Today’s Cervical Cancer Treatments

>>Hi. Welcome to our Facebook Live event on cervical
cancer. I’m Christina Annunziato from the Women’s
Malignancies Branch in the National Cancer Institute.>>And I’m Sarah Tempkin. I’m the Division Director of Gynecological
Ca– Gynecological Oncology at the Massey Cancer Center in Richmond Virginia at the
Virginia Commonwealth University and we’re here today to talk about cervical cancer.>>So Sarah why don’t you start out by telling
us what is the cervix? Where is that in your body; what part of the
body is that in?>>So sometimes women can actually be confused
a little bit about their own anatomy and so it’s remem– it’s important to remember that
the cervix is separate from the vagina and it is actually technically part of the uterus,
even though the two fun– the two organs function separately so they have different names and
the cervix functions to act as a barrier to infection so that the uterus is protected.>>Exactly. So you can imagine that the first place a
virus might infect if it was attacking the female genital track would be in fact at the
cervix, at the cervix part of the uterus. So what is HPV; what is human papillomavirus? Human papillomavirus is a very common virus. It is ubiquitous everywhere and it has about
100 different strains of the virus. Only about four or six of those strains can
actually cause cancer. Most of the viruses don’t cause cancer; most
of the strains don’t cause even genital warts and can be asymptomatic. But there are those few cervical– those few
viruses that infect the cervix that can lead to cancer, and those are the ones that we’re
worried about.>>We’re always talking about HPV and cervical
cancer together and part of the reason for that is because nearly all of cervical cancer
is caused by HPV.>>Absolutely, and that leads us to screening;
how can we detect HPV? Did you want to talk about screening guides?>>Yeah cervical cancer screening is very
very important, and it’s sort of a model for how to detect disease early. Even before we know about the HPV virus we
knew how to screen for cervical cancer, and the way that we’ve done that historically
for decades is through the Pap smear, and by using the Pap smear we’ve reduced the incidence
of cervical cancer very rapidly in the United States such that there’s only about 12,000
cases per year. But the Pap smear has now even become a better
test recently as we’ve known about HPV because for women over 30 the HPV test can be combined
with the Pap smear to make the test work better.>>And this is an important topic. Screening is something that we are going to
be posting comments about in our section on the– on the– in the comments.>>And so a woman who has an abnormal screening
test it doesn’t necessarily mean that there’s something wrong with you or with your cervix,
it means that you need additional tests to be done. And in the case of the Pap smear and cervical
cancer that usually means having a colposcopy, which means that a microscope is pointed at
the cervix and if there are any abnormalities a biopsy can be taken. And using the information from that procedure
a diagnosis can be made. If the cancer is diagnosed early and confined
to the cervix then usually surgery is performed as the next step. For some women this can be fertility sparing,
however, for the majority of women this includes a hysterectomy. If the cancer has spread further when it’s
diagnosed we generally refer to that as locally advanced cervical cancer and radiation therapy
is the main stay of treatment for this type of cancer, although we will often times combine
chemotherapy with radiation.>>And then if the cancer spreads beyond the
pelvis, if it spreads beyond the immediate organs then that’s where chemotherapy is used
in the frontline. Chemotherapy is usually a type of chemotherapy
called paclitaxel in combination with cisplatin and in 2014 it was shown that an anti-blood
vessel drug called Bevacizumab actually improves survival of women with advanced stage cervical
cancer such that Bevacizumab is now approved for use in front line from the FDA.>>So also when treating cervical cancer it’s
important to remember that one patient may not be treated exactly the same as another
one and your doctor’s going to make the ultimate decision and combinations of different types
of therapy may be appropriate for– for different– different patients.>>That’s a good point. That’s a good point. There are other chemotherapies that can be
used in addition to the ones that I mentioned. But even better than actually treating advanced
disease it would be better if we could even prevent it. Can we talk about vaccine and prevention?>>So cervical cancer prevention through vaccination
has been sort of a hot topic this month, which is cervical cancer awareness month, and one
of the reasons is that there was a statement from the cancer centers– NCI designated cancer
centers promoting its use and really saying this is important for cancer prevention. Traditionally the United States has sort of
lagged behind the United State– behind other developed countries in terms of vaccination
rates, but this year in 2016 we had six out of 10 girls vaccinated and five out of 10
boys vaccinated.>>That is great and we can also post in comments
more additional details about vaccination as well. What are the most important reasons to get
girls and boys vaccinated?>>So HPV, the HPV vaccination can prevent
HPV infection by nine different HPV types, seven of those are oncogenic or cancer causing. The– those tend to be the most prevalent
types of HPV that can cause cervical cancer. It’s very important to remember that the vaccines
should be given if possible before the onset of sexual activity so that a girl or boy has
