Tag: HPV

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Screening with Pap Test Should Not be Ignored

Barbuda - time to relax on a beach. (Dr. Noorali Bharwani)
Barbuda - time to relax on a beach. (Dr. Noorali Bharwani)

“The rate of death from cervical cancer is reduced by more than 80 per cent among women who have regular Papanicolaou (Pap) screening,” says an article in the Canadian Medical Association Journal (CMAJ December 9, 2014).

Every woman knows or should know the importance of regular Pap smear test. Since World War II, the test has been the most widely used and successful cancer screening technique in history. It is named after the Greek doctor who invented it – Dr. George Nicholas Papanicolaou.

Since the Pap smear was introduced in 1940s, deaths from invasive cervical cancer occur mostly among women who do not undergo regular screening. It is sad to note that women of lower socioeconomic status and those who are older, First Nations or immigrants are less likely to be screened regularly.

The article notes that screening intervals shorter than three years increase the risk of finding and investigating abnormalities that mostly resolve spontaneously. So it is unnecessary to do Pap smear more often than every three years. The drawback is that longer intervals require organized screening and recall programs to maintain high participation rates. This is not always easy.

At what age should we start doing Pap smear? This varies by jurisdiction, but most guidelines agree that harm from false-positive results outweighs potential benefits of Pap screening in young women. Women who have had a total hysterectomy for a benign disorder and women over 70 years of age who have had three normal test results within 10 years do not require Pap screening, says the article.

Choosing Wisely Canada recommendations on Pap screening are as follows:
1. Don’t use the Pap test for screening in women who are under 21 or more than 69 years of age (Screening should stop at age 70 if the results of three previous tests were normal).
2. Don’t do Pap screening annually in women with previously normal results.
3. Don’t do Pap tests in women who have had a full hysterectomy for a benign disorder.

How can we prevent cervical cancer by testing for human papillomavirus (HPV) infection? The answer to this question is not clear yet. It is work in progress. It is important to remember that HPV is a cancer-causing virus. We know infection with specific strains of HPV is a necessary precursor to cervical cancer. HPV types 16 and 18 are present in about 70 per cent of cervical cancers worldwide and are targeted in HPV vaccines. Some of the viruses cause genital warts – another sexually transmitted infection.

Who is susceptible to HPV infection? A woman who is sexually active, she has multiple partners or she has sexually transmitted infection. Then there would be an indication to do HPV test. The reason HPV test is not recommended for all women is because there is not yet sufficient data on its effect on mortality and incidence of invasive cervical cancer.

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HPV Vaccine for Boys Reduces Incidence of Genital Warts and Cancer

A couple taking a funny picture with their car. (iStockphoto)

In 2008, in one of my columns, I wrote about the importance of vaccination against human papillomavirus (HPV) infection. It is beneficial to young teens before they have had sexual contact. The vaccine has demonstrated high level of antibody response amongst teens who have not been exposed to the virus. Initially the target group was young girls. By preventing HPV infection, we can prevent deaths from cervical cancer.

The vaccine is almost 100 per cent effective against four types of HPV, two of which are responsible for 70 per cent of all cervical cancers. The vaccine may have cross-protection against some other HPV viruses. Unfortunately, HPV infection can occur with the first sexual intercourse, and half of Canada’s young women become sexually active by age 16.

In 2007, Australia became one of the first countries to implement a nationally funded HPV vaccination programme for girls and young women. An editorial in the British Medical Journal published on April 18, 2013 titled, “HPV vaccination – reaping the rewards of the appliance of science,” lauds the Australian effort and its success. The analysis of data on 85,770 new patients from six Australian sexual health clinics showed a remarkable reduction in the proportion of women under 21 years of age presenting with genital warts – from 11.5 per cent in 2007 to 0.85 per cent in 2011.

The near eradication of genital warts in young Australian women will probably have a major impact on the costs of sexual healthcare. Now it is time for the boys to do something about sexually transmitted infection. Many young boys are sexually active. They show up with venereal warts from HPV infection. Kudos to Prince Edward Island (PEI). It has become the first Canadian province to extend publicly funded school-based HPV vaccination to boys, as reported by the Canadian Press on April 19, 2013.

In 2007, the National Advisory Committee on Immunization (NACI) recommended that girls and women aged nine to 26 be vaccinated for HPV. In 2012, NACI included males of the same age in that recommendation to prevent genital warts and anal-genital cancers.

On April 25, 2013 the Canadian Press (CP) reported a policy statement released by the Society of Obstetricians and Gynecologists of Canada asking provincial and territorial governments to extend HPV vaccination programs to cover boys as done by PEI. Common sense would say that it is difficult to justify not offering boys the same protection as girls get.

CP report says provinces and territories have been slow to follow the advice, given the high cost of the vaccines, which are administered in three doses. A full course of HPV vaccine costs between $400 and $500 if purchased outside the provincial programs, where the shots are provided for free. But the experts say health care cost savings from reduction of genital warts and its consequence over months and years should take care of the cost of the vaccine.

It is time boys get the same protection as girls.

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Anal Cancer Can be Misdiagnosed as Hemorrhoids

Anal Cancer

You may recall, Farrah Fawcett, one of the Charlie’s Angels, was diagnosed with anal cancer in 2006. Three years later she died.

