by Dr. Christopher Chong
Chris Chong Women and Urogynae Centre, Gleneagles Hospital
CANCER - a word and disease that strikes pain and fear in everyone and sounds the death knell for those diagnosed with it. From time immemorial, doctors and scientists had tried to find the causes and cures for cancer. The strive towards these ends are still on-going and to date, in general, they are still mysteries. There are more knowledge and data on certain cancers, such as breast and cervix than some others, such as pancreas and brain. There are also cancers with pre-cancer stages and those with the possibility of screening and early detection - cancer of the cervix is the most common and studied one. Cancer of cervix hits about half a million women worldwide each year and half of them die from this disease. In Singapore, about 200 new cases are diagnosed each year and 80 of them may die, usually due to late detection of the disease.
So can cancer of the cervix be prevented?
The cervix is the door of the womb. The length of the cervix is about 4cm long. More than 10 years ago, cancer of the cervix was the 4th most common cancer in Singapore. Today, with increased awareness, vaccination and more patients doing Pap Smears, it is now the 10th most common cancer. Cancer of the cervix affects a very wide range of ages, the youngest being 15 and the oldest, more than 90 years of age. The most common age group is that between 40 - 50 years of age.
Cancer of the cervix is caused by the Human Papiloma Virus (HPV). There are more than 100 types of HPV in the body. Numbers 16 and 18 HPV will lead to cancer of the cervix in at least 70% of the cases. 50% of men and 50% - 80% of women will get HPV infection in their lifetimes. Most of these infection fortunately will disappear spontaneously with no treatment and most will not even know they have a HPV infection. HPVs that stay behind will cause diseases such as cervix, vulva and vagina abnormality, including cancer. HPVs are transmitted through sexual intercourse.
Vaccines had been developed against numbers 16 and 18 HPV to increase the antibodies in huge numbers. Antibodies are kind of like the soldiers protecting our body from infection, and in this context, to fight off invasion of the 16 and 18 HPV. The vaccination course involves 3 injections into the muscles ( usually the arm ), to be completed in 6 months ( 1st dose, then 2 months from the 1st dose and the last, 6 months from the first dose ).
The first study group of more than 3000 females to take the vaccine was in the USA, more than 11 years ago. 5 years after vaccination, in this group of females, it was found that protection against 16 and 18 HPV was almost 100%. As the result was stunningly good, another study was done up to the age of 45 years. This time, the protection was found to be almost 90%. Although the protection derived from vaccine drops with age, it is still proven powerful at the rate of about 90%.
It is clear that such vaccines are effective as they have remained on the shelves for more than 10 years. Many are still worried about side effects especially in the era of the internet where subjective / objective and perhaps some one-sided anecdotes or information may be found. Data from the vaccine company revealed that after the first 26 million doses of one of the vaccines in the USA, the serious side effects such as nerve problems and the subject collapsing was found to be less than 0.01%. Minor side effects are similar to many vaccines and include ache at the injection site, skin reaction and hardly any cases of fever.
Many countries these days recommend the vaccination for ages of 9 - 45 as the relevant studies were conducted up to age of 45. (It does not mean that from age of 46 onwards, there is no more protection from this vaccination - it is just that we do not have studies to provide the protection rate above age of 45.) However, with data of effectiveness of more than 10 years and with such high safety results, some countries in Europe have recommended that there should not be any upper age limit for vaccination and that the earlier the age at vaccination, the higher the protection rate. The only people who do not need the vaccination are those who had cancer of the cervix. Advocates advised that those who had HPV infection are still suitable for vaccination as vaccination generates antibodies
Unfortunately, vaccination does not wholly prevent cancer. Exceptions are in females who :
1. have many sexual partners
2. have sexually transmitted diseases
3. have strong family of genital cancers
4. are smokers
5. have recurrent vaginal / genital infections
may be more prone to abnormal cell changes and cancer of the cervix.
