According to the 2019 Human Papillomavirus and Related Diseases Report on Malaysia by the ICO/IARC Information Centre on HPV and Cancer, cervical cancer ranks as the third leading cause of female cancer and the second most common female cancer in women aged 15 to 44 years in the country.
Approximately 1,682 new cervical cancer cases are diagnosed annually in Malaysia.
Human papillomavirus (HPV) infection is a well-established cause of cervical cancer and there is growing evidence of HPV being a relevant factor in other anogenital cancers (vulva, vagina, anus and penis), as well as head and neck cancers.
“Any woman who is sexually active or used to be sexually active may be at risk of contracting cervical cancer, ” says consultant obstetrician and gynaecologist Dr Kavitha Nagandla.
HPV refers to a group of more than 200 related viruses, with over 40 types transmitted through direct sexual contact – vaginal, anal and oral sex – from the skin and mucous membranes of infected people to those of their partners.
Infections may not have any symptoms. However, prolonged and persistent infections with high-risk types can lead to cell changes, which if left untreated, may progress to cancer.
Studies reveal that up to 88.7% of invasive cervical cancers are attributed to HPVs 16 and 18.
Early detection via screening and vaccination can reduce the risk of cancer by up to 70%.
Cervical cancer is usually found in women who are in their 30s to 40s.
To mitigate the risk of cervical cancer in the female population, the Health Ministry introduced through schools, the HPV vaccination programme for girls aged 13, since 2010.
“The reason why pre-teen girls are vaccinated is because they are presumed to not have had any sexual contact at the age of 13, ” says Dr Kavitha.
HPV vaccines are highly effective in reducing the potential risk of infection for the types of HPV they target, when given prior to initial exposure to the virus.
When the vaccine is given, it stimulates the body to produce antibodies that will bind to the virus and prevent it from infecting cells in future encounters with HPV, thereby offering protection.
“This is the rationale for HPV vaccination in older women as well, as it cross-protects against other viruses that can cause cancer, should they be exposed to them in future.
“Hence, older women may not get 80%-90% protection like school children, but may get about 30% protection instead. Some cross protection is still beneficial, ” says Dr Kavitha.
Currently, vaccination to prevent cervical cancer is available for individuals until the age of 45 and may be extended until the age of 50.
In clarifying myths in relation to HPV and cervical cancer, Dr Kavitha says, “Cervical cancer does not run in the family like ovarian and uterine cancer. It is a lifestyle-related condition.”
Individuals with multiple sexual partners and/or are exposed to sex at an early age run a higher risk of being infected with HPVs and cervical cancer.
She adds, “Contraception like the oral contraceptive pill or jabs will not protect an individual from cervical cancer, although condoms may offer some protection against HPV infection.
“HPV cannot live outside the body and be transmitted via fomites like tabletops and bedsheets, as it requires a medium or cellular structure, and nutrients, for survival.
“The virus only infects at the cellular level and targets cells at the neck of the womb or cervix.
“Once minor surgery is done to remove the abnormal cells, the patient is potentially cured.”
Another common misconception regarding cervical cancer relates to vaccination and screening.
“Women need to understand that the vaccine does not offer 100% protection.
“It does not prevent other sexually-transmitted diseases (STDs), nor does it treat existing HPV infections or HPV-caused diseases, or protect against all HPV infections that cause cancer.
“Although the vaccine is very effective, we still need more data, and until then, women, regardless of whether or not they are vaccinated, are strongly advised to undergo regular screening.”
“The purpose of screening is to catch abnormalities in the cells early so that there can be early intervention, ” she says, adding that HPV not only causes cancer, but also non-cancerous conditions like warts on the hands, feet, eyelids, lips and genital area, which are highly treatable.
Screening for HPV
In identifying red flags related to cervical cancer, women should look out for symptoms like abnormal bleeding between menstrual periods, after sex or after menopause; discharge that is unusual in amount, consistency, colour or smell; frequent or painful urination; and pelvic pain.
“See your gynaecologist if you notice anything out of the ordinary, ” advises Dr Kavitha.
A Pap smear would usually be recommended by the specialist.
This is a procedure where a small brush or spatula is used to gently remove cells from the cervix to be checked for cell abnormalities that may lead to cervical cancer.
It is essentially a test that detects pre-cancerous cells and is done as part of a pelvic exam.
It is highly recommended to combine HPV DNA testing with the Pap smear.
An annual Pap smear, coupled with HPV testing, is important to ensure that both results are normal.
“If there is an option for HPV screening, we would advise the patient to do it, as a Pap smear alone is not sufficient to identify potential issues with the cervix.
“Although the Pap smear is the most common form of screening for cervical cancer, its sensitivity is only 50%.
“That’s why doctors are now advocating that along with the Pap smear, patients should also do HPV testing.
“It’s done in one shot and HPV testing is 99% sensitive, so you will feel so much more assured.
“In the United States, and now Britain, health authorities advocate doing only HPV screening as the primary screening over a Pap smear, ” says Dr Kavitha.
“There needs to be more awareness about the HPV test and how it is a more accurate form of screening.
“The sensitivity is so high, you need only repeat the HPV test every five years if confirmed negative, ” she adds.
In general, women aged 21-50 should get a Pap smear done annually.
If the results are normal two years in a row, then the test can be reduced to once every three years.
Women aged 50-65 should have it done every five years, while women aged 65 and above should get checked if they have signs and symptoms, i.e. post-menopausal bleeding.
Women who used to be sexually active should continue getting the Pap smear as they are still at risk of developing cervical cancer from past relationships.
A Pap smear is not required for women who have never had any sexual intercourse, as there is practically no risk of contracting HPVs nor cervical cancer.
Curable in early stages
Dr Kavitha shares: “If a patient’s Pap smear reveals the presence of cells that are slightly abnormal, we advise them not to smoke.
“Smoking and alcohol are high risk factors for women with some cell abnormality, as it encourages the rogue cells to multiply.
“Smoking may lower one’s immunity to diseases, so the virus that’s already present may cause abnormal cells to multiply faster.”
Cervical cancer is not only curable if detected early, but is also largely preventable.
With treatment and regular follow-ups with a gynaecologist, a woman with an abnormal Pap smear result has a good chance of preventing the development of cervical cancer.
On whether a woman can still have child if she has cervical cancer, she says, “In cases where the cancer is in its early stages and surgery is done to remove only abnormal cells in the cervix and the uterus is intact, there is a chance that the woman can become pregnant.
“However, that’s only possible if she has Stage 1 cancer and she must be on follow-up (with her doctor).
“The moment it is above Stage 1, it becomes quite impossible, because if you try to keep the womb intact, the cancer will spread.”
Dr Kavitha hopes that with increased awareness, fewer women will be afflicted with this preventable disease, resulting in a lower death rate from cervical cancer in Malaysia.
“Pre-invasive disease of cervix, which causes an abnormal Pap smear and is not cervical cancer yet, is potentially curable.
“Cervical cancer is also treatable and curable if diagnosed in the early stages. The treatment can be highly effective.
“There is no similar screening for womb or ovarian cancer, but for cervical cancer, vaccination and screening is available.
“There just needs to be more awareness for women to take the necessary preventive steps to ensure they stay in the pink of health, ” she says.
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