The saying that politics makes for strange bedfellows took on a new low when Michelle Bachman came out with her ridiculous statement against HPV vaccination. (In case you didn’t get the pun…HPV infection is most frequently transferred in a bed … or for that matter in any place that allows for sexual contact.)  So I’ll skip the part where we ask why a responsible parent would not want to help diminish the chance that her daughter would get cervical cancer or genital warts. (Yes, their may be parents out there who think that their daughter will not be sexually active with anyone but the man she marries, but what guarantees do they have that the young man she commits to did not have partners before or after he proposed to and married her.) Long-term large studies have shown negligible side effects from HPV vaccination. Sudden “mental retardation” which of course is a truly nonmedical and impolitic term, cannot suddenly occur from a vaccine given to an adolescent girl! (I have given hundreds of shots in my office and at most have seen a few “ouches” at the site of injection.) Okay, I have to stop now and become scientific. Here are the facts I promised in the heading of this week’s newsletter:

There are more than 40 types of human papilloma viruses or HPV’s that infect the general tract; approximately 15 types have been linked with cancers and are classified as carcinogenic or high risk. We now know (or at least the scientists who do the testing know) that 99.7%of cervical cancer specimens, as well as their precancerous predecessors, test positive for at least one of these high risk HPV’s. (Just in case you want to complete your viral numerical knowledge…they are HPV-16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 66, 68, and 72.) The most common onset of infection occurs in the first years of sexually activity. Thankfully most of the infections in young women and men resolve within 2 years. In a small proportion of women however, HPV infection persists. If this happens, the virus may enter the DNA of cervical cells and cause mutations, which over time can result in precancerous lesions that progress to cancer.  HPV viral infections are extremely contagious. (Put bluntly, a touch of a penis harboring the virus will pass it on.) And there are usually no lesions that signify viral presence. It’s a “down there” scenario akin to that portrayed in the movie Contagion; but with HPV, the consequences of the viral infection occur years later. If a woman has sex with someone, she essentially has a viral contact with everyone he or she has had sex with and everyone those individuals have had sex with… etc., etc.

So it’s not surprising that at least 80% of women will, at some time in their lives, have an HPV infection…most commonly when they are young or when they are exposed to the virus through new or non monogamous partners. In most young women, the virus will clear. In the few in whom infection persists, it takes at least 2 to 3 years for potential progression to a precancerous lesion and more time until it can cause cancer. So adolescents and young adults have a very low risk of developing cervical cancer.

Obviously many young women will initially harbor one of the HPV viruses and as a result may also have some mild changes in a Pap smear screening. If these changes are found and pronounced abnormal, they (and their moms) will go through a lot of unnecessary anxiety over something that usually clears up… and even worse they may go through unwarranted surgical procedures that can scar the cervix and impact their future ability to conceive or have a normal vaginal delivery.

To help avoid unwarranted concern and cut down on unnecessary procedures, the American College of Obstetricians and Gynecologists (ACOG) has released guidelines that should make us all relax with regards to screening. They state that Pap smears should begin no earlier than age 21. And from 21 to 29 women should be screened every 2 years. (But this does not negate the need for annual pelvic exams and, if necessary Chlamydia and other STD testing should be done more frequently.) It’s recommended that by age 30 all women should undergo screening with HPV testing as well as a Pap smear. If both tests are negative and the woman has no new partners, she can then be tested every 3 years. (But again a yearly pelvis exam should be done, and if a woman has a new partner or if she is not sure of the monogamy of her current partner, testing should be more frequent.) All women in high-risk groups (women with HIV, those on immunosuppressive medications, women exposed to DES in utero and women who test positive for high risk HPV or who have been treated for cervical precancerous or cancer) should be screened frequently.

The current vaccines protect against 2 types of high-risk HPV infections that cause 70% of cervical cancers. These vaccines will not cure or get rid of HPV infections that are already present. Hence the best way to help prevent cervical cancer is to vaccinate young women (and ideally young men) before sexual activity occurs. In medical parlance this is when the young person is “sexually naïve”. Because other high-risk HPV’s, which are not covered by the vaccines, can still cause 30% of cervical cancers,  young women who receive the vaccine will still need to begin cervical cancer screening when they reach the age of 21. But when administered at the right time the vaccine will insure that the majority of cervical cancers won’t occur. What’s political about that!

