US National Library of Medicine National Institutes of Health, Gynecologic oncology, 2016
Abstract
OBJECTIVE Women exposed to diethylstilbestrol in utero (DES) have an increased risk of clear cell adenocarcinoma (CCA) of the vagina and cervix, while their risk of non-CCA invasive cervical cancer is still unclear.
METHODS We studied the risk of pre-cancerous (CIN) lesions and non-CCA invasive cervical cancer in a prospective cohort of 12,182 women with self-reported DES exposure followed from 2000 till 2008. We took screening behavior carefully into account. Incidence was obtained through linkage with the Netherlands Nationwide Pathology database (PALGA). General population data were also derived from PALGA.
Risk of cervical intra-epithelial neoplasia and invasive cancer of the cervix in DES daughters, US National Library of Medicine National Institutes of Health, Gynecologic oncology, NCBI PubMed PMID: 27939984, 2016 Dec 7.
RESULTS The incidence of CIN1 was increased (Standardized Incidence Ratio (SIR)=2.8, 95% Confidence Interval (CI)=2.3 to 3.4), but no increased risk was observed for CIN2+ (CIN2, CIN3 or invasive cancer) compared to the screened general population (SIR=1.1, 95% CI=0.95 to1.4). Women with DES-related malformations had increased risks of both CIN1 and CIN2+ (SIR=4.1, 95%CI=3.0 to 5.3 and SIR=1.5, 95%CI=1.1 to 2.0, respectively). For CIN2+, this risk increase was largely restricted to women with malformations who were more intensively screened.
CONCLUSIONS An increased risk of CIN1 among DES daughters was observed, especially in women with DES-related malformations, probably mainly due to screening. The risk of CIN2+ (including cancer) was not increased. However, among DES daughters with DES-related malformations a true small risk increase for non-CCA cervical cancer cannot be excluded.
Screening samples will now be tested for human papilloma virus (HPV) first
In the United Kingdom, women aged 25 to 49 are invited for cervical screening every 3 years and from 50 to 64 every 5 years.
The process of cervical screening is to be changed to allow women to benefit from more accurate tests. After a successful pilot programme and a recommendation by the UK National Screening Committee, screening samples will be tested for human papilloma virus (HPV) first. This will be rolled out across England as the primary screening test for cervical disease.
Current testing process
At the moment, cervical screening samples are first tested using the cytology test. The sample is examined for abnormal cells that could go on to develop into cancer. However, the cytology test leaves room for abnormal cells to be missed, as they sometimes look similar to normal cells. Normal cells can also be misdiagnosed as abnormal.
Testing for (HPV is used as a secondary measure for samples needing further investigation. Women with mild or borderline cytology results are tested for HPV and if negative are returned to the routine screening programme. Women who are HPV positive are referred for a colposcopy, a medical examination of the cervix.
New testing process
In the new process, the sample will be tested for HPV first.
The majority (99.7%) of cervical cancers are caused by persistent HPVinfection, which causes changes to the cervical cells. If HPV is found it is a useful guide as to whether abnormal cells are present. Women can then be monitored more closely and any developing abnormal cells found sooner. If no HPV is present the test also minimises over-treatment and anxiety for women.
” These changes are a breakthrough in the way we test women for cervical disease. The new test is more accurate, more personal and will reduce anxiety among women. Cervical screening currently saves 4,500 lives a year, and this new test will ensure the early signs are spotted and treated earlier. “
said Jane Ellison, Public Health Minister.
The new testing process could prevent around 600 cancers a year, according to Cancer Research UK.
” It’s a huge step forward that the government is now introducing the HPVtest to improve cervical screening. Testing first for the human papilloma virus will help prevent more cervical cancers, as it can pick up the cancer-causing infection before any abnormalities can develop in the cells.
The need for improvements to the cervical screening programme was set out in the cancer strategy for England last year, so it’s good to see progress being made. “
said Sir Harpal Kumar, Cancer Research UK’s chief executive.
Hysterectomy and health risks: if given a choice, keep your ovaries
Ovary Removal Tied to Colon Cancer Risk, NY Times, MAY 4, 2016
Removal of the ovaries — a procedure known as oophorectomy — may increase the risk for colorectal cancer, a new study concludes.
Abstract
Population‐based analysis of colorectal cancer risk after oophorectomy, bjs, Apr 26, 2016.
Background The development of colorectal cancer is influenced by hormonal factors. Oophorectomy alters endogenous levels of sex hormones, but the effect on colorectal cancer risk is unclear. The aim of this cohort study was to examine colorectal cancer risk after oophorectomy for benign indications.
