Pap Smears for Young Women: A Waste of Time and Money—or Not?

A new study from Queen Mary College, London, has found that Pap testing for sexually active young women may not be such a good idea—in fact “doing more harm than good.” But there are a few caveats that women might want to consider before following standard one-size-fits-all advice.

The researchers, curious about the effectiveness of aggressive treatment for low-grade lesions that often heal themselves in young women, compared 4,012 women aged 20-69 who had been diagnosed with cervical cancer with a matched group of 7,889 cancer-free women.

The study found three things:

· The outcome was no different for young women with abnormal cells whether they received a colposcopy—a microscopic examination of the cervix, possibly including a biopsy of suspicious cells—or whether they were told to come back later for more testing. Pap screenings didn’t reduce cervical cancer incidence over the next five years for women aged 22-24, but there was a 43-60 percent reduction in incidence for women aged 30-37.

· There was no difference in outcome for women who had a colposcopy and excision of abnormal cells and those who didn’t, although the surgical group suffered more problems such as bleeding.

· Immediate colposcopys did not prove any more cost-effective than ‘watchful waiting.’

“When you look at the balance of benefits and harms, surveillance does as well,” said Eduardo Franco, a professor of epidemiology and oncology who co-authored an editorial about the study in the British Medical Journal.

England’s recent policy of offering Pap smears only to women over 25 (women in Scotland, Wales and Northern Ireland can still get them at age 20) has been under fire ever since the furor over reality TV star Jade Goody’s untimely death from cervical cancer at the age of 27.

Goody’s tearful phone call with a doctor telling her she had cancer, on-camera during Big Brother filming, has been viewed millions of times over the internet. The progression of her illness—the cancer had metastasized to her bowel, liver and groin—was followed by a horrified international audience and there was an unprecedented rush for Pap smears in the UK. The surge in requests became known as ‘the Jade Goody effect.’

English health officials maintained that the new 25-and-over policy followed guidelines set by the International Agency for Research on Cancer. Cervical cancer in under-25s is extremely rare, officials said, but changes in the cervix are very common. Screening at 20 could therefore result in unnecessary interventions that could, indeed, do more harm than good. The new study appears to bear out this belief.

Currently women in the US are advised to begin screenings within three years of starting sexual activity or upon turning 21, whichever comes first. The American Cancer Society is considering revising its guidelines because of the Queen Mary College study.

But here’s what you should think about.

One size doesn’t always fit all. Although a huge percentage of tests and procedures in the US are known to be unnecessary and it’s important to rein in costs, as an individual you need to make informed choices. While raising the blanket testing age to 21 may well make sense, you yourself have to be totally and completely honest with your gynecologist about your personal life, including:

· Number of sexual partners. The more partners you have, the more varieties of the HPV virus (that causes most cases of cervical cancer) you will be exposed to. Studies have shown that people with more sexual partners are more likely to get cervical, anal and oral cancers. Young girls are particularly vulnerable to HPV because cervical cells are unstable and changing rapidly; protective cervical mucous is also not being produced as efficiently as in later years.

· Smoking. Smokers are 14 to 27 times (times, not percent) more likely to develop pre-cancerous lesions than non-smokers.
· Diet. People with a diet high in vegetables and fruits are at least 50 percent less likely to develop pre-cancerous lesions.

If your gynecologist doesn’t ask you about these issues, it’s up to you to bring them up and ask whether you should get earlier testing, plus HPV testing, if you have higher risks. You should also be aware that in Britain, at least, the incidence of cases of the highest grade of pre-cancerous change, CIN3, in 20-24 year-olds has risen from 15.8 percent of all cases in 1999 to 19.3 percent of all cases in 2004, suggesting that either HPV is becoming nastier or risky habits are making younger women more vulnerable.

If you and your gynecologist do decide on delaying testing to, or on ‘watchful waiting’—according to the study, possibly a better option if testing detects pre-cancerous cells—try to make healthy lifestyle choices such as quitting smoking if you smoke and including lots of vegetables and fruits in your diet. These changes will help to bolster your immune system so that you can shake off HPV.

One last caveat: don’t think you’re safe if you’ve had the Gardasil vaccine against HPV. It protects against only four HPV viruses out of more than 100, at least 40 of which are known to be cancer-causing, and has proved to be 17-45 percent effective against pre-cancerous lesions. Its eventual effectiveness against cervical cancer is still unknown and replacement disease, where other strains of the virus fill the void left by vanquished strains, is a real possibility. Don’t forgo your annual visit to your gynecologist, and above all, be honest when you do go.

Farrah Fawcett's Cancer, HPV and Gardasil

Farrah Fawcett, like Jade Goody, has focused our attention squarely on the tiny, but very real, dangers of HPV. Last night a documentary dealing with the iconic actress’ struggle with anal cancer aired to an audience of an estimated 8.9 million viewers.