In the “there is nothing I can do about it” category, there was a very interesting article published in a recent Lancet Oncology. If you are taller than 155cm (just 5 feet 1 inches), the conclusions in this article should make you stand up and pay attention:

Researchers in the United Kingdom and Spain took data from the Million Women Study that has followed 1,297,127 (so more than a million) middle-aged women for 10 years. Among these women, 97,376 cancers occurred. The researchers grouped the women into height categories and compared them to a reference group that was 155cm tall. They then looked at the incidence of 17 different cancers. Lo and behold, the relative risks of 10 types of cancers were found to significantly increase by about 16% for every 10cm (3.94 inches) increase in height. So just to do the math for you; if your height is 5’5″ (the average woman’s height in the US is 5’4″) you are approximately 16% more likely than a woman who is a “petite” 5’1″ to get one of these cancers. If you are like me and are 5’7″ (170.1cm to be exact), according to this study, you’re about 24% more likely to develop certain malignancies than that 5’1″ woman.

The cancers that appear to be heightened by height (sorry, I couldn’t help but bring in minimal word play) include: colon, rectum, malignant melanoma, breast, endometrium, ovary, kidney, non-Hodgkin lymphoma and leukemia. The smoking related cancers (especially lung cancer) were, however, not strongly related to height. (Smoking itself is such a predominant factor that it cancels out height.) The researchers factored in other variables such as socioeconomic status, alcohol, body mass index, physical activity, age at menopause, number of births, age at first birth, menopausal status, use of birth control pills and hormone therapy and couldn’t detect a difference in these “height stats”. The finding that greater height increased risk for these 10 cancers simply did not vary as a result of these factors.

To make these results even more convincing, 10 other studies conducted on both men and women in Europe, North America, Australia and Asia found a similar correlation. Geography and race just didn’t seem to matter; which leads to the theory that there is a basic height (not mass) mechanism at work that increases cancer risk. And although no one is sure what causes this, there are several theories:

We reach our final height in our 20′s. Factors such as childhood nutrition and growth factors might be relevant to both gaining those inches and causing a later increase in cancer risk. Taller individuals may have more stem cells, which then have a greater opportunity to undergo mutations, or height may cause an increase in cell turnover (which means that as they die they create new ones to replace them) and this may increase the chance that mistakes are made and mutations leading to cancer occur. Whatever the theory, the realty of risk, when one is taller seems small but significant. Perhaps I shouldn’t decry the fact that my daughters never grew taller than 5’5″.

We can’t change our height, but the bottom line for this type of epidemiologic study is that those of us who are taller than 5’1″ should get appropriate cancer screening. But to be fair, this advice should not be height driven and should include all women!

 I have always felt that part of my medical title is a gender misnomer: “Fellow of the American College of Obstetricians and Gynecologists” (abbreviated FACOG). But then I guess “Fellowette” would sound weird. Every gynecologist who finishes her or his accredited residency and subsequently passes the written and oral boards becomes a FACOG of what we, the initiated, fondly call the College.
 
The College has recently issued new breast cancer screening guidelines, which, indeed, comply with what most physicians were already suggesting to our patients. But to do away with any confusion, I want to officially pronounce them…
 
They now recommend that mammogram screenings be offered annually to women from the age of 40. Previous College guidelines recommended mammograms every one to two years starting at 40 and annually beginning at age 50. The chief reason for this change is the issue of “sojourn time”. This is defined as the time between when breast cancer may be detected by a mammogram while it is very small, and before it grows big enough to become symptomatic (and can be felt). The greatest predictor of sojourn time is age. Women ages 40 to 49 have the shortest average sojourn time (2-2.4 years), while women ages 70 to 74 have the longest average sojourn time (4-4.1 years). So although the incidence of breast cancer is less in women in their 40′s, the window of opportunity to detect tumors before they grow is shorter than that of women after the age of 50. The five-year survival rate is 98% for women whose breast cancer tumors are discovered at their earlier stages. Waiting two years between mammograms in this younger age group may be too late for early detection and treatment.

Having stated this, the College does not recommend mammograms before 40 unless a woman is high risk for breast cancer. If she is, then earlier mammograms, frequent clinical breast exams and annual MRI (magnetic resonance imaging) may be recommended. Breast MRI is not recommended for women at average risk for developing breast cancer.

Other recommendations of the College include:

Clinical Breast Exams (CBE):  This should be done by your physician annually after the age of 40. CBE is felt to help detect breast cancer, particularly when used along with mammograms. Although the benefit of CBE isn’t clear for those younger than 40, the College continues to recommend CBE every one to three years in women ages 20-39.

Breast Self Awareness (BSA): This is the new term used instead of self-breast exams. Studies have indicated that the oft taught self breast exam, (you know start at 12:00 and kneed all your breast tissue with the opposite hand, either in quadrants or clockwise), has not shown a decrease in breast cancer mortality. On the other hand, we can’t discount all the women who have found their own lump and proceeded to have breast conserving and life saving surgery. So the College now recommends that women “understand” the normal appearance and feel of their breasts, and if they sense a change, no matter how small, that they report it to their physician.

