What is cervical cancer?

Cervical cancer starts in a woman's cervix. The cervix is the lower, thin opening of the uterus that connects the vagina (or birth canal) to the uterus (womb). Cervical cancer grows slowly over time and usually starts with abnormal changes to the cells on the cervix, known as dysplasia.

Who gets cervical cancer?

Any woman can get cervical cancer. It occurs most often in women over 30 years old.

What causes cervical cancer?

Nearly all cervical cancer is caused by the human papillomavirus (HPV). HPV is one of the most common sexually transmitted infections in the United States; it is estimated that more than half of sexually active adults will get HPV. There are 120 different types of HPV, more than 30 of which can infect the genitals. Genital types of HPV are either low-risk or high-risk based on how likely it is that they may cause cervical or other gynecological cancers.

Most often HPV will go away on its own, but if it does not, it could cause cervical cancer. Many women will have an HPV infection at some point in their lives, but few will get cervical cancer.

In addition to HPV infection, there are other factors that can increase the chances of getting cervical cancer. These include:

• Not having regular cervical cancer screening tests
• Not following up with your health care provider if you have had an abnormal result from a screening test
• Having HIV, the virus that causes AIDS, or another condition that makes it hard for your body to fight off health problems
• Smoking

What are the symptoms of cervical cancer?

Early on, there are usually no symptoms of cervical cancer. The longer a person has cervical cancer without treatment, the more likely they will have symptoms. Some of the symptoms of advanced cervical cancer can include:

• Abnormal vaginal bleeding
• Unusually heavy vaginal discharge
• Painful intercourse
• Painful urination
• Bleeding after intercourse, between periods or after a pelvic exam

If you have any of these symptoms, you should talk to your health care provider. These symptoms may be caused by something else; the only way to know for sure is to see your health care provider.

What should I know about screening for cervical cancer?

Cervical cancer is the easiest gynecological cancer to prevent with regular screening tests and follow-up. Over the last 30 years, the cervical cancer death rate has gone down by more than 50%, mostly due to the Pap test. Cervical cancer is most often found in women who have not been screened with the Pap test in more than five years or have never been screened at all.

There are two screening tests that can help prevent cervical cancer or find it early:

• Papanicolaou test (known as a Pap test or Pap Smear)

A Pap test is a procedure done in a doctor's office in which cells are taken from the cervix and looked at under a microscope. It is most often done during a routine pelvic exam. If the Pap test results show cells that are not normal and may become cancer, your health care provider will contact you. There are many reasons why Pap test results might not be normal. It usually does not mean you have cancer.

• High Risk (HR) HPV test

The HR HPV test looks for the high-risk types of this virus that cause most cases of cervical cancer. The HPV test can be done at the same time as the Pap test using either the same sample of cervical cells or a second sample taken right after the Pap test. A positive result for HR HPV means that you should be followed closely to make sure that abnormal cells do not develop.

Cervical Cancer Screening Recommendations for Women at Average Risk

• Cervical cancer screening should start at 21 years of age
• Pap test every three years between 21 and 29 years old
• Pap test and HPV test (co-testing) every five years between 30 and 65 years old or a Pap test every three years.

Many people confuse pelvic exams with Pap tests because they are usually done at the same time. The pelvic exam is part of a woman's regular health care. During this exam, the health care provider looks at and feels the reproductive organs. The pelvic exam may help find diseases of the female organs, but it will not find cancer of the cervix at an early stage. To do that, cervical cancer screening tests are needed.

Talk with your health care provider about how often you should be screened for cervical cancer. Women who may no longer be having sex or who may feel too old to have a child should still have regular cervical cancer screening. Cervical cancer is most often found in women who have not had a Pap test in more than five years or have never been screened at all.

How can I lower my chances of getting cervical cancer?

• The HPV vaccine prevents cervical cancer by protecting against the types of HPV that most often cause cervical cancer.
• See your health care provider regularly for a cervical cancer screening.
• Follow-up with your health care provider if your cervical cancer screening results are not normal.
• Use condoms.

