“The day I discovered I had precancerous cells in my cervix is one I won’t forget,” says Dubai resident Nancy Kinsley*. “Not because it was the worst day of my life, but because I refuse to let myself forget.”
For 36-year-old Nancy, this precancerous diagnosis eight years ago is a reminder not only that she cannot take her health for granted, but that having a regular Pap test (smear test), at the very least, is a health investment that pays off. Luckily Nancy discovered her diagnosis in time, before cervical cancer took hold, but sadly not in time to save her womb – she was advised to have a hysterectomy at the age of 29 due to her diagnosis. Nancy says she wasn’t willing to take any chances with her health, so she agreed with her doctor’s recommendation that she have a hysterectomy; a decision she now regrets. Though once standard practice for precancerous cells, hysterectomies are no longer common. Instead cutting, freezing or burning the diseased part of the cervix is usually recommended, says Dr Jennifer Kasirsky, specialist of obstetrics and gynaecology at Welcare Hospital in Dubai.
“It was devastating. I’m 36 and I cannot have children,” Nancy says. “It wasn’t that I was even careless about my health – I followed UK guidelines to have a Pap test every three years, yet within that time, I developed precancerous cells at the highest level, CIN3. The fact that I’d only ever had a couple of sexual partners made me think I really wasn’t at risk.”
Sunita*, 32, an Indian brought up in the UAE, was also diagnosed with precancerous cells (CIN3) three years ago and underwent an operation to remove part of her cervix. “It was successful and I’ve since gone on to have a baby, though with part of my cervix removed, it did require stitching at three months to ensure I wouldn’t miscarry.”
Having married at 18, Sunita had never had a Pap test, believing she wasn’t at risk of cervical cancer because she’d only ever had one sexual partner – her husband. It was only when bleeding occurred during intercourse that she got herself checked out and discovered she had CIN3. “It sounds ridiculous to say this now. I knew cervical cancer was caused by a sexually transmitted infection, but I didn’t think you’d be likely to get it with so few encounters. I guess I just didn’t like to think of myself as having such a thing, but anyone in a sexual relationship can get it and it’s nothing to be ashamed about.”
Although Sunita had a happy ending, her experience, like Nancy’s, highlights confusion about who gets cervical cancer and what preventative measures we should take and when.
The hidden disease
The leading cause of cervical cancer is the genital human papillomavirus (HPV) – an infection passed on during intercourse and/or during intimate genital skin-to-skin contact. “For between 90 and 95 per cent of women who have cervical cancer, HPV is the cause,” says Dr Denise Howard, consultant obstetrics and gynaecology, urogynaecology at HealthPlus Women’s Health Center in Abu Dhabi. So does that make every woman in a sexual relationship at risk – even those
who have been with just one partner? “Anyone who has had sex has been potentially exposed to HPV,” says obstetrician and gynaecologist Dr Mia Branch from the American Hospital Dubai.
And that’s the problem – HPV doesn’t necessarily have anything to do with your lifestyle and can affect anyone who is sexually active. The bad news: HPV is a very common infection. According to the Centers for Disease Control and Prevention in the US, approximately eight out of ten women will be exposed to HPV and 50 per cent of sexually active women will have HPV at some point in their lives. But before you panic, know that most women (around 90 per cent) who get HPV will recover automatically – their immune system will wage war against it, and will win within two years.
Not all HPV viruses cause cancer. “There are more than 80 types of HPV but it is types 16 and 18 that cause 70 per cent of cervical cancers,” says Dr Kasirsky. Types 16 and 18 cause precancerous cells, also known as dysplasia, of which there are three levels, from CIN1 (least severe) to CIN3 (most severe).