In March all eyes were on reality TV star Jade Goody, who died at the appallingly young age of 27 from cervical cancer. Now Fawcett, known for her portrayal of an abused woman in The Burning Bed and for her longtime role in Charlie’s Angels, has highlighted the perils of anal cancer. In 2006 she was diagnosed with the highly curable cancer and initially was thought have beaten it; the disease, however, returned and spread to her liver.

Furious about on ongoing series of detailed leaks about her condition to the National Enquirer, and knowing that they could only come from staff at the UCLA Medical Center, 62 year-old Fawcett set a trap worthy of the French Resistance and spurred new legislation in California to safeguard patient privacy—and she’s continued to tackle her disease with equal energy, even sharing with the public what was originally supposed to be private video footage of her ordeal as a way to spread awareness.

At least those 8.9 million viewers, then, are now to some extent familiar with the disease. Anal cancer is even rarer than cervical cancer. The American Cancer Society estimates that in 2009 there will be 5, 290 new cases diagnosed in the US, mostly in people in their 60s, and about 3,190 of those will be found in women. Because anal cancer can be treated very effectively if found in time, only about 710 of those cases will die.

It’s thought that the human papillomavirus, HPV, is the cause of anal cancer. As with cervical cancer, many—even most—people will be infected with the virus at some point but it clears itself in roughly 95 percent of cases; only when an infection becomes persistent does it cause real trouble. Smoking, sleeping around, and weakening the immune system through poor diet all increase the chances of an infection becoming persistent (smoking alone can increase the chances by up to 26 times), and in the case of anal cancer, having anal sex is certainly a risk factor. Some patients, however, have no risk factors.

Symptoms can include bleeding or itching around the anus, pain in the anal area, a change in bowel habits, a lump in the anal area, swollen lymph nodes in the anal or groin area, and abnormal discharge from the anus.

Problems can usually be detected with a digital exam during a Pap test, colonoscopy, or prostate cancer screening. Anal cytology testing, a relatively new test that’s rather like an anal Pap smear, can also be performed if a patient is high risk for one reason or another. Fawcett’s battle highlights for us yet again the importance of regular screening.

The new Gardasil vaccine (in use since 2006) aims to protect against two of the most commonly cancer-causing strains of HPV, 16 and 18, as well as two that cause genital warts, although a recent study shows that 16 has for some years been losing ground to non-vaccine types. Because there are more than 100 different strains of HPV, and of those more than 40 can cause cancer, replacement diseases may well be an issue if non-vaccine types decide to fill the biological vacancy left by 16 and 18.

Two recent placebo-controlled studies showed that Gardasil decreased the risk of different types of pre-cancerous cells by 17 to 45 percent. It’s not known how long the vaccine will remain effective but a recent study showed strong protection against HPV type 16 alone for 8.5 years.

The vaccine has been associated with a number of side-effects, including Guillain-Barré Syndrome, an unusually rapid form of ALS, paralysis, and convulsions and epilepsy. No causal link has been definitively proved as yet; critics point to a high number of VAERS reports, particularly compared to Menactra, a vaccine that is aimed at a similar population. When three young girls in Spain lost consciousness and convulsed—the two we know most about have been in and out of intensive care ever since—health authorities determined that the vaccine had not caused the convulsions, but could have triggered them.

Germany and Scotland are both considering changing or ending their HPV vaccination programs because of concerns about the efficacy of the program. Many people are looking to other preventatives currently in the development pipeline, such as an ointment made with GML that would also protect against HIV.

Because of the potential side effects and less than complete protection provided by both Cervarix and Gardasil, consumers should research the pros and cons of the vaccines for themselves Regardless of your opinion about Gardasil as an HPV preventative, however, HPV is indeed an issue that we should all be aware of, and one can only be thankful to public figures like Farrah Fawcett who are willing to go very, very public to that end.

Meanwhile, my very heartfelt prayers are with her, and with her family and friends too.

Why Gardasil Was Created: Jade Goody Dies of Cervical Cancer

Gardasil is such a controversial and flawed vaccine that it seems as if many people can think of it only as a much-hyped profit center for Merck.

But 27 year-old British celebrity Jade Goody’s death of cervical cancer on Sunday, Mother’s Day in Britain, reminds us that yeah, cervical cancer can kill. If an HPV infection is NOT shrugged off, as most are, and you don’t get an annual Pap smear to find pre-cancerous lesions early, then it can eventually kill. And we should take it seriously.

Which is why researchers probably saw the Gardasil vaccine as the Grail—regardless of what Merck did with it afterwards, by fast-tracking it to approval and marketing it aggressively; whatever your feelings about Gardasil, we have to give researchers credit.