Why Are HPV Vaccines Needed?

HPV vaccines prevent serious health problems, such as cervical cancer and other, less common cancers, which are caused by HPV (human papillomavirus). In addition to cancer, HPV can also cause other health problems, such as genital warts HPV is a common virus that is easily spread by skin-to-skin contact during sexual activity with another person. It is possible to have HPV without knowing it, so it is possible to unknowingly spread HPV to another person. Safe, effective vaccines are available to protect females and males against some of the most common types of HPV and the health problems that the virus can cause.

How common are the health problems caused by HPV?

HPV is the main cause of cervical cancer in women. Globally cancer of the cervix uteri is the second most common cancer among women with an estimated 529,409 new cases and 274,883 deaths in 2008. About 86% of the cases occur in developing countries, representing 13% of female cancers. In many countries in sub-Saharan Africa, Central and South America, South and South-East Asia, age-standardized incidence rates of cervix cancer exceed 25 per 100,000. In India, cancer of the cervix uteri is the second most important cancer in women over the past two decades. Globally Age Adjusted Incidence Rates (AAR) of cervical cancer is 15.3 per 100000, but for Indian women it is 27 per 100000. Though the urban population based cancer registries (PBCR) at Bangalore, Bhopal, Chennai, Delhi and Mumbai have shown a significant decrease in the AARs of cervical cancer, however; since over 70 per cent of the Indian population resides in the rural areas, cancer cervix still constitutes the number one cancer. Cancer cervix is the cause for 23.5% of all cancers in women in India. In 2008 it is estimated that 134,420 cases of cervical cancer cases occurred in India and of these cases there were 72826 deaths and these figure is projected to increase up to 116,171 by the year 2025.

What HPV vaccines are available in India?

Two HPV vaccines are licensed by the FDA and recommended by CDC. These vaccines are Cervarix (made by GlaxoSmithKline) and Gardasil (made by Merck).

How Are The Two HPV Vaccines Similar?

Both vaccines are very effective against HPV types 16 and 18, which cause most cervical cancers. So both vaccines prevent cervical cancer in women. Both vaccines are very safe. Both vaccines are made with very small parts of the human papillomavirus (HPV) that cannot cause infection. Both vaccines are given as shots and require 2 or 3 doses.

How Are The Two HPV Vaccines Different?

Only one of the vaccines (Gardasil) protects against HPV types 6 and 11 the types that cause most genital warts in females and males.
Only one of the vaccines (Gardasil) has been tested and licensed for use in males.
Only one of the vaccines (Gardasil) has been tested and shown to protect against cancers of the vulva, vagina, and anus.
The vaccines have different adjuvants-a substance that is added to the vaccine to increase the body's immune response.

Who Should Get HPV Vaccine?

Cervarix-TM (HPV4) and Gardasil-TM (HPV-2) are licensed, safe, and effective for females ages 9 through 26 years. IAP ACVIP recommends that all girls who are 11 or 12 years old get the 2 doses (shots) of either brand of HPV vaccine to protect against cervical cancer. Gardasil also protects against most genital warts, as well as some cancers of the vulva, vagina, and anus. Girls and young women ages 14 years or older should get 3 doses of an HPV vaccine if they have not received all doses yet.

Gardasil-TM can also be given in a 3-dose series for males aged 11 or 12 years, but not yet licensed for use in males in India. The vaccine series can be started beginning at age 9 years.

People who have already had sexual contact before getting all 2/3 doses of an HPV vaccine might still benefit if they were not infected before vaccination with the HPV types included in the vaccine they received. The best way to be sure that a person gets the most benefit from HPV vaccination is to complete full series before sexual activity begins.

Why is HPV vaccine recommended at ages 11 or 12 years?

For the HPV vaccine to work best, it is very important to get all doses before being exposed to HPV. Someone can be infected with HPV the very first time they have sexual contact with another person. It is also possible to get HPV even if sexual contact only happens one time.