So what can women do to protect themselves? Cancer Research UK has found that Pap tests have curbed a cervical cancer epidemic and saved 100,000 women in the UK since 1988. But despite a staggering number of lives saved thanks to the test, cervical cancer remains the second most common cancer in women. Worldwide, 275,000 women die every year from cervical cancer, and on average, one woman every minute is diagnosed with it. In the UAE the disease affects 7 per cent of women, second only to breast cancer, according to The Health Authority Abu Dhabi (HAAD). So what’s going wrong? Is it because women are not having regular Pap tests? Or is it because the test is unreliable? Dr Thomas Wright from Columbia University in New York, who ran a study on a new HPV-specific test says, “Up to a third of women diagnosed with cervical cancer have normal smear tests.” Professor Jack Cuzick from the Wolfson Institute in London, who also worked on the study, says, “There’s a realisation that the smear test is of inadequate quality.” Clearly, something is amiss.
Dubai-based Nina Judd’s* story supports the doctors’ claims. “At 26, during my three-yearly Pap, I was diagnosed with CIN1 and advised to return in a year for another test. The next year my Pap was normal, but the year after it reached CIN2. At this point I was given a biopsy and colposcopy, which revealed high-grade dysplasia, CIN3, which required a LEEP/LEITZ procedure,” says Nina. This procedure is used to treat cell changes and is done easily in the doctor’s office.
A test three months later revealed CIN3 was still present, so Nina was referred to a specialist gynaecological oncologist at Tawam Hospital who performed another biopsy – the results showed that she didn’t have abnormal cells. “It’s scary that in the last four years I’ve had Pap after Pap, going from negative results to high readings in the space of less than a year,” says Nina. “I’ve had unnecessary surgery twice, recovered, only to go back to the waiting game all over again – it’s stressful, terrifying and an ordeal I wouldn’t wish on anyone.”
Dr Kasirsky says the Pap isn’t always 100 per cent accurate. “There are cases when abnormal cells are missed. However, if you are having regular Paps, then it’s likely that if something is missed on one test, it will be picked up on the next one.”
So how often should we be having Paps? Is it enough to have a Pap test every three years as recommended in the UK? “Different health systems have different recommendations,” explains Dr Kasirsky. “In the US, it is recommended to undertake a Pap annually until the age of 30, after which it is every three years.” In the UK, however, it is recommended women get the test every three years from 25-49 and every five years from 50-64.
For Dr Howard however, the more worrying concern is the significant number of women not having Paps at all. “In my experience, there are a lot of women in the UAE not getting regular or even any Paps, and I don’t see many doctors telling them they need to either. Awareness is getting better, but it could be so much better. We find that younger women are more educated, while older women are less so,” says Dr Howard.
For women like Nancy and Sunita who have been through the nightmare of a precancerous diagnosis, the advice is that it pays to get a Pap test done annually.
So while the Pap test – despite its limitations – is necessary, its role is to help prevent cervical cancer, but it cannot tell you if you’re at risk of it. There is, however, another test that can help you determine if you’re at risk of cervical cancer, explains Dr Howard. The HPV test, which is available in the UAE, can detect if you have the virus, which has cancer-producing strains. Although this is good news, the downside is that there’s no medicine or cure for HPV, says Dr Kasirsky. Despite this, she still recommends women get tested, because armed with this knowledge, there are steps you can take to limit your risk of cervical cancer such as having more regular Pap tests.
Dr Howard also recommends women have the HPV test. “The next time you go for a Pap test, ask for an HPV test. The beauty of it is that it doesn’t require a separate screening as cell samples are taken at the same time. It’s a valuable tool in the early detection and prevention of cervical cancer,” says Dr Howard, who in following the American Obstetrics and Gynecology Association guidelines, suggests women first get tested for HPV three years after becoming sexually active or at the age of 21 – which ever comes first. This is especially necessary after the age of 30 as, according to HAAD, around half of all cases of cervical cancer occur in women aged 35-55.
What about the HPV vaccine?
Although it has had its fair share of controversy since it debuted in 2006, the HPV vaccine has been proven to dramatically reduce teen girls’ and young women’s chances of getting the HPV and the abnormal growths that lead to cervical cancer. “Women who get the HPV vaccine are at significantly less risk of developing dysplasia,” says Dr Howard. Viewed as a complement to screening, doctors say you should still have Pap tests, as the vaccine only prevents infection from the strands of HPV that are associated with 70 per cent of incidences of cervical cancer. Even with the vaccine, you are still not protected against other strains of HPV, which are responsible for the remaining 30 per cent of cervical cancers.
