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Today in Health & Wellness
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A Silent Epidemic

By: Melissa Montellano-Ngo, MDA Silent Epidemic

Seven Filipinas die each day due to cervical cancer caused by the human papillomavirus (HPV).  Based on the ICO Information Centre on HPV and Cancer (HPV Information Centre), cervical cancer is the second most common malignancy affecting Filipinas aged 15 to 44 years old. There are now approximately more than 35.6 million females over the age of 15 in the Philippines who are at risk of contracting this insidious and deadly disease.

Despite the alarming numbers, the screening rate for cervical cancer in the country is at dismal five percent to 13 percent of eligible women. Therefore, the majority of cervical cancers are detected late at stage 3 or 4. Regretfully, 75 percent of these women will die within five years of diagnosis based on the World Health Organization (WHO).

Without a doubt, increased awareness and proactive involvements in screening and preventive measures are needed to curb the negative effects of cervical cancer in our society. Below are some facts about cervical cancer to better understand the disease and to give emphasis on safe sexual practices, screening, and vaccination.

What causes cervical cancer?

Most cervical cancers are due to HPV infections. The virus is transmitted sexually, with affected individuals during early infection exhibiting no signs and experiencing no unusual symptoms. Majority or 90 percent of women develop mild or low-grade cervical cell changes and the HPV infection is spontaneously cleared by their immune system approximately within two years of exposure. However, for women with weak immune systems and for those contracting high-risk types of HPV infections, the virus is not eliminated.

Persistent HPV infections can lead to cervical cancer in as early as five to 10 years for those with compromised immune systems (i.e. with human immunodeficiency virus [HIV]) or after 15 to 20 years for untreated patients with normal immunity.

From over 100 types of HPV, there are at least 13 HPV types that are known to cause cancers.  Based from studies, the most common HPV types causing cervical cancer in the Philippines are types 16 and 18, and types 45, 52, and 58.

Aside from cervical cancer, HPV can cause cancers of the vagina, vulva (labia or “lips” of the external genitalia), penis, anus, head, neck, and throat. HPV types six and 11 infections can lead to anogenital warts called condylomata acuminata or to an uncommon condition involving benign tumors of the nose, mouth, and lungs called respiratory papillomatosis.

How is HPV infection transmitted?

HPV is mainly transmitted via sexual intercourse. However, the virus (genital or anal warts) can also be transmitted through direct skin-to-skin contact. Genital-digital manipulation or oral sex can also transfer the virus upwards into the cervix or to other organs of the body.

What are the risk factors for cervical cancer?

  • Numerous sexual partners
  • Sexual partner or partners (regular or casual) who themselves had numerous sexual partners
  • Early sexual activity (before 18 years old)
  • Other sexually transmitted diseases
  • Multiple pregnancies
  • Long-term use of oral contraceptives
  • Weak immune system
  • Cigarette smoking and early age of smoking
  • Family history of cervical cancer
  • Born to a mother who took diethylstilbestrol (DES) during pregnancy

What are the symptoms of cervical cancer?

Those with pre-cancer or early stages of cervical cancer (dysplasia or cervical intraepithelial neoplasia [CIN]) typically do not have any symptoms.

If a woman has one or more of the mentioned risk factors plus any of the symptoms below, it is best to consult a doctor for cervical cancer screening:

  • Abnormal vaginal bleeding (longer or heavier menstruation, spotting between periods, and bleeding after intercourse, menopause, douching, or pelvic examination)
  • Heavy or unusual vaginal discharge (watery or thick bloody discharge that may have a foul odor)
  • Lower abdominal (pelvic) pain not related to menstrual cycle
  • Pain during intercourse

Once the cancer has spread to other organs of the body, women with late stages or invasive cervical cancers may experience:

  • Constipation
  • Painful or difficult urination
  • Loss of bladder control or increased frequency of urination
  • Blood in the urine or stool
  • Leakage of stool or urine from the vagina
  • Lower back or pelvic pain
  • Swelling of the legs
  • Weight loss and fatigue
  • Loss of appetite
  • Bone pain
  • Anemia
  • Shortness of breath

How is cervical cancer detected?

