide younger females with a strong immune response against HPV types 16 and 18. The vaccine is most effective when given during adolescence, before the girls start having sex. However, those already infected with HPV may not benefit. Studies are being done on vaccine efficacy in women over 25 years of age.
'There was no time to even ask how it happened. All I wanted was for them to take the cancer out of my body,' she recalled.
Her husband, parents and relatives were also shocked. For many of them, cancer meant death, and anxiety was high when Ms Ho was wheeled in for a radical hysterectomy, a procedure in which the entire womb is taken out.
She went through about two months of radiation and chemotherapy, and it took her nearly a year to recover.
While Ms Ho, now 33, survived the cancer and is totally free of it, there are now vaccines for young women to protect themselves against cervical cancer.
Vaccine approved
In December 2006, the Health Sciences Authority of Singapore approved the vaccine Gardasil, made by Merck, Sharp & Dohme.
It is the first vaccine shown to protect against two strains of the human papilloma virus (HPV) - types 16 and 18 - that are responsible for about 70 per cent of cervical cancers worldwide.
Gardasil is also shown to protect against HPV types 6 and 11, which cause 90 per cent of genital warts, a non-threatening sexually transmitted disease. Genital warts are small flat bumps that occur on the penis or vulva and usually disappear by themselves or with anti-viral treatment. But they can reappear at any time because the virus always stays in the body.
A second vaccine, Cervarix by Glaxosmithkline Biologicals, was approved by the HSA in January this year. Cervarix is also shown to protect against HPV types 16 and 18, and possibly against other related strains of HPV infections.
Both vaccines are approved for females aged nine to 26. Experts say they are most useful when given to younger girls before they become sexually active.
The vaccines are ineffective once the virus is already present. They work by building immunity against two of the worst offending HPVs - types 16 and 18.
However, doctors say that long-term studies are needed to determine how long this immunity lasts.
There are hundreds of strains of HPV, 40 of which are passed through sexual contact. At least half of all sexually active women and men acquire genital HPV infection at some point in their lives.
Infections caused by this common virus often resolve themselves. However, those that persist in women can cause cell changes in the cervix, which lead to cancer over time.
'Most women recover from HPV infections with no health problems at all. However, a small number are linked to cancers of the cervix,' said Dr Ann Tan, consultant gynaecologist at Mount Elizabeth Hospital.
About 200 women here are diagnosed with cervical cancer each year and roughly half these cancers result in death. It is the fifth most common cause of cancer deaths among women here, after breast, colorectal, lung and ovarian cancers.
Regular Pap smears are the best way to detect early stages of cervical cancer. Doctors say that taking a vaccine does not do away with the need to keep screening for the disease.
Associate Professor Tay Eng Hseon, chairman of KK Women's and Children's Hospital's medical board, said at a press conference recently that the purpose of the vaccines was to give women the immunity to repel the virus and prevent an infection.
But the cost of vaccination is high, at around $230 an injection, with a total of three shots to be spaced over six months. The total cost is about $700.
Doctors here said that the take-up for vaccines here has been low, although no figures are available.
Cost and lack of awareness
Two significant barriers are cost and lack of awareness.
Dr Tan blamed 'vague awareness or a lack of awareness' as the biggest barrier. 'When you explain the data behind the vaccine and its usefulness, parents do come forward to pay for it,' she added.
Another barrier is a reluctance on the part of parents to vaccinate girls as young as nine against an infection that can only be passed through sexual contact.
'But we know that young people are experimenting with sex earlier, whether we like it or not. I would rather protect them,' Dr Tan said.
Women who have had a brush with cervical cancer or had friends diagnosed with it are choosing to vaccinate their daughters.
Madam Chin Chee Choy, 48, was diagnosed with the disease four years ago. She beat it with surgery and chemotherapy and now goes for a check-up every four months.
When she heard about the vaccine from a nurse at the Singapore General Hospital, she decided to get it for her two daughters aged 14 and 18.
'I wanted my daughters to get it because it would give me peace of mind. I like the added security of knowing that they are safe,' Madam Chin said.
Dr Daron Gale Ferris, director of the Gynecologic Cancer Prevention Center at the Medical College of Georgia in Augusta, Georgia, in the United States, was in Singapore recently to talk about the psycho-social attitudes towards the cervical cancer vaccines.
Dr Ferris, who was brought in by Merck, Sharp & Dohme said: 'It's entirely possible to contract HPV even in a monogamous relationship, so it's quite misplaced to bring morality into the picture.'
The bottom line is that any sexually active woman can contract HPV.
Ms Ho, who was married at 19, is almost a poster child for this fact. 'It's not about promiscuity. If I had a daughter, I would make sure she got the vaccine,' she said.
The United States, Australia and five European Union (EU) countries - Britain, France, Germany, Austria and Italy - have introduced vaccination against cervical cancer in their national health programmes.
As Dr Tan put it: 'This is a preventable cancer and as you know, prevention is better than cure. I have also told my teenage daughter about the vaccine and would want her to have it.'
This story was first published in Mind Your Body, The Straits Times on Feb 27, 2008.