Age Limit for Mammograms: The College has not reached a consensus on this, although, apparently the benefits of screening decline with increasing age compared with the harms of over treatment. So women over 75 should discuss whether to continue getting mammograms. (I feel that if a woman at that or greater age is otherwise healthy and expects to maintain her relative health for the next decade or more, she should continue to get those mammograms!)

We’re seeing fewer deaths from breast cancer… early detection as well as better therapies are helping. So let’s keep abreast of guidelines for both and maintain this trend.

I was asked to do an interview for the Oncology Show on SiriusXM on Wednesday, September 7. The subject was ovarian cancer. This month has been designated Ovarian Cancer Awareness month and since my website is all about awareness, (and I have to summarize the data for the radio show anyway) I thought I would share it with you. So here is a summary of the facts from the Ovarian Cancer National Alliance which you can also download at www.ovariancancer.org:

In 2010, an estimated 21,880 women had ovarian cancer in the United States and 13,850 women died, making it the most lethal gynecologic malignancy.

Unfortunately, the mortality rates from ovarian cancer have not improved in thirty years since the “war on cancer”. (They have improved for breast and cervical cancer.) Although this cancer is so often lethal, the Surveillance, Epidemiology and End Results (SEER) Program reports that as of 2006 in the US, over 176,000 women were alive who had been diagnosed with ovarian cancer and this included those who had been cured.

But before these scary facts cause a massive request for ovarian removal surgery (oophorectomy), I do want to put this disease in perspective… A woman’s lifetime risk of developing ovarian cancer is 1 in 71 (whereas our lifetime risk of developing breast cancer is 1 in 8). And we are all not out there requesting mastectomies!

Ovarian cancer primarily develops in women over 45 and indeed the median age of diagnosis is much older… 63. The average age of death from ovarian cancer is 71.

Survival rates depend on the stage of diagnosis. If the cancer is diagnosed early and is localized, the 5-year survival is 93.8%. (But only 15% of ovarian cancers are diagnosed this early). If it is diagnosed when it is regional, i.e. it has spread “only” to nearby lymph nodes or organs and tissue, the 5 year survival is 72.8%. (This represents 17% of the women diagnosed.) And if it has spread to distant organs or lymph nodes (about 70% of women), the 5 year survival goes down to 28.2% or less.

The reason that this type of cancer is diagnosed at such a late stage is that we don’t have reliable screening tests for ovarian cancer. Ideally, we would want a blood test that would be positive in early cancer… either a test for a protein that is specific to ovarian cancer, a sensitive genetic test for “typical” mutations seen in ovarian cancer cells or a marker of some kind that could alert physicians that the cancer is present. Most of you have heard about the blood test for CA 125. This is a protein that is often present in greater concentration in cancerous cells. Unfortunately, however, it can also be elevated for many reasons (other than cancer) in premenopausal women. Moreover, it is not elevated in 50% of early ovarian cancers and likewise is not elevated in 20% of advanced cancers. CA 125 also can be elevated for benign causes such as uterine fibroids, endometriosis, and inflammation of the fallopian tubes as well as other cancers. None of the organizations that give recommendations for health care and screening suggest that a blood test for CA 125 be routinely used to screen all women. However, if a mass is found and/or a woman who has had this cancer is followed it can be helpful in evaluating her tumor’s response to therapy.

There is one other blood test that has been approved to help delineate a benign from a cancerous ovarian mass… it’s called OVA1. Again, it’s not a screening test and is only currently approved in order to help distinguish whether an ovarian tumor or cyst is indeed malignant, prior to surgery (or to decide if surgery is necessary).

So how do we diagnose “a suspicious ovarian mass”? First, through pelvic exam (and yes even if you don’t need a Pap smear yearly, you should have a pelvic exam by your gynecologist.) Beyond a simple bimanual exam, trans-vaginal pelvic ultrasound may be an option. With this we can visualize the ovaries and “see” cysts and masses. Malignant tumors often show up as a combination of clear cystic areas, as well as opaque solid ones… the latter may look like fingers (or claws) that are ominously attacking the ovary and pelvis. Unfortunately, many of these ultrasounds are false positive… they show “things” that are not ovarian cancers and as a result unnecessary surgeries are done. (See my article in a previous newsletter titled, “To Screen or Not to Screen: The Current Data on Ovarian Cancer” with information from an article published in JAMA, June 2011.)