not yet been exposed to HPV. Some of that is about immune function in teenagers
as well.>>Yes I think there have been some recent
studies even that show that two vaccinations instead of the usual three can be given if
it’s given before the pre-teen years even, so well before the onset of exposure to the
virus. There– as I mentioned before there are human
papillomavirus strains that can cause infections that don’t cause cancer. There are also– there’s also the immune system
of the person who is infected that can actually fight the virus and get rid of the virus before
it causes cancer. But again there are– there’s very very strong
evidence that these vaccines can prevent cancer.>>And for girls and boys that missed the
vaccine it’s still available and approved up until age 26 so it’s re– it’s important
to remember that– that you can still go ahead and give it. And besides cervical cancer there are other
kinds of malignancies that can be related to HPV.>>Absolutely, the other malignancies include
malignancies of the throat, also of the other parts of the GI tract, and so those can also
be prevented by the vaccination. But what about if you do have cervical cancer
and the cervical cancer has spread to parts of your body? We have very exciting new research going on
throughout the country. As I mentioned, one of the hot topics in 2014
was the anti-antigenic drugs, and that was actually approved based on the most recent
clinical trial.>>That was an NCA– NCI funded trial.>>It was an NCI funded trial actually. What about some more recent trials with radiation?>>Well right now since radiation is really
the mainstay of treatment for locally advanced disease the NCI is investigate– investigating
other ways to make radiation work better. One of those ways is to add additional chemotherapy
with radiation at the completion of– of radiation and that’s actually an ongoing international
trial. There also are different agents that are being
combined with radiation and one of them is called Triapine, which can affect the way
that cells, cancer cells, function and their metabolism and that trial is also currently
underway and is NCI funded at various different sites within the United States.>>And in the intermural program here in the
NCI itself we have several immunotherapy trials going on for cervical cancer. Actually if you think of the way the cancer
is actually started it’s started by a virus and a virus can have effects on your immune
system. So there are researchers here at the National
Cancer Institute that are trying to use the immune cells actually to boost their anti-cancer
function.>>And then it’s also important to remember
that we may have other trials or there are other trials ongoing about how to improve
screening, vaccination, and quality of life for women who are affected by this disease,
and those are also– should be available on– trials dot– what is
the site?>> is where we have our
link. But again that’s in the comments and we can–
you can find more details there.>>So if cancer is– if cervical cancer can
be prevented or caught early then I guess one of the other questions that people ask
is why dos cervical cancer still exist?>>Mm-hmm. Right, so there have– there’s a lot of disparities
in healthcare throughout the United States. Actually 50% of patients who are diagnosed
with cervical cancer have never had a pap smear in their lifetime, so there is that
sort of lack of exposure to the healthcare system. Screening rates have been different between
different groups throughout the country, and there’s also issues with funding.>>Well screening rates are pretty similar
between different minority populations in the United States and there have been a lot
of programs where women who may not have health insurance or access to care are able to get
Pap smear screening. I think some of the problem comes in follow
up and access to treatment even when a screening test is abnormal. We looked at the rates of cervical cancer
treatments in Maryland a couple of years ago and found that actually women, underrepresented
minorities specifically black women, were 50% as likely to get surgery for cervical
cancer when compared to non-black women. And so access to care is– is a really important
question.>>Yeah, so I think the more recent findings
that two vaccines can be as useful as three that might help start less– start help leveling
the playing field for people if they have to sort of come back less in order to get
the same efficacy. To reiterate again both girls and boys can
get the vaccination and that’s– that can help stop the development of cervical cancer
and also other cancers, as we mentioned of the head and neck and other places in the
GI tract as well.>>And we haven’t yet seen a decline in cervical
cancer or HPV related cancers in this country but we have since the vaccine was approved
10 years ago seen a decline in the rates of HPV infections, which is very promising and
makes, I think, people like me who take care of women with this disease very hopeful that
over time we will see a reduction in the number of cervical cancer cases in this country,
because actually the rates of cerv– of vaccination have not had the same levels of disparities
as some of the– of access to some of the screening and treatment modalities that we’ve
had in this country, and some of that is that kids can get vaccinated at school or they
may have more access to vaccines than adults, who require treatment.>>And I think yeah, the effects of the vaccine
are going to take a while to be seen if we’re vaccinating the young population and then
the cancer doesn’t appear until later in life we won’t see those effects until maybe a decade
or so.>>So one thing I want to remind everybody
