We are not so desperate in the face of HPV, whose name we hear frequently these days and when we hear, we do not know what to do. It’s the misinformation that scares us.
Human Papilloma Virus, aka HPV, is the nightmare of women today. There is at least one woman with HPV or having a problem caused by HPV around us. If you wonder and type HPV into Google, the results are frightening. Such that you can believe you have cancer just by reading it. So, is HPV really that scary or is there something wrong with what we know?
So, let’s look at the facts about HPV. HPV is indeed the most common sexually transmitted infection today, and almost all sexually active individuals will be infected with HPV at some point in their lives. It’s scary to know how common it is, but the vast majority of HPV infections go away on their own within an average of two years without causing any problems. In a minority of cases, the infection becomes chronic, a small proportion of this group progresses to precancerous lesions, and even fewer progress to cervical cancer. Then, what could be the factors that determine chronic infection? In addition to the type of virus, the state of the immune system of the person is also very important. Therefore, a faster progression can be seen in HIV carriers. Other factors can be listed as the presence of other sexually transmitted infections, smoking, giving birth at early ages and multiple births. Let’s not be startled when we hear the word cancer, the time required for precancerous lesions to progress to cancer is 10-20 years. This long time gives us the chance to catch and treat precancerous lesions.
There are about 100 types of the virus we call HPV, and most of them are not associated with cancer. Types 6 and 11 that are not associated with cancer but cause genital warts in both men and women. We call cancer-associated types high-risk types. Of these, 16 and 18 are responsible for 70 percent of cervical cancers worldwide. Some of the other less common high-risk types are 31, 33, 45 and 58. High-risk types are associated with vaginal and vulvar cancers as well as cervical cancer in women. It has been shown to be associated with penile and anal cancers in men and throat cancers in both sexes. It’s important to keep in mind, though: the majority of infections, even with the high-risk types, will go away on their own. Among all these cancers, there is a screening program just for cervical cancer, and if a woman is screened only once between the ages of 30-49, her risk of dying from this cancer will be much lower. As you can see, the picture is not that dark.
Of course, the not-so-dark picture is true for countries that can implement these scanning programs, unfortunately. Worldwide, 500,000 women get this cancer every year and 274,000 women die from this preventable cancer, and as you can imagine, most of them are in underdeveloped and developing countries… However, the introduction of new, more low-cost and effective screening methods and HPV vaccines are promising developments.
There are three types of screening methods recommended by the World Health Organization. The first of these is the Pap Test or Pap Smear (PS). Here, a sample of discharge from the cervix is examined by a pathologist for cellular changes. The next step is determined according to the detected cellular change status. In the absence of cellular changes, the test is considered negative. Another screening method is HPV typing. For this, again, a sample of discharge from the cervix is taken first. This sample is simply checked for HPV first. If there is, it is determined whether there is a high-risk type virus by typing. If high-risk HPV is not detected, the test is considered negative. Pap smear and HPV typing can also be done together. Another method recommended by the World Health Organization (WHO), especially because of its low cost, but not used in our country, is to paint the cervix with acetic acid and apply the treatment directly in the presence of suspicious areas. Although this method has the advantage of applying treatment simultaneously, there may be over-treatment.
We are so afraid of getting cancer, so should we get a screening every year? Is it necessary if even a single screening between the ages of 30-49 reduces the probability of dying from cancer largely? WHO recommends that women aged 30-49 be screened with PS every three years and with HPV or HPV+PS every five years. Again, WHO does not consider screening before age 30 necessary; because even if HPV is detected in this age group, the probability of detecting pre-cancerous lesions is very low and the majority of HPV infections disappear spontaneously. However, the American Society of Gynecology and Obstetrics recommends that screening be performed with PS every three years (note, not HPV) between the ages of 21-30, and with PS every three years or with HPV+PS every five years for women between the ages of 30-65. It states that women over the age of 65 whose last two tests are negative can opt out of the screening.
So, what is the situation in our country? The National Cervical Cancer Screening Program implemented by the Ministry of Health envisages that all women aged 30-65 should be screened with HPV+PS every five years. In the screening, the presence of HPV is primarily sought, and if there is HPV, typing is performed. If a high-risk type is detected as a result of typing, PS is examined from the same sample. Women over the age of 65 whose last two scans are negative are excluded from the screening.
We’ve had the test done, and we’re looking forward to its result. After all, a high-risk HPV was detected. We go weak in the knees. We surf on the internet; we ask our friends… There is no need to worry so much. Let’s remember again, the process from pre-cancerous lesions to cancer is 10-20 years! Here, the clinician’s approach is important. After all, there is someone sitting in front of her/him with anxiety. Science says we can be comfortable. It matters which high-risk type it is; because if there is a positivity other than 16 and 18 and the PS is negative, it is enough to repeat the test one year later. If HPV 16 or 18 is positive, even if PS is negative, the next step should be colposcopy and, if necessary, biopsy to confirm the diagnosis. What we call colposcopy is to look at the cervix by enlarging it up to 40 times. During the procedure, the cervix is observed in the gynecological examination position and your cervix is examined using special dyes. It’s conducted a biopsy on suspicious areas. The biopsy procedure is a completely painless procedure. These tissues are also examined by the pathologist, and if there is a cellular change, the extent of the change is determined.
If the biopsy result is CIN 1 (minimum cellular changes), it can be followed up with annual PS for up to two years because 60 percent of these lesions can regress. For CIN 2 and 3, cryotherapy (freezing) or LEEP (ablating by using electricity) procedures can be performed, and then follow-up can be started at one-year intervals.
Let’s come to the most important question; can we protect ourselves from HPV? It is important to keep in mind that condoms are not 100 percent protective, as HPV does not require penetration for transmission. Another way to reduce the risk is to increase the age of onset of sexual intercourse and reduce the number of partners.
As in many infectious diseases, our most important weapon is the vaccine. HPV vaccines have been in use since 2006 and as of 2017, they are covered by the national vaccination program in 71 countries. This vaccine is not an active vaccination, it only contains virus-like structures. In other words, the vaccine itself does not cause infection and does not play a role in the treatment of an existing infection. There are two types of HPV vaccine. Both are protective against types 16 and 18. One of them is also protective against types 6 and 11 that cause extra genital warts. In 2017, the nine-valent vaccine, which replaced the quadrivalent vaccine (protective against 6, 11, 16, 18) but is not available in our country, come on the market; here, apart from 16 and 18, there is also protection against five different high-risk types.
Who can get vaccinated? The purpose of vaccination is primary prevention, and for this it is important to have never encountered the virus. Therefore, children aged 9-13 are the main target audience of the vaccine. Regardless of the type, the vaccine is administered in two doses before the age of 15. The second dose should be given no earlier than six months after the first. Three doses of vaccine should be given to people over the age of 15 and HIV positive. Vaccination can be done up to the age of 26, but the protection rates are lower. The point to remember is that vaccination does not require not to take screening test. The most common side effects associated with vaccines are discomfort at the injection site, dizziness and fainting. No other serious side effects have been reported up to the present, apart from an allergic reaction directly related to the vaccine. The question of who should we vaccinate may come to mind. Although girls are the primary target, it is recommended to vaccinate boys as well.
We are not so desperate in the face of HPV, whose name we hear frequently these days and when we hear, we do not know what to do. It’s the misinformation that scares us. Perhaps the saddest thing is that in many countries of the world, many women die from this completely preventable cancer because they cannot access vaccination or screening programs.
Translator: Gülcan Ergün
Proof-reader: Müge Karahan