How does getting HPV vaccine at ages 11 or 12 fit with other health recommendations?

Doctors recommend health check-ups for preteens and teens. The first dose of an HPV vaccine should be given to girls aged 11 or 12 years during a health check-up. Few other vaccines are recommended for preteens and teens. During one visit, either HPV vaccine can be given safely with these other preteen and teen vaccines. Check-ups during the preteen and teen years are also times when older kids and their parents can talk to their providers about other ways to stay healthy and safe.

What is the recommended schedule (or timing) of the HPV doses (shots)?

Only 2 doses of either of the two HPV vaccines HPV4 (Gardasil-TM) and HPV2 (Cervarix-TM) for adolescent/preadolescent girls aged 9-14 years are recommended by ACVIP and WHO. For girls 15 years and older, and immunocompromised individuals 3 doses are recommended. For two-dose schedule, the minimum interval between doses should be 6 months. Either HPV4 (0, 2, 6 months) or HPV2 (0, 1, 6 months) is recommended in a 3-dose series for females aged 15 years and older. CDC recommends that the second dose be given one to two months after the first, and the third dose be given six months after the first dose.

Are The HPV Vaccines Safe And Effective?

FDA has licensed the vaccines as safe and effective. Both vaccines were tested in thousands of people around the world. These studies showed no serious safety concerns. Common, mild adverse events reported during these studies include pain where the shot was given, fever, dizziness, and nausea. As with all vaccines, CDC and FDA continue to monitor the safety of these vaccines very carefully.

Do people faint after getting HPV vaccines?

People faint for many reasons. Some people may faint after getting any vaccine, including HPV vaccines. Falls and injuries can occur after fainting. Sitting or lying down for about 15 minutes after a vaccination can help prevent fainting and injuries.

Can HPV vaccines treat HPV infections, cancers, or warts?

HPV vaccines will not treat or get rid of existing HPV infections. Also, HPV vaccines do not treat or cure health problems (like cancer or warts) caused by an HPV infection that occurred before vaccination.

How Important Is It To Get HPV Vaccine?

The HPV vaccines are important tools to prevent cervical cancer and genital warts. As with all vaccines, the benefits outweigh potential risks.

Are there other HPV diseases that the two vaccines may prevent?

Studies have shown that Gardasil prevents some cancers of the vagina, vulva and anus which like cervical cancer, can be caused by HPV types 16 and 18. Studies of Cervarix have not looked at protection against cancers of vagina, vulva and anus.

Published studies have not looked at other health problems that might be prevented by HPV vaccines. It is possible that HPV vaccines will also prevent some cancers of the penis and some cancers of the oropharynx (head and neck cancers that are located around the back of the tongue and tonsils) due to HPV 16. Gardasil might prevent recurrent respiratory papillomatosis (RRP), a rare condition caused by HPV 6 or 11 in which warts grow in the throat.

Why aren't HPV vaccines recommended for people older than 26?

Both vaccines were studied in thousands of people from 9 through 26 years old and found to be safe and effective for these ages. The FDA will consider licensing HPV vaccines for other ages if new studies show that this would also be safe and effective.

Should pregnant women be vaccinated?

Pregnant women are not included in the recommendations for HPV vaccines. Studies show neither vaccine caused problems for babies born to women who got the HPV vaccine while they were pregnant. Getting the HPV vaccine when pregnant is not a reason to consider ending a pregnancy. But, to be on the safe side until even more is known, a pregnant woman should not get any doses of either HPV vaccine until her pregnancy is completed.

Sources:

• Frequently Asked Questions About Cervical. Available from: Cancer www.health.ny.gov
• Indian Academy of Pediatrics (IAP) Recommended Immunization Schedule for Children Aged 0 through 18 years – India, 2014 and Updates on Immunization: Available from: www.indianpediatrics.net
• IAP Guidebook on Immunization 2013-14. Available from: www.iapindia.org