Cancer of the cervix can present as :
1. post coital bleeding ( bleeding after intercourse )
2. abnormal per vaginal bleeding
3. abnormal vaginal discharge
Tumour growth on vaginal examination and pain are usually late signs. Often, pre-cancer abnormal cell changes and the cancer are picked up via routine Pap Smear.
Pap Smear involves a simple vaginal examination and using a brush to get cells from the cervix for examination in the laboratory. It is typically a quick and painless procedure. Professor Harald zur Hausen who won Nobel prize in Physiology or Medicine for his discovery of HPV, was quoted in the South China Morning Post ( Hong Kong newspapers ) that females who had been sexually active should have yearly Pap Smear examination. Many doctors with many years of experience will divulge that they had picked up abnormal cell changes or cancer even in ladies who had yearly Pap Smear - one can imagine how catastrophic it would be if these ladies were to do Pap Smears every few years or not to do Pap Smear at all!
Pap Smear is a good screening tool as cancer of cervix has a pre-cancer stage. If we can pick out the pre-cancer stage, with proper treatment, then it will not progress to the cancer stage. If the Pap Smear result is abnormal, then doctors will proceed to perform a Colposcopy ( looking the cervix under the microscope ) and often a biopsy ( cutting a tiny piece of the cervix ) to assess for abnormal cells changes.
Another interesting point that Professor Harald brought up in the same column was that, vaccinating the male is more important than vaccinating the females. The reason is that studies have shown that many young boys as early as age of 12 already had many sexual partners and the HPV is transmitted through sexual intercourse. Hence to protect the females, males should vaccinate too. Even if the male end up not having intercourse, vaccination protects against anal and oral cancer.
When one's resistance drops, in the long run, infection and cell changes can occur. It is "easier said than done" - I would suggest the following activities to improve one's resistance and hence immunity:
Unfortunately, vaccination does not wholly prevent cancer. Exceptions are in females who :
1. sleep well and reduce stress
2. exercise regularly
3. consume a balanced diet, preferably organic food
4. do not smoke
5. do not drink excessive amounts of alcohol
6. consider taking probiotics
7. consider taking vitamins.
In conclusion, cancer of the cervix is to a large extent preventable. To this end, other than being healthy and building up one's resistance, I advocate vaccination against HPV for both males and females, and doing regular Pap Smear examination is recommended. Vaccination does not take away the need for Pap Smear. It simply prevents HPV infection while Pap Smear helps pick out the pre-cancer not progress to the cancer stage. Last but not least, ladies and gentlemen, do take charge of your health to prevent the cancer of the cervix!
About the Author
Dr Christopher Chong
CHRIS CHONG WOMEN AND UROGYNAE CENTRE
Obstetrician, Gynaecologist and Urogynaecologist.
MBBS ( S'pore ), MRCOG ( London ), M MED ( S'pore ), MRACOG ( Australia )
Fellowship in Urogynaecology, Melbourne, Australia
Dr Chong is an Obstetrician, Gynecologist and Urogynaecologist in private practice and had been invited back as a Visiting Specialist to the KK Hospital to train the doctors and students. He is a pioneer in female Prolapse, Incontinence and Pelvic Floor Reconstruction surgeries in Singapore. He is the first few doctors in Asia to perform such surgeries, helping thousands of women with these common and embarrassing problems in the process. Dr Chong is a trainer in the specialty of Urogynaecology in Asia, and is a much sought-after speaker both with the media and in international Obstetrics, Gynecology and Urogynaecology conferences. Dr Chong had won many awards for his studies and researches, as well as his exemplary level of patient management. He is also one of the few Doctors accredited by the Ministry of Health to perform Assisted Reproduction work, including In-Vitro Fertilisation.
Dr Chong sits on the Medical Advisory Boards of Mt Alvernia and Gleneagles Hospitals. He is Founding and Executive Board member of the Asia Urogynaecology Association and the Past International Board of Director of the International Urogynecological Association. He is an examiner of the Royal College of Obstetricians and Gynaecologists Exam Course. He is an Editorial Board member of the International Urogynecology Journal and reviews many indexed international Journals.