Methods Women who had undergone oophorectomy between 1965 and 2011 were identified from the Swedish Patient Registry. Standard incidence ratios (SIRs) and 95 per cent confidence intervals for colorectal cancer risk were calculated compared with those in the general population. Stratification was carried out for unilateral and bilateral oophorectomy, and hysterectomy without specification of whether the ovaries were removed or not. Associations between the three oophorectomy options and colorectal cancer risk in different locations were assessed by means of hazard ratios (HRs) and 95 per cent confidence intervals calculated by Cox proportional hazards regression modelling.
Results Of 195 973 women who had undergone oophorectomy, 3150 (1·6 per cent) were diagnosed with colorectal cancer at a later date (median follow‐up 18 years). Colorectal cancer risk was increased after oophorectomy compared with that in the general population (SIR 1·30, 95 per cent c.i. 1·26 to 1·35). The risk was lower for younger age at oophorectomy (15–39 years: SIR 1·10, 0·97 to 1·23; 40–49 years: SIR 1·26, 1·19 to 1·33; P for trend < 0·001). The risk was highest 1–4 years after oophorectomy (SIR 1·66, 1·51 to 1·81; P < 0·001). In the multivariable analysis, women who underwent bilateral oophorectomy had a higher risk of rectal cancer than those who had only unilateral oophorectomy (HR 2·28, 95 per cent c.i. 1·33 to 3·91).
Conclusion Colorectal cancer risk is increased after oophorectomy for benign indications.
Heather – now cance-free – was diagnosed with cervical cancer a year before she became eligible for smear tests… she shares her tips
Heather wants to share her story so that there is more awareness around cervical cancer.
I want to share my story, to help others be more aware of the symptoms of cervical cancer. So that girls under 25 that are not entitled to a free smear know what to look out for and for those who are over 25 be more aware of the importance of going for your smear.
Symptoms
Abnormal bleeding
heavy or longer periods
between periods
after sex
after menopause
Foul smelling discharge
Pain or discomfort in the pelvis or during sex
Sources
Woman diagnosed with cervical cancer at 24 shares her symptoms online to help others, independent, 15/02/2016.
Cervical cancer is not just a young woman’s disease…
Pap tests are currently recommended for all women aged 21-65 though the authors of the review question whether screening should stop there. Routine Pap image by Ed Uthman.
Cervical screening programmes in many countries stop at around the age of 65 and much of the focus is often on younger women. For example, recent media campaigns in England and Wales have centred on lowering the age at first screening. Comparatively little attention has been given to older women despite the fact that they account for about a fifth of cases each year and half of deaths. Of the 3121 women diagnosed on average each year between 2009 and 2011 in the UK, only 64 were younger than 25 compared with 616 who were older than 65. As the population ages, this number of older women affected is set to increase. Susan Sherman and colleagues argue that screening programmes should reflect this.
Sources and more information
Cervical cancer is not just a young woman’s disease, BMJ 2015;350:h2729, 15 June 2015.
Review calls for urgent change to perception of cervical cancer risk in older women, Keele University, 15 June 2015 .
Cervical cancer screening: review calls for urgent screening changes, medicalnewstoday, 16 June 2015.
Estimating the benefits to men of offering HPV vaccination to boys
This post content is published by The BMJ, aiming to lead the debate on health, and to engage doctors, researchers and health professionals to improve outcomes for patients.
As richer countries consider vaccinating males, the focus for lower income countries should remain on cervical cancer prevention. Image of vaccination in man by Army Medicine.
Vaccination of girls against the human papillomavirus (HPV) has been implemented in most developed countries, driven by prevention of cervical cancer as a public health priority. Bivalent (Cervarix, GSK) and quadrivalent (Gardasil, Merck) vaccines protect against subsequent infection with oncogenic HPV16/18, and quadrivalent vaccine protects against HPV6/11, which cause anogenital warts. Although HPV vaccination effectively protects against external genital lesions and anal intraepithelial neoplasia in males, only a few jurisdictions have so far recommended universal vaccination of boys. These include Australia, Austria, two Canadian provinces, and the United States. In other countries, a cautious approach has been due, in part, to uncertainties around the population level impact and cost effectiveness of vaccination of boys.
In a linked article, Bogaards and colleagues estimated the benefits to men of offering HPV vaccination to boys. They used a dynamic simulation and a bayesian synthesis to integrate the evidence on HPV related cancers in men. The analysis takes account of indirect protection from female vaccination: heterosexual men will benefit from reduced HPV circulation in females, so if coverage in girls is high the incremental benefit of vaccinating boys is driven by prevention of the residual burden of anal cancer in men who have sex with men.
