Cervical cancer live chat with Justin Clark: 24.01.13

31 January 2013

Cervical cancer is one of the few cancers which can be largely prevented through regular screening. If diagnosed and treated early, most women recover completely.  However, if the disease has spread, it can be fatal; in 2008 more than 900 women in the UK died from cervical cancer.
As part of National Cervical Cancer Prevention Week, our live chat on Thursday 24 January offered expert advice and information ranging from prevention to treatment of the disease.

Expert Justin Clark, Consultant Gynaecologist from the British Medical Institute was on hand to answer all your questions. Here is what he had to say: Fiona asked: Can you explain why cervical cancer screening is so important? For example, why is there regular screening for cervical cancer from a young age but no other cancers?

Justin Clark: We have to be careful in screening that so as not to cause harm or waste money on ineffective programmes. However, cervical screening is very effective and has been key to reducing cervical cancer from a very common cancer to a much rarer one in the UK (sadly this is not the case in the developing world). The women mostly likely to develop cervical cancer are sexually active and aged 25-45, although women of other ages can also develop it. We recommend screening between the ages of 25-65; we used to screen women from 20 but we found that we were more likely to get false results in younger women and their risk of cervical cancer was actually quite low.

Tracy asked: Can smoking increase your chances of getting cervical cancer if you have HPV?

Justin Clark: Yes, this is because the common (and usually asymptomatic) HP virus can affect how cells on the cervix grow and develop, causing abnormal changes that may lead on to developing cancer. However, most women DO NOT go on to develop cancer because this usually takes many years to develop and the early pre-cancer changes are noted on routine smears. Smoking obviously is bad for us in general but in the cervix we think it impairs local immunity, making the abnormal changes of cells more likely.

JM asked: What are the risks involved in long term use of the contraceptive pill?

Justin Clark: We know that women who take the pill for over five years seem to be at a slightly higher risk of developing cervical abnormalities. However, this does not mean that the pill causes cervical cancer; there are many factors that are linked to this and of course the pill has proven to provide many health benefits both contraceptive and gynaecological. 

CD asked: What are the main symptoms of cervical cancer and how are these spotted in a smear test?

Justin Clark: Classically the symptoms to look out for are unscheduled vaginal bleeding, particularly in between periods or during/after sex. A smelly vaginal discharge is also another symptom to see your doctor about. Most women with these symptoms do not have cervical cancer but a simple examination and some minor tests (e.g. swabs for infection, pelvic scan) can provide much needed reassurance. If you regularly attend scheduled screenings (every three years 25-49 and every five years 50-65) then the likelihood of developing a cervical cancer in between screenings is very unusual, so the key is to not miss your screening smear appointments

London Girl asked: Is there anything I can do to prevent the development of cervical cancer?

Justin Clark: Yes, the most important thing is to attend your smear appointments. From a lifestyle point of view - don't smoke. The issue of sex is contentious because whilst HPV is passed through sex, only 1 in 3 of us carries HPV and 80% of us have probably had it but cleared it.  So whilst avoiding unprotected sex with new/short-term partners is good sexual health to avoid STIs, HPV is so common that most women in stable relationships have been exposed to the infection.

Jrog asked: I've had treatment for pre-cancerous cells and I wondered if you can tell me what this means and if I should be worried?

Justin Clark: The reason we can successfully screen for cervical cancer is because it can be detected BEFORE cancer develops. The PRECANCEROUS cells you have had detected are just that - abnormal BUT not cancer. The great news is that they can be simply treated with a small procedure, usually with you awake, which involves a gynae exam and a biopsy to remove the abnormal cells from the cervix. If the precancerous cells are of a very early type then you may not even need any treatment at all, just monitoring with another smear in 6-12 months or a more detailed examination of the cervix with a 'colposcope' - a type of specialist microscope.

Tracy asked: My sister got the HPV jag in her last year of high school. I'm only four years older but didn't get one. Why don't they offer it to everyone?

Justin Clark: We have known for a while that HPV causes the precancerous changes on the cervix and we also know HPV is very common (there are many different types). So the idea to use vaccination to provide immediate immunity to us is a great idea as it will lower the prevalence of HPV in society and so gradually less and less men and women will be exposed to it through sex. Less HPV = less cervical cancer development in turn. The development of the vaccine took time so it has only been available since 2008 to girls aged 12-13 in the UK. If you are older you can request it but if you have been sexually active there is a good chance you have already been exposed to HPV as it is so common and you have most likely already developed some natural immunity.

Hello111 asked: Are there any other ways to detect cervical cancer other than smear tests? I find them painful and uncomfortable.

Justin Clark: In the developing world some health charities go out to villages to examine women to look at the cervix to detect cervical cancer - however, whilst one may catch it earlier it has already developed (and still involves an exam) so it is in no way as good as screening which detects PRE-CANCEROUS changes. I am afraid there is no other way to detect early without a gynae exam. We are all aware that a pelvic vaginal exam is intimate, embarrassing and can be uncomfortable BUT it is really beneficial for you. If you are worried about the exam do not avoid your appointment; instead, go see the nurse/doctor and explain your anxieties and more time can be allocated. Occasionally examinations can be done under anaesthetic. In my experience women who have had previously bad smear experiences are fine when I take them, so often it may just be a more expert exam with a specialist that is required, especially if your cervix is a little hard to see (can be a problem in some women).