though is that when we’re talking about vaccination this has not yet meant that you don’t need
to be screened for cervical cancer. Even though you’ve had the vaccine you still
need to get your pap smear, which is recommended to start at age 21, and then see your doctor
and talk to your physician about any abnormal test results because even though the HPV vaccine
can prevent a lot of cervical cancer it does not have– it does not 100% change– chan–
it does not 100% prevent cancer.>>Absolutely. Absolutely, and as you mentioned, when you
get the Pap smear there needs to be consistent follow up. So let’s go ahead and take some questions. I believe we have received questions from
the audience. We have our first question here; do cervical
changes caused by HPV ever go away on their own?>>So since most people do get HPV at some
point in their life we know that not everybody who gets an HPV, actually a minority of people
who get the HPV virus will go on to develop cervical cancer. And so one way to think about this is that
most people clear the HPV infection on their own by their own immune system, and so– so
even with people who do have Pap smear abnormalities or even some of the colposcopy biopsy abnormalities
that we see we recommend watching them because they can go away on their own. This is not true for high grade cervical bi–
cervical lesions or for cancer; those should always be treated and taken very seriously
but those are– it’s important to remember that some of those– some of the HPV will–
will go away on its own.>>Yeah, so– so that is incorporated into
official guidelines that your gynecologist will be able to refer to. We have them in our comments as well and–
but this is something that should be an ongoing conversation with your treating doctor.>>Here’s another question I think Christina
you should probably answer that’s about what treatments for cervical cancer are being tested
right now.>>So there are many cervical cancer trials,
as we mentioned, on and one of the ones that I highlighted before
was the immunotherapy trials. That’s for patients with cervical cancer that
was treated initially and then has come back. That is a very exciting area and really can
show a lot of promise in the immunotherapy world. There are other trials, as Sarah mentioned,
to treat earlier stage disease in the initial setting and that involves adding things to
radiation or adding other drugs.>>There’s some trials adding immunotherapy
to radiation to see if those– if the combination of immunotherapy and radiation can do better
at killing cancer cells and may make either one of those treatment modalities more effective,
and I think that’s a really exciting new way that we’re trying to think about advanced
cancer care.>>Absolutely. So I think we just received another question,
where are we for targeted therapies relating to cervical cancer? And as we mentioned, there are a number of
very exciting new developments in cervical cancer. One of the ones that I mentioned earlier was
the anti-angiogenesis — anti-angiogenesis. We also have very exciting developments in
the pre-clinical setting that are moving towards the clinic, which are looking at cell cycle. We didn’t go into too many details about the
molecular aspects of HPV but it does– the virus itself does have proteins that can affect
the way the cell actually replicates itself.>>Well we talked about in the beginning how
almost all cervical cancer has– has HPV involvement in it, which means that almost we can use
that target and so I think part of the question is how do we use the target as effectively
as possible, and so, you know, this is where some of the immunotherapy– immunotherapy
can actually be sort of non-specific in some tumor types, but for HPV it can be– it can
be very– very specific. And there are new therapeutic vaccines which
are being developed as well, which are vaccines to actual proteins on the– on the cancer
cells that are related to the– to the old or active HPV infection. So some of those are very exciting as well.>>Yes very very promising. Yes absolutely. So we have another comment about which are
the best immunotherapy drugs for cervical cancer. These are– this is a very hot topic. Again, we have clinical trials ongoing that
are targeting these new areas of immunotherapy that have been recently approved for melanoma,
for lung cancer, and this is a way to sort of remove the suppression of the immune system
that cancer can cause. Cancer can block the way the immune system
functions and these new drugs are designed to block that block actually, remove that
block and allow the immune system to come in and kill the cells irrespective of the
individual proteins that we were talking about before.>>Right. And there was a very exciting publication
last we– last year– last year? Yeah last year about using–>>Last year now yeah.>>I think last year, about using some of
the therapeutic vaccines, so the difference between a preventative vaccine is that the
patient gets the vaccine before they develop the disease and a therapeutic vaccine is a
vaccine that patients get after they already have the disease and it’s to augment the immune
response. And so that trial actually– that clinical
trial when it was published revealed that some of the therapeutic vaccines are able
to help the body get rid of, not cancer, this wasn’t a cancer trial, but pre-cancerous lesions
in the cervix. And so that’s another exciting trial that’s
been partially completed and should– should continue, which is looking at a thera– therapeutic
vaccine in the– in a advanced cancer setting.>>Yes. Now these therapeutic vaccines are very promising. None have been yet FDA approved but they are
in clinical trials and again we can find some more information on those in our comment section.>>Because there’s so few really good standard