The findings reinforce those of prior analyses that found that adding boys to established vaccination programmes in girls becomes less cost effective as female coverage increases. The cost effectiveness of vaccination of boys also depends on other local issues, especially vaccine type and vaccine and administration costs. A threshold total cost per vaccinated boy for cost effectiveness can be identified at any level of coverage in girls: such analyses can provide policy makers with the maximum rational vaccine price appropriate to the local environment. If vaccine coverage in girls is lower, however, the most effective use of resources is likely to involve increasing coverage in girls, if feasible.
In some countries, vaccination of boys might not be cost effective, even at lower vaccine prices, due to higher administration costs. Recent developments towards reduced dose schedules could help. In 2013 the European Medical Agency recommended a two dose schedule for the bivalent vaccine in girls, in 2014 the United Kingdom switched to a two dose schedule, and the World Health Organization now recommends two doses for girls <15. Two dose schedules are the most cost effective option for girls provided protection lasts for ≥20 years and reduced dose schedules in boys are also likely to increase cost effectiveness if adequate efficacy is maintained.
Bogaards and colleagues highlight the importance of vaccination for prevention of anal cancer in men who have sex with men. In part due to uncertainties in natural history, the effectiveness of anal cancer screening is not established. Primary prevention with targeted vaccination of men who have sex with men is an attractive option and is potentially more cost effective than universal vaccination of boys. The US Advisory Committee on Immunization Practices already recommends vaccination of men who have sex with men up to the age of 26 years. Older men who have sex with men could also potentially benefit. The UK’s Joint Committee on Vaccination and Immunisation, as an interim position, recently stated that a programme to vaccinate men aged 16-40 who have sex with men with a quadrivalent vaccine should be considered, if cost effective. Lower coverage rates expected with targeted versus universal male vaccination are an important consideration, and the two approaches are not mutually exclusive.
Several other new developments should be factored in to future policy decisions. A recent study showed that the bivalent vaccine is effective in women aged ≥25 without a history of HPV disease. With a transition to primary HPV screening occurring in several countries, an interesting possibility to be evaluated involves “screen and vaccinate” strategies in older women—that is, offering HPV screening, followed by vaccination for HPV negative women with extended (or perhaps no) recall for this group. Secondly, a nonavalent vaccine (Gardasil9, Merck), which protects against an extra five HPV types, has recently been recommended for use in the US. In women, this will increase protection against cervical cancer in those who are fully vaccinated (from about 70% to about 90%) but as most HPV cancers in men are attributed to types included in current vaccines, tiered pricing structures for new generation vaccines based on differential incremental benefits (and thus differential cost effectiveness thresholds) in girls versus boys could be considered.
All these policy decisions must consider burden of disease, safety, effectiveness, acceptability, equity, and cost effectiveness. Although the focus in developed countries has now, appropriately, shifted to considering these issues for boys, men who have sex with men, and older women, broader efforts to prevent cervical cancer should remain the priority in low and middle income countries. Of the 610 000 cancers annually attributable to HPV worldwide, 87% are cancers of the cervix, and three quarters of these occur in countries with a low or medium human development index. Even if a substantial majority of young girls in such counties were vaccinated, hundreds of millions of older women would remain at risk—vaccination alone will not prevent an expected increase in cervical cancers in the next few decades, driven by population ageing. Here, the priority focus should be the development of integrated programmes for vaccinating young girls and screening older women. Based on experience in developed countries, this will also provide benefits for men through indirect vaccine protection.
Sources and more information: Who should be vaccinated against HPV? BMJ 2015;350:h2244, 12 May 2015.
Women Who Received HPV Vaccine May Need More Shots…
HPV Vaccination in Sao Paulo Brazil March 2014. Image via PAHO/WHO.
… there are more than 80 HPV types …
… if a woman is already infected with HPV, the HPV vaccine cannot eliminate this infection …
… vaccinated women are not guaranteed to prevent cervical cancer and/or not to be infected with HPV: women in the study who received the Gardasil vaccine were less likely to be infected with the four strains of the virus included in the vaccine: about 11 percent of vaccinated women were (still) infected with HPV 6, 11, 16 or 18, compared with nearly 20 percent of unvaccinated women…
… however, the women who received the vaccine were more likely to be infected with other high-risk HPV strains not included in the vaccine. About 61 percent of the women who received the vaccine were infected with another type of high-risk HPV, compared with 40 percent of women who did not receive the vaccine…
Read Women Who Received HPV Vaccine May Need Another Shot, livescience, April 22, 2015 and Comparison of HPV prevalence between HPV-vaccinated and non-vaccinated young adult women (20-26 years) , American Association for Cancer Research, Apr 19, 2015.