There is no need to panic. Anal cancer is fairly uncommon. It accounts for about one to two per cent of gastrointestinal cancers. About 4,000 new cases of anal cancer are diagnosed each year in the U.S.A., about half in women. Approximately 600 people will die of the disease each year.

In Canada, incidence of anal canal tumours is approximately 515 cases per year with annual incidence rate of 1.3 per 100,000 population. Review of cancer registry by researchers has shown that the incidence of anal cancer in Canada is increasing.

Anal cancers can be just outside the anus (perianal) or inside the anus. The anal canal extends from the anal verge to the upper border of the anal sphincters, and is approximately four to five cm in length. The skin for a five cm radius around the anal verge is called the perianal skin or anal margin.

What are the risk factors for developing anal cancer?

We do not know the exact cause of most anal cancers. But we know certain risk factors are linked to anal cancer. Most people with anal cancer are over 50 years old. Having anal warts significantly increases the risk. Anal warts are caused by infection with the human papilloma virus (HPV).

Persons who participate in anal sex are at an increased risk. Use of condoms is highly recommended to reduce the risk. Harmful chemicals from smoking increase the risk as well. People with weakened immune systems, such as transplant patients who must take drugs to suppress their immune systems and patients with HIV (human immunodeficiency virus) infection, are at a somewhat higher risk.

People with long-standing anal fistulas or open wounds are at a slightly higher risk. People who have had pelvic radiation therapy for rectal, prostate, bladder or cervical cancer are at an increased risk.

What are the symptoms of anal cancer?

Mostly they are no different than symptoms of hemorrhoids. That is why patients should stop saying, “Doctor, my hemorrhoids acting up again.” When you see your doctor, say what symptoms you have and let him/her make the diagnosis.

Most patients will complain about bleeding, itching, feeling of a lump, may have pain, narrowing of stools, discharge and staining of underwear and in advanced cases there may be enlarged groin lymph glands.

Biopsy is required to confirm the diagnosis. Treatment of anal cancer depends on the extent of the problem and may include surgery, radiotherapy and chemotherapy. Anal cancer can be prevented or picked up in early stages by eliminating the risk factors mentioned earlier and having your butt checked out on a regular basis. Follow the protocol for screening for anal, rectal and colon cancer. For more information, visit my website: www.nbharwani.com.

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Genital Warts Can Be Difficult To Eradicate

This is the most common sexually transmitted disease. It is estimated that one per cent of adults who are sexually active have warts in the genital or anal area. In the U.S. alone, one million people will develop genital warts each year. Of these, 25 per cent will have recurrent warts. And that is frustrating for the patient and the doctor.

Genital warts are also called condylomata acuminate or venereal warts. The warts are benign and are caused by human papillomavirus (HPV). There are at least 60 types of HPV. Genotypes six and 11 are found in over 90 per cent of cases of genital warts and genotypes 16 and 18 cause cervical cancers.

The virus is transferred from person to person or from contact with something someone has touched. In women, genital warts can grow on the outside or inside of the vagina, on the cervix, in the urethra or around the anus. In men, warts can grow on the tip or shaft of the penis, on the scrotum, in the urethra or around the anus.

How do you get genital warts?

Most, but not all, genital warts are sexually transmitted. Generally speaking warts are more common amongst people whose immune system is poor. But most people who get warts are healthy and well.

How do you know you have genital warts?

Most people with genital warts have no symptoms. By the time a person is infected and by the time the warts appear may be many months or years. The good news is most of those who get infected never develop warts.

The warts are soft fleshy lumps on or near sex organs or anus. Some people have itching or burning. Warts may be hidden in the vagina or anus.

What are the implications of the disease for patients?
The lesions are benign but they do cause psychosocial distress and may affect relationships as the warts are disfiguring and can be transmitted sexually. Genital warts also increase the incidence of cancer in the genital and anal area. Practicing safe sex is important. It is advisable to use barrier protection with new sexual partners. Condoms can reduce the risk of getting genital warts but warts can spread from areas not covered by a condom. Patients who are in stable relationship may not need barrier protection because the partner is already exposed to infection by the time patient sees a doctor.

How do we manage warts?

No specific treatment is appropriate for all patients and a person will need more than one treatment to clear the warts.

Most treatment plans will achieve clearance of virus within one to six months. In 20-30 per cent of patients new warts will occur over months or even years. Patients can treat themselves with podophyllotoxin (0.5 per cent solution or 0.15 per cent cream) and imiquimod (5 per cent cream). Imiquimod is expensive and podophyllotoxin takes longer to cure the condition.

Physicians can treat warts in the office by using trichloroacetic acid or by physical removal using cryosurgery (liquid nitrogen), electrosurgery and excision or laser treatment. In my surgical practice I use electrosurgery and/or excision.

The US Food and Drug Administration (FDA) has approved a new indication for a quadrivalent recombinant vaccine (Gardasil, Merck & Company, Inc) for the prevention of genital warts caused by human papillomavirus (HPV) types 6 and 11 in boys and men aged nine through 26 years. Since the vaccine does not cover all the viruses, about 30 percent of cervical cancers and 10 percent of genital warts will not be prevented by the current vaccines.

The HPV vaccine will not have an impact on an existing infection or any consequences of infection, such as anal and genital warts and cancerous or pre-cancerous changes that you may already have. It is very important to practice safe sex with your partner.

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