Despite some reports about its negative effects – there’s been talk of neurological problems and arthritis – Dr Kasirsky says there’s no evidence to suggest the vaccine isn’t safe. She recommends it for young teens, young women and those not yet sexually active. Dr Branch agrees. “Due to the prevalence of HPV infection, the HPV vaccine is strongly encouraged and is a worthwhile investment for women aged nine to 26.”
Abu Dhabi has taken action here. The first Arab country to introduce HPV vaccines for schoolgirls, HAAD now offers the vaccination to all school girls – for UAE nationals it’s free and for expats it’s Dh50. In 2010-11, 59 per cent of students received the vaccination and now HAAD is extending it to women up to the age of 45 who have never been sexually active.
But while this is great news for younger friends or for our daughters, how useful is this for the 30-year-old woman who never received the vaccine in her youth? The HPV vaccine territory for older women is uncharted as yet. The thinking is that if you’re older, you’ve probably been exposed to the virus’s four strains, so it won’t help you. But some doctors recommend it to older women who have had fewer than four sexual partners.
“The younger you are, the better the vaccine will work,” says Dr Kasirsky. “However, for those in their 30s who are considered high risk, I would say it’s worth having the vaccine.” A new study published in the British Medical Journal suggests that the HPV vaccine (Gardasil) can significantly reduce the likelihood of the disease even among women who have already been infected with HPV. The study found that the vaccine reduced re-occurrence of HPV-related diseases by 46 per cent among women who were infected prior to the vaccination.
For many women, getting the vaccination is a no-brainer. “Since my diagnosis, I’ve invested in the vaccine after discovering that it could limit risks – it’s worth a shot. I also have a Pap and HPV test annually now and advise all my friends and family to do the same,” says Sunita.
Ultimately, cervical cancer is largely preventable. When caught early, doctors at the HAAD say 92 per cent of cases are curable. The message from doctors at the HAAD and from women who have been through the emotional and physical roller coaster of being diagnosed with precancerous cells, is that when it comes to this disease, you have to be proactive.
“I don’t think cervical cancer or HPV awareness is where it should be in this region,” says Dr Branch. “I believe it is strongly limited by the culture and the taboo of discussing sexual issues.”
Regular screening, including routine Pap and HPV tests, as well as the vaccine, are all worthwhile investments in the fight against this disease. And the more action you take to prevent it, the more chance we have of saving the 70 per cent of women who catch it too late to be cured, and of limiting the number of women like Nancy, Sunita and Nina, whose lives have been affected by precancerous cells.
Limit your risks
This disease does not discriminate between shape, size, religion, nationality or status, but there are things you can do to reduce your risk by taking charge of your health.
LIMIT SEXUAL PARTNERS
Dr Kasirsky recommends limiting the number of sexual partners you have and using condoms. Though this is no guarantee, the higher number of sexual partners you have, the greater your risk.
PROTECT AGAINST LIFESTYLE FACTORS
Smoking, increased stress or a weakened immune system can increase the chance of HPV turning into precancerous cells. Your risk of HPV also increases if you have a poor diet or had a miscarriage.
HAVE REGULAR PAP TESTS
Have an annual Pap and request an HPV test to help detect the HPV virus before it leads to precancerous cells.
GET AN HPV VACCINE
There are currently two HPV vaccines on the UAE market. One protects against four types of HPV, types 16 and 18 (the most common of those causing cervical cancer) and types six and 11, which cause genital warts. The second vaccine protects only against HPV 16 and 18. Hospitals, including Welcare Hospital in Dubai and HealthPlus Women’s Health Center in Abu Dhabi, offer the vaccine, which is delivered in three doses, priced from Dh2,000-Dh2,500.
Make yourself and your friends and family more aware of cervical cancer and HPV.
Visit www.simplycheck.ae/thinkagain and take the cervical cancer quiz and spread the word Visit thinkagain.gsk-me.com or the Facebook page, Support Cervical Cancer Prevention.