Having given you these discouraging statistics, there are situations in which physicians can help patients achieve an early diagnosis and receive life-saving therapy. First, as you probably know, some ovarian cancers (probably 10% to 15%) are genetic. The currently known inherited mutations for ovarian cancer are in two genes: breast cancer gene1 (BRCA1) and breast cancer gene 2 (BRCA2). Eastern European women and women of Ashkenazi Jewish descent are at higher risk for carrying one of these mutations. Another known genetic link to ovarian cancer is hereditary non-polyposis colorectal cancer also called Lynch Syndrome. If a woman has a family history of ovarian cancer, early breast cancer, multiple family members with breast or ovarian or colon cancer she should talk to her doctor about genetic testing. And this should probably be done between the ages of 30 and 40. If indeed she is positive, then consideration should be made to having both ovaries removed (once she finished child bearing) as well as early screening for breast cancer with MRI and mammograms or even prophylactic mastectomy. Until the ovaries are removed, ultrasound and CA 125 blood tests should also be done.

There are other less significant risk factors for ovarian cancer, and these include:

·    Early menstruation (before 12)
·    Not giving birth to a child
·    Having a first child after the age of 30
·    Menopause after age 50
·    Obesity
·    Never taking oral contraceptives

(Notice that all these factors are associated with lengthened duration of the years that a woman ovulates… over time all those ovulations or at least the ovarian activity that accompanies them, may increase the risk of damage and mutations to ovarian cells.)

I know many women who have had fertility therapies have been told they are at risk… but it turns out that it’s the conditions that caused the infertility and the lack of early childbirth, not the therapy itself that may increase risk.

Finally, let me go over possible early symptoms; ones that you should bring to the attention of your physician. These include:

·    Bloating
·    Pelvic or abdominal pain
·    Difficulty eating or feeling full quickly
·    Urinary symptoms such as frequency and urgency

Obviously, these symptoms are very nonspecific and common. But if they continue for a few weeks, don’t ignore them. This is where a thorough examination, urine tests, pelvic ultrasound, blood tests and perhaps even CT scans or an MRI should be considered.

The next question that I am often asked is, “What can I do to prevent ovarian cancer?” There is no specific ovarian cancer prevention drug. However, we do know that if during your reproductive years you use oral birth control pills for 5 years you will decrease your chance of developing ovarian cancer by 50%. Also, it turns out that tubal ligation and hysterectomy (even if the ovaries are left intact) reduce the risk of ovarian cancer. And finally, for women who have the aforementioned mutation, removal of the ovaries will prevent the cancer (although in very rare cases a similar cancer of the peritoneum or lining of the abdomen can occur, but I repeat, this is very rare.)

Since this is ovarian cancer awareness month, I would not be doing my public health duty if I didn’t state that we now have gynecologic oncology-specialty surgeons who can give a woman diagnosed with ovarian cancer the best chances for survival by removing as much as possible of the cancer at initial surgery. So, if a diagnosis of an ovarian malignancy is made or felt to be possible, a specialized surgeon should be present at the initial surgery. And subsequent to that, oncologists are using life-saving and life-maintaining chemotherapies. New therapies are currently under investigation in multiple investigational trials.

In the future, treatment for a diagnosed ovarian cancer may include a personal vaccine against the specific cancer cells. Better yet, an accurate early diagnostic test will, we hope, be developed. So let’s all advocate for appropriate federal funding. We deserve it!

I just had to come out on my website… about one more reason not to smoke (or continue to smoke!). An article in the Archives of Internal Medicine titled “Midlife Smoking and Dementia” happened to catch my eye. It was a study of 21,123 middle-aged members of a health care system who participated in a survey between 1978 and 1985. Diagnoses of dementia, Alzheimer’s disease and vascular dementia were collected 23 years later and found in 5,367 individuals. Adjustments were made for age, sex, education, marital state, hypertension, high cholesterol, obesity, diabetes, stroke, heart disease and alcohol use (whew!). The researchers found that those who smoked more than 2 packs a day had over twice the risk of dementia, 2 1/2 times the risk of Alzheimer’s and 2 and 3/4 times the risk of vascular dementia as those who did not smoke during their middle age. The authors commented that smoking increases oxidative stress and inflammation which may be mechanisms involved in the development of Alzheimer disease.

Now I just want to add some additional smoking stats that appeared in an editorial in Lancet. (At least you’ll know I’ve been doing my medical journal reading.) Worldwide, close to 6 million people die of smoking related illnesses, including cancers, heart disease and stroke. And by 2030 the projected deaths per year from smoking will be as much as 8 million per year (That’s a small country!). The total death toll from tobacco use could be at least 1 billion in this century. Yes, governments in some countries (16 to be exact) have done something about this, such as banning smoking in public places, but most, especially low-income and middle-income countries have not.

Tobacco manufactures pay governments $133 billion in excise taxes, but governments spend less than $1 billion on tobacco-control policies. Obviously, the winners are the tobacco companies and the losers are those who still smoke and of course all those who help fund the billions of dollars in health care needed to care for them. Some of you may remember those smoking ads geared towards women: “You’ve come a long way, baby”. I think we should rephrase it to governments, states and all those yearning to be health and smoke-free… “You have a long way to go, so get going!”

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