I'll be honest, being a male GP I'm not exactly inundated with thousands of requests for Pap smears. But as a busy GP in a family medical practice, I’m regularly called upon to discuss cervical cancer, screening programs, and even the need for doing the Pap smear in the first place. What astounds me is the lack of awareness about these basics. Just what is the cervix? Why do we need to screen for cervical cancer? And just what is the fuss all about with this new HPV test.
The anatomy lesson!
The cervix is the narrow opening connecting the womb (uterus) to the top of the vagina. It's the part that 'dilates' when you deliver a baby, stretching from mere millimetres to about 10cm! Apart from its critical role in holding babies safely inside the womb, the cervix produces specialised mucous, with two vital roles. Firstly it lubricates the vagina, and secondly, the mucous assists sperm to travel up into the womb where it can fertilise the egg.
Cervical cancer occurs when the cells that line the cervix grow abnormally. These cells can grow into tumours, and even spread through the body. This year we can expect about 1000 Australian women to be diagnosed with cervical cancer, with only 70% expecting to survive beyond five years.
What increases my risk of getting cervical cancer?
We now know more than ever about cervical cancer, especially the fact that 99.7 percent of cervix cancer is caused by Human Papilloma Virus (HPV) infection. HPV is spread through sexual contact. Before cancer takes hold, HPV can sit happily in the cervix without any symptoms at all. But elsewhere in the body, we see HPV causing genital or general body warts, plus it's also linked with various other cancers. Whilst the HPV can be transmitted, the cancer itself is not contagious.
There are some other risk factors for cervical cancer:
Age. Most common over age of 35, very rare under 25.
Prolonged use of the oral contraceptive pill may increase cervical cancer risk. Thankfully this risk falls when you stop the pill. Please discuss this further with your GP if you are concerned.
Lack of regular cervical cancer screening.
Cervical cancer screening – the Pap smear.
Over 100 years ago Dr Georgios Papanikolaou researched cervical cancer and devised the test we call the Pap test, better known as the 'Pap smear'. But it wasn't until 26 years ago that the Australian government introduced a program of second yearly Pap tests for all women.
Thankfully the greatest majority of cervical cancers are slow growing, and the Pap test allows for a 'smear' of cervical cells to be analysed for early changes of cancer. By stepping in early, other tests and treatments can be done to prevent the progression to full blown cancer. The pap smear program has been a resounding success, with the rates of cervical cancer in women and the number of women dying halved.
The new HPV test.
The recent discovery linking HPV infection to cervical cancer has prompted a shift in screening techniques. Now, we have a test for the culprit itself – a targeted HPV test. This means we can find out whether the HPV is even active in a woman’s cervix, which means doctors can monitor changes more efficiently and even earlier than before.
From December 2017 the Pap smear as we know it will be phased out. In its place, women will have an HPV test every 5 years from the age of 25 until 74. Whilst it's common to be infected with the HPV virus when ladies are young, 95 percent of the infections are cleared naturally by the body within two years. Plus, it takes over ten years for any HPV infection to progress to cancer, which means cervical cancer is very rare under the age of 25. Therefore, it's very safe to only start testing from the age of 25.
What happens if the HPV test is positive?
If a woman is HPV positive, the exact strain of virus will be identified, which determines what happens next. The majority of women will then need the classic Pap smear. However, if they have the high risk HPV strains 16 and 18, they will need to see a specialist for detailed testing and procedures, such as a colposcopy.
Do you still need HPV testing if you had the vaccine?
In 2006 Professor Ian Frazer successfully developed and trialled the HPV vaccine Gardasil. It's done an amazing job to dramatically reduce the rates of HPV infection and cervical cancer. However, it's not the absolute answer. Even though the majority of young adults are now immunised, Gardasil only covers about 70% of the strains that lead to cervical cancer - the high risk HPV 16 and 18 strains. Plus, it's possible that women were exposed to harmful HPV strains before they were immunised. So the new HPV cervical cancer screening test is still needed by all ladies.
How is the HPV test conducted?
The HPV test is collected with a very similar technique to the Pap smear. Most women will still need the classic trip to their doctor, where a sample is taken with a swab or brush after that funny looking speculum is inserted. But there is some good news! There will be opportunity, in the first instance, for ladies to “self swab” in a similar way to how other sexually transmitted disease tests are conducted. But this must be under the guidance of a health professional – please chat to your doctor to find out more.
The final word.
By increasing the screening interval from two to five years, there's a risk we will breed complacency with regard to individual health – ladies will simply lose another reason to go and get a check up. Please don't ignore your health. I urge everyone to see a doctor at least once a year for a check up. The transition to HPV testing is a great leap forward, we are better protecting people against cervical cancer. But, there are other advantages - we are also avoiding the requirement for women to undergo countless unnecessary procedures, including cervical surgery, as cervical surgery can lead to incompetence of the cervix during pregnancy and preterm birth.