Elaine asked: I was diagnosed with abnormal cells in 2000. I had a colposcopy followed by a loop excision. I had three call backs six months apart and was given the all clear; however, I am still on yearly recalls. Every time I ask why I am told that this is the last yearly recall, but I get recall letters every year, and just wondered whether this implied a higher risk of abnormal cells in future.

Justin Clark: Elaine - it’s difficult to answer this without seeing your records; why not request an appointment with the consultant in charge to clarify. There may be a very good reason but in general after three yearly smears which are NORMAL you are put back to routine recall every three to five  years (depending upon age).

AXA PPP healthcare: Hi Justin, one of our bloggers asked if there is a certain time of the month you should have your smear test?

Justin Clark: Timing - not really. In general avoid menstruation (period time) just because the blood may make interpreting the smear test more difficult and a repeat smear more likely. However, modern ways of analysing smears (called liquid based cytology) have made the likelihood of an inadequate smear result (i.e. a repeat needs doing because a diagnosis could not be made) less likely whenever you have it done in your cycle.

AXA PPP healthcare: Thanks Justin, the HPV vaccine came in recently are there any new medical breakthroughs relating to cervical cancer?

Justin Clark: On-going research areas I am aware of include: better, more comprehensive vaccines; topical treatments for HPV; advances in key hole surgery, such that recovery times are quicker because surgery is less invasive, operations to preserve the womb in women without children; targeted radiotherapy and use of gene therapies to target HPV cell growth providing targeted treatment with less side effects.

Ruth asked: If you have been diagnosed with HPV cervical dyspepsia do you have to tell future partners about it?

Justin Clark: Ruth, you don't need to inform your partner; it won’t affect his health (as HPV so common) but you may want to tell him if you are worried so he can offer support. There is really no stigma attached as I said, most are estimated to have had HPV and the majority of us get rid of it with natural immunity. In contrast - genital warts, herpes, chlamydia, gonorrhoea, syphilis, trichomoniasis are STIs which require treatment at a sexual health clinic and partners should be made aware so barrier contraception can be used.
Also, 1 in 20 women will have HPV dyskaryosis (dysplasia) - it’s very common and bad luck, but usually naturally gets better OR resolves with simple treatment. If you smoke your chances of an abnormal smear are greater because you do not have as strong immunity on the cervix to get rid of the HPV; if relevant, try and stop smoking

Ruth: Okay, I don’t smoke but have immunity problems due to anaemia and an underactive thyroid, does that mean I am more at risk?

Justin Clark: No - immunity is important but only really with blood disorders, chronic disease (e.g. renal problems) and conditions requiring drugs which impair immunity. The most common type of anaemia (iron deficiency) does not affect immunity unless due to a chronic health problem, but can make you feel run down, so see your GP if worried. Thyroid disease is not relevant unless overactive, which is associated with severe weight loss.

AXA PPP healthcare: Justin we have had a question about the treatment of cervical cancer and the different methods?

Justin Clark: Treatment of cervical cancer - in short:

  1. Precancerous changes - local treatment of the cervix to remove abnormal cells.
  2. Early cancer - hysterectomy (removal of womb) or trachelectomy (removal of cervix only - for women needing fertility).
  3. Later stage cancers - radiotherapy + chemotherapy.

Mrs B asked: I have been diagnosed with several types of high risk HPV. Is it normal to have many types of HPV? There aren't any cancer cells according to what my doctor says. However, abnormal cells have been found. Is that dangerous? Can these cells affect me if I don’t start a treatment?

Justin Clark: HPV is very common - 1 in 3 of us (men and women) has it at any time and it is asymptomatic. Normally your body will clear it with time naturally - however the problem with HPV is that in some women such as yourself the infection affects the cervix and causes abnormal changes that are considered pre-cancerous. However, be reassured most women if left alone would not go on to develop cancer. Mild abnormalities may not require treatment; more advanced abnormalities require a very simple treatment to remove the cells from the cervix - this can be done without cuts during a gynae exam with you awake or asleep. So my message is if you have abnormal cells do not worry too much BUT attend your GP/hospital clinic if invited and follow their advice, which is standardised throughout the UK. Simple treatment or surveillance prevents cancer
As for types of HPV, there are over 100; higher risk types (subtypes 16 and 18) are associated with most precancerous changes to the cervix - that is all it means. Most women do have more than one subtype of HPV.

Melissa asked: How often should you look to get tested for cervical cancer? And which age group are most affected?

Justin Clark: The screening interval is the time between the screening tests. This used to vary between health authorities. But research reported in 2003 by Cancer Research UK showed that the screening interval should be decided by age. We can pick up the most cancers by screening women every three years if they are 25 to 49 years old and every five years if they are between 50 and 64.
For women between 25 and 49, three yearly screening prevents 84 cervical cancers out of every 100 that would develop without screening. Five yearly screening will only prevent 73 cancers out of 100, so the guidelines now recommend screening women three yearly if they are under 50.
It is acceptable and safe for women of 50 or more to have five yearly smears. Screening three yearly doesn't give any extra protection for this age group. This is probably because abnormal cells develop more slowly in women over 49. The NHS in England and Northern Ireland have adopted these recommendations. So if you are between 25 and 49 and live in England or Northern Ireland, your health authority will offer you three yearly cervical screening.