Jade Goody was a dental assistant when she soared to fame on the reality TV show Big Brother which endlessly films contestants corralled in a house for weeks at a time. Born to drug-addicted and impoverished parents she was brash, ignorant, and opinionated, soon becoming notorious for malapropisms such as "They were trying to use me as an escape goat."

But her survivor nature won her many fans, and perversely, she soon became a celebrity just for being a celebrity. There was one hell of a row when she put a racist slant on bullying during the filming of a follow-up Celebrity Big Brother, calling Bollywood actress Shilpa Shetty “Shilpa Poppadum” and snickering at her accent. Mixed race herself, though, she not unreasonably explained that “I treat everyone like that.” The two made it up, and in fact Goody learned about her cancer on camera during the filming of an Indian Big Brother.

Her disease progressed in the glare of camera flashes. She was criticized roundly for selling her life, including the rights to film her fantasy wedding to fiancé Jack Tweed while she was dying: she answered that she was storing up as much money as possible for her two young sons so that they would never live as she did as a child.

Goody did a great deal in Britain to highlight the need for regular exams. Although cervical cancer is not prevalent—in the US it ranks 14th on the list of cancers—and it rarely presents itself in young women, serious lesions resulting from persistent HPV infection do appear to be increasing. In Britain the highest grade of pre-cancerous change, CIN3, in 20-24 year-olds has risen from 15.8 percent of all cases in 1999 to 19.3 percent of all cases in 2004.

Gardasil has its issues, and I won’t be getting it for my daughters. But at least Merck’s scare tactics have raised awareness of HPV and the need for precautions, and I thank them for leading me to look at the alternatives (February 9, March 10).

Hopefully my girls will be sufficiently aware of HPV that they will never suffer as Jade Goody has. My thoughts and prayers go with her.

The Outrageous Jade Goody: Food for Thought about Gardasil and Cervical Cancer

Jade Goody, Britain’s brash reality TV celebrity, is still sparking controversy and discussion even while she’s dying.

Goody’s personal tragedy has done more to highlight the importance of regular smear tests and the risks of casual sex and smoking than perhaps anything else in the UK. When she found out—very publicly—that at the young age of 27 she is unlikely to survive the cervical cancer that has metastasized to her bowel, liver and groin, the rate of women seeking Pap smears in Britain soared by 21 percent.

So what’s to think about? Well…

Is HPV Getting Worse?

International focus on Jade Goody’s case threw up some unpleasant statistics.

Smear tests detect pre-cancerous changes, called CINS, as well as actual cancer. CINS are caused by persistent cases of HPV (human papillomavirus), a very common STD that normally resolves itself. However, in Britain the incidence of cases of the highest grade of pre-cancerous change, CIN3, in 20-24 year-olds has risen from 15.8 percent of all cases in 1999 to 19.3 percent of all cases in 2004.

This seems to suggest that any or all of the following are true:

· HPV incidence and virulence is worsening.

· Young women’s immune systems—healthy immune systems are the reason that most HPV cases clear up on their own—are weakening. Britain’s diet has notoriously deteriorated in the past decade, while the prevalence of smoking in the UK is greater in the 20-24 year old age group than in any other, and girls are now more likely to smoke than boys. Smoking increases the chance of an HPV infection becoming persistent by up to 27 times.

· Girls are having more unprotected sex with more partners at a much earlier age.

Bottom line: Regardless of whether you think Gardasil’s a good thing or not, take HPV seriously. Consider that it may be worsening (one of the fears about Gardasil is that it may create fiercer replacement diseases) and take the necessary steps to protect yourself.

Screening Age Row

And then there’s the NHS row. According to the Journal of Family Planning and Reproductive Health Care, researchers are upset with the 2004 NHS (Britain’s National Health Service) decision to quit offering Pap smears to women younger than 25 in England (women in the rest of Britain can still have the test at 20).

The NHS says that it is following guidelines set by the International Agency for Research on Cancer because cervical cancer in under-25s is extremely rare, but changes in the cervix are very common. Screening at 20 could therefore result in unnecessary, frightening, and potentially harmful interventions.

But Professor John Shepherd, a cervical cancer specialist and spokesman for the Royal College of Obstetricians and Gynaecologists, notes that some ten percent of cases are found in women under 30, and believes that younger women should be screened. Experts also note that fewer women come for the test when they start later, perhaps because it has not become a regular part of their adult life; they’re also concerned that women who have had the Cervarix vaccination will think they are fully protected and ignore the necessity for smear tests. Would Jade Goody be looking at a happier outcome had she gone for a Pap smear at 20 or even 25?

Bottom line: The American Cancer Society currently recommends starting regular screenings by three years after becoming sexually active, or by the age of 21, whichever comes first. Do it, whether or not you’ve had the Gardasil shot. Or, if the NHS/IGR guidelines make sense to you, discuss them with your doctor and, at the very outside, get the test by age 25.