A pelvic examination is done and samples for a Pap smear are obtained. The samples will be viewed under a microscope to screen for abnormal cervical cells. A biopsy or HPV testing is then performed to confirm the diagnosis.

In settings with limited financial resources, such as rural areas, visual inspection with acetic acid (VIA) may be done in place of a pap smear.

How often should women undergo screening?

Population

Recommendation

Women younger than 21 years

No screening

Women aged 21 to 29 years

Pap smear every 3 years

Women aged 30 to 65 years

Pap smear every 3 years OR High-risk HPV testing every 5 years

Women older than 65 years AND adequately screened previously*

No screening

Women who underwent hysterectomy with removal of the cervix AND no history of high-grade precancerous lesions or cervical cancer

No screening

Cervical cancer screening recommendations

* Based on guidelines, screening for cervical cancer can be discontinued in women with 2 consecutive negative HPV tests or 3 consecutive negative pap smears, with the last test performed within the past 5 years.

Why is regular cervical cancer screening important?

Most women with early stages of cervical cancer are asymptomatic. Pap smears only detect damaged cervical cells due to an HPV infection but not the presence of the virus per se. A patient may have contracted the HPV infection from an earlier sexual partner from several years or decades ago. The virus may have stayed dormant in the patient and may have just been recently activated by a weakened immune system causing changes in the cervical cells. It is therefore important for women with low-grade cervical changes to be monitored frequently. Screening is necessary to detect cervical changes that do not revert to normal or for those with progressive high-grade changes so that treatment could be provided early.

How is cervical cancer treated?

Cervical cancer may be treated with surgery alone or with radiation, chemotherapy or a combination of both, depending on the stage and medical condition of the patient.

How is cervical cancer prevented?

  • Sex education
  • Sexual abstinence (only measure with the absolute guarantee of prevention)
  • HPV vaccination
  • Monogamous relationship, fewer partners
  • Delayed first sexual intercourse
  • Use of condoms or diaphragms (safe sexual practices)
  • Regular screening (Pap smear, VIA)
  • Male circumcision
  • Avoidance and cessation of smoking
  • Healthy immune system

Who should receive HPV vaccination and when should it be given?

Vaccines are preventive measures and are not intended to treat HPV infections or cancers. Hence, vaccines are best administered prior to exposure to an HPV infection. It is recommended to vaccinate both girls and boys before they become sexually active. Nevertheless, even those already sexually active can benefit from the vaccine. For pregnant women, it is advised to wait after delivery.

What are the HPV vaccines available locally?

  • HPV Bivalent (Types 16 and 18) Vaccine, Recombinant (Cervarix®) – given in 3 doses at 0, 1, 6 months
  • HPV Quadrivalent (Types 6, 11, 16, and 18) Vaccine, Recombinant (Gardasil®) – given in 3 doses at 0,2, 6 months
  • HPV 9-valent (Types 6, 18, 11, 16, 31, 33, 45, 52, and 58) Vaccine, Recombinant (Gardasil 9®) - given in 2 doses for those aged 9 to 14 (0, 6-12 months) and in 3 doses for those 15 years of age and older (0, 2, 6 months)

Are vaccines against HPV safe?

Before vaccination, patients should be interviewed and examined by a medical professional to rule out any allergies or other medical conditions which prohibit administration.

HPV vaccines have been approved by the Food and Drug Administration (FDA) and the Department of Health (DOH). Vaccines are proven to be effective and relatively safe with usually only mild side effects. These minor and temporary side effects include pain, redness or swelling at the injection site, fever, fatigue, headache, nausea, muscle, or joint pain. Like other medical procedures, there have been reports of brief fainting spells and related symptoms (such as jerking movements) following injections. Patients are advised to sit or lie down during and 15 minutes after vaccine administration to avoid fainting and unnecessary injury.

Studies have shown HPV vaccines do not interfere with fertility. Furthermore, HPV vaccination is generally recommended because the benefits of the vaccine far outweigh the minor adverse effects and the detrimental consequences of HPV infections and cervical cancer. 

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