of care treatments with this disease, you know, we’re really excited about having patients
participate in clinical trials and it’s important to ask your doctor about clinical trials or
look on the NCI website to find what trials may be available to you in your– in your
area wherever you live.>>So we have another question, sort of getting
back to the– to the practice of this, and I think this would be a good question for
you, what age do you typically see cervical cancer being diagnosed for the first time?>>So cervical cancer– this is a really good
question actually, and it’s a little bit more complicated than you would think because in
different– different age groups get different– can get affected by cervical cancer differently. But most likely cervical cancer is diagnosed
starting at age 40 and then will level off– the rates will level off and plateau over
time. We recommend stopping cervical cancer screening
at age 65. However, recently, in fact this week, there
was a lot of press about a study showing that cervical cancer can continue– can continue
to affect women even as they get older and this is more pronounced in African American
women than in white women [coughs]. Excuse me. And so it’s important to, you know, it makes
us question some of our guidelines about when to stop– when to stop treatment and this
is something to talk to your doctor about. Certainly if you’ve had a history of an HPV
infection it may be useful to talk to your doctor about how often your screening should
be performed. The screening guidelines have changed a number
of times in the last decade such that some people are able to extend their interval between
pap smears but not everybody.>>Yeah I think that’s really important. It is really important to maintain a constant
conversation with your doctor when you’re discussing these issues about screening and
prevention and detection of early cervical cancer.>>Alright Tina I got my voice back.>>Okay go ahead.>>Can you– this is another question about
what kinds of cervical cancer are not related to HPV, because we’ve been talking about HPV
related cancers.>>Right, so as we mentioned before, HPV related
cancers, HPV cancers of the cervix are by far the most common type of cancer that we
see. There are rare types of cancer of the cervix
that are not related to HPV and these are small cell carcinoma of the cervix.>>You can get a melanoma of the cervix, which
always seem really– it’s very very rare also and seems strange to think about non-cutaneous
melanoma– melanomas.>>Yes you– so there are mucosa melanomas,
as you mentioned, that can affect the cervix and that can also affect other parts of the
female genital tract as well, exactly like you wouldn’t– you wouldn’t think of because
it’s not a sun exposed area. These types of cervical cancers have a completely
different approach to treatment. Typically they are as– if they’re very early,
again they can be excised with a procedure as Sarah was talking about at the beginning,
but typically they are treated very early with chemotherapy because they tend to be
chemo responsive. I’m thinking of the small cell type in particular.>>And then they’re always so complicated
because we’re so used to seeing HPV related cervical cancers. I think it’s probably several times a year
that I treat someone with a non-HPV cervical cancer and usually I ask for advice and it’s
presented at a tumor board so that multiple different opinions can be– can be combined
because these cases are very very rare.>>Right, and because they are so rare we
don’t really have standard guidelines and we base them on guidelines for other cancers
which have this sort of same picture which look the same but not necessarily came from
the cervix. So, for example, lung cancer is the most common
place to have a small cell cancer. So typically we would consider a small cell
cancer of the cervix to be treated the same way as lung cancer, but as you can imagine
that’s– there’s not a lot of evidence there, so it does take an ongoing group of people
to– to make these decisions and make these recommendations. But that brings us to another question that
we have here which is what kinds of questions should I ask my doctor before starting treatment? Sarah why don’t you take that one?>>Oh okay. So I mean I think it’s always really really
important to have good– to have questions prepared for your doctor, make sure that a
family member goes with you when you talk to– or a friend goes with you because sometimes
a visit with the oncologist can be very overwhelming and you want to make sure that you ask about
how this treatment is going to affect your quality of life, what the chances are that
this– that the cancer therapy is going to be successful, if there are alternatives,
and I always recommend that people see a second opinion whenever anything seems out of the
ordinary or if there are any questions that your doctor’s not answering well.>>I think another question that might be
interesting is if you are interested in participating in a clinical trial you might ask your doctor
are there any clinical trials available. There are clinical trials for all stages of
cervical cancer because we still have so many questions on what is actually the best way
to treat it and how we can improve on the treatments that we already have. So–>>And there may be prevention trials as well.>>Absolutely.>>That you might be– might qualify for also.>>Okay, great. So this was actually very enjoyable. Thank you so much.>>Thank you for watching.>>And thank you all for– for watching. We’re going to close now and again we have
a lot of resources available associated with this post.>>Thank you.

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